Authorities failing to learn lessons on custody deaths, report says

The same failings, such as problems with communication, healthcare and cell design, are consistently identified but learning is lost and changes are not being made, the campaign group Inquest said. There is nothing in place to make sure those failings are addressed and acted upon by the authorities, it added in a report.

More effective use of narrative verdicts and rule 43 reports, which enable coroners to raise concerns and make recommendations for changes to policy after inquests to help save lives in the future, “is overwhelmingly likely to assist in the saving of lives”, Inquest said.

It comes after the number of deaths in custody reached a “disturbing” eight-year high in 2011-12.

A total of 229 people died in prison, immigration detention or while staying in probation service-approved premises in 2011-12, a 15 per cent rise on the previous year, the prisons and probation ombudsman (PPO) said last month. Most, 142, were from natural causes.

“There are numerous examples where deaths have occurred in the same institution or in similar circumstances where a rule 43 report has been made previously, the Learning from Death in Custody report said.

At the end of an inquest into the death of a woman at Styal prison in Wilmslow, Cheshire, in 2001, the coroner made a rule 43 report about the need to set up a detoxification regime for women withdrawing from drugs. But it was not until six more women had died in the same jail that this was changed, the campaigners said.

“One of the striking features of this work has been our repeated experience of attending inquest after inquest where the same issues are identified as possibly contributing to the death,” the report said.

“The existing system is flawed. The lessons to be learned from the contents of these verdicts and reports are far too frequently lost; they are analysed poorly or ignored; misunderstood or misconstrued; dissipated or dismissed.”

It also warned that there was “no collation, analysis or central publication” of narrative verdicts, which could be used to help prevent “similar future fatalities”.

A National Offender Management Service spokesman said: “Strenuous efforts are made to learn from each death and 
improve our understanding and procedures for caring for prisoners.”

A Ministry of Justice spokesman said: “The new chief coroner has a full range of powers to drive up standards, including coroner training, as well as setting minimum standards of service.”