A new approach to investigating deaths in hospital?
In July 2015 the government announced its intention to create a new independent patient safety investigation service (IPSIS). Operating from April 2016, IPSIS will provide support and guidance to health and care provider organisations on investigations into serious patient safety incidents.
Deborah Coles has been appointed to the Expert Advisory Group, the panel set up to advise and help develop the new service. Her appointment follows considerable work
done by INQUEST focusing on the failure to operate an independent investigation framework concerning the deaths of psychiatric in-patients. She will work hard to ensure the experiences of bereaved families are central to that process.
The EAG is seeking the views of stakeholders, including service users and bereaved people who have experience of investigations. If you would like to contribute you can find out more here
Women in state care
Natasha Evans was a 34 year old woman who died in HMP Eastwood Park in September 2013 of kidney and heart infections which led to sepsis. She was serving a 4 month prison sentence for possessing the drug to which she was addicted. She was undergoing a detoxification programme. In September the inquest into her death found there was evidence of neglect
and “serious” healthcare failures and that had her symptoms been recognised sooner they could have been treated. Natasha’s death once again raises concerns about the quality of medical care afforded prisoners. It begs the question as to why, 8 years on from Baroness Corston’s report recommending fundamental overhaul of the way women are dealt with in the criminal justice system, courts continue to imprison vulnerable women, the majority of which have committed non-violent offences. Alarmingly there have already been five deaths of women in prisons this year. Four deaths were in Foston Hall including the death of Anna Craven who was serving an 8 week sentence for shop lifting. All of the deaths except one were self inflicted.
The case of Eleanor de Freitas raises further specific concerns regarding the treatment of women in the criminal justice system. Eleanor’s father has lodged an application with the Attorney General requesting a referral to the High Court to consider ordering a fresh inquest
into her death. Eleanor was a 23 year old woman, diagnosed with bi-polar affective disorder and a community patient of her local Mental Health Trust. She took her own life in April 2014 on the eve of a trial at which she was to be prosecuted for perverting the course of justice, following a complaint of rape she made to the police that resulted in the arrest of the accused man. This case raises crucial concerns about the way the criminal justice system deals with rape complainants as well as the safeguards that are in place surrounding the vulnerability and/or mental health of alleged victims.
August - a casework snapshot
August was a shocking snapshot of the scale and vulnerability of those dying in state care and detention this year. The volume and nature of the cases has been truly disturbing. In this month alone, the casework team was contacted for help in relation to 30 deaths occurring in prison, police, psychiatric and other state care.
Of the ten prison deaths almost all involved the death of vulnerable detainees with a history of mental health concerns. Seven of the deaths were self inflicted. One involved the death of a 21 year old. Two deaths occurred at HMP Winchester, bringing the number of deaths at Winchester to four in two months. One death possibly involved the use of force. One death was of an immigration detainee.
Of the nine police related deaths, almost all involved the death of vulnerable people, again many with mental health concerns. Three of the deaths occurred shortly after police contact. Several of the cases involved serious and basic failures of care and treatment of vulnerable detainees at police stations, including vulnerable intoxicated detainees. In two cases, the deaths occurred in police cells in circumstances where close observations should have been underway. For the first time since 2008/09, one person died after making an apparent suicide attempt while being held in a police cell. One case involved the shooting of a man with mental health concerns, only the second death from a police shooting since 2011/12. One case involved the death of a seventeen year old. One case involved the use of restraint. One case involved the death of a highly vulnerable man following his detention by Northumbria Police. According to the IPCC’s annual statistical report, two deaths in or following police contact also occurred in Northumbria in 2014/2015.
Of the other enquiries received, five involved deaths occurring in psychiatric care, four involved the deaths of people receiving care and treatment under a DOLS (Deprivation of Liberty Safeguards) arrangement, one concerned a death in a care home and one involved a military death.
It is hard to remember a more appalling month for new enquiries. The concern is that these deaths may represent a wider picture of increasingly stretched resources, falling standards of care and less humane approaches and treatment of those in the care of the state.
United Family and Friends Campaign
The United Family and Friends Campaign (UFFC) is due to have its annual rally on the 31st of October in London. Assembling at 12 noon at Trafalgar Square, there will be a silent procession along Whitehall followed by a protest outside Downing Street. The UFFC is a national coalition of families and friends of those who have died whilst in care of the state. Find out more about what the UFFC is about and details of the rally here
INQUEST engagement with Ministerial Board on Deaths in Custody
Deborah Coles represents INQUEST on the Ministerial Board on Deaths in Custody, which brings together decision-makers responsible for policy and issues related to deaths in custody at the Ministry of Justice, Home Office and Department of Health. Others on the board include senior staff from inspection, monitoring, investigation and regulation bodies and a number of NGOs.
Deborah presented two recent papers to the board, one on the problems of funding family legal representation at inquests into deaths in custody and the other outlining the key findings and recommendations arising from our evidence-based report on deaths in mental health detention. Both reports generated significant debate and follow-up meetings with the relevant policy leads within government departments. These issues are key strategic priorities for INQUEST and we will report back on progress.
INQUEST contributes to coroners’ officers training
Jointly organised by the Judicial College and the Office of the Chief Coroner, a new programme of coroners’ officer training is being delivered across the country. The training is intended to improve investigative skills and provide an update on recent legal developments.
INQUEST has been pleased to deliver a short lecture at each of the first three sessions on the experience of families and our work. Further sessions are planned in autumn 2015. We hope to remain engaged with training and support initiatives to improve the experience of bereaved families and their representatives'.
INQUEST held one of its Family Forums in June. The family forum gives bereaved families the opportunity to meet new people, to share their experiences, and to feed back to INQUEST their thoughts, feelings and ideas on a range of issues. It was a powerful day with compelling contributions from over 30 family members. The next Family Forum will be held in November. Please contact us if you are interested in attending.
“Even though we suffered the most horrendous circumstances, I left feeling uplifted.”
“Thank you for the opportunity to allow families to come together and share their experiences. It gives a sense of relief / comfort to hear others”
(comments from families attending the Family Forum)
Deaths in prison
Throughout June, July, August and September
there have been 84 Prison deaths in England and Wales. Of these, 31 were self inflicted, 43 were non self inflicted and 10 are still awaiting classification. Of the total, 11 were BAME, 4 of which were self inflicted, 4 not self inflicted, and 3 awaiting classification. There have been 81 male deaths, and 3 female deaths.
These deaths represent 48% of the total year to date, with 176 total deaths in prison since the turn of the year, 67 of which were self inflicted, and 3 of which were homicides. This represents a 14% increase in the number of prison deaths per month, rising from an average of 18 deaths per month from January to May, to 21 deaths per month from June to September.
Deaths following police contact
Throughout June, July, August and September there have been 10 deaths following Police Custody in England and Wales. Of these cases the cause of death in 6 is still unknown, with 1 incident of drowning, 1 caused by swallowing drugs, and 1 caused by gunshot wounds, and 1 as the consequence of a car crash. There were 9 male deaths, and 1 female death.
These deaths represent 50% of the total year to date. This represents a 25% increase in the average number of deaths per month during the period June to September, from that of January to May.
After over 21 years Helen Shaw will be leaving as co-director at the end of the year, although remaining connected to the organisation as an INQUEST associate, working on projects as and when required. We are now advertising for a newly created post of Operations Director.