Justice Committee
Oral evidence: Learning from Inquests, HC 778
Tuesday 3 November 2026
Ordered by the House of Commons to be published on 3 November 2026.
Members present: Catherine Atkinson (Chair); Janet Daby; Sir Ashley Fox; Warinder Juss; Tessa Munt; Mrs Sarah Russell; Dr Neil Shastri-Hurst; Vikki Slade; Tony Vaughan.
Questions 1 - 50
Witnesses
I: Richard Caseby, Johnny Santer and Dr Kate Szymankiewicz.
II: Deborah Coles, Executive Director, INQUEST; Dr Georgia Richards, Founder and Director of the Preventable Deaths Tracker, and AI+ Senior Academic Fellow, King’s College London.
Witnesses: Richard Caseby, Johnny Santer and Dr Kate Szymankiewicz.
Sir Ashley Fox: Good afternoon. I am the Member of Parliament for Bridgwater. I am a former solicitor and my interests are on the register.
Dr Shastri-Hurst: Good afternoon. I am the Member of Parliament for Solihull West and Shirley. Prior to coming to this place, I was a barrister who undertook a large number of inquests as part of my work. I was also a medical clinician working in Birmingham for a period of time at a number of hospitals, albeit not in the field of psychiatry.
Vikki Slade: Hello. I am the Member of Parliament for Mid Dorset and North Poole. My interests are as on the register, none relevant to this Committee but I should declare that I know Kate, as Kate and Ruth used to live in my constituency.
Chair: I am the Member for Parliament for Derby North and Chair of the Justice Committee. I am a non-practising barrister, having practised for 17 years, including undertaking work at inquests.
Tessa Munt: I am the Member of Parliament for Wells and Mendip Hills in Somerset. I am also the chair of the all-party parliamentary group for penal reform and a director and vice-chair of WhistleblowersUK, a not-for-profit organisation.
Warinder Juss: Good afternoon. I am the Member of Parliament for Wolverhampton West. I am a member of the GMB trade union central executive council. I am a solicitor but not practising at the moment. I am co-chair of the APPG on legal and constitutional affairs and an officer and member of various other APPGs.
Mrs Russell: Hello. I am the Member of Parliament for Congleton in Cheshire. I am a solicitor and I chair the all-party parliamentary group on access to justice. I have other interests on the register, as you would expect, including as a member of various trade unions.
Janet Daby: I am the Member of Parliament for Lewisham East in London. I have nothing to declare for this Committee. All my interests are on the register, as usual.
Tony Vaughan: Hi there. I am the Member of Parliament for Folkestone and Hythe. I am an associate tenant at Doughty Street Chambers and I am a barrister. I have practised for many years and hold a practising certificate.
Johnny Santer: Thank you very much, Catherine. I am the founder and campaign director for Gabe’s law, after we had the Multi-Storey Car Parks (Safety) Bill introduced to Parliament in 2023. I am here really because I believe—through lived experience, and the lived experience of others I have been in contact with—that the current system is, unfortunately, woefully inadequate. It is broken.
Richard Caseby: Hello. I am here on behalf of my son, Matthew, who died at the age of 23 back in 2020. He had suffered an acute psychotic episode and, three days after being admitted to the Priory Woodbourne hospital in Birmingham, he escaped. He escaped over a very low fence while left unaccompanied in a courtyard. Other patients had escaped over the same fence before. The Priory had done nothing to fix it and 14 hours later he stood in front of a train. I had rushed up from London to search for him and I was 200 yards away from him when he was hit by the train, just two miles from the hospital, but mercifully I did not actually see it happen.
I have campaigned extremely hard over several years for accountability in my son’s case through the investigative process, which I did myself, the coronial process, the criminal process—because the Priory was convicted in a Crown court— and finally the civil litigation that followed. Along the way I have learned there are many urgent changes that need to be made to the coronial service and specifically the PFD report process and how it functions once the inquest is over.
Dr Szymankiewicz: Thank you, everyone. I am here really as Ruth’s mum. I am a GP, my husband is a cancer surgeon, and our daughter Ruth died just over four and a half years ago. She was an inpatient at the time in an NHS-commissioned, privately run hospital, with an eating disorder. She had been there for four and a half months, and we spent every day of that time fighting for her to be placed somewhere more appropriate, for her to have the care that she needed, for her to have access to her family.
Her inquest was just last summer. The jury at her inquest concluded that she had been unlawfully killed, which is pretty much the most damning outcome you can have at an inquest. There was a whole litany of systemic failures that they listed for that. Our coroner did not decide that he should go ahead with issuing a PFD. Our experience really, having been through that whole incredibly traumatic process, was that it did not really lead to anything. Nothing really has changed from when Ruth was in that hospital, from when she died.
I have ended up following all sorts of threads in trying to create that change myself with various things such as the Mental Health Act last year; with work that I am doing with the Department of Health in trying to enable children in mental health units to have access to their families, which seems like a really basic principle; with trying to get a national eating disorder strategy and a tick and Tourette’s disorder service. There are so many elements, as that jury found in that list of failures.
I am here because it feels like the inquest process does not really serve a purpose to create a change. As someone who professionally likes to learn—as we all know, mistakes are made and things happen—we have to reflect, learn, and make changes based on that. That is what I would like to see from the coronial process and ultimately from PFDs.
Johnny Santer: Yes sure. Unfortunately, I was just re-traumatised the night before I went into my inquest because, despite asking both Merseyside police and the coroner’s office for the bundle, it was not forthcoming. This was after I had already been forced to reschedule the inquest. Gabriel died a preventable death on 3 October 2020. The original inquest was scheduled for 23 December; they wanted me to attend for inquest just two days before the first Christmas without my son. I had to get it postponed until later in January, alerting the clerk that my daughter’s birthday was mid-January and asking if we could possibly avoid that date as well. There you have it; I went into that inquest pretty much completely blind.
Johnny Santer: I was aware of the main four questions: who died, where they died, how they died and when they died. However, obviously now knowing what I know and having been through a very similar inquest that had incredible representation, I know what an inquest is capable of doing.
Johnny Santer: No, unfortunately I did not.
Johnny Santer: Importantly, a prevention of future deaths report. The circumstances around this are important because the inquest that I was sitting in on was the inquest for a young man who died in very similar circumstances to my son, Gabriel—a young man called Josh Perry, who died from a fall from a multi-storey car park in Liverpool in 2025. That was the second death from that same multi-storey car park within three years.
I had actually written to the operator after the first death and asked them what they were going to do to make that structure safe to protect the most vulnerable members of my community and to address the impact that these preventable deaths have on the community. Needless to say, I did not get a response from that operator, and then Josh was allowed to die a very preventable death just two years later. Having seen the barrister, Christian Weaver, represent Josh’s family at inquest—I am proud to say I was able to introduce Josh’s family to Christian to facilitate that—the difference was just worlds apart.
Richard Caseby: Well, before the inquest—between Matthew’s death and the first pre-inquest review—I had already started my own investigation using freedom of information requests and subject access requests. I did this because I knew that the Priory was deliberately trying to cover up the truth of what had happened; that was plain to see. In my career, I have been a managing editor of two national newspapers; I knew how to mount an investigation.
At the start, I knew very little about the inquest process. I do not think I had even covered one as a reporter, so I did not really know much. I made a big mistake at the beginning, thinking—well, I was arrogant enough to think—that I could do it myself, which would have been a huge mistake. Then I read this book, “Inquests: A Practitioner’s Guide”—all 800 pages— and I got a very clear view that I might actually need a lawyer. Thanks to the charity INQUEST, I actually found one who specialised in inquests, Craig Court at Harding Evans, and then a barrister, Oliver Lewis at Doughty Street Chambers. Both were excellent. Excellent.
As Matthew was in state detention, in the custody of the state, it was an article 2 inquest. It was held before a jury and lasted three weeks. What I did not know until I had been through it was the emotional effect it can actually have on you. It is really hard. The coroner, Louise Hunt in Birmingham, who was brilliant—an excellent coroner—opened it by telling everyone that we were all there for the same reason: to find out why and how Matthew had died.
Actually, we all know that is basically a false assurance; well-meaning but naive. That is not what happens in an inquest—at least, not like the one I was involved with. The Government have repeatedly said that families are put at the heart of the inquest process, but in my experience, and those of many families, they most certainly are not. Johnny probably had a similar experience. Families usually enter this coronial arena believing everybody present is only concerned with discovering the truth. As I say, nothing could be further from the truth.
Public bodies such as NHS trusts, the Priory and the police all turned up fully armed with battalions of highly paid lawyers. Most of them were funded by taxpayers’ money. Luckily, thanks to a campaign led by the charity INQUEST, I got exceptional case funding. I had vowed I was not going to spend my own money on this—I would have done it myself. I got legal aid.
The single concern of all those other interested persons—I think that is the name—is just to protect the reputations of their own organisations by deflecting any hint of accountability on to each other, to you, or to whatever it might be. I found it shocking. It was manipulative, obfuscating, defensive and aggressively adversarial towards families. I have seen a lot in my life but I was truly shocked. Does that help?
Dr Szymankiewicz: We all have very similar experiences, albeit from different event backgrounds. I was aware of inquests from a professional capacity and speaking with coroner’s offices, but I had no idea what an inquest such as this would actually look like. We had already gone through a lot. The police were investigating Ruth’s death under charges of corporate manslaughter, and the CQC launched a criminal prosecution investigation that it later dropped. We have not been able to have access to what it actually looked at, so we were stumbling through all that before we were able to even start the inquest process.
It was purely by chance that my sister read a very small article that mentioned the charity INQUEST. I phoned it, not knowing where we even started and it was the one that actually explained what the process would look like. It was the one that suggested that we should have legal representation and linked us with our fantastic solicitor, Charlotte Haworth Hird. I do not know how we would have got through that process without her, the barrister and, subsequently, the KC she enlisted. She was very experienced in inquests and recognised very early on that the legal teams from the other side, as it were—everyone comes back to it being an inquisitorial process—would make it feel like a battle. Having spent four and a half months fighting for Ruth while she was alive, we were then fighting every step of the way to try to get her voice heard, and to even address the questions that we had. I do not know how that would have even had a chance of happening without the legal support.
In terms of potential outcomes, they were the ones who explained to us what the coroner would give the jury. Again, like Richard, it was an article 2 inquest with a jury, and it lasted nine days. The coroner guides the jury on what they are allowed to have as their outcomes. Our legal team really had to push him to offer anything more than suicide or neglect, to allow that scope to be wider. On the last day of her inquest he actually said, “I can see I have been blinkered. Thank you to the jury for seeing the wider picture” because he had been so focused on those four questions. The question of how she died was really simple; it was really clear. She should not have been left unattended with access to the means by which she ended her life.
However, for us, that was not it. We wanted to know how on earth our 14-year-old daughter was made to feel so utterly isolated and trapped that the only way she could see out of there was by not being here anymore. That was what we wanted to know. That was not just about the four and a half months of her being there. That was about all the decisions leading up to her going there. There were just so many layers to it. That is why inquests are really important. However, you are at the mercy of the person who is sitting there overseeing it, and that is very variable. I am conscious I have strayed slightly off the question there.
Dr Szymankiewicz: Yes.
Tessa Munt: Gosh, my goodness.
Dr Szymankiewicz: If I had not picked up that phone, I do not know at what point anyone would have told us that we were eligible for legal aid to have legal representation. Even understanding the language used is a barrier; I am sure I am just as guilty of using medical jargon, but I found myself sitting through those pre-inquest hearings and coming out the other end and realising I did not actually understand half of what was just said. I do not know how you would go through the inquest itself without that legal help.
As Richard and Johnny said, it is re-traumatising. For us, we were not even able to start grieving Ruth properly until after that process because we had to hold all that information in our heads, trying not to lose track of it. It was four years from when she was admitted, virtually to the day, that the inquest went ahead. It took several months for both of us before we could even think about going back to work. It really, really—I cannot explain how that feels.
Tessa Munt: I thank all three of you for being so brave. Thank you very much.
Richard Caseby: Let us take a step back slightly. I knew that having an independent report into what had happened with Matthew was going to be massively important. Before the inquest, I had fought for about 40 days to get the NHS trust to commission an independent investigation into his death because the Priory one was just unforgivable. It was led by one of Britain’s leading psychiatrists, and they found like two core reasons why he died and 29 contributing factors. That was extremely damning, because he had only been there three days. That became the central plank of the inquest, as well as the freedom of information requests I had put into both the trust and the Priory.
I knew heading down this path towards what I wanted was not just a PFD but a conclusion of death contributed to by neglect by the treating hospital—that is what I wanted. That is the most serious one outside of unlawful killing. One of the core reasons why there was a PFD was because actually during the inquest—that was about a year and a half after Matthew’s death—another patient escaped over the same fence from the same hospital. Nothing had been done, even after Matthew’s death. How could a coroner not issue a PFD?
Anyway, I was content with a PFD but even at the last-minute during submissions, the Priory was arguing that there should not be a PFD. How do you do that? I know you can go through the motions as a barrister, as a lawyer and think, “Well, I might as well throw that in, I might as well try that.” However, it was pretty unforgivable behaviour by the KC who represented the Priory. Anyway, I was satisfied with the PFD. It was good. As I said, Louise Hunt is a great coroner. It covered things such as record keeping, record keeping quality, risk assessment, serious incident reports. Honestly, all the things that happen time and again, year after year, with deaths at Priory hospitals.
There was one recommendation that was outstanding and it was about fence height. Matthew had escaped over a fence that was about 7 feet—7 feet 6 inches—and really should have been 9 feet. He was as tall as me, he was 6 foot tall. He was a personal trainer; he was well built. I inspected the hospital courtyard; without even standing on tiptoe, I could put my hand to the top of the fence, and he was left unaccompanied in that courtyard. He had made three attempts over those three days to escape before. Not that each shift knew about them because they got the notes all wrong.
There was also a recommendation to the Department of Health and Social Care stating that there should be standard guidelines for perimeter fences and security in acute mental health units. If you know anything about mental health units—sorry if this is a bit detailed, but I will try to make it fast—there are three levels: acute, which has maybe 3,500 beds in this country, medium, and then high. There are only regulations on the height of fences in outside areas in medium and high security units. This seems a little bizarre, because if someone is held under the Mental Health Act and is sectioned for their own safety and they want to escape, why would you not keep them safe with a recommended fence height?
Anyway, it was what happened afterward that matters. I do not know whether you want me to explain now what the Department of Health and Social Care did or did not do, but to be perfectly honest, I was satisfied by what happened to the Priory. It increased the fence height in about a dozen of its mental health facilities afterward. Although, admittedly, that might have also been because I basically bullied the CQC into bringing a criminal prosecution against it.
Richard Caseby: Yes, it is.
Vikki Slade: People in different circumstances would not have had the wherewithal to do that—
Richard Caseby: Absolutely.
Vikki Slade: Or they might have been managing other children at home; their own grief. You said that you thought that the prevention of future deaths report happened because of that additional death that happened. Do you think—
Richard Caseby: Sorry, just to be precise: it was not a death that happened—someone escaped.
Richard Caseby: I do not want to take anything away from Louise Hunt, because she is an excellent coroner. She may well have done that for somebody else, but to be fair the evidence was overwhelming.
To your point, I could play upon my previous career experience, but I am very well aware that people are not as privileged as me. I am middle class, I have resources, I could give up full-time work as soon as Matthew died to investigate this. I basically had the networks, money and wherewithal to grind down these institutions and to bend them to my will. Had I been a single mother with two other children working a minimum wage, I would have been crushed. I would have been crushed by the system.
Vikki Slade That was the bit I was trying to get to. Thank you, Richard.
Johnny Santer: The impact has been huge, really. I have had to go through a similar process as Richard, in as much as I have taken the organisation that I feel is directly responsible for Gabriel’s death, which was Q-Park, through civil action. We are still awaiting the verdict from that.
To be honest with you, I do not think any of that would have happened had we had the prevention of future deaths report because it would have highlighted the absolute obvious issue that was at stake here. Gabriel fell from an edge perimeter, which is a very similar sort of circumstance, I suppose, to Richard’s case. Gabriel fell from an edge perimeter on a multi-storey car park, and that edge perimeter is currently mandated, by approved document K of the UK building regulations, to be 1.1 metre. This is despite the fact that the parking industry produces suicide prevention strategy, and it is such a well-documented issue that it just seems almost insane that this has not been raised before now.
What I know subsequently from other inquests that have happened—as I alluded to before—is that a prevention of future deaths report should be a very powerful tool to focus the attention and the relevant authorities into recognising that there is an issue here around, guess what, preventable deaths.
As we did not get a PFD it has meant that, six years on from Gabriel’s preventable death, there is still no action that has been taken against the organisation, Q-Park, by any authority. This is despite the fact that Gabriel fell from an edge perimeter that did not even meet the building regulations. I established that fact in court, but I had to go through the process of civil action because nothing had been established in the inquest. Literally nothing.
Mrs Russell: I am so sorry to hear that.
Johnny Santer: Yes. Sorry.
Mrs Russell: You do not have to apologise to us. Kate?
Dr Szymankiewicz: I have mixed feelings. We were completely baffled as to why on earth our coroner would not have issued a PFD. The list of contributory factors to the unlawful killing outcome was long and specific, but also very general across the background of what we know is happening again and again in mental health services, particularly for young people. There were issues such as lack of training for staff, access to social media and the internet, and lack of access to her family. It was a long list, and it seemed crazy that the coroner’s justification for not issuing a PFD was to bring in somebody high ranking from Active Care Group to come to say, “Oh yes, we are doing all these wonderful things now,” and sit there explaining how marvellous they were.
It was very, very strange sitting there listening to them say all this stuff and realise we were expected to take them at their word when actually we were told a lot of these same things about what they did when Ruth was admitted. Those things clearly did not happen. They could just sit there and say that they were doing things magnificently and no one was going to check up on whether they were actually doing any of it. We know that actually it is not just one provider; we know it is not just Active Care Group. We know there are plenty of people in the Priory. We are so heavily reliant on that private sector.
To be honest, I am not necessarily sure a PFD would have made any difference. There have been so many similar cases, time and time again, with issues such as sending children out of area or sending children to adult units. That stuff is constantly coming up in PFDs, yet there is still no action. I am not convinced that these reports do not just go off to a drawer somewhere in Whitehall. It is great that there was some action for Richard’s son but I am not sure I have any faith that PFDs do anything more than allow the coroner to give some recommendations.
Johnny Santer: Sorry, can I just pick up on one fact that Kate so eloquently alluded to? Since Dr Georgia Richards posted on the prevention of future deaths live tracking portal about multi-storey car park safety deaths and the resulting PFDs, there has been 22 deaths since 2013 on the exact same issue. They are all almost verbatim in terms, and it is such a narrow parameter that we are looking at, is it not? It is the edge perimeter of multi-storey car parks. There might be other things alluded to but in essence, they are all the same.
I am in absolute total agreement with Kate here. What is even the point? You can have prevention of future deaths report after prevention of future deaths report, and nobody takes any accountability or responsibility.
Richard Caseby: I totally agree with Johnny on that. I know Deb Coles is going to speak to this, but all you have to do is look at the Lampard inquiry. It is investigating 2,000 deaths in Essex. It is shocking how many of those deaths have had PFDs and they say the same thing year in, year out. You surely want to take a look at that.
Johnny Santer: Well, it is a really good point, because what we are talking about and concentrating on here is PFDs. Dr Georgia Richards will be able to speak to this with much more authority and eloquence than I can, but PFDs only represent a tiny fraction of outcomes from inquests.
When we are talking about Gabriel’s case, the fact that he did not have a PFD from his preventable death, alongside the fact that we know now there are at least 23 other prevention of future deaths reports from this exact same preventable death scenario, there are still hundreds of other people who have died in the exact same way as Gabriel whose deaths are not recorded or represented, therefore there has been no learning from those deaths. What we actually need is a system that looks at all deaths that end up in the inquest process, rather than just focusing on the very narrow outcome of a prevention of future deaths report.
Richard Caseby: In all honesty, it cannot be that difficult these days. I did some work for the Serious Fraud Office about its disclosure documents, and people are now starting to use AI to cross reference words. Up to now, it has always been done manually, but it cannot be that difficult in this age of AI to rapidly identify trends in these cases. There are around 650 PFD reports a year; that is not many. Anyway, sorry, Johnny—I didn’t mean to chip in.
Johnny Santer: No, it is absolutely fine.
Warinder Juss: Kate, do you have anything else to say on top of that?
Dr Szymankiewicz: It is a difficult one. I agree with Johnny and Richard in that we need to make the guidance for what leads to a PFD much more consistent for coroners. It is not an either/or, it is both really because every inquest has outcomes that we can learn from. However, because it varies so widely across all sorts of different fields, directing that down to the appropriate departments and then making sure something is actually being done about it without anybody overseeing that, it is all just getting lost in the ether.
Richard Caseby: Exactly.
Johnny Santer: I agree 100%.
Dr Szymankiewicz: I have a few thoughts on that because the actual coronial process itself is still very flawed. Ruth’s inquest went ahead with vast swathes of missing records; there were several months of her care that they just did not provide records for. We were refused our requests for several of the witnesses who we felt would have been able to answer questions about her therapy. We also asked for an independent expert witness to be brought in, rather than just relying on the consultant who ran that ward saying how things should be done.
One of the things I feel would be really helpful—particularly for deaths within mental health settings—would be to have a separate investigation to provide the evidence because you are relying on the providers to bring that. If we had not had our legal representation pushing for that, you would be looking at the case without even having the evidence to go through, so you are not getting a full picture in the first place.
The disparity between individual coroners is also a really big issue. As soon as our solicitor heard who our coroner was going to be, she said, “I’m going to have to set your expectations right now. It is going to be very hard to get him to look beyond the immediate picture.” That seems like madness. I understand that coroners come from all different backgrounds and experiences, but it feels like there needs to be a lot more guidance. The best analogy I can think of is, if I am duty doctor and I am triaging all the patients coming in that day, I pretty much guarantee that anyone under five and anyone over 80 is definitely going to need to be seen. I suppose I feel it should be similar. Surely any deaths involving children or young people need more looking into.
We have all spoken about that disparity between the family trying to let their loved one’s voice be heard and looking at things openly, versus what inevitably feels like defensive behaviour from the other side. I know there are many different contexts to inquests, but having that level playing field would be really helpful. I am sure the outcome and level we achieved was partly because our solicitor advised that the other side would be bringing a KC and so she applied for funding for us to have a KC so that it felt like an equal footing. There are lots of other thoughts, but that is probably plenty to go with.
Johnny Santer: The night before I was—
Johnny Santer: The night before the inquest.
Tessa Munt: Oh my God.
Johnny Santer: I had not had the information with regard to witness statements or toxicology reports; the coroner’s bundle basically. The whole of the information that I was going to be expecting at inquest did not come to me until 7.30 pm the night before the inquest. I was then reading through it for the first time and there was evidence in the bundle that was brand new to me throughout that whole period from October until the end of January. That was where the re-traumatisation happened because I was like, “Oh my God, what has actually happened here?” It was mind-blowing.
Johnny Santer: I have recently been engaging much more thoroughly with stakeholders everywhere and working with Merseyside Police on the public health issue that obviously Gabriel’s death represents. We are trying to do work around suicide prevention, and that is basically what the Multi-Storey Car Parks (Safety) Bill will be. The police encouraged me to make a complaint, and this was at the end of 2025. The complaint was split between things that the police was going to answer and things that the coroner was going to answer. I have had replies back from Merseyside police and it was actually the senior coroner for Merseyside, André Rebello, who also sits as the honorary secretary for the Coroners’ Society. They are woefully inadequate as well, I am afraid.
Richard Caseby: I want to speak to Kate’s point. Although I keep saying I had a terrific coroner—I did—I tried to help support other families who were going through something similar. In that period before the death, they are notified about the inquest and do not have legal representation; I speak with them. This enormous variability among the quality of coroners is utterly shocking.
I intervened in one. It was the death of a young girl at a Priory hospital in Cheadle Hulme, and it was the fourth death in less than a year at the same hospital. The father could not speak English, and he had his brother there who could speak a bit of English. I attended and wrote to the pre-inquest review, even though I was just a member of the public. I wrote to the coroner to say, “You need to instruct these people that they have to get legal representation because they are going to be walked all over.” The things that coroners say and do—not my experience but the experience of others—is shocking. There seems to be huge variability between a coroner and a judge. You will have your own views but there is a general consistency about judges, whether in civil or criminal cases. With coroners, it is wild out there.
Dr Szymankiewicz: In terms of afterwards, we have not had any further correspondence from the coroner’s court at all. Our expectation from the police investigation, which had looked at corporate manslaughter, was that it was incredibly hard to prove that hierarchical knowledge going upwards without doubt even though there was an unlawful killing outcome. In a criminal court a very different level is needed to prove that. There are some discussions about that unlawful killing verdict in the coroner’s court.
It is really important. We have not pushed, to be honest, to go any further in other investigations. As a family, we have her two younger sisters. Our youngest is now 13 and somehow we both manage to keep working within the NHS. There is only so far your energy can take you. No one else has picked it up. I do not know if other unlawful killing verdicts have gone on to.
We have big questions about CQC. We are deeply unhappy at how it has handled its investigation, which could have been a prosecution. We were told that there was a loophole because it issued a warning to Huntercombe Hospital the week before Ruth died about its observation levels, which were clearly a big factor in Ruth’s death. It was then unable to prosecute but it has not released any of its information to us as to what it has looked at in its report. We have questioned that through our solicitor but we have been told we are not allowed to access it.
Mrs Russell: Please do not think I am suggesting that you should have done any more than you did.
Dr Szymankiewicz: Not at all. I know a lot of families would really want to push for justice but, for us as a family, there is no justice for Ruth. Ruth has gone for us as a family. I need to hold on to a little of hope that things can change for other people. That is why I am here.
Richard Caseby: Can I add something to what Kate said about the CQC? The CQC is a terrible regulator. Between Matthew’s death and the inquest, I asked it to go in and look at the hospital again and do an inspection. It did and it found it to be good, as it had previously. I said, “You have to be kidding; look what I found.” After the inquest, I said, “You are going to go in there again and you need to do another inspection because there has been a PFD.” It could not avoid it and it found it inadequate. Surprise, surprise. I said, “Right, this is the evidence I have collected. This is the evidence of the independent investigation report by one of the leading psychiatrists in the UK.”
Luckily, I had argued for six weeks with that psychiatrist to get this question in the terms of reference: did the Priory undertake all reasonable measures to prevent harm to Matthew while he was detained in their care? If she said no to that, I would probably have had the grounds for a prosecution under the Health and Social Care Act. I did and the Priory was prosecuted. It pleaded guilty on a corporate charge and it had to pay a fine of £650,000. It would have been £1 million had it not pleaded guilty, and it is the highest fine in its history. You have to bully these organisations, these public bodies and these regulators to get anything done.
Johnny Santer: Can I come in on that as well? I put that question to Merseyside police quite early on. The coroner found in Gabriel’s case that it was an open verdict. He felt there was not enough evidence to give a verdict of suicide in Gabriel’s case because there is this question of intent around what had happened.
In this country, we have an absolutely appalling record on holding corporate bodies to account. That is why I tried to have a conversation with Q-Park about the fact that my son had died a preventable death. I was urging it to review all its internal procedures so that this could never happen again. That was the main reason for my first interaction with its managing director, Adam Bidder, via a GDPR request. His initial response to that GDPR request was, “I will get back to you within the 28 days that is mandatory.” He did, and then he said, “We do not have to talk to you because your son is dead.” I was a grieving father trying to find out all the information that his organisation held about the preventable death of my son and, at the earliest opportunity, he wanted to shut me down. He concluded that communication with me by saying, “But you may have redress through a legal process.” His first communication as the managing director of a company that has over 250 multi-storey car parks in the UK and Ireland and is part of a much bigger group—third largest operator in Europe, almost bottomless pockets—was to force me into premature legal action.
Luckily, I had already been in contact with my local MP, Maria Eagle, about what we were going to start to get into and I had made sure that her office was copied into all the communication. It was only intervention from her office to pull it up on this that we started a dialogue, which then lasted approximately nine months before it completely shut me down again. It left me no option other than to seek redress through a civil case, and the only reason I did that was to obtain the information that it was withholding. It is jaw-dropping. It is so damning. Ignoring prevention of future death reports, refusing to do any risk assessments to make its structures safe, which I am told contravenes health and safety legislation. Nobody is holding it to account. I have to do this all on my own volition.
Richard Caseby: My ideal is what INQUEST is basically asking for. It talks about an oversight body; I would call it a commissioner for the prevention of future deaths. It does not have to be a big organisation. A high-profile individual who is not afraid to speak out, with a small secretariat looking at the trends, going out there and finding out whether these things have actually been followed up with NHS trusts, the police, prisons and so on. That would be ideal, but it does not need a huge number of people. We are talking about public inquiry and PFD recommendations. As I have said, there were 650 last year. I do not know how many independent public inquiries have been or closed.
There is a debate about an existing body doing this. In all honesty, I worked in Whitehall for five years as a senior civil servant, and there has been talk about the National Audit Office. The National Audit Office is a public spending watchdog; it is all about value for money. It does not quite fit there. It would just be a separate organisation with the NAO. I can understand why there is that debate because the NAO is something that gives scrutiny to all Government Departments. If you have ever been with your permanent secretary at the Public Accounts Committee, that is the one they fear most and they always try to best the head of the NAO.
I am not sure that that is really the right answer. It should be a commissioner who has powers of embarrassment for these organisations. I am not saying all PFD recommendations should be enforced because some are actually, I would not say ludicrous, but just impossible to put in place. They are too expensive, not value for money, and you might get a coroner covering their own backside because they want to placate the family or something else. I may be arguing against myself on that, but it is true that not all PFD recommendations are great ones. However, a secretariat could spot the ones that come up time and again. The Lampard inquiry is looking at all the PFDs in those 2,000 deaths and finding the same things have happened again and again.
Johnny Santer: I would just echo what Richard has already said. What I am constantly finding out and coming up against is this question of accountability and being able to ensure that whatever system we put in place, and we probably will end up hopefully with a new system, there is actually some power that they can wield particularly with regard to corporate responses. Obviously, that is where my lived experience lies. We saw this after 2008, did we not? Unless there is a real fiscal or moral hazard for the organisations involved, they will not do anything about it. They literally will not do anything about it. In our case, the organisation has gone out of its way to make sure that it does not have to do anything above the absolute statutory minimum, and it has not even applied that.
Dr Szymankiewicz: I have very similar thoughts to Johnny and Richard. I agree that it needs to be a new and separate body. I like the idea of someone such as the Children’s Commissioner. You are right, they need to have the power to enact those changes and follow up. I would envisage them being able to feed down, whether that is to health and safety, and say, “Have you done that?” Or link into Government and say, “Do we need to have some legal changes here?”
Just talking aloud today, I am realising that Ruth’s inquest said that she was unlawfully killed but nothing has come from that. Who is accountable? For me, it is getting those things to change. Somebody who can look at those repeated things that are coming in and say, “Okay, that clearly is a theme. How do we make this happen?” You need them to be innovative.
I am all too aware that, by the time it comes to the shop floor, top-down often does not translate terribly well, but we have to start somewhere, and having an oversight mechanism for all this to feed into would be really helpful.
Richard Caseby: I would say that you need that commissioner for prevention of future deaths—or whatever you want to call them—but unless you are plugged into the parliamentary system it is not going to work. It has to be plugged in somewhere and it needs to be plugged into something such as the Public Administration and Constitutional Affairs Committee because then, like the public service ombudsman, it is the Public Administration and Constitutional Affairs Committee that that plugs into. That has an effect all across Government rather than a single committee. As you say, recommendations are going to affect the Department of Health and Social Care or whatever, so reporting to the Justice Committee does not feel quite right. It needs to be something that is over all Government.
Richard Caseby: Yes.
Dr Szymankiewicz: I was gathering my thoughts there. Next to me, just to remind me why I am here, I have a picture of Ruth. We need to hold at the forefront of all this that people have lost very special loved ones. It feels like a vast system, but actually—I am speaking for myself, but a lot of families feel very similar—to somehow survive all this you hope that we can learn from it. That is what we have the opportunity to create and change. Let us bring the Minister in. Let us speak to the Ministers of all these different Departments and bring everyone together. Let us make this happen. Let us create an oversight mechanism that is actually going to make a difference to all these deaths.
Johnny Santer: There you go. [Interruption.] I have Gabriel and Kitty here with me as well, Kate. I never go anywhere without them in my bag just to remind me again why I am doing this. What is it for? It is to honour Gabe’s memory, but it is for all the others who have died these preventable deaths.
The work I have been doing over the last six years, the families I have been involved with through the Hillsborough Law Now collective, and with the families on the steering group for the national oversight mechanism, all we ever want as families is exactly what Kate said: for us to learn these lessons from the mistakes that have been made. They are so glaringly obvious in so many instances, and the complete inertia from anyone in any position of power is so devastating. Who here is actually going to stand up? In all these cases, I can categorically say that it is so obvious what is wrong and what is right. It really is as simple as that. What is wrong, what is right, and what are we going to do about it?
Richard Caseby: A simple message really is: “End the cliff edge of prevention of future death reports.” It just falls off a cliff. Appoint a commissioner to follow up reports, spot trends and fix those worst failings.
The chief coroner’s guidance already states: “PFDs are vitally important if society is to learn from deaths. A bereaved family wants to be able to say his death was tragic and terrible but at least it should not happen to somebody else.”
Every single bereaved family, and us all, are sick to death of this mantra— particularly in the public sector—of lessons will be learned, because they are not. After all the investigations, after all the traumatising inquest hearings, the fixes, the solutions, they are rarely put in place. We need an oversight body now.
Chair: That brings us to the end of questions, but I would really like to thank you. The evidence that you have given has been so articulate and brave. You have shown great strength and we really appreciate the time you have spent with us. Thank you.
Witnesses: Deborah Coles and Dr Georgia Richards.
Deborah Coles: I am the executive director of the charity INQUEST, which works with families following state-related deaths.
Dr Richards: I am an epidemiologist based at King’s College London, sitting across the health and law faculties. I am also an associate tutor at the University of Oxford and the founder and director of the preventable deaths tracker, which we will talk about this afternoon.
Deborah Coles: I found that evidence extremely powerful but also really upsetting. I feel quite angry about it. I know Kate, Richard and Johnny, but to be perfectly honest, we could have suggested a whole series of families who would have told you very similar accounts of their experiences of the system. There is such a culture of harmful actions or omissions by state and private bodies that are leading to avoidable deaths and resulting in inquests. Yet the preventative potential of those inquests is completely undermined by the lack of any framework to monitor compliance with actions taken in response to inquest findings.
I will talk about findings in the context not just of prevention of future deaths reports but of narrative conclusions that inquests can return about systemic failings and, of course, recommendations that result from other kinds of investigations and inquiries. You have heard from three individuals who have had the worst thing imaginable happen to them, yet they are the ones who have to be the advocates for change. Accountability should be a legal and operational duty of the state rather than a burden placed on grieving families.
Dr Richards: I would like to thank the families again for sharing their experiences. As Deb said, it is almost unimaginable that that could happen, but we have 36,000 inquests every year across the country in England and Wales, so there are 36,000 families who have had this experience. PFDs only represent 1.7% of all inquests so less than 2% of all inquests get a PFD.
PFDs are not enough. They will not help us learn from inquests; they will only help us learn from 1.7% of all inquests. That is why—with my work—we are calling for a national statutory database of all inquests so we can identify trends and patterns for learning and prevention after every inquest that happens across the country.
Dr Richards: I am happy to start, and Deb can come in at any point. There are two main conclusions that can occur at the end of an inquest. The first is short-form conclusions, which can be things such as suicide, natural causes, accidental road traffic accidents or alcohol and drug-related, and they can also add on “contributed to by neglect” with those short-form conclusions.
The most common conclusion, which we have found in 44% of all PFD reports, is a narrative conclusion where the coroner will then describe other factors that led to, caused or contributed to the death. Regardless of the conclusion, that does not lead to any mechanism, follow-up or learning. The examples we just heard before had different conclusions and that did not change the outcome of a PFD or any learnings from those deaths.
Deborah Coles: One problem is that there is no central repository or database where all jury conclusions and records of inquests are actually held. Some very significant narrative conclusions are often returned in deaths where there has been evidence of systemic failure or identifying a whole series of systemic failures—you heard Kate talk about the jury identifying in her unlawful killing conclusion. Unless there is a PFD or an organisation such as INQUEST does a press release where we would put in the findings of that jury, they are not collated anywhere. Going back to Georgia’s point, it just means that really important evidence about systemic failure that could result in proper learning is just lost.
Deborah Coles: I can talk about the national oversight mechanism now or wait until a little later—it is entirely up to you. What you have heard from the families just points to the fact that all the families INQUEST works with have had the worst thing imaginable happen but all are motivated to try to ensure it does not happen to anybody else. At the moment, we have a broken system—across both inquests and inquiries—where families go through very protracted, distressing processes in the hope that there will be change. Yet we have no mechanism from which we can see what actually happens from a post-death investigation to a recommendation to implementation. Irrespective of whether a recommendation is accepted, there needs to be oversight and transparency of that recommendation and how it is being responded to.
Chair: There will be some specific questions on the national oversight mechanism, so I am sure you will get that opportunity.
Dr Richards: Before we can start to follow up, we need the right evidence and data. It is not good enough to just focus on these PFD reports, because we will not include deaths such as Ruth and Gabe in that data, and without having that full picture we are really not going to be able to learn across the country. For the data component and the analysis and trends, I am obviously biased as an academic, but there is something about the academic freedom and independence of academics who conduct research in environments that are not swayed by political policies or different biases that may come in. An academic institution is independent and has academic freedom to analyse and present that data in the most evidence-based way. There is a place for independence, where the data sits outside Government and is analysed in a very objective way before being presented to Government for action.
Dr Richards: I have a few things to say. The first is that, since about 2023, we have seen an increase in the number of PFDs being written. It was sitting at about 450 and has increased to about 550 to 600, so in the last three years we have about 100 extra PFDs coming through. Whether that is positive or not is at the discretion of the coroner. We track reports every day and have tracked every report that has ever been issued from 2013 until today.
We also track response rates. We were the first platform to ever track responses, which we started doing in 2020. When we started, less than a third of all PFDs had responses published. Three years later, that increased to about 40%, because we have live tracking and we name and shame organisations that do not respond.
Last January the Office of the Chief Coroner started publishing a list of non-responses to PFDs. That has led to two-thirds of all PFDs having responses, which is a positive increase. For 2024, 92% of reports have all responses published, which, in the coroner world—as we have been talking about this afternoon—is a huge achievement.
While it is great that we are seeing that improvement in response rates, there have been some recent changes by the Office of the Chief Coroner—started this May—that I am very concerned about. One change is delaying the publication of PFD reports purely for an administrative purpose to help the Office of the Chief Coroner, which goes against open justice and transparency.
Dr Richards: It is at the discretion of the chief coroner. We now have to wait at least 56 days until they have responses for any sharing of PFD reports, which is a concern. The second thing is that they have changed the report and response structure, which I was really looking forward to because we made recommendations last time that we need to improve the consistency of PFD reports and basic things such as reporting age and date of death. You would think that is a simple thing to report in a PFD, but it often does not get reported; we have 1,000 PFDs with no ages, which is concerning. These new templates were published on 1 May, and they make it almost impossible to see who actually responded to the PFDs. They used to respond on letterhead, so it was very easy to see.
Dr Richards: Correct; it is on the website. The new template of the PFD is very confusing: it repeats itself and is structured in a very poor way. I was really looking forward to these new reforms that were suggested by the Committee to improve the consistency and standard of PFDs, but we have really taken a step back despite the positive increase. We are getting about 100 more PFDs in the response rates, but overall, these arbitrary administrative changes really demonstrate there is no digital infrastructure in the coroner system to enable learning from inquests.
Deborah Coles: Just to highlight another positive, in their prevention of future deaths reports, a lot more coroners are now noting other such reports that they or colleagues may have made. That is something that we certainly raised when we did some training for coroners a number of years ago. Both Georgia and I did training for coroners, and I like to think that perhaps coroners’ understanding of the importance of those PFD reports—particularly to families—has influenced the increase of these reports to public health and safety, with a caveat, of course, if any notice is paid to them.
There are some ongoing problems. You heard in the evidence from Kate and Richard about the way in which lawyers representing public and corporate bodies still treat the whole PFD process within inquests. You also heard about the extremely adversarial way in which lawyers will try to persuade coroners that they should not make a PFD, often by introducing evidence of action that they say has been taken. There is no way of testing whether what organisations say has happened is actually happening on the ground. It is not like a coroner can look at a suicide prevention system—by gaining access to prison, say—and see whether anything has changed. Secondly, it absolutely undermines the potential use of these reports for national learning. Even if something has been remedied within a local area, these reports should be informing learning on a national level.
The other problem is the way in which reports are drafted, distributed and published. When we look at the PFD reports that we see in the context of inquest work, they are often quite formulaic. They often look like they are just a cut-and-paste job, and very often focus on, “Oh, well, we’ve reminded staff of a particular policy.” They are often tick-box exercises. There is a report that I was involved in—a piece of research that the independent advisory panel on deaths in custody did—looking at prevention of future deaths reports, where we actually delved into this area in quite a lot of detail. What did not surprise me was that when we did the research it showed that more formulaic approach.
Many coroners are also very frustrated with the current system. They make reports because they have identified that the failings in an individual death need to be remedied in order to protect lives in the future, and yet their power stops at the point that they make a report. We know that there is no proper follow-up to see what action has actually been taken and how change has impacted on the ground. My frustration from INQUEST’s perspective as an organisation that works around deaths in a variety of state institutions is that we see the same issues being repeated time and time again within individual settings—such as prisons or mental health settings—and the wider care sector.
Deborah Coles: In the justice context an example would be the ACCT process in prisons, which is the suicide prevention process. I will just check the notes that the policy manager has given me, which say that, at the time of writing, the chief coroner’s website showed over 60 PFDs that refer to the ACCT process in prisons. Issues raised include the fact that ACCTs are not always opened where evidence shows that they should be, a lack of accountability when ACCTs are not properly monitored, particular concerns about monitoring and observation of at-risk prisoners, and very poor quality assurance.
There is one particularly interesting case—of a prisoner in 2024. The coroner reported that the ACCT care plans were still being overlooked. In a prevention of future deaths report six years earlier, they had issued a PFD at the same prison, indicating that ACCT case reviews were not being adhered to. Sadly, that is just one small example.
Kate was reflecting on the context of the death of her daughter in a privately run mental health setting, and that the issues that Ruth’s inquest flagged up were depressingly familiar to other deaths of children whose cases we had worked on in mental health settings. For us there is nothing more frustrating than to see those same repeated failures, but for a family who have engaged in a process in the hope that change will come, you can just imagine how retraumatising it is to read of a death in similar circumstances.
The PFD system is a broken system. It speaks to the lack of accountability of the organisations responsible for the care of people in those institutions. It is bad enough that there has been a death where somebody is completely dependent on somebody else for their care and well-being; that is shocking. You would expect that when somebody dies the biggest concern of those institutions would be, “How can we learn? How can we stop this happening again?”
What we see within the culture of a lot of inquests is that reputation management becomes the primary concern. It is not about learning or reflecting; it is about resisting full and proper scrutiny—“How can we resist a prevention of future deaths report? How can we mitigate the risk of a very critical narrative conclusion?” Then the inquest stops, and all the organisations concerned too often just sit back, breathe a sigh of relief and issue some trite press release—as Richard was saying we could write the script. They will say, “We will learn the lessons. We will ensure that this is all taken seriously.”
Very often, that is the last thing families will ever hear from the institutions, which is absolutely disgraceful. Then the families have to chase down organisations to try to find out what has actually happened and what has been done. You can issue a formulaic response and say something, but you need to go back in six months or a year’s time and find out whether that change has actually improved things on the ground. Otherwise what happens—as we see at INQUEST—is that those deaths continue.
Deborah Coles: We had to work hard on this one; the nature of the system makes it quite difficult to find out what positive change there has been because we do not always find out about it. Hence the fact that a good oversight mechanism could actually celebrate good practice as well as identify changes that are needed. We have an example in Awaab’s law, which followed a PFD that noted a host of gaps in the policy framework to address damp and mould in social housing. That led to joint agency guidance on the issue and the creation of Awaab’s law, which provides a time limit by which social housing or landlords need to get the issue sorted.
Another example that is both positive and shows some inherent systemic problems with the current system is around Seni’s law, on the use of force in mental health units. That followed the restraint death of a black man called Seni Lewis by police in a mental health setting. It was part of a pattern of similar deaths following restraint resulting in prevention of future deaths reports and the predecessor to the rule 43s.
Those deaths were very high profile, had a lot of parliamentary interest and resulted in some concentrated action by policing and mental health organisations. Driven by Seni’s family working with INQUEST and their MP, Steve Reed, we saw the creation of the Mental Health Units (Use of Force) Act 2018. That was very positive, but there were a number of elements within the Act that were not enacted in 2018.
Since then, it has been left to the family, with the help of ourselves, to try to drive the full implementation of that Bill. It is an example of something that can be very positive, and you can see some positive initiatives that follow deaths that have received a degree of public and parliamentary interest. It is then left once again to the family to try to ensure that that change is actually followed through.
Dr Richards: There are of course several high-profile cases that have led to change, and I will touch on three. First, the death of Martha Mills that led to Martha’s rule, which has been rolled out across the NHS and more recently for maternity care. The NHS claims it has saved 500 lives. That was the result of a PFD and the tireless campaigning of Martha’s mum. She is a journalist so obviously has the expertise, tenacity and the other factors that Richard and Johnny were talking about, to really drive forward that campaign.
Secondly, the death of headteacher Ruth Perry, which led to changes in Ofsted’s recording of school inspections. At the same time as that PFD came out, there was a Committee inquiry ongoing, a change in leadership and a lot of journalism and media reporting. It is never just the PFD; it is always a combination of other factors.
The final example is that I have worked closely with the Natasha Allergy Research Foundation, now Natasha’s Foundation, which came from the death of Natasha after consuming a sandwich at Pret. Natasha’s Foundation has done incredible work with many families who have children with allergies. Natasha’s law was enacted in 2021 following the tireless campaigning of her family. More recently we have had the creation of Benedict’s law, which is now implementing allergy training in schools.
This is all driven by families. We have really created this two-tiered system that is driven off class and campaigns, and which is really the backbone of how we learn from inquests at the moment. It means we have inequalities in the system and that the deaths of those who matter most are really not being counted.
The Government need to take a look at themselves and answer the question of how we learn from deaths. Inquests play a small but important role in that, but there are many statutory bodies that have been set up. There are silos across every Government Department, and public bodies are all doing their own things. The Justice Committee has a unique perspective to bring together all those statutory mechanisms from road, rail, marine, child death and domestic homicide reviews. The list of statutory mechanisms that exist really needs to come together; we cannot have these inequalities where it is driven by class and campaigns.
Dr Richards: In the tracker, we look at that. We record where there have been any policy reforms after PFDs and track those over time. These are random, often arbitrary and really knee-jerk reactions from the Government to high-profile cases. We monitor those high-profile cases that lead to that, but at the moment there is no evidence base or systematic way to do that in a way that is equal across all inquests. We do it in the tracker, but it is very much a knee-jerk reaction response.
Deborah Coles: The only thing I would really add to that is that, sadly, we do that but in the context of a death happening—maybe in the same institution, revealing the same issues—that shows that the learning from previous deaths has not been enacted. Bearing in mind the Justice Committee’s interest in prisons, there have been a number of repeated deaths in individual prisons—HMP Woodhill being a good example—where there have been a succession of critical inquest outcomes and the same issues keep being repeated.
Following a number of recent deaths in HMP Lowdham Grange, the HM Coroner Service for Nottingham City and Nottinghamshire has written to ask Nottinghamshire police to investigate because of the repeated and similar failings identified in those cases. In the absence of any proper mechanism to actually do that deep dive and see what action has been taken, it is often that you only know when the same thing happens again.
Dr Richards: I just gave the news of the new template that obviously has not worked to improve the consistency. There needs to be a digitalisation of the PFD system. The Chancellor announced last weekend the AI strategy for Government, and I know the coroner service could really deal with some basic IT infrastructure that would improve the consistency and standardisation of PFDs.
The other area is around the guidance and training that have been improved. Overall, there is an element of it being at the discretion of the coroner. We have geographical variation in how they are issued across the country. We cannot require a coroner to write a PFD, but we can improve the digitalisation of how they actually write those, where the data goes and how it flows. At the moment it is all driven off an individual coroner area emailing that to an organisation. It is emailed back and then emailed to the chief coroner system and manually published as a PDF document on a website. The fact that we are relying on that PDF email to save a life is a real national scandal in terms of the infrastructure that we are relying on for a life to be saved.
Deborah Coles: There is also a question of to whom these reports are disseminated. We have quite often found that you will look at a PFD and question why it has not been more broadly circulated to those whose attention should be brought to some very serious systemic failings. The coroner’s system is ill-resourced, and that is something that is impacting on families’ experiences of the inquest system from start to finish.
In terms of the point about the quality and consistency of PFD reports, it is also about coroners recognising that you should make a report irrespective of whether you think that an organisation has addressed something at the local level. I feel very strongly about the fact that these reports should be viewed as a really important opportunity for learning when something has gone catastrophically wrong, and should be made irrespective of any organisation arguing otherwise.
Dr Richards: I know for a fact that the Department of Health and Social Care and NHS England do not get all the individual PFDs that go to NHS trusts, so the short answer is that there is no national learning. I could delve into that a lot, because I have sat for many meetings with CQC, HSSIB, NHS trusts, NHS England and the Department of Health and Social Care to try to bring these organisations together to have a national approach, which is exactly what the tracker does. We can bring all those PFDs together for all health and social care-related PFDs, but there has been no appetite or interest to have a national approach to analysing all PFDs relating to the health and social care system.
Deborah Coles: It is pretty scandalous how bad the system is within different organisations. This is not something that we are just talking about today; you have already referred to the previous Justice Committee inquiry into this, and we have been talking about it for decades now in various bits of Government and various Committees. It is not something that Government are not live to.
For every family you hear from, there are hundreds of families who have had the worst experience possible. Yet we cannot say with confidence that those organisations are going to respond in a humane way to families and tell them what they intend to do to make sure this does not happen again. That co-ordinated and cross-sector learning that is so important to public health and safety is still not happening.
Dr Richards: I can talk about that because we track the timeliness. I mentioned some stats earlier. It used to be less than a third, but now more than two thirds of reports have responses. In terms of timeliness, we also look from the date of death to the date of PFD report—a new dashboard we have just published on the tracker. If we are going to learn from deaths, we need to have near real-time reporting and responses. That is exactly what the tracker is there to do: analyse that information in real-time as it comes through.
We have seen an increase in response rates, which is positive but the big challenge we have is that any organisation can request an extension for responses. Now with the new guidance from the Chief Coroner that PFDs are not to be published until all responses are received, it could be years and years before we get to look at PFDs that are being written today.
The Department of Health and Social Care is one of the worst offenders; it will just request an extension and could get a six-month to two-year extension. The coroner could say no, but the coroners that I speak to really want to get those responses to the families, and the families often ask the coroner, “Do you have a response for my PFD?” This timeliness of both issuing PFDs—because we need to save lives now, not in five years—and the timeliness of reporting and taking action, is really crucial to having any type of system where we can learn from inquests. It is a huge challenge and a real problem.
Dr Richards: The short answer is no. It is at the discretion and opinion of the coroner as per the Coroners and Justice Act 2009. There is case law from 2022—R (Diarra Dillon) v. HM Assistant Coroner for Rutland and North Leicestershire—in which someone who lost their brother in prison from an anaphylactic reaction did a judicial review of the decision not to issue a PFD. This decision was handed down by the court to say that it was lawful for the coroner not to issue a PFD. We now have case law to say that it is at the discretion of the coroner. There is no threshold that a case must reach—whether civil or criminal—for when a PFD will or will not be issued.
There is huge geographical variation. I have some coroners that have never issued a PFD and there are others who have issued hundreds of PFDs. There is no way that we can enforce a PFD. Now we would not take judicial review on a decision not to issue a PFD, because we have case law that says it is lawful not to issue a PFD.
Deborah Coles: From our experience late disclosure is an ongoing issue, whether you are represented or not. What is so shocking about Johnny’s evidence is the fact that it is quite clear that he was not given any information about his legal rights. He articulated the inhumanity of the process so well but to give somebody disclosure the night before the inquest into their child is just so cruel and simply should not happen.
Legal representation from the outset can make a real difference for a family because you then have lawyers who understand the inquest process, can make the necessary requests to the coroner for disclosure and hopefully get disclosure in a timely way in advance of the inquest. It is important just to say how legal representation can impact a family’s experience of an inquest because from the outset they know that they are supported at a deeply traumatic time as early as possible.
It is worth mentioning that the Hillsborough law is currently making its way through the parliamentary process. One issue that we are waiting for Government to make a decision on is the point at which funding for families’ representation is made, which we are calling the trigger point. The point I want to make here is that for bereaved families who are about to go through a very complex legal process, the earlier that they have access to a lawyer who knows what they are doing the better. Not only does it mean that they can get on with the post-death cultural practices, grieve and look after other family members knowing that their interests are being represented by a lawyer, but they can impact the potential scrutiny afforded to their loved one’s death. They can make representations to the coroner about the kind of evidence that they should hear and impact any pre-inquest investigation so that that investigation examines evidence as far as possible and can help minimise the experience that Johnny had. They will get disclosure in advance, so they have some degree of preparation for what is going to come up at their subsequent inquest.
Of course, that can impact the scope but it can also mean that a family lawyer can stand up to some quite aggressive adversarial conduct that we see by state and corporate lawyers in the context of what I mentioned earlier about arguing against a particular jury conclusion and the making of a PFD report. State and corporate lawyers are very good at knowing how to argue against the making of a PFD. When I did coroners training I highlighted how some firms would advertise their services online and it would effectively be, “If you want to try to avoid a PFD, come to us.” I am not talking about all lawyers; I should make that clear. In some highly contentious cases there has been really appalling conduct by lawyers.
It will be very interesting to see whether Hillsborough law and a duty of candour and more openness and transparency will change the culture within inquests. One would hope—if we try to move away from this defensive culture and concern with reputation management—we could have a cultural change and see inquests as a vital opportunity for learning and prevention, which is really something that is in the interests of us all.
Dr Richards: With the Hillsborough law coming through, if we had a national database of all inquests we could actually monitor the impact of it. We have no national database to monitor legal representation, who does or does not get it, decisions on PFDs and what will happen with Hillsborough Law. If we see an increase or decrease in PFDs, a properly structured statutory database would allow us to actually evaluate policies such as the Hillsborough Law to see the impact and outcomes.
Deborah Coles: I can follow up this answer with our latest briefing on this, but it is about the point at which an interested party is designated by the coroner. We cannot afford to wait for that because obviously it can be some time before there is a pre-inquest review. It may not be evident straightaway whether somebody is an interested person, but in a lot of the cases that we are involved in, it will be very evident if you are talking about a death in a state institution, by way of example, or a death involving a corporate body where the expectation will be that the state or corporate body will be represented. Irrespective of whether the state or corporate body is represented the family should have access to funding at the earliest opportunity. That is what we are currently debating with Government over.
Deborah Coles: Absolutely, yes.
Tessa Munt: Perhaps you could put your views on that in writing to the Chair. We would encourage you to do so.
Deborah Coles: Yes.
Tessa Munt: Can I just interject on your interjection? I sat on the Health Bill Committee and pushed really hard for cover for contractors and subcontractors. Where you have a council or hospital, for example, that has contracted its services out to a car park company, they might be covered. They might not but there is an element of that that probably needs to be drilled down into, because that is private provision contracted by public services. My view is that that should be included but there is a bit of pushback on that.
Dr Richards: To give context around data in terms of what we know from the statistics that get published—there is no national database—last year there were 360 deaths in prison and about 600-odd deaths in state custody. That only represents 1% to 2% of all deaths in state custody in all inquests--a very small proportion of the 36,000 inquests that happen every year.
We do not have data on the other public service-related deaths because we do not have a national database, so it is not possible to say what the statistics look like. It could create this third-tier system where those that are solely managed by the state—as in deaths in a state prison—would obviously get legal aid. There will be a majority of inquests where families will not have legal aid, such as Johnny’s family. The data is not there yet but state custody deaths are about 2% of all inquests.
Chair: I am conscious of time, as we have not yet reached our questions about the national oversight mechanism. Let us move on to Janet’s questions.
Deborah Coles: I will be as quick as I can and then we can follow it up with more information. The proposal for a national oversight mechanism has come out of our frustration with the current system and after lots of consultation with families, lawyers and academics. Effectively, it bridges the gap between recommendations being issued after post-death investigations and meaningful, potentially life-changing recommendations and change actually happening.
We are proposing that it would be a new independent public body that would collate, analyse and crucially follow up on recommendations made following investigations into state-related deaths. That would include inquests, statutory and non-statutory inquiries, reviews and investigations. As I say it would have three main functions, which we can follow up on. Georgia’s tracker is a good example of what is actually possible in the context of PFDs. The second point would be the analysis; this is particularly important. It would be able to analyse the themes, patterns and issues coming out of the recommendations that are made following all these processes.
Crucially, the third would be to follow up. A mechanism would need those clear powers to follow up and report on action or inaction through the ability to gain access to information and, importantly, work with other regulatory or prosecution bodies, for example. It would be independent of Government. That is really important, because inquests and inquiries involve deep scrutiny into all arms of the state. That function on an operational independence of an oversight body is critical to public confidence and its ability to function effectively.
Another important key principle is that the views of bereaved people, victims and affected communities should be built into the governance and operation of a NOM. We have suggested previously that this could potentially be done through an advisory board made up of those groups. The reason for saying that is that, from what you have heard thus far, families are very often the drivers trying to effect change, but they never hear from anybody about what has actually happened, which is crucial.
The accountability to Parliament is important and speaks to a question that the Chair mentioned earlier about the role of Committees. We would see the NOM as having a very significant analysis and research function. Given it would cover quite a lot of different areas it could produce thematic, specialist reports on different areas. For example, for the high number of prison deaths, it could analyse, follow-up and report to you as a Committee in the same way as the Housing, Communities and Local Government Committee looked at Grenfell and the fact that what preceded Grenfell was the Lakanal House fire and an inquest. We saw the contempt with which that report was treated. The NOM would, importantly, have a key transparency role, which is to bring this information into the public domain. That is really important because clearly one of the issues is about the lack of transparency and accountability of those responsible for change.
Finally, one frustration is that we have been talking about these issues for many years now. At the moment, a lot of energy seems to be expended on what could carry out this role—Richard talked about the National Audit Office—rather than thinking about the key role that one body could play and making this a really very powerful body to try to drive change. That of course cuts across so many important areas of public health and safety. Having reflected at length about what would be possible we have come to the conclusion that a new body needs to be set up and properly resourced.
Janet Daby: How long has INQUEST been working on this in terms of a new body and this type of strategy?
Deborah Coles: As an organisation we were set up in 1981. The work around the national oversight mechanism and the current iteration has probably been for a few years now. We have met with various Governments around this and given evidence to all sorts of different Committees. There is a lot of debate within Government at the moment about what should happen. Obviously PACAC is hearing evidence at the moment, particularly about the focus on inquiry recommendations.
In our view these issues are very important and often interlinked. Richard spoke about the Lampard inquiry, which was set up because of the repeated nature of deaths involving mental health services in Essex. It had to be a statutory inquiry because there was a lack of co-operation from senior management with the initial review that was set up. In a way it speaks to the difficulties that we have identified in following up what change has actually happened.
Finally, the reason we think it is so important is that Johnny spoke to the fact that he subsequently found out—through the benefit of Georgia’s work—about other deaths that have occurred. A NOM could almost have that alert system. Where you see these patterns, you can spot recurring dangers across different institutions and escalate those concerns. It could be a vital resource for parliamentarians, coroners, inquiry chairs and academics.
We cannot wait any longer. Every year we have these conversations and see avoidable deaths occurring at great cost. Of course, there is the human cost and trauma of these avoidable deaths and the cost to the public purse because death investigations and public inquiries are expensive. Why are we putting families and victims through these processes only to ignore the learning that can potentially flow from them? That is a really cruel system.
Dr Richards: There cannot be a mechanism without the national database and knowing what deaths are occurring across the country. I would encourage that the first two parts of the mechanism—to collect and analyse reports—should be independent of Government and at an institute that has academic freedom to analyse that data in a transparent way.
The preventable deaths tracker already collects and analyses all PFD reports. We have lots of different types of dashboards that issue live alerts when new deaths occur; we have already built the infrastructure to do that component. We analyse every PFD that comes through and we have produced the live alerting system for multi-storey car parks for Johnny. That infrastructure already exists and has been built.
PFDs are not enough. If there is a mechanism that just focuses on public inquiries and PFDs, it is going to be a really biased system. It needs to look at all inquests. The final bit is that we produce live dashboards that update in real time. Your reports often sit on someone’s shelf and gather dust. It is 2026 and we have lots of digital infrastructure where we can build these live systems. I would edge away from an annual report and focus on a digital live reporting system such as the one we have already built at the Preventable deaths tracker.
I know we have run out of time, but this already exists for children in England by way of the national child mortality database, which collects all deaths of children in England. It already exists in many Commonwealth countries that have adopted the coroner service. I am from Australia, where it started in the year 2000--it is 26 years old. Originally, it existed in Australia, New Zealand, Canada and the US. This is not an innovative thing that we are explaining. A national coroner system database exists in other countries that have coroner systems. We need to get the right data and tools to start learning from inquests.
Janet Daby: It sounds like it is crucial information for the Committee to hear about.
Dr Richards: After the previous evidence that I gave in February 2024, I met with the then Minister for victims, Mike Freer, straight after that meeting. He just said, “We will not fund this; put a paywall in,” which is exactly what happened at the conclusion when I got home that evening. I still have had no funding from anyone for the digital infrastructure. My team is now funded by a philanthropist; they fund two team members, and we have two more joining in time. I still self-fund the digital infrastructure behind the tracker. It is very difficult to get funding for building digital infrastructure in a research environment because it is research answers research questions. I bear the burden of that financial cost.
From an other-country perspective, the triggering event that led to the national coronial information system in Australia was that there was a royal commission into the deaths of our indigenous people. They identified 99 deaths that had occurred in prison. That was the triggering inquiry that made the recommendation to Government that we need a national database to ensure we are counting the lives that we are losing for our First Nations people. That happened in the late 1980s and early 1990s. Several feasibility studies in the 1990s led to that in 2000.
In Canada it was driven by the opioid crisis, which is what my PhD was on. I was looking at how we could prevent deaths from opioid overdoses and the increased prescribing that we were seeing in long-term pain medications. The Government went to the coroner’s office in Canada and asked how many people are dying from opioids. They could not answer that because they did not have a national coronial database. That now exists; it came into effect in 2016. There were two small legislative changes in the Ontario Act, for example, that led to that national database. It is possible but it needs to be statutory to be sustainable. If I am not here, there is no preventable death tracker.
Dr Richards: Yes. The way that I have now decided to work is actually just to follow what government policies are going through Parliament, for example violence against women and girls; we continually see deaths of children and partners in PFDs that come through. Road traffic accidents and suicides are others. There are so many deaths that we cannot choose.
We just follow what policies are going through Parliament, which is how we target what deaths to look at. I was hoping covid would be the moment that we realised that we could and need to do this. I was thinking a global pandemic would be enough; it clearly was not. I really do not know what else to do. We just tabled an amendment last night to the Health Bill that would enable this national database for all inquests.
The final thing I should probably say, which is controversial, is that the Ministry in charge—the Ministry of Justice—is the worst responder to PFDs. It has only ever responded to 30% of all reports. This Committee could really take this forward and try to understand what is happening at the Ministry of Justice and how it is using PFDs. It should be a role model and come out with 100% of all PFDs responded to so that I can take that to the Department of Health and Social Care, the Department for Transport and the Department for Education and show them that the Ministry of Justice is the leader. They are 100%; everyone else should follow. Justice Ministers could become role models—that might be a lever for change. I could talk about lots of other deaths that are tragically happening every day across the country and that we could use as a mechanism for this.
Chair: That is a sobering insight that you have shared with us.
I suppose that leaves me with two things. First, reflecting on what I said earlier about the article that Richard had written regarding the fact that there is no enforcement power through a PFD, what are the powers that this organisation would need?
Secondly, given your absolute clarity that PFDs are not the way to go—PFD is a microcosm; we have seen that today with the two that did not happen—if no PFD exists, how can an organisation have powers over something that did not happen? Where there is a PFD, what are the powers and what are you looking for in that? In terms of the non-PFD cases, how would having powers actually work in those cases?
Deborah Coles: The point that has been well made is about the importance of collating inquest conclusions because they are such an important body of evidence. Within the non-proposal, we talk about recommendations from investigations, which obviously includes inquests and the different investigations that would take place prior to an inquest being held. The other thing to say about the narrative conclusions is that jury findings of systemic failure have to be treated as important sources of learning.
I completely agree with Georgia’s points about a national database and the value of having data. A big area where we are being failed is the lack of follow-up on all these recommendations and on the evidence that is identifying systemic failure. There is nobody who is following up on what happens to this evidence. How is it changing things for the better? That is why we have come up with that proposal.
There is no organisation—according to our knowledge anyway—that has the specified role in its governing statute or terms of reference to look at conclusions of investigations into state-related deaths. That is where there is that real accountability gap. There is a complete disconnect between the inquest process and then learning and prevention across different government agencies.
Just to the point that Georgia made about the Ministry of Justice, given that that is the Department that is responsible for coroners, it is quite shocking that we are here in 2026 giving evidence about something that has remained a consistent theme for decades. We should be learning from that. We have a point of inertia here and as I said in my previous answer, unless we do something and do it quickly, you will continue to hear from families such as the ones you have heard from today.
Chair: That is a powerful point to end on. That brings us to the end of questioning and of this session. I know you have worked on this for a very long time. We are really grateful for that work and for your time today.