Source · Deaths in custody oversight
Independent Advisory Panel on Deaths in Custody
60 reports
262 recommendations
3 with response
19 case investigations
Thematic reports, panel guidance, commissioned research and case investigations examining deaths and serious harm in state custody. Source: iapondeathsincustody.org.
Article 2 Investigations: Deaths and Near-Deaths in Custody
19 individual case investigations into deaths, near-deaths, serious self-harm and assaults in prison custody, commissioned under Article 2 ECHR
Reports
6 Dec 2011
Cross-cutting
Review of Rule 43 and narrative reports of restraint deaths
Thematic Report
Themes from the Independent Advisory Panel (IAP) on deaths in custody review of Rule 43 Reports, narrative verdicts and investigations reports where restraint was identified as a direct cause of contributory factor in the death.
31 Oct 2011
Cross-cutting
Review of medical theories of restraint deaths – Care Solutions UK Ltd
External Research & Analysis
A review of the medical theories and research relating to restraint related deaths, commissioned by the Independent Advisory Panel (IAP) which forms the second tier of the Ministerial Council on Deaths in Custody.
24 Sep 2011
Mental Health Act Detention
Family Listening Day
External Research & Analysis
The IAP commissioned INQUEST, to deliver a second family listening event so that we could hear from families who had experience of the investigation and inquest process after their family member died whilst detained under the Mental Health Act (MHA).
1 Sep 2011
Mental Health Act Detention
IAPDC Listening Day Report – September 2011
External Research & Analysis
On Thursday 22nd September 2011, 11 families (comprising 19 family members and friends), who have direct experience of the investigation and inquest system following the death of a relative whilst in mental health detention, met members of the Independent Advisory Panel (IAP) on Deaths in Custody (and representatives of its secretariat).
11 May 2011
Cross-cutting
Workstream paper on Article 2-compliant investigations
Guidance
8 recs
Early workstream paper examining whether investigations into deaths in custody and detention meet the Article 2 ECHR standard of independence and effectiveness. Contains 8 recommendations on investigation quality, oversight and research.
8 recommendations
1.
Research should be undertaken to review the quality of independent investigations carried out by Strategic Health Authorities.
2.
National Patient Safety Agency (NPSA) good practice guidance on the ‘Independent Investigation of Serious Patient Safety Incidents in Mental Health’ should be re-written when the future governance of NPSA’s functions has been decided to address the shortcomings addressed by the …
3.
Those responsible in the new NHS Commissioning Board should produce adequate guidance to clarify when independent investigations into deaths of detained patients should be triggered; to ensure the person commissioned to conduct the investigation is independent of the provider; and …
4.
The Care Quality Commission should devise a specific, discrete role in relation to reviewing deaths of detained patients and consider whether it can undertake and/or commission investigations. It should report back to the Ministerial Board on progress.
5.
The PPO should follow up the analysis conducted in 2009 of clinical reviews, in conjunction with the IAP, to examine the effect of shared governance on quality; timeliness and independence of clinical reviews, six months after implementation, and regularly thereafter. …
6.
The PPO should be placed on a statutory footing to ensure independence from the Ministry of Justice.
7.
All deaths in Secure Children’s Homes should be investigated by the PPO.
8.
The model for providing standard-setting, guidance and oversight for Coroners should focus on deaths in custody to consider, monitor and ensure improvement in relation to the following: Delays Disclosure/access to documents Family participation Public funding for …
4 Feb 2011
Prisons & Probation
Psychosocial influences on prisoner suicide: A case-control study of near-lethal self-harm in women prisoners
External Research & Analysis
Psychosocial influences on prisoner suicide: A case-control study of near-lethal self-harm in women prisoners – Lisa Marzano, Keith Hawton, Adrienne Rivlin, Seena Fazel – 4 February 2011 (link opens as PDF in a new window)
21 Jan 2011
Cross-cutting
Report of the IAPDC’s cross sector restraint deaths workshop
External Research & Analysis
5 recs
Report of a cross sector workshop convened by the Panel on deaths following the use of restraint across custodial settings. Contains 5 recommendations on restraint practice, training and data.
5 recommendations
1.
The IAP recommends that local police forces submit use of force and restraint statistics on an annual basis to a suitable central body for monitoring and analysis purposes
2.
The IAP recommends that custodial sectors develop protocols to ensure that investigations are triggered in cases where the use of restraint has resulted in the near death or serious injury of an individual
3.
The IAP recommends, in due course, that the RAB should ensure that the systems of restraint used in LASCHs are accredited
4.
The IAP recommends the creation of national guidance for UKBA detention staff on how to safely restrain children under the age of 10
5.
The IAP recommends that further discussions are undertaken with RAB to establish the feasibility of them holding an extended meeting once a year to include representatives from all of the custodial sectors in order to share best practice and learning. …
2 Aug 2010
Cross-cutting
IAPDC Listening Day Report (August 2010)
Thematic Report
16 family members, who have direct experience of the investigation and inquest system following the death of a relative whilst whilst in the care of the state met members of the Independent Advisory Panel (IAP) on Deaths in Custody and representatives of its secretariat.
5 Jan 2009
Cross-cutting
Forum for Preventing Deaths in Custody: Report on Article 2-compliant investigation of deaths in custody
External Research & Analysis
Forum for Preventing Deaths in Custody: Report on Article 2-compliant investigation of deaths in custody. Will a death in custody always be subject to independent investigation?
21 Dec 2007
Cross-cutting
The Fulton Report: Review of the forum for preventing deaths in custody
External Research & Analysis
Review of the Forum for Preventing Deaths in Custody: Report of the independent reviewer.