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July 1, 2015

Deaths in Custody: a National Review

The Harris Review 1 published on 1 July 2015 was asked to examine whether appropriate lessons had been learned from the self-inflicted deaths in custody of 18-24-year-olds that had occurred after ACCT 2 was fully rolled out in April 2007, and if not, what lessons should be learned and what actions should be taken to prevent further deaths.

The Review considered a wide range of evidence and material in coming to its conclusions, including inquest findings and any Coroner’s reports on preventing future deaths. HHJ Peter Thornton QC, the Chief Coroner, gave evidence, and the Review included findings from a RAND Europe/University of Cambridge study, which concluded that there was evidence across all prisons that some “straightforward lessons from inquests had not been learned”.

While the Terms of Reference did not specifically include it, the Review found it essential to look at the processes that follow a self-inflicted death for a full understanding of the deaths examined and the mechanisms for learning or failing to learn from them.

The Report comments, “Each of those deaths represents a failure by the State to protect the young people concerned. That failure is all the greater because the same criticisms have occurred time and time again. Our findings echo the criticisms and recommendations made consistently and repeatedly throughout the last fifteen years and more. Lessons have not been learned and not enough has been done to bring about substantive change”.

The Review found concerns among prison staff about being unfairly blamed following a death, and a fear of the inquest process itself. Staff suggested that more support was needed in preparing for the inquest process and this would help secure more positive learning experiences from deaths in custody. Perhaps this at least in part explains another theme, which was the failure of the prison to involve the family in a transparent manner, leading to distrust of the process. The Review stressed the importance of effective family participation in the investigation following a death and the vital role of bereaved families in inquests.

It was also recognised that there was a lack of a specific mechanism to ensure that the recommendations in the Prevention of Future Death reports are implemented, despite the new processes introduced by The Coroners and Justice Act 2009.

The Review made a range of recommendations including the following that may have implications in respect of inquests:

  • Coroners should be given the remit, where they think it appropriate, to look beyond the circumstances of any individual death to see whether there were other factors that occurred earlier in the prisoner’s history that might have contributed to the death.
  • The Chief Coroner should be provided with sufficient resources to enable him to report on themes emerging from Prevention of Future Death reports involving deaths in custody.
  • All inquest findings, Prevention of Future Death reports and responses that relate to deaths in custody should be centrally collated and available for public search (subject to any necessary redaction).
  • Families of the deceased should have a right to non-means tested public funding for legal representation at an inquest. The costs of legal representation for the families should be borne by NOMS 3.
  • An analogous duty to a “statutory duty of candour” 45 upon NOMS and its staff should be imposed in respect of deaths in prison custody. It should be made clear, that there is, for example, a duty to co-operate with any inquest.

The recommendations listed in this article, in relation to the duty of candour and funding for representation of families at inquests are “primary” recommendations of the Review, and the remainder are “secondary”. None are listed as “fundamental”. Nevertheless, the Review clearly recognises the important role of the inquest in learning lessons for the future.

Kirsty Real


2 Assessment, Care in Custody & Teamwork. “ACCT is a prisoner-centred, flexible care-planning system ACCT is used for those who are believed to be at risk of self-harm or suicide.

3 National Offender Management Service.

4 As recommended by The Francis Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, now being introduced throughout the health service. The Equality and Human Rights Commission has recently proposed that a duty of candour could be extended to investigations and inquiries into non-natural deaths in detention.

5 Candour is defined in this way by the Francis Report (para. 22.1): ‘Candour: the volunteering of all relevant information to persons who have, or may have, been harmed by the provision of services, whether or not the information has been requested, and whether or not a complaint or a report about that provision has been made’.