<p>Independent Advisory Panel on Deaths in Custody MBDC 64</p><p>Analysing the Impact of Coroners’ Rule 43 Reports Relating to Deaths in Custody on Learning</p><p>Introduction</p><p>1. The Panel recommended to the Ministerial Board on 4 March 2010 that they should seek more qualitative evidence of the current systems in place for sharing learning and monitoring action plans developed following a death in custody. The Panel’s study on the impact of delays to death in custody inquests1 was aimed at tackling the problem of the relevance to learning and we are pursuing recommendations made to bring about improvements in that area. </p><p>2. Coroners’ Rule 43 reports are key to how the state discharges its duties under Article 2 to examine the wider circumstances of a death and to highlight failures that the state should remedy. They are the key tool, following inquests, from which learning about deaths in custody can be drawn. The Panel decided to focus on analysing their impact on organisational learning in order to capture examples of good practice and to make recommendations for change.</p><p>3. We have previously identified the difficulties with accessing Rule 43 reports and the lack of resource dedicated to analysing trends in learning. Although the Ministry of Justice reports on timeliness of responses to Rule 43 letters and high level themes across all deaths every six months2, there is no central work to understand trends in the learning or monitoring of the key issues (including repeated recommendations about the same problems) in Rule 43 reports and how the learning is implemented. The most recent report from the Ministry of Justice shows that in the last reporting period 233 Rule 43 reports were written, which is the highest number since records started in 2008. </p><p>4. INQUEST has recently published a report, “Learning from Inquests: A New Framework for Action and Accountability”3 which is also due for discussion at the </p><p>1 http://iapdeathsincustody.independent.gov.uk/wp-content/uploads/2011/11/Delays-in-DiC-Inquests- IAP-Cross-Sector-Learning.pdf 2 http://www.justice.gov.uk/publications/policy/moj/summary-of-reports-and-responses-under-rule-43-of- the-coroners-rules2 3 http://www.inquest.org.uk/publications/learning-from-death-in-custody-inquests</p><p>1 Independent Advisory Panel on Deaths in Custody MBDC 64</p><p>Ministerial Board meeting in October. The Panel welcomes this report and have been mindful of the findings in addition to our own analysis when making the recommendations in this paper. </p><p>5. The INQUEST study highlights concerns about the number of repeated recommendations made by coroners and the lack of apparent traceable, local and national implementation of these to prevent deaths in similar circumstances. They would like to see better integration of learning from inquests with recommendations arising from other investigation reports. They also note problems with inconsistent practices amongst coroners.</p><p>6. The IAP thinks that learning from deaths in state custody must be made a higher priority for all custodial organisations, and hopes that the appointment of the Chief Coroner will lead to a significant improvement in how learning is analysed and implemented to lead to sustained improvements. </p><p>7. This paper explains the high level findings that have contributed to our recommendations to the Ministerial Board on Deaths in Custody.</p><p>Background and purpose of the analysis</p><p>8. Before commissioning the analysis, the IAP has examined the processes for collating and disseminating learning from investigations and Rule 43 letters in each of the organisations in remit. The secretariat also made arrangements with the MoJ to receive all copies of Rule 43 letters, and responses, about deaths in custody cases. The records cover letters written since 2004 and although they have been able to draw out broad themes from the learning points, it has not been possible to establish the impact of these letters on the relevant custodial organisations. The Panel recognised that more resources would be required to undertake meaningful qualitative analysis of the reports and to determine whether the learning is being shared and acted upon. </p><p>9. In order to improve on the level of analysis, we commissioned Mendas to deliver a qualitative study on the impact of Rule 43 letters on learning to prevent </p><p>2 Independent Advisory Panel on Deaths in Custody MBDC 64</p><p> future deaths. Specifically, we asked them to consider how Rule 43 letters are written; how organisations deal with them and use them as tools for learning. The Panel wanted to know how learning was being used to inform policy and training, and how it was fed back to operational staff and communicated to bereaved families. </p><p>10. The analysis aimed to examine further the impact of Coroners’ ‘recommendations’ in Rule 43 reports; particularly their impact on changes to policy and practice to prevent future deaths in the individual custodial sectors. </p><p>11. The researchers were provided with 182 Rule 43 letters written following deaths in custody, and they selected a sample of 30 cases to focus on, which had been written after November 2007. Their report is attached at Annex A and contains a number of suggestions for improvement, which the Panel has considered in order to formulate the recommendations in this paper.</p><p>Key findings and recommendations</p><p>12. The researchers thought that those involved in implementing learning in each of the organisations needed a better understanding of relevant evidence about how to effect change as a result of Rule 43 letters. This would ensure that the learning makes a real difference to reducing future deaths in custody by supporting practitioners to make changes that could be sustained over time, rather than re- stating or amending guidance and policy. There are some useful resources in the report at Annex A, to which the organisations might refer in order to develop their understanding of how to implement change.</p><p>Circulation and access to Rule 43 reports and responses is problematic</p><p>13. MoJ receives all Rule 43 reports written by coroners and most of the responses. However, their six-monthly analysis focuses on timeliness of the responses rather than any in-depth comment on the quality or trends arising from the learning, which would be a useful resource for the custodial organisations as well as those bodies that inspect or investigate them. The function of summarising Rule 43 reports will be transferred to the Chief Coroner in due course, who will report on key </p><p>3 Independent Advisory Panel on Deaths in Custody MBDC 64</p><p> themes (amongst other factors) in an annual report to Parliament. The Panel hopes this will provide some quality assurance to coroners and drive a greater focus on identifying themes in the learning. </p><p>14. In addition, we would like to see more coordinated efforts in the custodial organisations to use the themes identified as they apply to particular settings. In order to facilitate this, we recommend that the Chief Coroner’s office develops a fully searchable, publicly accessible, database of all death in custody Rule 43 reports, which includes sufficient information to identify themes and trends – and for the information to be accessible to custodial organisations and others for the purposes of learning. Processes need to be put in place to ensure that all reports and responses are recorded on the database. </p><p>Recommendation 1 </p><p>The Chief Coroner’s office should develop a fully searchable, publicly accessible, database of all death in custody Rule 43 reports, which includes sufficient information to identify themes and trends for inclusion in the annual report to Parliament. The information should also be accessible to custodial organisations and other relevant organisations for the purposes of learning and research. Processes need to be put in place to ensure that all reports and responses are recorded on the database.</p><p>Timeliness of Rule 43 reports has an impact on the efficacy of the learning</p><p>15. Lengthy delays between deaths and inquests have an effect on the relevance of learning identified by coroners in Rule 43 reports. The Panel raised this concern, previously, as part of its report on delays to death in custody inquests4, which showed that 24% of coroners’ caseloads (a snapshot taken between September 2010 and January 2011) were cases older than two years. We made a number of recommendations aimed at improving case management of inquests and the specific problems that lead to delays. These were difficult to pursue in the absence of the Chief Coroner, but the Chair of the IAP has since had a positive meeting with Peter Thornton QC, who took up post as Chief Coroner on 17 September 2012. The Chief 4 http://iapdeathsincustody.independent.gov.uk/news/iap-report-on-delays-to-inquests-into-deaths-in- custody/</p><p>4 Independent Advisory Panel on Deaths in Custody MBDC 64</p><p>Coroner will have a duty to report on inquests that have not taken place within a year of notification of death, and the Chief Coroner has confirmed that he will be taking forward a number of solutions to reduce delays to inquests, including allocating cases across areas, improved case management and funding. The Panel will continue to monitor this issue.</p><p>There is a need for organisations to improve the integration of learning from inquests with activity to implement recommendations from other investigations following deaths</p><p>16. The analysis shows that organisations often have a coherent process for responding to Rule 43 reports, aimed at producing a timely response. However, as there is no framework to support analysis of trends and themes, the learning does not always lead to concrete changes in practice. The Panel thinks that organisations could use Rule 43 reports more effectively as learning tools and should integrate the learning arising from Rule 43 reports with their activity on implementing and monitoring action plans from other investigations (e.g. PPO, serious untoward incident reports and IPCC), and make use of the evidence base on learning to support operational staff to make changes to their practice. </p><p>Ongoing coroner training is needed to improve when and how Rule 43 reports are written</p><p>17. The Panel has previously recommended improvements to coroner training, provided by MoJ and the Coroners’ Society, on writing Rule 43 reports. The current analysis shows that there is a case for continued improvements to training, and consistency as to when Rule 43 reports are made under the leadership of the Chief Coroner. Training will be transferred in due course to the Judicial College. The Panel therefore recommends that the training should include guidance on writing Rule 43 reports that would achieve greater consistency. </p><p>5 Independent Advisory Panel on Deaths in Custody MBDC 64</p><p>Recommendation 2</p><p>Training for coroners should include guidance about when Rule 43 reports should be made to promote greater consistency in their approach to deaths in custody inquests. </p><p>Cross sector learning and Sharing Rule 43 reports</p><p>18. It is important that organisations with responsibility for investigating and inspecting custodial settings have sight of coroners’ Rule 43 reports so they are aware of the key learning points identified. This should also enable such bodies to check whether learning has been implemented and sustained, to prevent similar future deaths in custody. There are also a range of local and regional forums at which custodial organisations could join together to promote relevant learning from deaths in custody. </p><p>Recommendation 3 </p><p>The IAP in conjunction with members of the Ministerial Board to identify organisations that should be routinely copied to Rule 43 reports in order to support and monitor implementation of the learning – and to pass on details of this suggestion to the Chief Coroner. </p><p>Independent Advisory Panel October 2012</p><p>6</p>