Coroners take action on deaths in custody

Coroners are making more recommendations about how to avoid deaths in custody, according to the latest report from the Ministry of Justice.

The latest statistics on “rule 43 reports”, where coroners make reports to prevent future deaths, show that deaths in custody account for 11% of reports made, up from just over 6% in the two previous reporting periods.

Since July 2008 coroners have had a wider power to make reports to prevent future deaths and a person who receives a report must send a response within 56 days.

The MoJ Report highlights a case reported by the Inner South London Coroner, where a man who had been arrested for breach of the peace died in a police station cell as a result of cocaine intoxication and the development of a variant of excited delirium/acute behavioural disorder.

Among the failures identified by the jury were a lack of police training and failures of communication between police officers and the doctor called.  The man lay on the cell floor in the prone position without moving for about twenty minutes before police and medical staff went into the cell, at which time he was found to be dead, despite an ambulance being called and waiting outside.

The rules are due to change again when provisions of the Coroners and Justice Act 2009 comes into force (see our post).  The change will make a coroner’s report, and an official response to it, mandatory where in the coroner’s opinion action should be taken to prevent the occurrence or continuation of circumstances creating a risk of other deaths.

Recently the Court of Appeal considered that rule 43 had been breached where a coroner failed to address in his rule 43 report action (or inaction) taken after a prisoner was found hanging in his cell (though this was strictly obiter as the appeal was taken on narrower ground).  Lord Justice Sedley observed that

the want of equipment, training and effective procedure which the undisputed evidence revealed was so eloquent of action that needed to be taken to prevent similar fatalities that the coroner cannot have believed otherwise.

Almost a third of the reports issued by coroners between October 2009 and March 2010 related to hospital deaths, with the major issues being those of communication, procedures and protocols, and staff training.

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