Learning from Death in Custody Inquests: A New Framework for Accountability

This report by INQUEST examined how learning was continually being lost due to serious flaws in the post-inquest processes.

An earlier version of INQUEST's current call for a National Oversight Mechanism, Deborah Coles and Helen Shaw argued in 2012 that the absence of a mechanism to capture and act upon the data coming out of costly inquests lead to futher preventable deaths. 

The report criticises the lack of monitoring and analysis following Rule 43 reports, now referred to as Prevention of Future Death reports (PFDs); Rule 43 refers to The Coroners Rules 1984. 

43.  A coroner who believes that action should be taken to prevent the recurrence of fatalities similar to that in respect of which the inquest is being held may announce at the inquest that he is reporting the matter in writing to the person or authority who may have power to take such action and he may report the matter accordingly.

Click below to read and compare the 2012 report and the 2023 National Oversight Mechanism briefing.