PSO 2710 : FOLLOW UP TO DEATHS IN CUSTODY

Chapter One: Introduction

ChapterTwo: Immediateaction _

Chapter Three: Reportingrequirements _

Chapter Four: Contact with Press Office and media .

Chapter Five: Supportfor staffand prisoners,--.. . .. :,

,napter Six: Follo_-up.supportfor thefamily ...... : "

Chapter Seven: Preparation for the inquesti

Chapter Eight: Funeral arrangements . .

Chapter Nine: Disclosureof information to the family and their legal representative s

Cha_)terTen: The Inauest/

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CHAPTER ONE; INTRODUCTION

Overview

1. This chapter explains the purpose of.the Order and draws attention to particular features.This Order should be read in conjunction with PSO 2700 Suicide and Self-Harm Prevention, PSO•1301 Investigating a Death in Custody and the Standard .on .Handling a Death in Custody.

Purpose of the Order ....

2. This Order is for use b.yPrison Service and Contracted Out Services staff wherea prisonerdies whilst in their custody. All deaths must be handled under the procedures contained.in thisOrder. _

Mandatory provisions " " ..

• ..Throughout the Order mandatory provisions are. highlightedin italic type. " ". -.. .

.Superseded instructions -..

4. The Order replaces the previous PSO 27i0 • "Follow up to deaths in custody" and any •previous instructions issued relating to procedures.following a death in custody. It also replacesthe provisions of PSO 8801 Dress Code for Staff Giving Evidence in Court insofar as they re/ate toinquests and PSO 1400Incident Management Manual on notification•of deaths.in Custody. This.PSO should alsobe read in conjunction with PSO 2700: suicide and Self-harm.prevention. This iscurrently ._.inumuaration. ., _........ - "--,.# I-- AF_ -

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CHAPTER TWO: IMMEDIATE ACTION ON DISCOVERY OF APPARENT DEATH

Overview

Thischapter describes the actions to be taken immediately by staff on the discovery of a prisonerwhoappears to have died. This chapter should beread in conjunction with PSO 2700: Suicideand self-harm prevention.

Key procedures

2. The following procedures are to be followed on the discovery of an aPparent death. ThisSection does not apply where prisoners are known to be dying of natural causes and who may dieeither in custody in the health care centre or in outside hospital.

Initial action

Summon help and request emergency medical assistance and first aid equipment.

4. Enter the cellas soon as possible. Staff can do so alone, taking into 'account any risk factorsthat may exist for their own personal safety and the safety of the establishment by doing so. If thecell is entered as soon as the discovery is made staff may be able to take immediate action to helpsave a prisoner's life (see paragraphs5-7 below).

5: If a ligature has been used, support the prisoner, cut the ligature whilst preserving the knot if.. possible, and place the prisoner's body onto his/her backon a flat, solid surface (e.g, the floor, or

a solid based bed withoutthe mattress). Staff Shouldobtain appropriate equipment tocut theligature•andattempt resuscitation(see PSO 2700).- . .

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:• 6. Check for signs of life; i.e. breathing, pulse, any movementof the body... - . - -. ..

• 7. •If the prisoner is not breathing;staff should attempt resuscitation unless the prisoner is clearly.dead. One obvious sign is.the onset of dgor mortis Ofthe limbs. Rigor morris is a condition of

' treme stiffnessaffecting the arms and legs.after death, making it.virtually impossible to .bendthe_ists,elbows or kneeS. In the absence of anyclearsign of death, resuscitation should - ..

commence and be•maintaineduntilthe arrival of a memberof the healthcarestaff.or other•healthcare professional (see also paragraph 8 below).... "

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8..Onlya doctor (or if at outsidehospital.aDoctorthere) can certifytheprisoner dead and•resuscitation is to be attempted until such time as.death is pronounced or healthcare professionals :

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_-1 r assume responsibilityfor the incident. : " " " . '" "" :. . . • " ' . " " "" . " " " '. : . !;..: i. . :."_.. . ._ -, _'. .. " . . . . :.. :• .. . . . • . • " . . ._. .. -. , - .., .

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: 9..-After the prisoner hasbeen taken to1outsid_hOspita/formedicaiattention orhas_been i: .::pronounced dead and •thebody removed,,the cell must then be sealed, .leaving everything in/tuntouched, to await the arrival ofthe Police (and the SIO) who wil! wish toexamine if to make anassessment of whether there are any suspicious circumstances (the Coroner's officer will normally " •arrange for the body:to be removed to a mortuary.i If the deceased was.taken to anoutside ...... •

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10. fit is essential that all relevant evidence is preserved. Where any letters have beenwrittenwhich are pending in outgoing post, the Coroner's office should be advised of their existence as.heymay contain evidence relevant to the •Coroner's inquiry. Otherwise the next of kin should beinformed of their existence and asked how they wish the mail to be dealt-with.. If the Coroner'sofficer�police insist that all property remain in a shared cell, the cell,mate must be re-located and

• issued with temporary kit until Such time as their property is cleared for return:. . _ ". . - . ..

11. A record must bekept of the names of all those entering the scene including .those prisoners.located in adjacent cells.

12. Where appropriate, arrange forachaplain or other minister of religion of.the appropdatedenomination to administer last rites.

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;HAPTER THREE: REPORTING REQUIREMENTS

Overview

This chapter describes the reporting .requirements following any death in custody.

Key procedures. . . . " .

1. On the event era death, the establishment must notify the following; by telephone - .° ,

• The police who will inform the Coroner's Officer.. . . ..

• National OperationsUnit (NOU)in accordancewith Chapter 2 "Reporting procedures" of PSO. 1400: Incident Management Manual who will.inform ; .

o Minister's Private Office • . •

a _The Director General's office

a TheDirectorofSecurity,s office - " ... ."

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• r_ The Area Manager,. Director of High Security or appropn'ate OperationalManager ... :. . -

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2. Provide NOU.with an initial Incident Report Via the ComputerisedIncident Reporting. " :: " '_ ". . . . : " .... . •

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4. Notify next of kin and any other person the prisoner has reasonably requested be informed.While other key notifications are taking place, staffshould ensure that earlyarrangementsare.madefor the next of kin to be informed before details are passed on to the media (see Chapter

" Four). The decision on how to inform next of kin should take into accountindividual• circumstances,especially the distance from the establishment. However, unless inappropriate for geographicalreasons (ie distance from establishment and timetaken to travel), it is recommended that unlessthere are Verygood reasons notto do so notification should bemade in person by a visit to thenext of kin .bythe governor (or in his/her absencethe deputy) and chaplain/other religious leader.Notification of the next of kin must•take place as soon aspossible•after the death.

5. Domestic circumstances and any anticipated reaction.from the neighborhood will.need to betaken into consideration; both the police and the probation service may have valuable informationand advice. In some instances notification via the police will be preferable, either because of.concerns over a••visitor.to ensure that the family are: notified-assoon as possible. It may,.however, be more appropriate in some cases to telephone .thistragic news and speak to the familypersonally. Knowledgeof the family will be essentia] in determining how.to,proceed in such cases.

r"_/here ,thepoliCeor the telephone areused,.it is important to ensure that a member.of staff is in,_ntactwith the next of kin at the first available opportunity to offer a visit from the governorand

chaplain or to ascertain whether they wish to visit the establishment.

6.: It is important thatwhoever is in contact with the next of kin give them•as •muchfactualinformation as is known at this stage and.whothe, family can contact for •outside.support. It is vital. -that•there is prompt liaison with the coroners office and that the family are told of the need to act "•quickly if they wish.to see the.body of the •deceased-beforethe post mortem takes place: This isespecially important if there is a long journeyto be made.

7. A note describing the arrangemen{s to inform theinextof kin, including details of the meeting, :.should•be retained by the governor for possible inclusion in internal :investigation reports. It is- •• .. •

• 'recommended, for example,•thatwhere either the police or the telephone are Usedto notify the.. "• next of•kin, a note is made.of the :reasonsfor doing so. Also to describe the follow-up.contact with

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15.Fo pris otify " i:. :... r convicted, oners, n -, _ i-. i:'., • . . . . . ".:.'.. "." . ." : - - . " " " . i . _i '::,: i ..... : " .- . " _ '"• ... • • . . . - ...

:...'.,. the eational.identificationBureau atNew Scotland•Yard by means of.an F99 (these forms may:. ii .:-... be:obtained from Branston stores quoting reference number DFO08)-" " -..i . ." . .

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sp ome " " ":--. . ".'. . " . . . ..:: ° _ the re onsibfe probationofficer inthe pnsoner s h area.• • • ...... ., ..

S For unconvicted/unseritencedpfisoners, notify.-, .: , :-.i. :.. i ' -.:-- i.. , -.: i i.- : .i " " :2 . " • i ""

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"• the committing court, solicffors and the probation officer responsible.

17. For civil prisoners notify -

• the Official Soficitor

18. For all young.offenders�juveniles notify- . _ . .

• the social• worker officer in the prisoner's home• area.

19. For [uveniles, notify- :

• the appropriate Youth Offender Team. _ . . • .

• the Youth Justice Board. . ,.. . • .

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• local social services (if in their care) , " , i i.' . . " .. • .- • . ". _ "'. - . . - . .

.J. Where establishments mayhold immigration detainees or those awaitin# deportation, pleasenotifythe Detention Services Policy. Unff (DSPU) Of the Immigration and NationalitY Department on020 8760 2525 (during office hours), Colleagues may also need to discuss any handlingarrangements following such a death with DSPU. _ "

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21. Notify consular officials (where appropriate). : _ .... _

22. Notify other prisoners, especially friends or associates in the establishment. Check also• foranyrelatives or co-defendants in other establishments buttake account of the i_,ishes of the ne_ of kin. "about who is to be told Or not told.• _ "

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CHAPTER FOUR: CONTACT WITH THE PRISON SERVICE MEDIA RELATIONS UNIT ANDTHE MEDIA

Overview

This chapter describes procedures relating to contact with the Prison Service Media Relations Unitand dealing with the media.

Key procedures

2. Media Relations Unit are obliged to inform the media of an apparent suicide. In addition tobasic details, they also require more detailed information from establishments. This enablesMedia Relations Unit, not only to build a complete picture as early as possible, but also to providemore detailed information, if requested. The contact number to use is: _ This is aprivate "hotline" for use by establishments and the number should not be given to the media. The

/:-hotline is staffed between 07.00-22.00 hours during the week. Out of office hours (ie 22.00-07.00._urs and all weekend) the duty officer may be paged on _'. Unless the prisoner.is

likely to be the subiect of hi.qh level media interest; restrict contact with the duty officer out of hoursonly to those cases considered urqent.

3. In providing information to Media Relations Unit, the following will normally be required.

Prisoner Details

• Full name:• Prison number.• Date of birth:• Status:

• First date in prison custody:• From what court:• Forwhat sentence:

." Sentence length:Offence/charge:When first received at your prison: "

• Ethnic origin:• Home area:

4. As explained, Media Relations Unit may also require more detailed information. This mayinclude the following.;

Circumstances surroundinq the death

• How does he/she appea r to have died? " "• When was he/she discovered?•.Who discovered him/her?

• Where was he/she discovered e.g. normal cell, safer cell, health care centre, segregation unit?• Was he/she on their own in the cell?• What was any ligature made of?• From where was he/she hanging?

Has resuscitation attempted?• I f so, by prison staff or medical officer?

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• Who pronounced him/her dead; and when and where?• Was the prisoner considered a suicide risk?• If so, when was the last time he/she was seen prior to discovery?• Was there an open or closed F2052SH?• Has a suicide note yet been discovered?• Has the Coroner been informed?

Other Information

•Is the death being treated as suspicious by the police?•If yes, are they conducting an investigation?•Have next of kin been informed?

•Who and where are next of kin, e.g. mother, sister, which town?•Is the prisoner concerned likely to be of interest to the media?•When was the last self-inflicted death in the prison?•How many self-inflicted deaths has the prison had in last 12 months?•Are any outstanding inquests imminent?

-_ •Are there any other facts which if would be useful for Press Office to be aware of?

4. Media Relations Unit will not normally .qive details of a death to the media prior to next of kinand the coroner bein.q informed. They will ensure that sufficient time has elapsed to allow theprison to arrange for the next of kin to be informed. Exceptionally, if next of kin cannot be told forwhatever reason within reasonable time, Media Relations Unit, in consultation with the prison, may'choose to release details. In normal circumstances details will be released to the media by MediaRelations Unit at the latest within 24 hours of the death. From the information given, MediaRelations Unit will draw up a brief factual statement. The death will be made public by MediaRelations Unit giving the statement to the Press Association (a national news agency).

5. There may be follow-up calls from the media. If they are from national media refer them to theMedia Relations Unit on_ If they are from regional/local media contact the dutygovernor who may wish to talk to them and is at libertyto do so, but must keep to a factualcomment. If the duty governor or designated person does not wish to speak to regional/localmedia then they may also be referred to the Media Relations Unit.

' Remember that, depending upon the time of day, prisoners (or others from outside thestablishment) may have used the telephone to pass the news outside very quickly.

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CHAPTER FIVE: SUPPORT FOR STAFF AND PRISONERS

Overview

This chapter describes the arrangements necessary to provide support for staff and prisoners aftera death in custody.

Key procedures

2. Priority must be given to communicating the facts about the death to prisoners and staff of aflgrades on duty in-the establishment. Care should be taken to notify those staff who are off duty butwho were closely involved with the Prisoner. Itmay be useful to issue a written statement toprisoners to defuse rumour and myth; however this will depend upon local judgement. Ifit isdecided to issue a written statement, this should be done with care and consideration for the

feelings of other prisoners.

The Suicide Prevention Team and Care Team must work closely on agreed strategy to support

staff and prisoners. This strategy must include provision for an immediate post-incident debrief (ie"hot debrieF') Ofstaff involved in the incident and local contingency plans should reflect this andinclude provision for both a senior member of staff to act as debriefer and a duty care teammember to be identified and, if necessary, cared in on duty.

4. Operational debriefing is part of the investigative process. An immediate post-incident debrief-is an essential part of the staff support process and should be carried out before staff go off duty.It is to be conducted away from the scene of the incident and inan informal atmosphere. If is mosteffectively carried out in a group but this is not always possible. It enables staff to talk throughtheir experience and feelings and to 'wind down' before going.off duty. It frequently enablesindividuals to give themselVes permission to accept further support. Debriefing is a function ofmanagement but should be executed in close conjunction with the care team, who will provide thefollow-up support. Where appropriate, ie where a death has happened at night, consideration maybe given to allowing staff involved to go off duty or if atthe end of their shift to miss the next one.This will be a matter for local management to decide.

J. There are broadly three levels of support available tostaff followingany incident, including adeath in custody. Firstly, the Care Team will establish contact with any member of staff who wasinvolved in, or may be affected by the death to offer support. If required, the Staff Care andWelfare Service (SCW) will arrange for a Critical Incident Debrief to take place - this is anopportunity for staff involved to meet together informally with trained debriefers (who are fromwithin the service but outside the prison) to review what they know of the incident, their thoughts,impressions and feelings: Participants will have the opportunity to talk about how they are copingand any concerns that they may have for the future. Finally, if it becomes evident that a memberof staff may require personal counselling, they are to be encouraged to contact the relevantwelfare officer for the prison. SCW will, on request, consider whether it is appropriate foreither anin-service or external counsellor to see the person concerned. If further advice on staff debrief isrequired, SCW may be contacted on

6. The skills and experience of the chaplain or other religious leader and local Samaritans mustbe considered in providing support to both staff and prisoners.

Any prisoner who may have been particularly affected by the death should be offered support._nparticular, Listeners/Peer supporters may have been supporting the prisoner who has died.

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Where appropriate, they are to be offered the opportunity for a debrief with the Samaritansassoon as possible. Staff should also be alert to the possibility that some pdsoners may have -leightened vulnerability •followinga death and may require extra •supervisionand support.Particular attention should be given to those currently on open F2052SH and who may be affectedby the death. Sensitivity is needed to avoid raising anxieties unnecessarily.• The use of Listenersor.other similar peer supportschemes for those prisoners who are affected by a death may alsobe appropriate. It may:also be appropriate to locate such prisoners in a Care Suite._

8. When the cell in which the 'prisoner died .is put back into normal •use, prisoners may askquestions and •raisequeries about the death. An understanding and supportive approach will'hasten the return to normality, The Chaplain may wish to hold a memorial •service to which thefamily of the.deceased, staff and prisoners should be invited.

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, _ _ : : i : i : : i ::-6997---. - . .

CHAPTER SIX: FOLLOW-UP SUPPORT FOR THE FAMILY.

Overview

This chapter describes the arrangements necessary to support the family of the deceased.

Key procedures.

2. It is almost impossible to sufficiently emphasise,the importance of keeping the relatives .informed, both in terms of what they are told and how. This needs to be carefully thought throughin every case as each set of circumstances brings its own complexity. Death in custody oftenbrings to the fore many unexpected elements or reactions for all involved with the deceased._It-isimportant to be aware of and sensitive to the individual needs of a family. "

.3. Common and natural reactions at this stage are shock, guiltl suspicion and anger,.and theseemotions may affect not only the relatives but almost certainly some staff and other prisoners.

• _r-_4anagingthe impact of this within the establishment may be demanding but must not cloud the_ntactwith the:family who may also be copingwith media versions ofevents and possibly media

approaches, depending on the level of interest.

4,. A senior member Ofstaff must be appointed as thenamed point of.contact for the family and a •.second person named as availabie in thefirst person's absence, Details of contact points are to _

• i be notified to the family as soon as possible, together with a commitment to keep the family fully_ .informed of.any developments in the case. It •is important thatthe two people acting as points of: :

••contactare be able to.contain their own feelings or uncertainties in order to fulfil their role, It •is. •_....••also recommended that neither should have been directly•involved in the incident.. Continuity in.._..dealingwith.the family will enable the establishment to meet its primary task, i.e, to establish _ •.. '.

" _.rapportandtrust with the family in helping themto come termswith Whathas happened; to_ . _. -,_ .•maintainconsistency in•what is said at a timewhen many questions•cannot be answerediandi• _

•" .mostimportantly, offe r practicalhelp,--including advice on where togo to for further.assistance....._i i:'_,.• • . : ...., " .. - ...i . . _. ". - . : .: .... - -'.."'.. ". :'.

;5. A factual account is t0be given of eventsieadingup.to the death; how thedeceased was " _ "

i-idisc°vered and Whateffortsat resuscitation were made. It is.vital that all details given have been • :" orough!y •checkedbecause any inaccuracies at this point willar0usesuspicion andhoStUity_..i:

i_._../hich cannot beeasi!y rectified later.-.•Theaccount•should not be so sanitised•that it •tellsthe family:,• •nothing. ••Goodintentions may lead people to withhold or skirt •roundfacts which might be painful • ,. .-•" for the giver togive and which he/she may considertoo painful•for the family.to receive...Ofcourse...-.!.:.:

• great sensitivity is.neededin unfolding events to •distressedpeople but factual knowledge may. " ' ",- '. help them bettertoaccept what has i_appened. It is important not to be evasive and care should " " .;..

be taken to listen for.unexpressed .needs•or questions. Bringing these out may help the bereaved .-.•..• .i-;"-and also reassure them about the establishment's willingness tobe as open as possible; •Equallyit " "'_ !swrong to give false assurances in trying to ease •theirfeelings or of those doing the telling. .•• • . ; -

..... : . " " " _:i ".... "; " - : .. - " ' • ' " " " " " " " " : " '" ' " " " " " "- "" ' "_" •• ... . . . .... ..-. . , " • . . . : .

"6i... Speculation and opinion about how.or whythe death occurred is to. be.avoidedi It is imp0rtant."::" :i":.-for the governor's representative to be confident about explaining theboundaldes of.what he/she "':.. ':

:..can. say. Many of the matters which the famUyrequire information on may be the •subjectof the • ;. •-•.:.•••i-internal investigation (seealso Chapter 9; Disclosure of information):.-The role of the investigation....

" and.theinvestigation team should.be.explained to the family aswell as-thefact thatSeni0r • : ..... " :-.._i investigating Officer (SIO) will be.in contact with them: It is, however, important that a distinction .:, '_.:. •ismade betweenthe SIO's and the establishment's role in deaJingwith thefamily and relatives,. ......." :'imaryresponsibility for offering support andadvice up to and in some cases after the inquest " •.

" -. . .- .." . , .- • -. " • .• . . ... restswith the establishment. ., : .; ; " " ,.. " :. .... . .__ .. ••- • .... . . • . . . . ... ::

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It would •also be helpful to explain the role of the coroner and the inquest. The family should beencouraged to contact the police and the coroner's office forinformation about their procedures..

7. Following a death, the governor should send a letterof condolence and suppqrt to the family.This letter should also invite the family to visit the establishment. Many find comfort in visiting thescene of the death and meeting staff and prisoners who knew the deceased. Offering facilitiessuch as placing flowers in or near the place of death, or for the chaplain or appropriate religious.

leader• to say •prayerswith them can mean a great, deal to the bereaved. The invitation should bekeptopen •as time passes since some.families may not be ready to take it up immediately for avariety of practical and emotional reasons,-and may not think to ask later. If most contactis byphone or if the familydo not come to the•establishment, an offer to visit them at their home whei:e

• •theymay feel more secure, should be considered. Willingness to have face to face contact can" . . . .- •

' add•much in-these circumstances even though it may be difficult for both sides/ ' ....., . . . . . :

.... • " •." i . " " " - " .. '

•", i..-"-._.Continued contact and support for the family up to and after the inquest can provide a great • ':. _ • . . . :

.Ap in assistingthem to come to terms Withthe loss of a loved one. Such support may continue,. _ •• if appropriate, up to and - in.some casesi- beyond the inquest. Itis important that the family can -

• .:.refer any other queries they mayhave to the prison at any time.. " " - ....... _...:. . i.. , . " - ' • .. : " : . ._ . . . . .. : • . " : . " , • .. . •

_ 91 Providing information and soundpractical helpat this stage will assist the bereavement.I..... • .•:•.- •process..It may be helPful to prepare a booklet or-informationsheeti based on-the contentsof this.• PSO, to.explain what happens in relation.to the investigation, inquest; etc. following a death.and i•.--•. whichmay affectthe family. In addition,:the leaflet prepared by the organisation INQUEST, in. :

• conjunction with the Prison ServiCe,will be of help .and is to be forwarded•to the family at the "' '' _ . • , , ". . " . - . . • .." . , .

adi t opp ity .... . • ...,...e es ortun .- - :. ! : .. . . . . .• .. : .-

. 10..When in contact with the family, the issue offuneral expenses mayarise.. Financial: :--" _ .i..:.:- -assistance maybe offered in :appropriatecases-(see Chapter 8 for more detailed guidance). • :

' i.. i1..The handing over of personal effects including all monies heldonbehalf of'the deceased . --. . .• .__!"needstobe done with care andsensitivify. Great.care must betaken'inensuring that all the

. •. . • . . . " . " . . .

(.' _perty ispreserved and handedever. Aft property mustbecarefully listed against theproperty . /._i..• .ard. "Aft clothing must-be cleanedand pressed.. A signed.receipt.must be obtained,for aft. - .:.. . . . . . . . .'.. . . .

• ..property and monies handed over.. Thehanding over of Property should not normally take place . _" until the POlice/coroner•haveindicated that.they donot require these items as..evidence...These ".--

•i items,should thenbe placed in a•Suitable:bag or carrier or it may behelpful to ask relatives to bring " " •: .anappropriate sized,bag, ie a suitcase. Remember this is all theyhave !eft ofsomeone theyhave .._: .loved. In the rare event that.there is disputeoverthe rightful inheritor of the deceased'spersonal .:• possessions, it may be necessary to Seek legal advice through Safer Custody Group,-but-usually•. ' '• •_-_such conflict should be referred to the _?.oronerto give advice as to who he/she deems the•next of. "/.kinl • ".... : - .... : .... " " .... " " " ...." -, " . . . . : • • .• - .. • . . . :." " . .... ".. ,

.... " ":'" "" " "" " " " " •' " "" '" ' " "" " " " • "" " : " "" " "'" " i'."-... .... . • . . : ..... . ..., . . . • . . .

:".-_:.-12,Theinquest.can be a traumatictime for the family (seechapter lO),wheretheyrnay " .- " ;-_. :..:... eXperience mixed emotions about both the establishment and the Prison.Service as a whole:. It is . :._.:- possible thatat an inquest,despite there-having been good relations until that point; thefamily will ....." '..displaysigns of blame or resentment towards •PdsonServiceofficials. It is important.that staff; ••.:-"behave in a thoroughly professional manner d,uring this time andcontinue to actin a•supportive• .. :ti.!.::

...... . . • .. .." _ . ..

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CHAPTER SEVEN: PREPARATION FOR THE INQUEST

Overview:. . . .. .

This chapterdescribesthe proceduresfor thepreparationforthe inquest.. . . . . . .

Key procedures ..

•2. In all deaths•in custody, the Coroner must be notified. The governorwill need to •writebriefly•t°the Coroner giving basic details on what is known about the circumstances of•the deathat that i• • :

• time. Attach a copy of the memorandum from the medical officer•not!fyingthe governor of the :_• i •death. : : : :

• . -. .. . . . , " • . . . . .

.-•- . ,, . . • . , . . . :. . . - . • •. .. , • • ..

.......31 The Medical Officer should contact the Coronefsofficer fo[ the name of the relevant Home.:. nffice pathologist to seek permission to attend the post mortem, if he/she wishes to attend, i

. • .• -. . ". :. .* . " . . " . • • . • . .. : •" " . - . - • . '. . • : -.

. 4. :A"liaison •officermust be appointed, as part of thepreparatory groundwork for the internalin(/estigation into the death, to draw together the necessary documents to which theinvestigating :

• team will need to have access. It simplifies matters if that individual also acts as the Inquest " -. Liaison Officer forcontact Withthe Coroner (see Chp.10.4 for further details on this role).. • _ _ .

- ._ : .. _.. . !i : ...:" " " :.. - -.- ..

'• 5. In-preparation for theinquest, all relevant documents mast be collated to bepassed on to the '- Coroner..The Coroner must be advised what document_ exist and be providedwith.all ....

i:i:- documentation requested.. Such .requestsare usually madeby the Coroner's.officers who •conduct• .. . . . . . . • . *. . . . . ": . . - . . • ..

.: ..iithe inquiry on the Coroner's directions. • " -. ......... ,-• . . • . .. . .. .. •

' :: 6, Some Coroners reqUireoriginals of documents ratherthan copies(with copiestaken, and - -i. i::: retained at the establishment). This may boa matter fo[ localagreement.. Howevei:,.the prison •must retain the original F2050 and F2052SHs (if.any were opened); in :asecure cabinet and " •, :provide copies for the coroner. A signed receipt for any original documents removed must be - . ..... obtained from the coroner's.officer. . - • •" . • . . • . . . ". .. .

:(': "" "" " " '"' "-" i.._"'.'-:. "" "" :": ".i"": " "" " "" '" " "

.i./_ .The medical officer must ensure that.afthealth records (includingdental records):are .._- " _ :i./.assembled into .theInmate.Medical Record, Two good quality copies must be taken (one for.use :_" " by:the prison). The original must be retained and stored in a locked cabinet with signed only.: .',..access for staff(other than the SIO) until after the inquest. The other copy should be passed to:_ " _. the Coroner. " ; .... : .... " " ' " ' .... "• . . • . . • . . .. . . ". .. , .' .

" .... • - " '.. '.i " • - " .- " ..... -.:.::." "..._&Ensure that copies are taken of all original statemen-ts/dOcumentspassed over to the Coroner; .".. ikeep a summary list of aft documents.- It must be remembered that a Coroner's Court is a court of "

• record..Therefore all data supplied must be.both full and accurate_ • .... " - : " . : :L:.:; :" • • .: . i i:: ;'.,' • ' :

• , . . .. • . . '.. ;. -. .

:;!-1.i. In s0me-oases, police investigatingthe death may wish to take away any relevant documents : '.i::.:;:i'or physical evidence concerningthe deceased, Where possible, they Shouldbe asked to take: I: , '• copies as the originals may be required by thecoroner (they may either:have Sight•ofthe originals:: " •

' :: or watch copies beingmade if they wish t0 satisfy themselvesthat all documents have been •" provided).. However, iftheyinsistthat originals shouldbe Supplied the.Police must complete and ... •• _ign a receipt •ofall the documents or evidence taken. If there is any dispute over who should,.. -. :.:-

ave :theoriginals,"ie either-the-coroneror police,it is a matter for the:two parties to resolve " " - ':""•..between themselves. : .: . . ..

• " " __i-//- ':! : "-...... ., . .. ".....::: ....-. ..." -. . ..- ...... . ... : .: .... - . ...i ": :. " _": :::::.i... i.- . " '" " . - "

12. Any request from solicitors representing theprisoners family for disclosure of documents, prior'o the inquest, must be referred to the CA, who will consult with the Coroner and seek advice,where appropriate of Treasury Solicitors and SCG.

13. As soon as theinquest date is known, notify the relevant Trade Unions, chair of the Board ofVisitors, ScG,. the CA, the Controller (where applicable) and the Press•Office.

14. Prior to the inquest a preparatory briefing,meeting must be held with aft staff Called•as •,witnesses (for more detailed guidance see Chapter 10). Where-legal representation isprovided,

. Treasury Solicitors and Counsel will attend the pre-inquest briefing meeting, normally arranged for• the day before the start•of the inquest. Treasury Solicitors will be in contact to make the :

arrangements. Ample time must be allowed so that contentiousissues and staff concerns are fullyaddressed. You may also find it helpful:to contact the Press Office shortly before the inquest

•-commencesto discuss options for handling anymedia interest. _.

i5. A senior representative of the establishment must attend both the briefing meetingand the__-":"._questin anticipation of questions on rules and procedures which maybe asked-by the coroner.

.taffare to be.informed that they must not wearuniform, to inquests(see Chapter1.4). Advicefrom-Treasury Solicitors is that the wearingof uniforms while givingevidence has in the past "caused upset to families of the deceased. Instead smart •casualclothes (for example as defined in

• paragraph 2.2 of PSO 8801) are.to be worn. ".... - -

16. Once the outcome of the inquest is known, inform the Press Office •immediately.who.willprovide advice if the governor feels a formal press statement is necessary. .

17. The CA and SCG must be informed of the result of the inquestby telephone or.fax as..soonaspossible.

- " , - " L . -

" -. -." {. - . , . ..-: . - . .

18.A brief report must be submitted to the CA, copied to SCG, summarising any newinformation •i •or area of criticism highlighted•at_theinquest andindicatingany follow-up action to be taken.locally

or implications for Prison service policy .....

,19, In contracted-out services, the inquest liaison officer will keep the'controlter/monitor fully"_" " r_ . .. . """ fo 't-ned.The report of the inquest willbe copied to the coatroller/morY.rtorandtoContractsand:

ii Jompetition Group and Prisoner Escort Custody Services. The Controllei'/Monitor, by arrangement; .:•,:. with the area manager/Head of PECS, will normallj/attend any inquest likely to attract media.• 'ii' _interest or Wherethe reputation of the Prison Service may be at stake_: .. • .. _ _ . '

•• . . . " . . .'- .

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• -, .. . . .

CHAPTER EIGHT: FUNERAL ARRANGEMENTS

Overview

This chapter describes the proCedures•for making the funeral arrangements.

Key procedures ....

2. The funeral can go ahead as soon as the Coroner issues a certificate allowing burial orcremation or removal of the body out of the•country. A floral tribute from the governor and staffofthe establishment for the funeral may.be a welcome gesture.

• . . . . ... - . ... , . " .

3. If no executors/personal representatives (or they decline to take responsibiiity forthe funeralarrangements), then ;

--- Make arrangements for asimplefuneral; the prison chaplain has a statutoryobligation to•ensurethat there are appropriate arrangements for the conduct of the service, Choose•burial orcremation, •bearingin mind the cost (unless there are religious reasons for optingfor•one rather.than the other): In case of burial a plot shouldbe purchased and the grave marked:

4. If executors/personal representatives wish to arrange the funeral;. . . _ . .- .

• •Ascertainsensitively•at •anearly stage whether the family is likely to have difficulty meeting•the- . ..- .

cost of a funeral. • •-- .- . . ... '- . . ". •

5•_:if execUtors/personalrepresentatives•are unable to meet:some•orall of the cost of the funeral;,the fol!owing applies; -' ".... _ ?: : ' ;; i ; -

;- Wherethe personl or their partner,who hastaken responsibi!ityfor makingthe funeral : ,i . arrangements arein receipt of benefits, they may be eligible to makea Claim•for a Social•Fund_ i Funeral Payment; This part of the Social Fund is a grant,•not atoan, and isnot repayable bY i.: . the claimant.• However, Social•FundFuneral Payments are •recoverablefrom the deceased's

•iI' _estate, Whereone exists. Direct any enquiries to the local Benefits Agency office for •helpand ; :;i_ - advice. If theSocial Fund paymentdoes not meet the full cost Of the funeral discretion may be i•_;• used in deciding whether to provide a "to,up" paymentto cover the remainder of the amount.

" " " ' i" . " - . . _" . . ., " . "" • .. . : " " .. "" ": . . • " -" ." .. "., " "'" . _, . :" "... . -. .' .

"7 " " " . • -i" .... " " " " . .- . .'. . . "''_:'. - . '- " "" ". ,. . . .. '. .'. _'"." .'". ..

6. ill•executors/personal Representatiges are•unableto meet the cost of the funeral and are not •.- . . . . . ,- .... .'.: .. ... -

•.••entitledto payment fromthe SocialFund;•. • _i 7; i i i:' _ " • _ :• • . . - , -. .. • . . ".._'

• . - ...... : , .. .' . •

• * where it is clear that the nextof kinis unable to meet the cost of the funeral and fail in their ,•••: i-i claim for a payment from the Social Fund, the Govemor mayoffer an'ex-gl'atia payment •_-- ..

_i ;•-•; •(normally up to a maximum•of £2, 000)from hisiher budget. •Cheques should be.made •payable• to the funeraldirector. This may also coverthe costof•transportingthe body.home,:but not - ••/..' -7.... .

•....."

•- extra expenses such asobituary•notices,floral tributes or gratuities. The Governor may,•• •however,wish to consider making an ex-gl_atiapayment irrespective•of whether the family are ;:•

:; :. entitled to a payment from_the•SocialFund.• • . __.; ; . ? :

;- 7: Where the amount claimed exceeds £2,000or executors/persona!representatives iiveabroad -"_ndcannotafford to transport the bodyhome any ctaimmust be referredto the CA for approval of

i , roposedpayments. Submit details of the family's financial circumstances and anyassets left by •- • ,:- . ". . " ." . ".." ;:. . " ' • . . " .. . ;. ' :. ..... .'..." . ." ' . . • ." . ..- ." .. . ". ". . . • . . , " . . " . ...

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the deceased at the prison and indicate whether assistance has been sought from Social Security.TheCA may •wish to consider financial assistance to the establishment in.exceptional cases.

8. Directors of contracted-out services must present to the CA any case in which financialassistance is approp_ate.

9. If required, contact Safer Custod,, Group for further advice ..... "....

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' SCLO";HAPTER NINE: DI SURE OF INFORMATION - • . .• . - . • '.• .

... . _ • . • . • •

• " . , . - . • .. . . . .

PSO 1301: "Investigating a death in custody': provides details ofthe procedures for handling 'requests from the-family or their legal representatives and third partie s for the.disclosure.of .information: ........ .... "• ... • . ..

• . • . , .• . ." ,. • . . : , . - .• . • . . . . .

. • _ • .. • . . .• - , . - .

• 2. In contacts with the family; the governorand staff are bound to receive enquiries about thecircumstances of the death_ The bereaved have a right to know how a relative died and -colleagues are encouraged to be open as possible in such•circumstances.However, caremust be

• taken not to release •information which can only be •establishedby the internal-investigation or the." iinquest. Where any request for information beyondfactual details surrounding the death "

(including the circumstances.leading up to it).is received, a substantive response, to this request: :should be deferred until the investigation has taken place._iThe information required by the family ....

. _ . " . -

• iwill often formpart of the report.

Where any request for information is receivedprior to the inquest from.third parties, these : .,equests will normally be refused unless the Coronerhas ruled thatthey are properly interestedpersons for the inquest. Advice•on disclosure,issues may besought from .the CA .or•SCG.

. . . .., :

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• • . . .

• . ,. . . . ..- .

. . •-,• . • .. • . . ,-. .,

-. . . . - .

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- . . '' -. '.. . . .. . ...- . . . "" . . . . .

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. • . . .... .- : .-. . • .:_. .- .'. ,.. : • . "_ •' . • , , . . . .. ... . - . . • . . . - .

- .-.... . .. •

CHAPTER TEN • THE INQUEST

Overview

.This chapter describes key responsibilities of Staff; arrangements: for legal representation;pre-inquest briefing; post-inquest action; and an explanation of the inquest process and outcomes.

2, It is important to remember that the inquest before• a jury is required by law and is an . • . •inquisitorial rather than an adversarial process. The purpose of the inquest is to determine whodied, and how, when and where. This distinguishes it•from the internal Prison Service investigationwhich is to establish matters about prison policy, procedures and practices: It is alsoquite •common.for the public hearing tO take place several•months after the.death and the interim period.may presentdifficultiesfor staff and the establishment when staff have.to recall events again aftera periodof time. --

eylprocedures '._ . . .....• _ .._...:..._..._................- . . .

: ". " .;.. . . .. - . " .

3. The.foll0wing.procedures in respect of an inquest into the death of a prisoner in custody should-be followed. -.

-Appointin.q an inquestliaison officer ......

4. • It is good practice to nominate a member of Staff at the establishment to liaise with the•Coroner's office throughout and be responsible for preparations for the.inquest. ]dea!ly this

•-individual wilt also perform the role of liaison officer to the Prison Service Senior Investigating• .Officer (see. Chp 7.6).. The. key dutie_ ofthe inquest liaison officer will be to" . i " " -...-

..... i .. " " .. ... . . . ._. . ..

• assist the Coroner and Coroner's officers in their enquiries, includingsuggestions'on "documents and people they might want to.see --" • " ' " - . . .. • _ '.-.._

" - i. -: ._.- _ .:...--. , " ' ..." . .--

• find out the date•of the inques t and.inform SCGand Area Managerassoonas possible • - . .-. . . . . .... . _ . _ . ... _ ..

the chair of the _ " " " " ' '; inform BoV of the inquest date " .... " " " " -- •• . . : . .:" .'.. . • ... . . . . --: .

. . . . .- .. -

. ._ .. . : ... . . .. . " .... . -. . • . .". -- . .

:ii "° ' keep intouch•withthe •Coroner'soffice about important developments; e.g." invoi_'ement of. _ .;-: ':. :_..•:--pressure groups, •legal representation of family,• Summoning Ofnewwitnesses, Postponement "

.. :"-'--liaise with SCG and press Office with regard to anymedia interest " i-."i..---.i .: . : ........• .. . • • . .. . •

.'' : -.... '. . .,

::"" ns that pn's areaware:of Wha expect d rece/ve._... .:..".:._ ,, e ure potential staff and oner witnesses, t to an' _ appropriate advice and support ' _ _- . " ..... :". : i..i_ ....i-_- " :.:':. .i _.".: ."_....:.

_, .t .". "'.

- • wherea prisoner Listener is called, as a witness ensure that the Samafitans are inforrned.and :!..." -i- brought in to give advice on evidence and confidentiality • .. i: ". . ..: ' ! !.._.- :: i.._

_ -" " ' . . ' " " . .. " '...i-' : T : .-_-"- " ' .- . :. .-:i""- , . .".'i_,".::. : -"_ ._." . -. '.

• = .refer eovmembers to: theBoV Secretariat at headquarters foradvice and suppoff when. SoV ' i-.....-.-. .i"mernbers are to be Called upon as•witnesses i :i 'i: --_: 'i..:. i. _"...': " " -"ii. ..... . ._".'i:-'.:...-.-_i

• " = '" " :""."" • .i _."-". .... " """ " ' " " " 'i " : .."... - .. -" .i _-.., " ,. ..• -- _ • " " "" ''"" " " .... ..i .: . .',•- .: - - ... , • " .. . . ..... . . .. . ......._- i_ _ ._".._: . . . .. _. .. • : ...-. .. . •

• ii i : i i• ' " " ..... " " " ._i:. : 'i: - _ . -. ... _. - .. .. ." ,. . -... : _- . -. . .- . , . .. .

; provide a contact point for the Treasury Soficitor to arrange the provision of information whichis required either before or during theinquest

• inform the staff welfare officer of the date of the inquest

. arrange a pre-inquest briefing forstaff, attended by the Treasury Solicitor's representative and•Counsel where legal representation has been requested. Thelegal representative of any ....rele_,antstaff association may also wish to attend.

:: • organise the attendance of staff witnesses at the inquest and ensure they are appropriately. .'..

supported during the inquest and debriefed,afterwards, involving the Samaritans to support anyprisoner or Listener who hasgiven evidence

• take a note of the key points ofthe inquest and submit a short report to the govemor, theoperational manager and the Safer Custody Group on the outcome of•the inquest

. - • .

.;.• arrange for a post-inquest.de-brief meeting to whichall those who attended the inquesi, plus-available members of the Suicide Prevention Team,:should be invited ....... • ": : '.:

.. . . :

Arran.qementsfor leqal representation for the PriSonService ..

5. The general policyof.the Prison Service is to arrangelegal representation at inquests in anycasewhere the governor considers it necessary in the interests of the establishment and.its staff...This will then be arranged by SCG through the Treasury Solicitor's office. Costs are met byHeadquarters. It is recommendedthat legal representation is arranged for inquests, as many.•

-;families are now themselves legally represented. Members of the BoV - who should inform theDirector's Secretariat if they are required toattend as.a witness- will also be represented by:TreasurySolicitor's. Wherestaff elect to be represented by their own:Trade Union_costswill not. : ' :be met.by the Prison Service.Treasury Solicitors will not legally represent contractors or their .staff. " -

• _" . . . - : .... - .. .

. "" . . - . .." .. . " - . -

6. ,•Any request for legal representation.must be made by the governor to SCG as early as "; • "." ...

. possible.•Where it is decided initially not to request representation, the matter shouid be.kept. • -. ,..

("-"ruder review in the light of developments. " .... .. • ;. -.. ". .-.. . . . . ..... • . . . , . -.. ".-

(, Any subsequentdecisions on legal representation should be taken as soon as possible;.: Treasury Solicitors ideally need at least three weeks' preparation time: Representationcan be.•

arranged more urgently, but it is then moredifficult to prepare:the documents thoroughly, organisea pre-inquest briefing and appoint suitable Counsel....... "

8, The purposeof legal representation is to: " " "- _ . . . .. .

.L.. ." ,. . .- _'" . . . - .... . ..

-. o ensure that all the facts are available to the coroner and.the jury,•including any background {0..the case which may.not beobvious (e.g. in connection with.the general regime and routines•.of

: the establishment) :.: • .... : .- ........ - '- . .. . : .. . . ....

- ensure that proper andfair questions are put to staff ...... " ; " : ". . . . _ - " ". .. : ". . •

. . . . - . .... "-- . .'..

. - " .

" • ask questions duringthe inques{ in order to Correctany unjustified or misleading sta!ements' made - - " ........ .....

. ...... . .. .".- -... . ".- . . - .- . . .-

• . . . " . . . - " .. _ -." .... : . .... " . . ..

provide advice andsupport {o staff before and during the inquest . ..... . :. . - . . . .'.?. . - .. " . : .

........... -7006-.-, _i -",." " ' " : : " " " - " ". . ..- . . . . .... . .. . : "

.. . . .

• It is notthe purpose of legal representation to prevent embarrassment or attempt to gloss overirregularities, though it may be importantto enable the jury to see the decisions and actions of-

. staff in their proper context. " -

9. In considering the need.for legalrepresentation,_take into account the following factors: . ..

• the feelings Ofthe staff concerned

• public and mediareaction to the death . =.- _--•. . ..

• the involvement of any interest groups

• whether the family.appear Criticalof the Prison Service. -.. . . ,.: • . : :

.-• whether the.family (orany other party) are to be legally represented. . . . .

'_" wriether.thereare aspects of_thecase on which the Prison Service could be opento criticism(whether or not the criticism is felt to be justified) -

10. Where legal representation is requested, SCG Wiilinstruct the TreasurySolicitor's office.•Treasury Solicitors will then select and brief Counsel: .-" ,

11. Counsel will-be briefedto represent the•.interests-ofall staff concerned, as well as thoseof the. .PrisonService as a wholel if.their conduct may be.called into question. It is of course open toany

-member •of staff to arrange his/herown lega! representation at the inquest. This can, however,- lead .toextended cross-questioning, therebypro!onging the inquest,and cause tension between

:.. staff which reflects On.theestablishment..It is •generallyhelpfUlfor the.interests of allstaff to be• -.jointiyrepresented_ " - .... . _. , -- _ . . - . :. " '-

. .'.. - . ..-. ".

12..The.exception to this would be when the interests of an individual member of staff Clearly ' . "conflict with those of thePrison ServiCe,for example, because ofvei_ serious failureof " '-professional duty. Such Caseshave been extremely;rare in recent years..In these circumstances,. ....

. .;t..-"reasury Solicitors would advise the member of •staffconcerned as early as possiblet0 seek '_pa.raterepresentation. This Would generally.follow Consultationbetween the Treasury.Solicitor - "

...and the relevantStaff association or pr0fessionalbody. The various legal .representativeswouldthen seek to work together to.ensure thateveryone is properly supported_

• ":.... . .. -_ . ": , . . . : ._... ' . • , .. ......: • . .. .-.'. . . . ..

:.:_:Pre-inquest bdefinq . -, ' . .: .• - i " " " "

" .= . . . ...

:. 13. TheTreasury Soiicitor's representative and COunselwill wish to have a .briefingmeeting with;./the staff orother witnesses involved, such as BoV•members, involved prior-tothe inquest..Usually:

" •i:thisis.held .the day before theinquest.to save.legal costs,•but an earlier meeting may be arranged-_.-..:...::- if.there are particular difficulties whichneed tobe discussed and possibly .additionalstatements.": .. ". -. . . . • . ....

_. -.taken.- . ..... , - ....-_ . ... .. ",.." . • ".-... . . . - . .

" 14..Staff should be given adequate notice of.the meetingsothey can prepare for itand consider.,..any questions they:want to ask.. ._- ::.-__i . _. " " " " ..... " :"

-. -. .. . . . - ..

15.-The purpose of the briefing is to:. ' '• . . . . .. .. .-. •-

. .- -.. . . --

-- . explain•.the purp0seand procedures oftheinquestand go throughthestatements WithStaff. -. . - . , . . ":

. .- ....

' - "7 007-... . . • . . . - .

. . . . ...

. . .. ..-.... ,.: - ... . . . .. : .... . . . . .

b

• : • , :.

; . • • • • :•

la ify poi f detail ......• c r ntso - : .... : -:. _ ....'. . . .

• advise staff how to conduct themselves - .... . " •- . :'• " , i ': " " • ":

• - . . ' . . • '. • . . " . ..

16.•Staff canexpect to be asked some probing queStionsatthe bdefing. Theipurpose of this is to:...try to pre-empt any difficulties at-the inquest"itself, .notto "catch them out". It may be•helpful for a-member of staff•with previous experienceof inquests to attend the meeting. Some staff may •wishto see the Treasury Solicitor privatelY.•Staff attending an inquest should be aware that that it is •

" essential that•they answer all questions fully and truthfully; witnesses are sworn in on Oath. If a'.... question is.not understood, they should indicate that: .. - - " .. .

• ". . .. .- :. • ... • ._ . . :"• • : . . .- . . . :" , _ • '. -_. • _. '..

17: Staff may, at this point (and they may be reminded by Treasury Solicitors), need to note that•-they •shouldensure that in giving•evidence they refer to the deceasedas:"Mr/Mrs/Miss, etc." rather•' than simply by their surname. Care should also be taken in the use of prison terminology while• . .

• . giving evidence(forexample, use of such terms as "feeding-"often causes•upSet). " • . .• . . . . . . . . . ... . . • , . • . - . . , • . .

• " ... " . . " ,.. : . . . . . . . .• . •

;.The inquest process: " . - -" : "" ".... " " " :!':i : :" " '": ........• . • . . . . .

•18:An inquest before a jury is held into .anydeath•in.pris0nCustody. The-requirement for a jury " ' 'reflects the fact that there may be mattersof public interest involved. The power which the state

: exercises over prisoners through the Prison Service is.the reason forthis, extra.:.. level_of . . :bility_ . - .accounta .: - .... .. _•

• .. . •• . .. .. . . _. :. !

• : - . ...-" . . . ...• .. .-_ - . .. • .. ..- ., . .

: " 19.The purpose of the inquest.•is strictly limited by legislation.-It is to find out who died.and how,•. .where and when.the death occurred. Its concern,is facts; not opinions, .• '-. •. . ... . . -'. . . "". .. :.. _:.: •

20: The inquest does n0t, atpresent, apportion blame:t0organisations 0r individUalsiandthe " " :.:• Verdict does not d_termine .any issue of civil or criminal liability. Coroners areentitled, however, to -

.write to theauthorities based onobservations they mayhave adsingfrom evidence heard • " ." ". . . . . . .. .....

• .(Coroners Rules 1984; Rule 43): - • - " -- . ..." . ", ....... .... : .:_.. ".. -. :.:-...." - . . - . • . -. . ... • .-. . . - • . ... . " . : ..

• . . • . : ;. "." . . - " .. ": . ,..

2•1.The Coroner is an independent judi(iiai officer appointed by the:relevant councii:(n0rrnallythe ::::County Council). Heorshe must have .at least fiVe.years•experience as either .lawyeror doctor;

.. me have both. Coronersnormally.have dePuties and assistantdeputies who canstand in .for •.•i :

• -..Coroners in-their absence and who havethe same powers andduties. • " - . .....-...-_..• "...:.... ::... '..... '.' ... • _ : . . . .. .• ,." . ..'" .. • ,, , . . ., .: : : .- . : , : -::.• -. .- ,-. . • :: ,, - - ..

, : 22,-.AlthoUghthere is an increasingtendency forlegal representationtobecome the.norm, the ' " '" inquest is an inquiry;.not a trial. The-Coroner Wil!call anyone to give evidence•who.is thought able .:........ toshed light on how the death .oritscircumstancescame about: The witness will be expected to. "

, . . ,. , . . .: ' . ".

...-•.givefactualanswers_to.questionsputbytheCoroher... ...- :-.- _" . • ..... . ;. .- . "• : • ., : : " .. ". - . . . ... , ... " -.. , - • - . . , " . . ..... .. • . : ..- . .-" . . ", : • ..

". :-•23.Families ofthe deceasedare not entitle_ to legai aid'forthem to be represented asthe inquest ..• . • . . • . . . ", , . . ..-- • " ".

.-i:"is not regarded•asa trial,contested,by "parties".- " •-....: : . : " - .- : • - . • . . "• : : : ::. .-::.: .::: " i " .... .... .i: :..: . '../

". ::24. Questions.may:also be asked at the Coroner's discretion by:any interested p&rtywhohas a',- genuine:interest in.thedeath,, and they :mayalso be legally:represented. Legal aid is not; however,

-.available,' " " : " ' " " :: " ' :::..::i i:..-.. .--i :" ':-:.7...... . . . . . - . • . . • . .

" • " " _: "" : ' " • i. .- ' " • 'i '.: .. :. -.251Thejury may alsoask questions Ofwitnesses. •`` :.. : .......

.. ... : -.. . . -. -. .. . • :;.. ....-!"..: . .- • . : ..

i ,6:.."Itis the dUtyof theC0ro:nerto ensure that the questioning of witnesseSis limited t0"reievant.?':i -:. -' :factual matters: " .: " : • " - " " " : : : :-- " . :: :. :: " - :- _- "i" ' " "::.:. -. i.. " : " " " : ,. :. : .:.. .. :: .: . ::.. . .".. ..-7008-.... -

Openin.q-theinquest.

27. The inquest is usually opened within a few days of the death. The purpose of this is simply toestablish who died, and for the Coroner to authorise burial, cremation or removal of the body afterpost-mortem if he/she so directs. The •Coronermay wish to retain the body, often for such.purposes •as.a second post mortem: A Home Office pathologist will.usually undertake suchexaminations. The inquest is then adjourned to a later date.

28. The length,of time betweenthe opening of the inquest andits resumption will depend upon anumber of factors, including the scale of the inquiries being made by or on behalf of the Coroner,matters which come to the .Coroner'sattention, finding a suitable date and venue and satisfying - -the-different schedules of the witnesses. Everyeffort should be made to minimise the delay,which can be.distressing for everyone. Prompt responses to requests for documents orinformation go a long away to assistand greatly reduce the likelihood of.an application f0r:an •.adjournment which can takeplace where documents have not been made available in advance.". - .Themajority of •inquestsare completed within six to twelvemonthsalthoughin particularly_omplex or contentious cases the delay can be much.longer. " . .. -.... -......... -......

]he inquest inquisition•,verdict and its implications

'29. After all the evidencehas been heard the Coroner will give the jury asumming-u p and indicate.-which verdicts they may or maynot consider on the basisof the facts,

" 30..Before the summing-up, the legal.representatives present may ask to •addressthe Coroner on .....lega! points connected with the possible verdicts. The jury will be askedto retire while these pointsof.law are argued. The Coroner will listen to the argumehts but will decide for himself/herself.what

-Should•be put before the jury. ... - -- " ..... - ,. .

. --.. . . .

31. The inquisiti0n-itself is made up offive elements: .... " :

• :.(i) who was the deceased?. . . • ..._ . .- ,

• . . . : . "• • . .'- . .... .. .

- (ii) .. " what was the injury, illness or disease which.caused death?: • ... • -._ " ." . . .

• . ..: . . . -

.... ,,iii ' the time, place and circumstances at or-in which the deceased died. ': i. ". ... .. _,-_. .• . . .

.-(iv)" -, the •finding(this is wha;tis.usually referred to as "the verdict") •/ : . _. . " : " .: . ...'" . • , : . " - .

• - .- . . : . . .

' (v) the.particulars required forregistrati0n.. " ' .... " '.. . .. :'. ".. - . .

. . . . • ._ : ". .

...32. The-usual verdicts recorded at inquests into prison deaths are: .,.... ..... . ... . . -. ....... . .. . . ..... --- .__ ... . _.. --

_-!- Suicide:; Often;recorded as "he/she killed himiherself"i The prisoner look his/her life :as a":/! A. i:.;..1::/. deliberate and intended act. (This 'intention must be estabiished against the cdminal-standard Of-. :..: "

-- ..proof,i.e. •beyondreasonable doubt; for all other verdicts_apartfrom-unlawful killing,/the standard ••• ...: "_..:ison.balanceofprobabilities•.)• . : " _ " " " " '...- .._:.-_. " - ; • ...._ . . .

=:i_:: ." " :i : : _: " : _:_ " " " ..... _ "• i _ ; i _I :_i:.. :. :- _ .7 :. _i' • : '::- . Misadventure/Accidental death(There isn0 legal distinction between:the two); either the' : . . .. :-:'" prisoner injured him/herself to such an extent that.he/she:di.ed,but death was unintentionail or.the ... •• nrisoner pursued•an activity in a Waywhich had fatal but unintended conSequences,Sometimes. ':. :•--, 'corded in cases of apparent suicide wherethe intention to die is not clearly:established.. " -:. '-.. "" . • • . • . • • ... . - .. "?- .,..-.. • - .." • . :. - ., . . •. -. . . . . • • . .. ..- . .• :• ... ...... .. ",." • " . . . •_. , ....

.... ....... "•

• " " " " ' " ....= " " " _ .-:7009,...- . . " - , - . . • . .." . . . . -• " . . . . .'. .;- ... : • ..,

" " " " " .: : ... : --": :-.....i,......, .... "-:;:..",.. " :. .... " "

- Open; there is insufficient evidence to show exactly how the prisoner died. Sometimes recordedwhere the prisoner's motives are unclear.

Natural causes; self-explanatory.

Unlawful killing; self-explanatory

Neglect (formerly known as lack of care); see below.

33. The jury can describe the circumstances of the death in answer to"time, place, etc", but it isnot allowed to record additional comments to its conclusions. It cannot, for example, state its viewson how the death might have been prevented or who might have been at fault.

Findinqs of Neqlect

34. In certain circumstances, which have been:increasingly strictly defined as a result of case law,a finding of, previously, "lack of care" or, as now, "neglect" may be added to the verdict by using*he words "aggravated by neglect or contributed to by neglect". . _

35: This has traditionally been a rare verdict. Following an appeal court judgement (Jamieson,Weekly Law Reports, July 1994) which sought to clarify the circumstances under which a findingof neglect is appropriate, lack of care has been replaced by the adding of neglect to the verdict.This has been more closely defined as a gross failure to provide adequate physical or medicalcare which directly contributed to the death. There is, however, clear evidence following .a recentincrease in neglect verdicts that some coroners now take the view that where there has been a"causal connection" between a gross failure to act and the death or, indeed, evidence ofnegligence rather than neglect (as defined in Jamieson) is clear, a neglect verdict may be offeredas an option to the jury. Experience has been that when neglect is offered, a jury will frequentlyuse it as part of the verdict.

Action after the inquest

36. Follow-up action after the inquest to be taken or considered in the following.areas:

' Report to SCG/Area Office Security/PECS

• InformPress Office on--immediately of outcome and, where appropriate,.discuss handling plan for any media interest. " "

• Support for staff: Attending an inquest is often a stressful and intimidating experiencefor staff.Witnesses (ie staff and prisoners) are to be debriefed, giving them the opportunity tOexpresstheir feelings about the proceedings and the verdict. Further involvement by the Staff CareTeam may be necessary in some cases and managers may wish to invite the welfare officer toany de-briefing meeting.

• Contact with the family: Inquests are traumatic for close relatives and friends; theestablishment should be prepared to provide all necessary support during the inquest as wellafterwards. They may have further-questions which they do not feel could be addressed withinthe scope of the inquest, and feelings which need to be dealt with. Further information andsupport from the establishment may be helpful in some cases.

-7010-

• Reviewoftheinquestfindings:Any new findingsarisingoutoftheinquestwhichhaveimplicationsforlocalpolicyand proceduresmustbe reviewed.The Suicide Prevention Teammust be involved in this review in cases of self-inflicted death. In many cases the review will bestraightforward as the Prison Service internal investigation should already have identified allthe relevant issues. Occasionally, however, new information will have been revealed or theremay be specific comments by the Coroner which need to beconsidered. It is particularly•important that any "neglect" finding is the subject of careful review.

• Public relations: It may be worthwhile to issue a press statement Wherethere has been mediacoverage of the inquest. Do not issue anything without consultation with the PressC)ffice.Further contact with the Coroner may also be helpful if theestablishment has been criticised.The Coroner must be given a report on changes made to local practice,-or even be invited tothe establishment to see the regime for him/herself.

Chalien.qin.qan inquestverdict

37. Any decision of aCoroner's court, including the verdict itself, may be subject to judicial review :- .'-,vthe High Courton the grounds that it waswrong in law or suffered from a proceduraldefect, or..-.

.atthe Coroner lacked judsdiction or acted unreasonably, or that his/her enquiry has not been fullenough. The review is not an appeal butmay result in the original verdict being quashed and a..fresh inquest ordered to be held by-the same or a.different Coroner.

38. An application for judicial review maybe made by any person with a sufficient interest in thecase (such as a relativeof the deceased or any person whose conduct is called into question) andmust be made within 3 months:of the decision..The leave of a judge is required for the application.and all interested persons should,be served with notice of the proceedings and given an. : i '

.- •opportunity to submit a witness statement as evidence before a hearing by the Divisional•Court atwhich they may be legally represented." " _ • " ...... " ' _ : ;- . .. ." . • : _... ..'. . .: • -

' . .- . .-." . : _.. ".... . • " .. .., " . ."'_':.'. •

. . . - ... . . • . ""

• :39. There:•arenumerous Cases•wl_ichhave clarified the circumstances in-which a C0roneffs courtdecisionrnay successful!y.15echallenged.As well asthe verdict itself; deciSions.relatingto the - :.,. :

• summoningof a jury or the holding of a post-mortem may be challenged by way of judiCial review. •The mannerin which a Coroner sums up to the jury or the evidence which he/she calls or omits to

,--.-r,all may be-a cause of quashing,the inquest. The.verdict may be found objectionable on the -r ,_undsthat no••reasonable•Corone{"or jury.could have reached it on the evidence available: , .:' : " : i..: .-.. " ..: ... ; .!., .. . : :...: .- :. : ..... .. . •: . 140,The'remedies available on revieware discretionary. Even if there has been a procedural I " ..: defect.or insufficient inquiry, the court Will not order a fresh inquest unlessthere is a probability of •

" a differentverdict being reached and.it is within-theinterests of justice. If new evidence be.comes.: _.:. available a fresh inquest may be ordered if the court believesit would have made a matedal.

;differenceifadmitte d. It would be very.rare for the Prison Service to contemplate judicial review; it ._. would have to-be weighed carefully againstthe possible adverse.._ffects0f a re-opened inques.tas ::i• well as the•possible importance to future similar cases. ' : : • -

" :' ". -'- .. - - .... .... "" " " "" • i . ."" :'i_ ".." "• . . .. .- "..i._ :.'.... ; : .i i._ _._ ; • .. .

.. . . • . . . . . ..

.Implications.of inquestsfor civillitiqation.... " " :: • i:. .. • " _ ":- : _:_ _,- ::i _i : " ! -_ i: _ :: " _ :

41. tt may be that the prisoner,s family decidesto bring a civilaction against the Prison.ServiCe;.. :following the inquest. They maybe encouraged to do this by evidence emer_tingatthe inquest or:. ..

by the verdict, although the inquest has no legal beadng Onquestions of Civilor criminal liability. " '

_21.SCG will be responsibie for liaison witb theestablishment and theTreasury Solicitorascivil i.:.-oceedings take their course. Death in custody cases are to be handled ;similarlyto other." _... • •

. . . - - . . ... ' . ' . • . . .. .. . .- - .

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litigation cases. Where there are any issues arising which are specific to death in custody policyl_dvice or instructions will be provided by SCG.

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