Bereaved families have hit out at a loophole that allows coroners’ warnings to be left to “gather dust” instead of stopping future deaths. They want an independent group to make sure recommendations are actually carried out.
After an inquest, coroners can issue Prevention of Future Death reports to try to stop similar losses of life but the changes are not legally enforceable.
The charity Inquest says its campaign for an overhaul has been boosted by the Independent Advisory Panel on Deaths in Custody (IAPDC).
This group suggested the Government sets up a new body to audit, follow up and collate recommendations.
Deborah Coles, former panel member and executive director of Inquest, said: “Families go through protracted and complex inquests after deaths in detention in the hope that no other family will go through the same experience and that positive changes occur.
“Yet time and time again, we are seeing repeated patterns of failure which contribute to these often preventable deaths.”
Ms Coles added: “We need to maximise the preventative potential of these reports that too often simply gather dust.”
Richard Caseby, whose 23-year-old son Matthew died after going over a low fence at the Priory Hospital Woodbourne in Birmingham, gave evidence to the panel.
The inquest jury had ruled Matthew’s death was contributed to by neglect at the hospital when he was left unattended. Mr Caseby said: “The coroner made a clear recommendation to the Health Secretary about the height of fences in acute psychiatric units.
“I still have no idea whether anything has been done to stop this from happening to another family. The only way to fix this is for a national commissioner to ensure that coroners’ reports are followed up and their recommendations enforced.”
The panel found that the preventative potential of reports “is not currently being fully realised, with families criticising the current system as ‘nothing more than a paper exercise’.”
Both coroners and families express “deep frustration” that further deaths take place under the very circumstances they have previously warned about or experienced, it said.
Coroners’ concerns were often “only cursorily addressed by respondents, or simply not addressed at all”.
Recipients of a coroner’s report are under a legal duty to consider and respond but there is no sanction if they do not. The panel also found that the reports vary greatly in quality, are often published long after the inquest and may not be sent to the organisations best placed to help.
The IAPDC is an advisory body co-sponsored by the MoJ, Home Office and DHSC with the central aim of preventing deaths in custody.
