Justice Committee
Tuesday 3rd November 2026
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14:32
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14:32
Warinder Juss
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Warinder Juss
Hello. Good afternoon, I'm Warren Digits. Member of Parliament for Wolverhampton West. I'm a member of the GMB trade union Central Executive Council. I'm a solicitor but not practising at the moment. I'm co-chair of the Appg on Legal and Constitutional Affairs and officer and member of various other appgs.
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Ashley Fox
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Ashley Fox
Thank you very much, Catherine. So my name is Johnny Santer and I am the founder and campaign director for Gabe's Law. After we had the multi-storey car Park Safety Bill introduced into Parliament in 2023. And I'm here really because I believe through lived experience and lived experience of others who have been in contact with that. The current system that we have, unfortunately at the moment is, is woefully inadequate. It's broken.
14:34
14:34
Speaker 2
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Speaker 2
Hello. My name is Richard Caseby. I'm here on behalf of my son Matthew, who died at the age of 23 back in 2020. He suffered an acute psychotic episode , and three days after being admitted to the Priory Woodbourne in hospital in Birmingham, he escaped. He escaped over a very low fence whilst 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'd 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 didn't actually see it happen. So I 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. And along the way, I've learned there are many urgent changes that need to be made to the coronial service, and specifically the FD report process and how it functions once the inquest is over.
But mercifully, I didn't actually see it happen. So I 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. And along the way, I've learned there are many urgent changes that need to be made to the coronial service, and specifically the FD report process and how it functions once the inquest is over.
14:35
14:35
Speaker 3
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Speaker 3
Thank you everyone. I'm a here really as Ruth's mum. I am a GP, my husband's 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'd been there for four and a half months, and we'd 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. And 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. And there was a whole litany of systemic failures that they've listed for that. Our coroner didn't decide that he should go ahead with issuing a FD, and our experience, really having been through that whole incredibly traumatic process, was that it didn't really lead to anything . And nothing really has changed from when Ruth was in that hospital, from when she died. And I've ended up following all sorts of threads in trying to create that change myself with with various things, with the Mental Health Act last year, with work that I'm doing with the Department of Health, trying to enable children in mental health units to have access to their families, which seems like a really basic principle, but also with trying to get national eating disorder strategy and a tic and Tourette's disorder service.
There are so many elements as that jury found in in that list of, of failures. But really that I'm here because it felt like the inquest process doesn't really serve a purpose to create a change. And as someone who professionally kind of likes to learn and that's how we all, all, you know, mistakes are made, things happen, but we have to reflect and we have to learn and we have to make changes based on that.
And that's what I'd like to see from the coronial process and ultimately from PhDs.
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. And there was a whole litany of systemic failures that they've listed for that. Our coroner didn't decide that he should go ahead with issuing a FD, and our experience, really having been through that whole incredibly traumatic process, was that it didn't really lead to anything . And nothing really has changed from when Ruth was in that hospital, from when she died. And I've ended up following all sorts of threads in trying to create that change myself with with various things, with the Mental Health Act last year, with work that I'm doing with the Department of Health, trying to enable children in mental health units to have access to their families, which seems like a really basic principle, but also with trying to get national eating disorder strategy and a tic and Tourette's disorder service.
There are so many elements as that jury found in in that list of, of failures. But really that I'm here because it felt like the inquest process doesn't really serve a purpose to create a change. And as someone who professionally kind of likes to learn and that's how we all, all, you know, mistakes are made, things happen, but we have to reflect and we have to learn and we have to make changes based on that.
And that's what I'd like to see from the coronial process and ultimately from PhDs.
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Ashley Fox
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Ashley Fox
Yeah, sure. No problems. Tessa. Unfortunately, I was just retraumatized the night before I went into my inquest because despite asking both Merseyside Police and the coroner's office for the bundle, it wasn't forthcoming. And this was after I'd had to reschedule the inquest. Gabriel died a preventable death on the 3rd of October 2020. The original inquest was scheduled for the 23rd of December, two days before Christmas, before the first Christmas without my son. And that's when they wanted me to attend for inquest, so I had to get that postponed until later in January, alerting the clerk that my daughter's birthday was mid-January.
So could we possibly avoid that date as well? And there you have it. So I, I, I went into that inquest pretty much completely blind.
So could we possibly avoid that date as well? And there you have it. So I, I, I went into that inquest pretty much completely blind.
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Ashley Fox
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Ashley Fox
Just the four questions I guess. You know the the the who died, where they died, how they died and when they died, you know, so I was aware of that. But 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.
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Ashley Fox
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Ashley Fox
So importantly a prevention of future deaths report. So and the circumstances around this are important because the inquest that I was sitting in on was the inquest of 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, 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 the impact of these preventable deaths that they have on the community.
And needless to say, I didn't get a response from that. Operator. And then Josh was allowed to die a very preventable death. And just two years later. But having seen the barrister, Christian Weaver, represent Josh's family inquest, and I'm proud to say I was able to introduce Josh, his family , to Christian to facilitate that. And the difference was just it was worlds apart. Thank you, thank you.
And needless to say, I didn't get a response from that. Operator. And then Josh was allowed to die a very preventable death. And just two years later. But having seen the barrister, Christian Weaver, represent Josh's family inquest, and I'm proud to say I was able to introduce Josh, his family , to Christian to facilitate that. And the difference was just it was worlds apart. Thank you, thank you.
14:42
Speaker 2
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Speaker 2
Well. Well, before the inquest between Matthew's death and the first Pre-inquest review, I'd already started my own investigation using freedom of information requests, subject access requests, because I knew that the Priory was deliberately trying to cover up the truth of what had happened. And that was plain. And because in my career, I've been a managing editor for two national newspapers, I, you know, I knew how to mount an investigation. But at the start, I knew very little about the inquest process. I mean, I hadn't I don't think it even covered one as a reporter. So I didn't really know much.
And I made a big mistake at the beginning of thinking, oh, I was I was arrogant enough to think I could do it myself, which would have been a huge mistake. And then I kind of read this book, you know, the inquest practitioner's guide, you know, the 800 pages. And then I got a very clear view that I might actually need a lawyer. And thanks to the inquest charity, I did actually found one, one who specialized in inquest, and that was Craig Court at Harding Evans and then also a barrister, Oliver Lewis, at Doughty Street Chambers.
And both were excellent, excellent. Because Matthew was in state detention and in the custody of the state. It was an article two inquest. He was held before a jury and it lasted three weeks. What I didn't know until I'd been through it was actually the emotional effect that can have on you. It is really hard. The coroner, who was excellent, Louise Hunt in Birmingham. Name check. She was brilliant. Excellent. Coroner opened it by telling everyone that, you know, we're all here for the same reason, to find out why and how Matthew had died. But actually, we all know that that is basically a false assurance.
It's well meaning, but it is naive. That is not what happens at an inquest, not like the one I was involved with. You know, the government has repeatedly said that families are put at the heart of the inquest process. But in my experience and those of many families, they are most certainly not. I mean, families usually probably like Johnny, you know, you enter this coronial arena, you know, believing that everybody present is only concerned in discovering the truth. And as I say, nothing could be further from the truth. You know, public bodies like NHS trusts, like the Priory, the police, you know, they all turned up fully armed with battalions of highly paid lawyers.
You know, most of them were funded out of taxpayers money. Luckily, and thanks to a campaign led by the inquest charity, I did get exceptional case funding because I actually vowed I was not going to spend my own money on this. I'd do it myself, but I got legal aid. But the single concern of all those other interested persons, I think the name is there. You know, the single concern is just to protect the reputations of their own organisations by, you know, by deflecting any hint of accountability onto each other or to you or whatever it might be, you know, and I found it shocking, you know, it was manipulative, obfuscating, defensive, you know, an aggressively adversarial towards families.
He was truly shocked. You know, I've seen a lot in my life. Does that help?
And I made a big mistake at the beginning of thinking, oh, I was I was arrogant enough to think I could do it myself, which would have been a huge mistake. And then I kind of read this book, you know, the inquest practitioner's guide, you know, the 800 pages. And then I got a very clear view that I might actually need a lawyer. And thanks to the inquest charity, I did actually found one, one who specialized in inquest, and that was Craig Court at Harding Evans and then also a barrister, Oliver Lewis, at Doughty Street Chambers.
And both were excellent, excellent. Because Matthew was in state detention and in the custody of the state. It was an article two inquest. He was held before a jury and it lasted three weeks. What I didn't know until I'd been through it was actually the emotional effect that can have on you. It is really hard. The coroner, who was excellent, Louise Hunt in Birmingham. Name check. She was brilliant. Excellent. Coroner opened it by telling everyone that, you know, we're all here for the same reason, to find out why and how Matthew had died. But actually, we all know that that is basically a false assurance.
It's well meaning, but it is naive. That is not what happens at an inquest, not like the one I was involved with. You know, the government has repeatedly said that families are put at the heart of the inquest process. But in my experience and those of many families, they are most certainly not. I mean, families usually probably like Johnny, you know, you enter this coronial arena, you know, believing that everybody present is only concerned in discovering the truth. And as I say, nothing could be further from the truth. You know, public bodies like NHS trusts, like the Priory, the police, you know, they all turned up fully armed with battalions of highly paid lawyers.
You know, most of them were funded out of taxpayers money. Luckily, and thanks to a campaign led by the inquest charity, I did get exceptional case funding because I actually vowed I was not going to spend my own money on this. I'd do it myself, but I got legal aid. But the single concern of all those other interested persons, I think the name is there. You know, the single concern is just to protect the reputations of their own organisations by, you know, by deflecting any hint of accountability onto each other or to you or whatever it might be, you know, and I found it shocking, you know, it was manipulative, obfuscating, defensive, you know, an aggressively adversarial towards families.
He was truly shocked. You know, I've seen a lot in my life. Does that help?
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Speaker 3
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Speaker 3
I think we all have very similar experiences, although different kind of backgrounds from it all. I was aware of inquests from a professional capacity and speaking with coroners offices, but I hadn't had any idea as to what an inquest like this would look like. And we we had actually already gone through the police were investigating Ruth's death under charges of corporate manslaughter, and the CQC also launched a criminal prosecution investigation, which they then dropped. And we haven't been able to have access to what they actually looked at. But so we were stumbling through all of that before we were able to start the inquest process, and it is purely by chance that my sister read a very small article which mentioned the charity inquest.
So I picked up the phone to them, just not knowing where where we've started. So they were the ones who actually explained what the process would look like. They were the ones who suggested that actually we should have legal representation. They were the ones who linked us with our fantastic solicitor, Charlotte Heyworth heard and she. I don't know how we would have got through that process without her and the barrister and subsequently the case. See, she enlisted. She was very experienced in inquests and , and recognised very early on with this that the legal teams from the other side, as it were.
And, you know, everyone comes back to it's an inquisitorial process, but it felt like 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 and get her voice heard, to even address the questions that we had , and I don't know how that would have even had a chance of happening without the legal support in terms of kind of potential outcomes. They were the ones who explained to us what the coroner would give the jury, because again, like, like Richard, it was an article to inquest with a with a jury, and it lasted for nine days.
But they the coroner guides them on what they're allowed to have as their outcomes. And again, we our legal team really had to push him to offer anything more than suicide or neglect to a allow that to be wider. And he actually said on on the last day of her inquest, he said, I can see I've been blinkered. And thank you to the jury for seeing the wider picture because he'd been so focused on those four questions, which are really important, on how she died. But that bit was really simple. It was really clear she shouldn't have been left unattended with access to to, you know, how she actually ended in her life.
But that for us wasn't that wasn't 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. And that's what we wanted to know. And that was not that was not just the four and a half months of her being there. That was the actually all the decisions about her going there that, you know, there are so many layers to it. And I think that's why inquests are really, really important.
But you are at the mercy of the person who's sitting there overseeing that. And that is very, very variable. And I'm conscious I have strayed slightly off the question there.
So I picked up the phone to them, just not knowing where where we've started. So they were the ones who actually explained what the process would look like. They were the ones who suggested that actually we should have legal representation. They were the ones who linked us with our fantastic solicitor, Charlotte Heyworth heard and she. I don't know how we would have got through that process without her and the barrister and subsequently the case. See, she enlisted. She was very experienced in inquests and , and recognised very early on with this that the legal teams from the other side, as it were.
And, you know, everyone comes back to it's an inquisitorial process, but it felt like 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 and get her voice heard, to even address the questions that we had , and I don't know how that would have even had a chance of happening without the legal support in terms of kind of potential outcomes. They were the ones who explained to us what the coroner would give the jury, because again, like, like Richard, it was an article to inquest with a with a jury, and it lasted for nine days.
But they the coroner guides them on what they're allowed to have as their outcomes. And again, we our legal team really had to push him to offer anything more than suicide or neglect to a allow that to be wider. And he actually said on on the last day of her inquest, he said, I can see I've been blinkered. And thank you to the jury for seeing the wider picture because he'd been so focused on those four questions, which are really important, on how she died. But that bit was really simple. It was really clear she shouldn't have been left unattended with access to to, you know, how she actually ended in her life.
But that for us wasn't that wasn't 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. And that's what we wanted to know. And that was not that was not just the four and a half months of her being there. That was the actually all the decisions about her going there that, you know, there are so many layers to it. And I think that's why inquests are really, really important.
But you are at the mercy of the person who's sitting there overseeing that. And that is very, very variable. And I'm conscious I have strayed slightly off the question there.
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Speaker 3
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Speaker 3
If I hadn't picked up that phone, I don't know at what point anyone would have said, or perhaps, you know, you are eligible for legal aid to have legal representation. Yeah. Just even even the understanding the, the language that is used. And I, you know, I'm sure I'm just as guilty using medical jargon, but sitting through the Pre-inquest hearings and coming out the other end and saying, I didn't actually understand half of what was just said. That's just the, you know, and then the actual, I don't know how you would go through the inquest itself.
Like Richard said, it is. And Johnny too, it is. Retraumatising. I think for us almost. And I think and going through that, I don't think we were even able to start grieving properly until after that process, because we had to hold all of that information in our heads, trying not to lose that. And, you know, it was four years from when she was admitted virtually to the day that that inquest went ahead. So. So, yes, it took several months for both of us before we could even think about going back to work. It really, really, I can't explain how how that is.
Like Richard said, it is. And Johnny too, it is. Retraumatising. I think for us almost. And I think and going through that, I don't think we were even able to start grieving properly until after that process, because we had to hold all of that information in our heads, trying not to lose that. And, you know, it was four years from when she was admitted virtually to the day that that inquest went ahead. So. So, yes, it took several months for both of us before we could even think about going back to work. It really, really, I can't explain how how that is.
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14:51
Vikki Slade
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Vikki Slade
So surprisingly, having read all of the case cases, only Richard's case ended with a the issuing of a Prevention of Future Deaths report, which is shocking given given the circumstances. And I've read that you you specifically said that the scandal was that the coroner has no powers of enforcement in terms of the what that report has said. So can I just ask you specifically, Richard, what was your reaction to the Prevention of future deaths report in your case and the way in which it was responded to?
14:52
Speaker 2
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Speaker 2
Let's take a step back slightly. I knew that having an independent report into what had happened with Matthew was going to be massively important. So before the inquest, I fought for like 40 days to get the NHS trust to commission an independent investigation into his death, because the Priory one was just unforgivable, and it was led by one of Britain's leading psychiatrists. And they found, like, two core reasons why he died and 29 contributory factors. So it was extremely damning because he'd only been there three, three days. So that became the central plank of the of the inquest as well as a lot of, as I say, freedom of information requests I'd put into both the trust and the Priory.
So I knew we were heading down this, you know, this path towards what I wanted was not just a PhD, but a verdict. Sorry. Conclusion of death contributed to by neglect, by the treating hospital. That's what I wanted. And that's the most serious one outside an unlawful killing. I mean, one of the core reasons why there was a PhD was because actually during the inquest, which was about a year and a half after Matthew's death, another patient escaped over the same fence from the same hospital during the three week inquest. So nothing had been done even after Matthew's death.
So how could a coroner not issue a PhD anyway? So I was content with the PhD. But even the Priory, right at the last minute on submissions, was arguing that there shouldn't be a PhD. I mean, how do you do that? I mean, I know you can go through the motions as a barrister. As a lawyer. Well, I might as well throw that in. I might as well try that. But it was pretty unforgivable behavior by the KC who represented the Priory. Anyway, the PhD I was satisfied with. It was good. As I said, Louise Hunt is a great coroner.
You know, it covered things like record keeping, record keeping, quality risk assessments, serious incident reports. I mean, honestly, all the things that happen time and time again at deaths at Priory Hospitals time and time again, year after year. But there was one that was outstanding. It was about fence height because Matthew had escaped over a fence. It was about, I think it was about 7 foot or 7 foot six. And really it should have been nine foot, you know, it was as tall as me. It was six foot tall. He was a personal trainer. He was well built.
And he and I inspected the hospital courtyard. You could put your hand. I could put my hand without even standing on tiptoe to the top of the fence. And he was left unaccompanied in that courtyard. And he'd made three attempts over those three days to escape before. Not that each shift knew about them, because they got the notes all wrong. So there was also a recommendation to the Department of Health. You know, there should be a standard guidelines for perimeter fences and security in acute mental health units. And as if you know anything about mental health units, sorry if this is a bit detailed, but I'll try and make it fast.
There are three levels of mental health units. There's acute maybe 3500 beds in this country, medium and then high. And there are only regulations on height of fences and outside areas in medium and high, which seems a little bizarre because if someone is held under the Mental Health Act and is being sectioned for their own safety and they want to escape, why wouldn't you keep them safe with a with a recommended fence height? Anyway, it was what happened afterwards, and I don't know whether you want me to explain that now, and what they, the Department of Health did or didn't do, but I was satisfied by what happened to the Priory, to be perfectly honest, because they increased the height in fences in about a dozen of their mental health facilities afterwards.
But that might have also been the product, because I basically bullied the CQC to bring a criminal prosecution against him.
So I knew we were heading down this, you know, this path towards what I wanted was not just a PhD, but a verdict. Sorry. Conclusion of death contributed to by neglect, by the treating hospital. That's what I wanted. And that's the most serious one outside an unlawful killing. I mean, one of the core reasons why there was a PhD was because actually during the inquest, which was about a year and a half after Matthew's death, another patient escaped over the same fence from the same hospital during the three week inquest. So nothing had been done even after Matthew's death.
So how could a coroner not issue a PhD anyway? So I was content with the PhD. But even the Priory, right at the last minute on submissions, was arguing that there shouldn't be a PhD. I mean, how do you do that? I mean, I know you can go through the motions as a barrister. As a lawyer. Well, I might as well throw that in. I might as well try that. But it was pretty unforgivable behavior by the KC who represented the Priory. Anyway, the PhD I was satisfied with. It was good. As I said, Louise Hunt is a great coroner.
You know, it covered things like record keeping, record keeping, quality risk assessments, serious incident reports. I mean, honestly, all the things that happen time and time again at deaths at Priory Hospitals time and time again, year after year. But there was one that was outstanding. It was about fence height because Matthew had escaped over a fence. It was about, I think it was about 7 foot or 7 foot six. And really it should have been nine foot, you know, it was as tall as me. It was six foot tall. He was a personal trainer. He was well built.
And he and I inspected the hospital courtyard. You could put your hand. I could put my hand without even standing on tiptoe to the top of the fence. And he was left unaccompanied in that courtyard. And he'd made three attempts over those three days to escape before. Not that each shift knew about them, because they got the notes all wrong. So there was also a recommendation to the Department of Health. You know, there should be a standard guidelines for perimeter fences and security in acute mental health units. And as if you know anything about mental health units, sorry if this is a bit detailed, but I'll try and make it fast.
There are three levels of mental health units. There's acute maybe 3500 beds in this country, medium and then high. And there are only regulations on height of fences and outside areas in medium and high, which seems a little bizarre because if someone is held under the Mental Health Act and is being sectioned for their own safety and they want to escape, why wouldn't you keep them safe with a with a recommended fence height? Anyway, it was what happened afterwards, and I don't know whether you want me to explain that now, and what they, the Department of Health did or didn't do, but I was satisfied by what happened to the Priory, to be perfectly honest, because they increased the height in fences in about a dozen of their mental health facilities afterwards.
But that might have also been the product, because I basically bullied the CQC to bring a criminal prosecution against him.
14:56
Vikki Slade
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Vikki Slade
So can I just go back, if that's okay? You've explained how much investigation you did, and presumably that's linked to your your previous background, right? You know, people in a different circumstance either wouldn't have had the, the wherewithal to do that. They might have been managing other children at home, their own grief. Yeah. You said that you thought that the prevention of future deaths report happened because of that additional death that happened.
But do you think.
But do you think.
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Speaker 2
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Speaker 2
I don't want anything to take anything away from Louise Hunt because she is an excellent coroner. She may well have done that for somebody else, but the evidence was was overwhelming, you know, and to your point, you know, I could play upon my, you know, previous career experience. But, you know, I'm very well aware that people are not as privileged as me. You know, I'm middle class, I have resources I could give up full time work as soon as Matthew died to investigate this, you know, and I had the basically the network's money and wherewithal to basically grind down these institutions and to, you know, to bend them to my will.
But had I been a single mother with two other children working a minimum wage, you know, I'd have been crushed. I'd have been crushed by the system.
But had I been a single mother with two other children working a minimum wage, you know, I'd have been crushed. I'd have been crushed by the system.
14:58
Sarah Russell
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Sarah Russell
This question is TC and Johnny. And in both cases, I just want to start by saying I'm so sorry for your loss. And thank you for coming today to talk to us. So in common with a number of my constituents who've had young family members who have died in avoidable circumstances, I know that you in each case, your family didn't have a prevention of future death report. And what has the impact of that been? And Johnny, do you want to answer first and then Kate, please.
14:58
Ashley Fox
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Ashley Fox
I mean, I think the, the, the impact has been huge, really. You know, I've had to go through a similar process as Richard in as much as I've just taken the organisation that I feel is directly responsible for Gabriel's death, which was. Q Park through civil action. And we're still awaiting the verdict from that. And, you know, I don't think any of that would have happened had we had the Prevention of Future Death report, to be honest with you, because it would have highlighted the absolute obvious issue that was at stake here. So Gabriel fell from an age perimeter.
You know, it's very similar sort of circumstances as opposed to to to Richard's case, Gabriel fell from an anti perimeter on a multi-storey car park. And that edge perimeter at the moment is mandated by building regulations document okay approved document K to 1.1m. And this is despite the fact that the parking industry produces, you know , suicide prevention strategy. And it's such a well documented fact that it just seems almost insane that this hasn't been raised before this issue. And what I know subsequently from other inquests that have happened, as I alluded to before, you know, that prevention of future death report should be a very powerful tool to focus the attention and the relevant authorities into recognising there is an issue here around, guess what, preventable deaths.
So yeah, it's meant that, you know, six years on from Gabriel's preventable death, there's still no action that's been taken against the organisation. Q Park by any authority. And this is despite the fact that Gabriel fell from an age perimeter that didn't even meet the building regulations. And I established that fact in court. But I had to go through that process of civil action because nothing had been established in the inquest at literally nothing.
You know, it's very similar sort of circumstances as opposed to to to Richard's case, Gabriel fell from an anti perimeter on a multi-storey car park. And that edge perimeter at the moment is mandated by building regulations document okay approved document K to 1.1m. And this is despite the fact that the parking industry produces, you know , suicide prevention strategy. And it's such a well documented fact that it just seems almost insane that this hasn't been raised before this issue. And what I know subsequently from other inquests that have happened, as I alluded to before, you know, that prevention of future death report should be a very powerful tool to focus the attention and the relevant authorities into recognising there is an issue here around, guess what, preventable deaths.
So yeah, it's meant that, you know, six years on from Gabriel's preventable death, there's still no action that's been taken against the organisation. Q Park by any authority. And this is despite the fact that Gabriel fell from an age perimeter that didn't even meet the building regulations. And I established that fact in court. But I had to go through that process of civil action because nothing had been established in the inquest at literally nothing.
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Speaker 3
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Speaker 3
I have mixed feelings because. I think we were completely baffled as to why on earth our coroner wouldn't have done PhD, because the list of contributory factors to the unlawful killing outcome was was long and specific, but very general. Across the background of what we know is happening again and again in mental health services, but particularly for young people. So, you know, there were things like kind of lack of training for staff and access to social media and the internet, lack of lack of access to her family. It was a long list. And, and. It seemed crazy that his kind of justification for not doing a PhD was to bring in somebody from high ranking, from active care group to come and kind of say, oh, yes, we're doing all these wonderful things now and sit there and say how marvellous they were.
But for us to all take that at word. And it was very, very strange sitting there listening to them say all this stuff that we were actually told a lot of this stuff with what they did when Ruth was admitted, but it clearly didn't happen. And they could just sit there and say that they were doing things magnificently and, and no one was going to check up on whether they were actually doing any of that. And the fact that actually it's not just one provider. We know it's not just active care group. We know there's plenty of people, the Priory, we are so heavily reliant on that private sector.
But to be honest, I'm not sure necessarily that a PhD would make any difference because there have been so many similar cases again and again with things like sending children out of area, sending children to adult units, that stuff that is coming up in PhDs that actually there's still no action. So I'm not sure that it doesn't just go off to a drawer somewhere in Whitehall. And, and it's great that Richard, there was some action for his son, but I'm not sure I've got any faith that currently the PhDs do any more than the coroner giving some recommendation.
But for us to all take that at word. And it was very, very strange sitting there listening to them say all this stuff that we were actually told a lot of this stuff with what they did when Ruth was admitted, but it clearly didn't happen. And they could just sit there and say that they were doing things magnificently and, and no one was going to check up on whether they were actually doing any of that. And the fact that actually it's not just one provider. We know it's not just active care group. We know there's plenty of people, the Priory, we are so heavily reliant on that private sector.
But to be honest, I'm not sure necessarily that a PhD would make any difference because there have been so many similar cases again and again with things like sending children out of area, sending children to adult units, that stuff that is coming up in PhDs that actually there's still no action. So I'm not sure that it doesn't just go off to a drawer somewhere in Whitehall. And, and it's great that Richard, there was some action for his son, but I'm not sure I've got any faith that currently the PhDs do any more than the coroner giving some recommendation.
15:04
15:04
Ashley Fox
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Ashley Fox
Sorry, can I just pick up on just that one fact that Kate so eloquently alluded to? There's been 22 now, 23 because since Doctor Jorja Richards posted on the prevention of Future death trackers, LA live tracking portal about multi-storey car park safety deaths and prevention of future death reports that are issued. As a result. There's been 22 since 2013 on exactly the same instance that you know that they will be almost verbatim the same in terms of. Exactly. And it's such a narrow parameter, isn't it? What we're looking at, it's the edge perimeter of multi-storey car parks.
There might be other things that are alluded to, but in essence they're all the same. So I'm absolutely in total agreement with Kate here. It's like, what is even the point at the moment when you can have prevention of future deaths report after prevention of future death, report after prevention of future death report. And nobody nobody takes any accountability, takes any responsibility. You know.
There might be other things that are alluded to, but in essence they're all the same. So I'm absolutely in total agreement with Kate here. It's like, what is even the point at the moment when you can have prevention of future deaths report after prevention of future death, report after prevention of future death report. And nobody nobody takes any accountability, takes any responsibility. You know.
15:05
Speaker 2
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Speaker 2
I mean, I totally agree with Jonathan that, I mean, all you have to do is I know Deb Cole is going to speak to this about the Lampard inquiry. It's investigating 2000 deaths in Essex. You know, how many of those is shocking? How many of those deaths have had PhDs. And they're the same thing year in, year out. You surely want to take a look at that.
15:05
Warinder Juss
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Warinder Juss
Thank you for all that you've said so far. I mean, we've heard that there are cases where a PhD should have been prepared and there wasn't one. And even when there is a PhD, it makes you wonder what the point of that PhD is because it relies upon the organisation who is in receipt of the PhD, to do something about it. The coroner has no enforcement powers. The PhD cannot be followed up in any way. So we've got those problems in existence anyway. But from your own experiences, are there any other problems that you see exist with the current approach to following up on inquests?
15:06
15:06
15:06
Ashley Fox
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Ashley Fox
I think it's a really good point here, because what we're talking about and concentrating on is PhDs and Doctor Jorja Richards will be able to speak to this much more, with much more authority and much more eloquently than, than I'll be able to. But PhD is only represent a tiny fraction of outcomes from inquests. Okay, so when we're talking about in, in Gabriel's case, the fact that he didn't have a PhD from his preventable death and the fact that we know now there are at least 23 other prevention of future death reports from this exact same preventable death scenario.
There's hundreds of other people that have died, exactly the same deaths of Gabriel that aren't recorded or represented, and there's no learning from those deaths. So what we actually need is a system that looks at all deaths that end up in the inquest process and are not just focusing on this very narrow outcome of a prevention of future death report.
There's hundreds of other people that have died, exactly the same deaths of Gabriel that aren't recorded or represented, and there's no learning from those deaths. So what we actually need is a system that looks at all deaths that end up in the inquest process and are not just focusing on this very narrow outcome of a prevention of future death report.
15:07
Speaker 2
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Speaker 2
And it can't be that difficult these days. In all honesty, I did some work for the Serious Fraud Office about their disclosure documents. And, you know, people are now starting to use AI to actually, you know, check words through up to now, it's always been done manually, but it can't be that difficult in this age of AI to actually rapidly go through trends in these sorts of PhD reports. There's like 650 a year. I mean, that's not many. Anyway, sorry, I didn't know.
15:08
15:08
Speaker 3
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Speaker 3
I think it's it's it's a difficult one isn't it. But I it, I agree with with Johnny and Richard there in that actually we either need to make the guidance for what. Leads on to a PhD much more consistent. For coroners. Not it's probably not either, isn't it? But both really it's looking at because every, every inquest has outcomes that we can learn from. But it's such, you know, it varies so widely aren't they. It's all sorts of fields that that is relevant to, but without anybody overseeing that and able to then direct down to the appropriate departments and then to make sure something's being done about that, it just is all getting lost in the ether.
15:09
Warinder Juss
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Warinder Juss
Just occurs to me that we're following an inquest. There is culpability, that there should be a PhD in every one of those cases, but backed up with some kind of enforcement procedure whereby if the organisation isn't doing what the PhD says, somebody should follow that up. Exactly. Maybe the the way forward 100%.
15:09
15:09
Speaker 3
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Speaker 3
A few a few thoughts on that really, because I think the actual coronial process itself is, is still really very flawed. Ruth's inquest went ahead with vast swathes of missing records. So we had several months where they just didn't bring the records for those we we were refused our request for a lot of the witnesses who we felt would have been able to answer questions about her therapy. We also asked for an expert witness to be brought in, rather than just relying on the consultant who ran that ward, saying, you know how things should be done.
And I know that one of the things that I think would be really helpful, particularly for deaths within mental health settings, is actually to have a separate investigation to provide the evidence, because you're relying on you're relying on the providers to be bringing that. And if we hadn't had our legal representation, even with them pushing to have that, we you're looking at stuff without even having the evidence to go through. So you're not, you're not getting a full picture in, in the first place. I think that disparity between the individual coroners is a really big one.
As soon as our solicitor heard who our coroner was going to be, she she said, I'm going to have to set your expectations right now. It's going to be very hard to get him to look beyond this kind of immediate picture and that that seems madness. You know, I understand that coroners come from all different backgrounds and different experiences, but actually. It feels like there needs to be a lot more guidance as to I think the best analogy I can think of is if I'm duty doctor, I'm triaging all the patients coming in that day.
I pretty much guarantee that anyone under five and anyone over 80 is definitely going to want, they're going to be needing to be seen. I suppose it feels similar. Surely there's similar ways of doing that within saying, well, actually any children, any young people with deaths, surely they're going to need more, more looking at it. And that disparity, I think we've all spoken about between the family trying to. Let their loved one's voice be heard and to look openly versus what inevitably feels like quite defensive behaviours from the other, other side. And I know there are so many different contexts to inquests, but I think having that level playing field would be really helpful.
I know I'm sure are outcome and kind of level that we got to was partly because our solicitor did say, well, look, actually the other side will be bringing a KC and so she applied for funding for us to have a KC so that it felt an equal footing. There's lots of other thoughts, but that's probably plenty to, to, to go with.
And I know that one of the things that I think would be really helpful, particularly for deaths within mental health settings, is actually to have a separate investigation to provide the evidence, because you're relying on you're relying on the providers to be bringing that. And if we hadn't had our legal representation, even with them pushing to have that, we you're looking at stuff without even having the evidence to go through. So you're not, you're not getting a full picture in, in the first place. I think that disparity between the individual coroners is a really big one.
As soon as our solicitor heard who our coroner was going to be, she she said, I'm going to have to set your expectations right now. It's going to be very hard to get him to look beyond this kind of immediate picture and that that seems madness. You know, I understand that coroners come from all different backgrounds and different experiences, but actually. It feels like there needs to be a lot more guidance as to I think the best analogy I can think of is if I'm duty doctor, I'm triaging all the patients coming in that day.
I pretty much guarantee that anyone under five and anyone over 80 is definitely going to want, they're going to be needing to be seen. I suppose it feels similar. Surely there's similar ways of doing that within saying, well, actually any children, any young people with deaths, surely they're going to need more, more looking at it. And that disparity, I think we've all spoken about between the family trying to. Let their loved one's voice be heard and to look openly versus what inevitably feels like quite defensive behaviours from the other, other side. And I know there are so many different contexts to inquests, but I think having that level playing field would be really helpful.
I know I'm sure are outcome and kind of level that we got to was partly because our solicitor did say, well, look, actually the other side will be bringing a KC and so she applied for funding for us to have a KC so that it felt an equal footing. There's lots of other thoughts, but that's probably plenty to, to, to go with.
15:13
15:13
Tessa Munt
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Tessa Munt
So, Kate, I was going to ask you if you might actually write to the chair with your thoughts, if that's possible, and that would extend to both of you. Johnny, I had one particular question I wanted to ask you, and that was you referred to the fact that you'd had an original date of the 23rd of December. Then you'd shunted it on and asked for avoiding the middle of a future month. But I think you said that you hadn't received the bundle until the night before.
15:13
15:13
15:13
Ashley Fox
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Ashley Fox
The the night before the inquest, I. I had not had the information with regards to witness statements with regards to toxicology reports, with regard. So the coroner's bundle basically that is the whole of the information with what I was going to be expecting at. Inquest did not come to me till 730 on the night before the inquest, and then I'm reading through this, okay, for the first time. And there's evidence that is in that bundle that was brand new to me throughout that whole period from October till the end of January. And that was where the Retraumatization happened, because I was like, oh my God, what has actually happened here?
It was it was mind blowing.
It was it was mind blowing.
15:15
15:15
15:15
Ashley Fox
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Ashley Fox
No it's fine. Would so I've I've recently and this has only recently because I've been engaging much more thoroughly with stakeholders everywhere. So Merseyside Police through work that I'm doing with them, moving on through the public health issue that obviously Gabriel's death represents. And we're trying to do work around, obviously, suicide prevention. And that's basically what the multi-storey car park safety bill will be. You know, the, the, the, the police encouraged me to actually make a complaint. And this was just at the back at the end of 2025. Okay. And then the complaint was split between some things that the police was going to answer and some things that the coroner was going to answer.
And I've had replies back from both Merseyside Police, and it was actually the senior coroner for Merseyside, Andre Rebello, who also sits as the honorary secretary for the Coroners Society and. That's woefully inadequate as well, I'm afraid.
And I've had replies back from both Merseyside Police, and it was actually the senior coroner for Merseyside, Andre Rebello, who also sits as the honorary secretary for the Coroners Society and. That's woefully inadequate as well, I'm afraid.
15:16
15:16
Speaker 2
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Speaker 2
I just want to speak to Kate's point there. You know, although I keep saying I had a terrific coroner, and I did, you know, I helped or tried to support other families who are going through something similar, you know, in that period before the death and the notified about the inquest. And they don't have legal representation. You know, I speak with them, but there's this enormous variability among coroners, the quality of coroners. It is utterly shocking. I actually intervened in one in it was the death of a young girl at a Priory hospital in Cheadle Hulme.
And it was the I think it was the fourth death in about less than a year at the same hospital, and the father couldn't speak English, and he had his brother there who could speak a bit of English. So I. You know, I attended and wrote the Pre-inquest review, even though I was just a member of the public and wrote to the coroner to say, you need to instruct these people that they have to get legal representation because they were going to be walked all over. But the things that coroners say and do not, my experience, the experience of others is shocking.
And there seems to be huge variability between a coroner and a judge. And, you know, you might you will have your own views. But, judges, there is a general consistency about judges, whether in civil cases or criminal cases. But coroners, it's wild out there.
And it was the I think it was the fourth death in about less than a year at the same hospital, and the father couldn't speak English, and he had his brother there who could speak a bit of English. So I. You know, I attended and wrote the Pre-inquest review, even though I was just a member of the public and wrote to the coroner to say, you need to instruct these people that they have to get legal representation because they were going to be walked all over. But the things that coroners say and do not, my experience, the experience of others is shocking.
And there seems to be huge variability between a coroner and a judge. And, you know, you might you will have your own views. But, judges, there is a general consistency about judges, whether in civil cases or criminal cases. But coroners, it's wild out there.
15:17
15:18
Sarah Russell
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Sarah Russell
Primarily to Kate, but it may well be relevant to all three of you. Obviously, there'd been an unlawful killing finding. I wondered if there was then any follow up in terms of potential gross negligence manslaughter, because that feels like the natural step. Had anyone talked to you about that beforehand? Did anyone talk to you about it afterwards?
15:18
Speaker 3
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Speaker 3
In terms of afterwards, we have not had any further correspondence from the Coroners Court at all. I think our expectations of of of. From the police investigation, which had looked at corporate manslaughter, was that it was incredibly hard to prove, without doubt, that kind of hierarchical knowledge going upwards. So even though there was the unlawful killing outcome, I think obviously in a criminal court, it's very different level, level of, of needing to prove prove that. And I know that there is there are some discussions about that unlawful killing verdict in, in the coroners court. I think it's a really important one because I think it you know, we we have we haven't pushed, to be honest to go any further in other investigations.
I think as a family, you know, we've got two younger sisters. Our youngest is now 13. We're somehow both managed to keep working within the NHS. There is only so far your energies can take you. But but in terms of. Yeah, no one else has picked up. I don't know whether other unlawful killing verdicts have then gone on to actually have. We have big, big questions about CQC. We're deeply unhappy with how they have handled things with their investigation, which could have been a prosecution. We were told that there was some kind of loophole because they issued a warning the week before Ruth died to Huntercombe hospital about their observation levels, which is clearly a big factor in Ruth's death.
They were then unable to prosecute, but they haven't released any of their information to us from what they've actually looked at in their report, and we've questioned that through our solicitor, but we've been told we're not allowed to access it.
I think as a family, you know, we've got two younger sisters. Our youngest is now 13. We're somehow both managed to keep working within the NHS. There is only so far your energies can take you. But but in terms of. Yeah, no one else has picked up. I don't know whether other unlawful killing verdicts have then gone on to actually have. We have big, big questions about CQC. We're deeply unhappy with how they have handled things with their investigation, which could have been a prosecution. We were told that there was some kind of loophole because they issued a warning the week before Ruth died to Huntercombe hospital about their observation levels, which is clearly a big factor in Ruth's death.
They were then unable to prosecute, but they haven't released any of their information to us from what they've actually looked at in their report, and we've questioned that through our solicitor, but we've been told we're not allowed to access it.
15:20
15:20
15:20
Speaker 2
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Speaker 2
Can I just add something to this? Kate said about the CQC. The CQC is a terrible regulator. Between Matthew's death and the inquest, I asked them to go in and look at the hospital again and do an inspection and they did, and they found it to be good as they had previously. I said, you've got to be kidding, you know, look what I found after the inquest. I said, okay, you're going to go in there again and you need to actually do another inspection because there's been a PhD. So they kind of couldn't avoid it and they found it inadequate.
Surprise, surprise. So I said, right, this is the evidence I've collected. This is the evidence of the independent investigation report by, you know, one of the leading psychiatrists in the UK. And luckily , I had argued for six weeks with that psychiatrist to get this question in the tour, the terms of reference. And he was did the Priory undertake all reasonable measures to prevent harm to Matthew while he was detained in their care? Because I knew if she said no to that, I'd probably have the grounds for a prosecution under the Health and Social Care Act, and I did, and the Priory was prosecuted and they pleaded guilty and on a corporate charge, and they had to pay a fine of £650,000.
It would have been a million had they not pleaded guilty. And it's the highest fine in their history. But you have to bully these organizations, these public bodies and these regulators to get anything done.
Surprise, surprise. So I said, right, this is the evidence I've collected. This is the evidence of the independent investigation report by, you know, one of the leading psychiatrists in the UK. And luckily , I had argued for six weeks with that psychiatrist to get this question in the tour, the terms of reference. And he was did the Priory undertake all reasonable measures to prevent harm to Matthew while he was detained in their care? Because I knew if she said no to that, I'd probably have the grounds for a prosecution under the Health and Social Care Act, and I did, and the Priory was prosecuted and they pleaded guilty and on a corporate charge, and they had to pay a fine of £650,000.
It would have been a million had they not pleaded guilty. And it's the highest fine in their history. But you have to bully these organizations, these public bodies and these regulators to get anything done.
15:22
Ashley Fox
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Ashley Fox
So can I come in on that as well there, Sarah? So I put that question to Merseyside Police quite early on. The coroner found in Gabriel's case that it was an open verdict. He couldn't really. Well, there wasn't enough evidence, he felt, to be given a verdict of suicide in Gabriel's case, because there has to be this question of intent around what had happened. And, you know, in this country we have an absolutely appalling record of particularly holding corporate bodies to account. And this is exactly why I, I try to have a conversation with Q-park about the fact that my son had died of preventable death, and I was urging them to review all of their internal procedures so that this could never happen again.
And that was the main reason for my first interaction with their managing director, Adam Bidder, via a GDPR request . And his initial response to that GDPR request was that I'll get back to you within the 28 days. That's mandatory. And he did. And then he said, we don't have to talk to you because your son's dead. So this is a grieving father trying to find out all the information that his organisation holds about the preventable death of my son . And at the earliest opportunity, what he wanted to do was shut me down. And he concluded that communication with me by saying, but you may have address through a legal process.
So his first communication, the managing director of a company that has over 250 multi-storey car parks in the UK and Ireland, and as part of a much bigger group, third largest operator in Europe, almost bottomless pockets was was to force me into premature legal action. Luckily, I'd already been in contact with my local MP, Maria Eagle, about what we were going to start to get into, and I'd made sure that her office was copied into all of the communication, and it was only the intervention from her office to pull them up on this that we started a dialogue, which then lasted approximately nine months before they just then completely shut me down again, and then 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 I knew they would be withholding. And it is jaw dropping. It is so damning. Ignoring prevention of future death reports, refusing to do any risk assessments to make their structures safe, which I'm being told it contravenes health and safety legislation. Nobody is holding them to account. I have to do this all of my off my own volition.
And that was the main reason for my first interaction with their managing director, Adam Bidder, via a GDPR request . And his initial response to that GDPR request was that I'll get back to you within the 28 days. That's mandatory. And he did. And then he said, we don't have to talk to you because your son's dead. So this is a grieving father trying to find out all the information that his organisation holds about the preventable death of my son . And at the earliest opportunity, what he wanted to do was shut me down. And he concluded that communication with me by saying, but you may have address through a legal process.
So his first communication, the managing director of a company that has over 250 multi-storey car parks in the UK and Ireland, and as part of a much bigger group, third largest operator in Europe, almost bottomless pockets was was to force me into premature legal action. Luckily, I'd already been in contact with my local MP, Maria Eagle, about what we were going to start to get into, and I'd made sure that her office was copied into all of the communication, and it was only the intervention from her office to pull them up on this that we started a dialogue, which then lasted approximately nine months before they just then completely shut me down again, and then 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 I knew they would be withholding. And it is jaw dropping. It is so damning. Ignoring prevention of future death reports, refusing to do any risk assessments to make their structures safe, which I'm being told it contravenes health and safety legislation. Nobody is holding them to account. I have to do this all of my off my own volition.
15:25
Speaker 1
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Speaker 1
I ask you, there's a live debate at the moment about how you design a new follow up system for inquests. So do do you have a view on which organisation should be responsible for monitoring and . And for following up on the outcomes of inquests? Could I start with Richard and then Johnny and then end with Kate?
15:26
Speaker 2
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Speaker 2
Yeah. My ideal is what inquest is basically asking for. And you know, they talk about it in an oversight body. I would call it like a commissioner for the Prevention of Future deaths. And it doesn't have to be a big organisation, you know, a high profile individual who's not afraid to speak out with a small secretariat, looking at the trends, finding out, going out there, finding out whether these things have actually been followed up with an NHS trust or the police or with prisons, etc. that would be an ideal, but it doesn't need a huge number of people.
We're talking about public inquiry recommendations and we're talking about PhD recommendations. And as I said, there were 650 last year. I can't remember or don't know how many independent public inquiry have been closed. I know there's a debate about an existing body doing this. And, you know, in all honesty, I worked in Whitehall for five years as a senior civil servant. And I know there's been talk about the National Audit Office. Well, you know, the National Audit Office is, you know, it's a public spending watchdog. You know, it's all about value for money. It doesn't quite fit there.
You know, they should just be a separate organisation with the now. But I can understand why there is that sort of debate, because the Nao is something that gives scrutiny to all government departments. You know, if you've ever been with your permanent secretary, the public accounts inquiry, that's the one they fear most. And they always try and best the the head of the Nao. So I'm not sure that that is really the right answer. I think it should be, you know, a commissioner who has powers of embarrassment for these organisations. I'm not saying all PhD recommendations should be enforced because some are actually, I wouldn't say ludicrous, but actually just impossible.
They're just impossible to put in place. They're too expensive. It isn't value for money. And often you might get a coroner actually covering their own backside because they want to placate the family or something else. And I know I may be arguing against myself on that, but it is true that not all PhD recommendations are great ones. However, a Secretariat could actually spot the ones that come up time and again. Just as the Lampard inquiry is looking at all the PhDs in all those 2000 deaths and finding the same things have happened again and again.
We're talking about public inquiry recommendations and we're talking about PhD recommendations. And as I said, there were 650 last year. I can't remember or don't know how many independent public inquiry have been closed. I know there's a debate about an existing body doing this. And, you know, in all honesty, I worked in Whitehall for five years as a senior civil servant. And I know there's been talk about the National Audit Office. Well, you know, the National Audit Office is, you know, it's a public spending watchdog. You know, it's all about value for money. It doesn't quite fit there.
You know, they should just be a separate organisation with the now. But I can understand why there is that sort of debate, because the Nao is something that gives scrutiny to all government departments. You know, if you've ever been with your permanent secretary, the public accounts inquiry, that's the one they fear most. And they always try and best the the head of the Nao. So I'm not sure that that is really the right answer. I think it should be, you know, a commissioner who has powers of embarrassment for these organisations. I'm not saying all PhD recommendations should be enforced because some are actually, I wouldn't say ludicrous, but actually just impossible.
They're just impossible to put in place. They're too expensive. It isn't value for money. And often you might get a coroner actually covering their own backside because they want to placate the family or something else. And I know I may be arguing against myself on that, but it is true that not all PhD recommendations are great ones. However, a Secretariat could actually spot the ones that come up time and again. Just as the Lampard inquiry is looking at all the PhDs in all those 2000 deaths and finding the same things have happened again and again.
15:28
15:28
Ashley Fox
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Ashley Fox
Yeah, it's just really echoing what Richard's already said. But you know what I'm constantly finding out and coming up against is that, you know, it's this question of accountability and also the question around, you know. Being able to ensure that whatever system we put in place. And I think that, you know, we probably will end up hopefully with a new system that there's actually some, some power that they can wield, you know, because particularly with regards to say, you know, corporate responses, because obviously that's, that's, you know, where my lived experience lies. And we saw this after 2008, didn't we?
Unless there is, you know, real fiscal or moral hazard for these organisations involved, they just will not do anything about it. Like literally will not do anything about it. You know, in, in, in our case, you know, the organisation has gone out of its way to make sure it doesn't have to do anything above the absolute statutory minimum. And they haven't even applied to that.
Unless there is, you know, real fiscal or moral hazard for these organisations involved, they just will not do anything about it. Like literally will not do anything about it. You know, in, in, in our case, you know, the organisation has gone out of its way to make sure it doesn't have to do anything above the absolute statutory minimum. And they haven't even applied to that.
15:29
15:29
Speaker 3
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Speaker 3
Very similar thoughts to Johnny and Richard of I agree, I think it needs to be a new and separate body and I, I like the idea of like the children's commissioner or someone. But you're right, they need to have the power to enact those changes and to, to follow up. And I suppose I would envisage them being able to feed down to the appropriate, whether that's health and safety or, and, and to then say, well, actually, have you done that? Or to link into government say, well, okay, actually we do. We need to have some some legal changes here or.
But I think that separate body of that accountability, I suppose actually partly just talking it aloud today of realising that, yes, you know, Ruth, her, her inquest said that she was unlawfully killed, but nothing has come from that. So who, who's accountable who. And for me really it's it's getting those things to change. Actually, 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'm all too aware that top down, often by the time it comes to the shop floor, it doesn't translate terribly well.
But we have to start somewhere. And, and I think having an oversight mechanism for all of this to feed into would be really helpful.
But I think that separate body of that accountability, I suppose actually partly just talking it aloud today of realising that, yes, you know, Ruth, her, her inquest said that she was unlawfully killed, but nothing has come from that. So who, who's accountable who. And for me really it's it's getting those things to change. Actually, 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'm all too aware that top down, often by the time it comes to the shop floor, it doesn't translate terribly well.
But we have to start somewhere. And, and I think having an oversight mechanism for all of this to feed into would be really helpful.
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Speaker 1
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Speaker 1
And obviously, this is the Justice Select Committee, but each department and area has their their own. And we're able to to question and put things to ministers, including the Secretary of State. What would your views be on whether individual select committees would be able to to raise concerns if that thematic work was done, particularly where you've got multiple deaths, what would your view be on select committees taking a role in that?
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Speaker 2
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Speaker 2
I'd say that you need. Sorry, I just jump in. I'd say you need that sort of, as I say, Commission for Prevention of Future deaths, whatever you want to call them. But unless you're actually plugged into the parliamentary system, you know, it's not going to work. It has to be plugged in somewhere, and it needs to be plugged into something like Constitutional Affairs Committee because then, you know, like the Public Service Ombudsman, I think it's Constitutional Affairs Committee that that plugs into. So that can be has an effect all across government rather than a single select committee, because, as you say, recommendations are going to affect the health department or whatever.
So reporting to the Justice committee doesn't feel quite right. It needs to be something that's overall of government.
So reporting to the Justice committee doesn't feel quite right. It needs to be something that's overall of government.
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Janet Daby
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Janet Daby
Thank you. If you had one message that you'd like to get to the government on how to improve how we learn from inquests, what would that question be? So I believe this is the last question. So this is a tricky to get you to think about. You know, how can we improve what we learn from inquests and what is that message to the government. I think we can start with you, Kate.
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Speaker 3
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Speaker 3
I gathering my thoughts there. I've got next to me just to remind me why I'm here, a picture, I don't know, it probably won't show, but of of Ruth. I think we need to hold. At the forefront of all of this is that people have lost very, very special loved ones. And it feels like this vast, big system, but actually I speaking for myself. But I think a lot of families feel very similar is that somehow to survive all of this. You hope that we can learn from that. And, and that's what we have the opportunity to create, to change is to.
Let's bring the minister in. Let's speak to the minister of all these different departments. Let's bring everyone together and let's make this happen. Let's create an oversight mechanism that's actually going to make a difference to all of these deaths.
Let's bring the minister in. Let's speak to the minister of all these different departments. Let's bring everyone together and let's make this happen. Let's create an oversight mechanism that's actually going to make a difference to all of these deaths.
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Ashley Fox
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Ashley Fox
Yeah, I just. There you go. I've got Gabriel and Katie there with me as well. Kate. They never I never go anywhere without them in my bag. Just to remind me again why am I doing this. What's it for. And it's to to honor Gabe's memory and but it's for all the others that have died, these preventable deaths. And, you know, the last six years, the work that I've been doing and the families that I've been involved in through the Hillsborough Law now collective, and now with the families on the steering group for the national oversight Mechanism.
It's that's all we ever want as families is exactly what Kate said for, for us to learn these these lessons from the mistakes that have been made. But they're so glaringly obvious in so many instances. And the complete lack of inertia by
It's that's all we ever want as families is exactly what Kate said for, for us to learn these these lessons from the mistakes that have been made. But they're so glaringly obvious in so many instances. And the complete lack of inertia by
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Speaker 3
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Speaker 3
To do about it? Perfect. A simple message really is end. The cliff edge of prevention of future death. reports just falls off a cliff. You know, appoint a commissioner to follow up, report, spot trends, fix those worst failings. You know, the Chief Coroner's guidance already says 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 he shouldn't have to. Somebody else, you know? But every single bereaved family and all of us, you know, were sick to death of this particularly public sector mantra, you know, of lessons will be learned because they aren't, after all the.
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Tessa Munt
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Tessa Munt
Any immediate reflections on what we've heard? Yeah, I mean, I can I can start. I mean, I find that evidence extremely powerful but also really upsetting. And I feel quite angry about it because 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, very similar accounts of their experiences of the system. And I would say that there is such a culture of harmful actions or omissions by state and private bodies that are leading to avoidable deaths, resulting in inquests. And 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.
And I'll talk about findings in the context of not just prevention of future death reports, but narrative conclusions that inquests can return about systemic failings and, of course, recommendations that result from other kinds of investigations and inquiries. And I would say that you've heard from three individuals who've had the worst thing imaginable happen to them, and yet they are the ones who are having to be the advocates for change. And accountability should be a legal and operational duty of the state, rather than a .
And I'll talk about findings in the context of not just prevention of future death reports, but narrative conclusions that inquests can return about systemic failings and, of course, recommendations that result from other kinds of investigations and inquiries. And I would say that you've heard from three individuals who've had the worst thing imaginable happen to them, and yet they are the ones who are having to be the advocates for change. And accountability should be a legal and operational duty of the state, rather than a .
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Speaker 6
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Speaker 6
Of all inquests. So less than 2% of all inquests get a PhD. So PhDs are not enough. They they will not help us learn from inquests. They'll only help us learn from. 1.7% of all inquests. And that's why with my work, we're calling for a national statutory. database of all inquests so we can identify. trends and. patterns for learning and prevention.
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Tessa Munt
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Tessa Munt
Or of any learnings from from those deaths. I think just following on from that, I mean, one of the problems is that there's no central repository or database where all jury conclusions or records of inquests are actually held. And so some very, very significant narrative conclusions which are often returned in deaths where there's been evidence of systemic failure. And where you heard Kate talk about the jury identifying in her unlawful killing conclusion, identifying a whole series of systemic failures, unless there's a PhD or an organisation like inquest, do a press release where we would put in the findings of that jury.
They're not collated anywhere, which, you know, going back to George's point, you know, it just means that really, really important evidence about systemic failure that could result in proper learning.
They're not collated anywhere, which, you know, going back to George's point, you know, it just means that really, really important evidence about systemic failure that could result in proper learning.
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Tessa Munt
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Tessa Munt
Was there anything further you'd want to add before I bring in Georgia? I mean, if you'd like me to talk about the national oversight oversight mechanism, now, I can. Or if you want to wait until a little bit later. It's it's it's a matter, you know, it's entirely for you. I mean, I think, you know, what you've heard from the families just points to the fact that all the families that inquest work with have had the worst imaginable happen, but all are motivated to try and ensure it doesn't happen to anybody else. And at the moment, we have a broken system.
And I would say that that's that's across both inquests and inquiries where families go through very protracted, distressing processes in the hope that there will be change. And yet we have no mechanism from which we can see what actually happens from a Post-death investigation to a recommendation to implementation, and irrespective of whether or not a recommendation is accepted, there needs to be that oversight and transparency of .
And I would say that that's that's across both inquests and inquiries where families go through very protracted, distressing processes in the hope that there will be change. And yet we have no mechanism from which we can see what actually happens from a Post-death investigation to a recommendation to implementation, and irrespective of whether or not a recommendation is accepted, there needs to be that oversight and transparency of .
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Speaker 6
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Speaker 6
I'm sure you'll absolutely get that opportunity. Georgia. So I think before we can start to follow up, we need the right evidence and the right data. So if we're just it's not good enough to just focus on these PhD reports because we won't include deaths like Ruth and Gabe in, in that data. And without having that full picture, we're really not going to be able to learn across the country. But I think for, 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 that conduct research in environments that aren't swayed by.
independence of. academics that conduct research in environments that aren't swayed by.
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Speaker 6
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Speaker 6
Or different sort of biases that may come in. So as a sort of at an academic institution, we are. independent and we have academic freedom to analyze and present that data in the most sort of evidence based way. So I think there is a place for an. independent where the data sits outside of government and is analysed in a very. objective way, and presents that and presents that data .
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Tony Vaughan
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Tony Vaughan
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Speaker 6
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Speaker 6
We've seen an increase in the number of PhDs being written. It was sitting at about 450. This is increased to about. 550 600. So in the last three years, we've got about. 100 extra PhDs coming through. Whether that's positive or not is up the discretion of the coroner. We track every report that's ever been issued from. 2013 until today, every day. And we also track response rates.
So we were the first platform to ever track responses. We started doing that in 2020. And when we started in.
So we were the first platform to ever track responses. We started doing that in 2020. And when we started in.
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Speaker 6
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Speaker 6
This is now sitting at. 92% of all reports for. 2024 have all responses published, which in the coroner world, as we've been talking about this afternoon, is a huge achievement. But while that is great, we're seeing that improvement in response rates. There have been some recent changes by the Chief Coroner's Office. This which started this May, which I am very concerned about. One of those changes is.
delaying the. publication of PhD. reports purely for.
delaying the. publication of PhD. reports purely for.
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Speaker 6
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Speaker 6
Which I was really looking forward to because we made. recommendations last time , that we need to improve the. consistency of PhD reports and improve basic things like reporting age and date of death. You would think that's a simple thing to report in a PhD, which often doesn't get reported. We have. a thousand PhDs with no age, which is concerning . These new these new templates got published also in May on.
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Speaker 6
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Speaker 6
Easy to see this is on some website or how could I see that correct on the website. And the new template of the PhD is very confusing. It repeats itself and it's structured in a very poor way. So I was really looking forward to these new. reforms that were suggested by the committee to improve the consistency and standard of PhDs, and I think we've really taken a step back despite the. positive increase in, you know, we're getting about 100 more PhDs in the response rates.
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Tessa Munt
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Tessa Munt
Legal powers? Why are the actual substantive changes occurring? I mean, just just to highlight another kind of positive. And that would be that a lot more coroners are now noticing, noting in their prevention of future death reports, other prevention of future death reports that they may have made or colleagues may have made. And I think that's something that we certainly raised when we did some training for coroners a number of years ago. And also, I think I mean, both Georgia and I did did did training for coroners. And I like to think that perhaps coroners understanding of the importance of those PhD reports, particularly to families, has kind of influenced and also, you know, the importance of these reports.
Well, that the importance of these reports to public health and safety, with the caveat, of course, you know, if any notice is, is paid to them. I think just, just to talk about some of the kind of ongoing problems. I mean, and you heard this in the in the evidence from Kate and Richard, and that is around the way in which lawyers representing public bodies and and public and corporate bodies still treat the whole PhD process within inquests and the extremely adversarial way in which lawyers will try and persuade coroners that they shouldn't make a PhD, often by introducing evidence of action that they say has been taken.
And I think what's important to say there? Well, there's two things. One is that there is no way of testing whether or not what organisations say has happened is actually happening on the ground. There's no way of testing that. It's not like a coroner can go and actually look at a particular system, say, within a prison, a suicide prevention, access to within a prison, whether or not that's actually changed. But secondly, absolutely undermines the 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 on a national level.
I think the other problem is the way in which reports are drafted, distributed and published. And quite often when we look at the PhD reports that we see in the context of inquest work, they are quite formulaic. They often look like they just kind of cut and paste. They very often focus on, oh, well, we've reminded staff of a particular policy or and, you know, they often kind of tick box exercise. And there's a report that I was involved in a piece of, of, of research that the independent Advisory panel on Deaths in custody did looking at prevention of future death reports, where we actually kind of delved into this area in quite a lot of detail.
And I think, you know, what didn't surprise me was that when we did the research, it did show that kind of more formulaic approach. But also, I think many coroners themselves are very frustrated with the current system because, you know, 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. And yet 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.
And and, you know, my, I think my frustration from inquest perspective is that, you know, as an organisation that works around deaths in a variety of state institutions, we do see the same issues being repeated time and time again, both within individual settings, individual prisons, mental health settings, or we see the same issues being repeated within.
Well, that the importance of these reports to public health and safety, with the caveat, of course, you know, if any notice is, is paid to them. I think just, just to talk about some of the kind of ongoing problems. I mean, and you heard this in the in the evidence from Kate and Richard, and that is around the way in which lawyers representing public bodies and and public and corporate bodies still treat the whole PhD process within inquests and the extremely adversarial way in which lawyers will try and persuade coroners that they shouldn't make a PhD, often by introducing evidence of action that they say has been taken.
And I think what's important to say there? Well, there's two things. One is that there is no way of testing whether or not what organisations say has happened is actually happening on the ground. There's no way of testing that. It's not like a coroner can go and actually look at a particular system, say, within a prison, a suicide prevention, access to within a prison, whether or not that's actually changed. But secondly, absolutely undermines the 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 on a national level.
I think the other problem is the way in which reports are drafted, distributed and published. And quite often when we look at the PhD reports that we see in the context of inquest work, they are quite formulaic. They often look like they just kind of cut and paste. They very often focus on, oh, well, we've reminded staff of a particular policy or and, you know, they often kind of tick box exercise. And there's a report that I was involved in a piece of, of, of research that the independent Advisory panel on Deaths in custody did looking at prevention of future death reports, where we actually kind of delved into this area in quite a lot of detail.
And I think, you know, what didn't surprise me was that when we did the research, it did show that kind of more formulaic approach. But also, I think many coroners themselves are very frustrated with the current system because, you know, 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. And yet 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.
And and, you know, my, I think my frustration from inquest perspective is that, you know, as an organisation that works around deaths in a variety of state institutions, we do see the same issues being repeated time and time again, both within individual settings, individual prisons, mental health settings, or we see the same issues being repeated within.
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Tessa Munt
Kind of wider. Give us a flavour of these recurring issues in this justice context. In the justice context, I think probably an example of the act process in prisons, which is the process, the suicide prevention process. I think in I'll just check my notes that policy manager has given me for this. At the time of the time of writing this, the Chief Coroner's website website shows over 60 PhDs which refer to the Act process in. In prisons, issues raised include the fact that acts are not always opened, where evidence shows that they should be a lack of accountability when acts are not properly monitored, and particular concerns about monitoring and observation of at risk prisoners and very, very poor quality assurance.
And it's interesting, there's one particular case of a, of of a prisoner in 2024 where the coroner reported that the Act, act care plans were still being overlooked, noting that in a prevention of future death report six years earlier, they'd issued a PhD at the same prison indicating that Act case reviews were not being adhered to. And I think that's I mean, sadly, that's just that's one kind of small example, but it is indicative of and Kate was reflecting on this, you know, in the context of the death of of her daughter in a privately run mental health setting, that the issues that Kate's inquest, sorry, Ruth's inquest flagged up were depressingly familiar to other deaths of children that we, you know, whose cases we'd worked on in mental health settings.
So those kind of patterns of systemic failure. And there's nothing, you know, for us, there's nothing more frustrating to see those same repeated failures. But for a family who 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. So in terms of the the PhD system, it it is it is a broken, I think in in, in my view, excuse me, it's a broken system. And it also, I think it, it, it kind of speaks to the, the lack of accountability of those organisations responsible for the, the care of people in those institutions.
And, you know, I think there's one, you know, it's bad enough when it's bad enough that there's been a death. I mean, that's, that's shocking where somebody is completely dependent on somebody else for their care and, and, and their wellbeing. You would expect that where somebody dies, that the biggest concern of those institutions would be, how can we learn? How can we stop this happening again when what we see within the culture of a lot of inquests is this reputation management, it becomes the primary concern. It's not about learning, it's not about reflecting. It's about how can we resist full, proper scrutiny?
How can we resist a prevention of future death report? How can we risk mitigate the risk of a very critical narrative conclusion? Then the inquest stops. And I think too often what happens is all those organisations concerned just sit back and they breathe a sigh of relief. They think that they issue some trite press release about, as Richard was saying, about, you know, we can write the script, learn, we will learn the lessons, we will ensure that, you know, this is all taken seriously very often. That's the last thing families will ever hear from any of those institutions, which I think is absolutely disgraceful, you know, and then it becomes the families who chase down organisations to try and find out what has actually happened, what have you done.
And the importance of the follow up is to make sure that, you know, you can issue a formulaic response and you can say something you need to go back, you need to go back in six months time. You need to go back in a year's time and find out, has that changed actually improve things on the ground? Because otherwise what happens is what we see .
And it's interesting, there's one particular case of a, of of a prisoner in 2024 where the coroner reported that the Act, act care plans were still being overlooked, noting that in a prevention of future death report six years earlier, they'd issued a PhD at the same prison indicating that Act case reviews were not being adhered to. And I think that's I mean, sadly, that's just that's one kind of small example, but it is indicative of and Kate was reflecting on this, you know, in the context of the death of of her daughter in a privately run mental health setting, that the issues that Kate's inquest, sorry, Ruth's inquest flagged up were depressingly familiar to other deaths of children that we, you know, whose cases we'd worked on in mental health settings.
So those kind of patterns of systemic failure. And there's nothing, you know, for us, there's nothing more frustrating to see those same repeated failures. But for a family who 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. So in terms of the the PhD system, it it is it is a broken, I think in in, in my view, excuse me, it's a broken system. And it also, I think it, it, it kind of speaks to the, the lack of accountability of those organisations responsible for the, the care of people in those institutions.
And, you know, I think there's one, you know, it's bad enough when it's bad enough that there's been a death. I mean, that's, that's shocking where somebody is completely dependent on somebody else for their care and, and, and their wellbeing. You would expect that where somebody dies, that the biggest concern of those institutions would be, how can we learn? How can we stop this happening again when what we see within the culture of a lot of inquests is this reputation management, it becomes the primary concern. It's not about learning, it's not about reflecting. It's about how can we resist full, proper scrutiny?
How can we resist a prevention of future death report? How can we risk mitigate the risk of a very critical narrative conclusion? Then the inquest stops. And I think too often what happens is all those organisations concerned just sit back and they breathe a sigh of relief. They think that they issue some trite press release about, as Richard was saying, about, you know, we can write the script, learn, we will learn the lessons, we will ensure that, you know, this is all taken seriously very often. That's the last thing families will ever hear from any of those institutions, which I think is absolutely disgraceful, you know, and then it becomes the families who chase down organisations to try and find out what has actually happened, what have you done.
And the importance of the follow up is to make sure that, you know, you can issue a formulaic response and you can say something you need to go back, you need to go back in six months time. You need to go back in a year's time and find out, has that changed actually improve things on the ground? Because otherwise what happens is what we see .
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Tessa Munt
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Tessa Munt
PhD reports have actually brought around positive change. I can give you. I think we have to work hard on this one, because I think the nature, the nature of the system makes it actually quite difficult to find out what positive change has been, because we don't always find out about it. Hence the fact that a, you know, a good oversight mechanism could actually celebrate good practice as well as identify, you know, changes that are needed. We have an example of our law, which followed a P of D, which noted a host of gaps in the policy framework to address damp and mould in social housing.
And that led to joint agency guidance on the issue and led to Arabs law, which provides a time limit by which, you know, social housing or landlords need to get the issue sorted. Another example, which is both positive and also I think, shows some of the inherent systemic problems with the current system is around Shaina's law, which is the use of force in mental health units, which was which followed the restraint death of a black man, Shanee Lewis, by police in a mental health setting. And it it was one of a pattern of similar deaths following restraint, resulting in prevention of future death reports and the pre.
The predecessor to those rule 43. And it saw some. Those deaths were very high profile and had a lot of parliamentary interest and resulted in some concentrated action by policing and mental health organisations and driven by Shani's family. Working with inquest and their MP, Steve Reed, saw the legislation use of force in mental health units being enacted. Now that was very positive, but there were a number of elements within the use of force bill that weren't enacted, and this is going back to 2018, and since then it's been left to the family with, you know, with the help of of ourselves to try and drive the full implementation of that bill.
So it's an example, I think, of something that can be very positive, and you can see some kind of positive initiative, initiatives that follow deaths that have received, you know, a degree of kind of public and parliamentary interest. But then it's left once again to the family to try and ensure that that change is actually followed through. So .
And that led to joint agency guidance on the issue and led to Arabs law, which provides a time limit by which, you know, social housing or landlords need to get the issue sorted. Another example, which is both positive and also I think, shows some of the inherent systemic problems with the current system is around Shaina's law, which is the use of force in mental health units, which was which followed the restraint death of a black man, Shanee Lewis, by police in a mental health setting. And it it was one of a pattern of similar deaths following restraint, resulting in prevention of future death reports and the pre.
The predecessor to those rule 43. And it saw some. Those deaths were very high profile and had a lot of parliamentary interest and resulted in some concentrated action by policing and mental health organisations and driven by Shani's family. Working with inquest and their MP, Steve Reed, saw the legislation use of force in mental health units being enacted. Now that was very positive, but there were a number of elements within the use of force bill that weren't enacted, and this is going back to 2018, and since then it's been left to the family with, you know, with the help of of ourselves to try and drive the full implementation of that bill.
So it's an example, I think, of something that can be very positive, and you can see some kind of positive initiative, initiatives that follow deaths that have received, you know, a degree of kind of public and parliamentary interest. But then it's left once again to the family to try and ensure that that change is actually followed through. So .
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Speaker 6
Kind of two examples. Richard. Yes. So there are, of course, several high profile cases that have led to change. And the three I'll touch on very. briefly is the death of Martha Mills, which has led to Martha's rule, which has been rolled out across the NHS and now more recently for maternity care, which has had is NHS claims it's saved 500 lives. So that was the result of a PhD.
But it wasn't just the PhD, it was the tireless campaigning of Martha's mum and she's a journalist.
But it wasn't just the PhD, it was the tireless campaigning of Martha's mum and she's a journalist.
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Speaker 6
And the other factors that Richard and and Johnny were talking about to really drive forward that campaign. Another one is the death of headteacher Ruth Perry, which led to. changes in Ofsted. recording of school inspections. But at the same time that that PhD came out, there was a select committee. inquiry also ongoing. There was a change in leadership, there was a lot of. journalism and media reporting. And so it's never just the PhD. It's always a combination of other factors. And the final example is I've worked closely with the Natasha Allergy Research Foundation, now the Natasha.
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Speaker 6
But that was the tireless campaigning of her family. And more recently, Benedict's Law, which is now. implementing allergy training in schools. But all of this is driven by families. And so we've really created this two tiered. system that's driven off class and campaigns. And so that's really the backbone of how we learn from inquest at the moment. It is means we have. inequalities in the system. And it means the deaths of those that matter most are really not being counted. And so the final thing to to say to this is, I think the government needs to take a look at itself and answer the question of how do we learn from deaths, where inquests play a small but important role in that.
But there are many statutory bodies that have been set up, their silos across every government department and public bodies, and they're all doing their own things. And so the justice committee is in a unique perspective to bring together all those statutory mechanisms from road, rail. marine child death reviews, domestic homicide reviews, the list of statutory mechanisms that exist really need to come together. And .
But there are many statutory bodies that have been set up, their silos across every government department and public bodies, and they're all doing their own things. And so the justice committee is in a unique perspective to bring together all those statutory mechanisms from road, rail. marine child death reviews, domestic homicide reviews, the list of statutory mechanisms that exist really need to come together. And .
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Neil Shastri-Hurst
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Neil Shastri-Hurst
Have this. inequalities where it's driven by class and campaigns. You've both sort of set out how PhDs can be a force for good if applied properly, often as part of the solution, opposed to the solution in and of itself. Working alongside. campaigns that run. alongside it. I just wonder whether you have a view of how, how generally possible it is to determine whether a PhD has an .
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Tessa Munt
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Tessa Munt
Tracker, but it's a very much so knee jerk reaction response. The the only thing I'd add to that really is that sadly we do it, but it's in the context of when a death happens in maybe in the same institution, revealing the same kind of issues, which shows that the learning from previous deaths have, have, have not been enacted. I mean, there's an example of just bearing in mind the justice committee interest in prisons. There have been a number of of repeated deaths in in individual prisons, Woodhill prison being a good example, where there have been a succession of critical inquest outcomes and the same issues keep being repeated.
And recently the Nottingham Nottinghamshire coroner, following a number of deaths in Loudon Grange Prison, has written to Nottingham Nottinghamshire Police asking them to investigate a pattern of deaths at Loudon Grange because of the repeated and and similar failings that have been identified in in those cases. So I would say, in the absence of any proper mechanism to actually do that deep dive and see what action has been taken, it's often you only .
And recently the Nottingham Nottinghamshire coroner, following a number of deaths in Loudon Grange Prison, has written to Nottingham Nottinghamshire Police asking them to investigate a pattern of deaths at Loudon Grange because of the repeated and and similar failings that have been identified in in those cases. So I would say, in the absence of any proper mechanism to actually do that deep dive and see what action has been taken, it's often you only .
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Speaker 6
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Speaker 6
Approach or a more consistent approach is taken to them? Yeah. So I just gave the news of the new template that obviously hasn't worked to improve the consistency. I think there needs to be a. digitalisation of the inquest of the PhD system. So the Chancellor announced last weekend about 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 PhDs. So that is certainly one area. The other the other area is really around the guidance and training, which has been improved.
But overall I think I think we can't. There is an element of it's at the discretion of the coroner. So we have geographical variation in them getting issued across the country. I don't think we can require we can't require a coroner to write a PhD, but we can improve the. digitalisation of how they actually write those and where the data goes and how that data flows, because at the moment it's an email, it's all driven off an individual coroner area, emailing that to an organisation. They email that back that then gets emailed to the chief coroner system and gets manually published as a PDF document on a website.
So that is the fact that we are relying on that PDF email to save a life is a real national scandal in terms of .
But overall I think I think we can't. There is an element of it's at the discretion of the coroner. So we have geographical variation in them getting issued across the country. I don't think we can require we can't require a coroner to write a PhD, but we can improve the. digitalisation of how they actually write those and where the data goes and how that data flows, because at the moment it's an email, it's all driven off an individual coroner area, emailing that to an organisation. They email that back that then gets emailed to the chief coroner system and gets manually published as a PDF document on a website.
So that is the fact that we are relying on that PDF email to save a life is a real national scandal in terms of .
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Tessa Munt
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Tessa Munt
Respond to them. And I just wonder whether, Miss Coles, you've got anything to comment on that aspect of it. I mean, I think there's also a question of to whom these reports are disseminated, because I think what we found is quite often you'll look at a PhD and your question why it hasn't been more broadly circulated to those whose attention should be brought to, you know, some very serious kind of, you know, systemic failings. I think that George's point I mean, the coroner's system is is ill resourced. And that is a that is, I think, something that's impacting on families experiences of the inquest system from start to finish.
But just in terms of your point about the quality and consistency of PhD reports, I think it's also about coroners recognising that, you know, you should make a report irrespective of whether or not you think that an organisation has addressed something at the local level. I feel very strongly about the fact that, you know, these reports should be viewed as a really important opportunity for learning when something has gone catastrophically wrong, and those reports should be made, irrespective.
But just in terms of your point about the quality and consistency of PhD reports, I think it's also about coroners recognising that, you know, you should make a report irrespective of whether or not you think that an organisation has addressed something at the local level. I feel very strongly about the fact that, you know, these reports should be viewed as a really important opportunity for learning when something has gone catastrophically wrong, and those reports should be made, irrespective.
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Neil Shastri-Hurst
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Neil Shastri-Hurst
Of any. organisation arguing otherwise and just picking up on that. You've identified the importance of shared learning, and I think most of us who have worked in any sort of large. organisation recognised the importance of that. I can almost predict the answer, but how well do you think, particularly in, say, the health care setting, for.
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Speaker 6
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Speaker 6
Through PhDs. I mean, I know for a fact that Department of Health and Social Care and NHS England do not get all their individual PhDs that go to NHS trusts. So there is no national learning. Is the. Is the short answer. I could delve into that a lot because I've sat for many meetings with CQC, Seb, NHS trusts, NHS England, Department of Health and Social Care to try and bring these.
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Tessa Munt
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Tessa Munt
Analyzing all PhDs relating to the health and social care system. I mean, I would I would just say I think it's pretty scandalous how bad the system within different organisations is. I mean, this is not something that we're just talking about today. This is something that you've already referred to the previous justice committee inquiry into this, but this is something that we've been talking about for decades now in various bits of government, in various select committees. It's not something that government aren't alive to. And so I, I, I kind of think that, you know, for every family that you hear from, there are hundreds of families for whom they've had the worst experience possible.
And yet we cannot say with confidence that those organisations are going to respond in a not only in a humane way to families and, and tell families what they intend to do to try and make sure this doesn't happen again. But that kind of coordinated learning and cross-sector learning, which is so important, you know, to public health and .
And yet we cannot say with confidence that those organisations are going to respond in a not only in a humane way to families and, and tell families what they intend to do to try and make sure this doesn't happen again. But that kind of coordinated learning and cross-sector learning, which is so important, you know, to public health and .
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Speaker 6
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Speaker 6
The timeliness. So I mentioned earlier some of the stats. It was less than a third. Now we're more than two thirds of reports have. responses in terms of timeliness. We look at also from the date of death to the date of PhD report. And this is a new dashboard we've just published on the tracker to show if we need to learn from deaths, we need to have near real time. reporting of of this and near real time responses. So that's exactly what the tracker is there to do to analyse that information in real time as it comes through.
So we have seen an increase in response rates, which is positive. But the big challenge we have is any. organisation can request an. extension for responses. And now, with the new guidance from the chief coroner that won't publish PhDs until all responses are received, it could be years and years before we get to look at PhDs that are getting written today, because the Department of Health and Social Care is one of the worst.
So we have seen an increase in response rates, which is positive. But the big challenge we have is any. organisation can request an. extension for responses. And now, with the new guidance from the chief coroner that won't publish PhDs until all responses are received, it could be years and years before we get to look at PhDs that are getting written today, because the Department of Health and Social Care is one of the worst.
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Speaker 6
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Speaker 6
And they will just request for an. extension and they could get a six month extension, a 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 are often asking the coroner, how do you have a response from my PhD? So this timeliness of both issuing PhDs, because we need to save lives now, not wait five years. And the timeliness of reporting and taking action is really crucial to having any type of system where we can learn from inquest. So it's a huge challenge .
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Warinder Juss
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Warinder Juss
Real problem. So we heard that in Ruth's case, Kate's daughter, there was a finding of unlawful killing, but no PhD PhD report was issued. And we've heard earlier from Doctor Giorgio Richards that in less than. 2% of cases is a PhD prepared. So how is it. determined whether or not a PhD should be produced? Are there any clear guidelines for the coroner to indicate to the coroner that .
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Speaker 6
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Speaker 6
Where a brother, someone who lost their brother in prison from an anaphylactic reaction. He took a the coroner. He did a judicial review of the decision not to issue a PhD. This decision was handed down by the court to say that it was lawful for the coroner to not issue a PhD. So we now have case law, which means a coroner. It's at the discretion of the coroner. There is nothing. There's no. threshold that a case must reach, whether it be a civil or a. criminal case, it doesn't reach any sort of threshold for when a PhD will or won't, won't be issued.
And so there is just huge geographical variation. I have some coroners that have never issued a PhD, and there's coroners that have issued hundreds of PhDs. So it's there is no there is no yeah. Way that we can enforce a PhD or whether we can't even take. Now, we wouldn't take judicial review on a decision not to issue a PhD, because we have case law that .
And so there is just huge geographical variation. I have some coroners that have never issued a PhD, and there's coroners that have issued hundreds of PhDs. So it's there is no there is no yeah. Way that we can enforce a PhD or whether we can't even take. Now, we wouldn't take judicial review on a decision not to issue a PhD, because we have case law that .
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Tessa Munt
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Tessa Munt
So I am so shocked by what you've just said in the last five minutes. I'm dear, oh dear. Can I take you back, if I may, to. Sir Johnny said something about the bundle arriving so late, which places somebody at an even greater disadvantage. Does that happen only to litigants in person, if I can use that phrase? Or does that happen in the case of people who are represented as well? And how common is it, do you know? Yeah. I mean, from our experience, late disclosure is, is an ongoing issue whether or not you're represented or, or not.
I mean, I think what's so shocking about about Johnny's evidence is the fact that it's quite clear that he wasn't given any information about his his legal rights, that the process I mean, I think the inhumanity of the process is he articulated so well. But to give somebody disclosure the night before the inquest into their child, I mean, that is just so cruel and it just simply shouldn't happen. I would say that legal representation for a family from the outset can make a real difference, because obviously you then have lawyers who understand the inquest process, who can make the necessary requests to the coroner for disclosure, and hopefully get disclosure in a timely way in advance of the inquest.
And I think it's important just to say how legal representation can impact on 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. At the moment, it's just worth mentioning that Hillsborough law is making its way through the parliamentary process, and one issue that we are waiting for government to make a decision on is the point at which funding for families representation is made, what we're calling the trigger point, and and the kind of point I'd 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're doing, not only means that they can get on with the kind of post-death cultural, you know, practices and, you know, grieve and look after other family members, etc., knowing that their interests are being represented by a lawyer.
But it also means that they can impact on the potential scrutiny afforded to their loved ones death, because they can make representations to the coroner about the kind of evidence that they should hear, they can impact into any pre-inquest investigation, so that that investigation does examine evidence as far as possible and can help minimize the experience that Johnny had, which is that they will get disclosure in advance. So they have some degree of preparation for what is going to come up at at the subsequent inquest. And of course, the other thing I would say is that, you know, that can impact on on the scope, but it can also mean that a family lawyer can stand up to some of the kind of quite aggressive, adversarial conduct that we see by state and corporate lawyers.
In the context of what I mentioned earlier on, which is about arguing against a particular jury conclusion, arguing against the making of a PhD report, because state and corporate lawyers are very, very good at knowing how to argue against the making of a PhD. When I did coroners training, I highlighted some of the firms how they would advertise their services online, and it would, you know, effectively be if you want to try and avoid a PhD, come to us. And I mean, I, you know, that is that that that is real. And I'm not talking about all lawyers.
I mean, you know, I should make that clear. But in some of the some of the most contentious cases, there has been really appalling conduct by those lawyers. And it'll be very interesting to see whether or not Hillsborough law and a duty of candour and more openness and transparency will change the culture within inquests, because one would hope that if we try and move away from this defensive culture and this kind of concern with reputation management, that we could have a cultural change and see inquests as that really vital opportunity for learning and prevention, which is .
I mean, I think what's so shocking about about Johnny's evidence is the fact that it's quite clear that he wasn't given any information about his his legal rights, that the process I mean, I think the inhumanity of the process is he articulated so well. But to give somebody disclosure the night before the inquest into their child, I mean, that is just so cruel and it just simply shouldn't happen. I would say that legal representation for a family from the outset can make a real difference, because obviously you then have lawyers who understand the inquest process, who can make the necessary requests to the coroner for disclosure, and hopefully get disclosure in a timely way in advance of the inquest.
And I think it's important just to say how legal representation can impact on 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. At the moment, it's just worth mentioning that Hillsborough law is making its way through the parliamentary process, and one issue that we are waiting for government to make a decision on is the point at which funding for families representation is made, what we're calling the trigger point, and and the kind of point I'd 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're doing, not only means that they can get on with the kind of post-death cultural, you know, practices and, you know, grieve and look after other family members, etc., knowing that their interests are being represented by a lawyer.
But it also means that they can impact on the potential scrutiny afforded to their loved ones death, because they can make representations to the coroner about the kind of evidence that they should hear, they can impact into any pre-inquest investigation, so that that investigation does examine evidence as far as possible and can help minimize the experience that Johnny had, which is that they will get disclosure in advance. So they have some degree of preparation for what is going to come up at at the subsequent inquest. And of course, the other thing I would say is that, you know, that can impact on on the scope, but it can also mean that a family lawyer can stand up to some of the kind of quite aggressive, adversarial conduct that we see by state and corporate lawyers.
In the context of what I mentioned earlier on, which is about arguing against a particular jury conclusion, arguing against the making of a PhD report, because state and corporate lawyers are very, very good at knowing how to argue against the making of a PhD. When I did coroners training, I highlighted some of the firms how they would advertise their services online, and it would, you know, effectively be if you want to try and avoid a PhD, come to us. And I mean, I, you know, that is that that that is real. And I'm not talking about all lawyers.
I mean, you know, I should make that clear. But in some of the some of the most contentious cases, there has been really appalling conduct by those lawyers. And it'll be very interesting to see whether or not Hillsborough law and a duty of candour and more openness and transparency will change the culture within inquests, because one would hope that if we try and move away from this defensive culture and this kind of concern with reputation management, that we could have a cultural change and see inquests as that really vital opportunity for learning and prevention, which is .
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Speaker 6
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Speaker 6
Thank you. Did you want to add anything? The only thing to add is around with Hillsborough coming through. If we had a national database of all inquests, we could actually monitor the impact of Hillsborough. We have no national database to monitor legal representation. Who gets it, who doesn't get it? Decisions on PhDs and also what will happen with Hillsborough. And if we see an increase in or a decrease in PhDs, a national.
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Speaker 4
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Speaker 4
I make the sorry, did you want to. I was just in relation to trying to get. representation in as early as possible. Obviously the Hillsborough law will apply in cases and inquests where a public body is an interested person. Is there anything further that you think needs to be done so that the decision as .
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Tessa Munt
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Tessa Munt
To who are the interested persons happen at an early stage? Yeah, I mean, I think I, I think that the, the , what there needs to be, and I can follow up this answer with, with our latest briefing on this. It's about the point at which an interested party is designated by the coroner, and we can't afford to wait for that, because obviously it can be some time before there's a Pre-inquest review. It may not be. It may not be evident straight away as to whether somebody is an interested person. But in a lot of the cases that we're involved in, it will be very evident if somebody, you know, if you're talking about a death in a in a state institution, by way of example, or if you're talking about, you know, a death involving a corporate body, where the expectation will be that the state or corporate body will be represented.
But irrespective of whether or not the state or corporate body is represented, the family should have access to, to, to funding at the earliest opportunity. And that's what we're currently.
But irrespective of whether or not the state or corporate body is represented, the family should have access to, to, to funding at the earliest opportunity. And that's what we're currently.
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Tessa Munt
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Tessa Munt
Body or a private body involved in a preventable death. Can I just interject on your interjection? Is that all right? So I, I sat on the bill committee for the bill and pushed really hard for contractors and subcontractors and subcontractors and subcontractors. So where you have, for example, a council or an hospital that's using perhaps they've contracted their services out to a car park company. They might be covered, they might not. But I think there's a, there's an element of that that probably needs to be drilled down because there is private provision contracted from public services.
And my view .
And my view .
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Speaker 6
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Speaker 6
Be included. But I think there's a bit of pushback on that. But to give context around data, in terms of what we know from the statistics that get published, because there is no national database. We know last year there was. 360 deaths in prison and about six in including those, there was about. 600 odd deaths in state custody. So that only represents. 1 to 2% of all deaths in state custody of all inquests.
So that is a very small
So that is a very small
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Speaker 1
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Speaker 1
Of data on the other public service related deaths because we don't have a national database. So it's it's not possible to give what the statistics look like, but it likely could create this third tier system where those that are solely managed by the state, as in deaths in prison, in a state prison would obviously get legal aid, but there'll be majority of inquests where families won't have legal aid like Johnny's family. So the data isn't there yet.
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Janet Daby
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Janet Daby
So I think I would ask if if we could move on to Janet's questions. Thank you. I'll try and put the two questions together because of time as well. So obviously inquest is to Deborah. First, Deborah's inquest is calling for a national oversight mechanism to follow up on. recommendations made by. inquiries and inquests. Could you just tell us what that is and how it would work? And then the second part of the question, which is probably for yourself, for both of you, really, but and if you can outline how the.
national oversight mechanism .
national oversight mechanism .
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Tessa Munt
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Tessa Munt
Would work in conjunction with data, really? Yeah. I mean, I'll be as quick as I can and then follow it. We can follow it up with with more information. I mean, I think the, the, the proposal for a national oversight mechanism has come out of our frustration with the current system. And after lots of consultation with families, with lawyers and with academics, and effectively it bridges the gap between recommendations being issued after post-death investigations and meaningful, potentially life changing recommendations and change actually happening. So that's the kind of first thing and what it what we're proposing is that it would be a new independent public body which would collate, analyse and, crucially, follow up on recommendations made following investigations into state related deaths.
So that would include inquests, statutory and non-statutory inquiries, reviews and investigations. And as I say, it would have the three main functions collating. And we can we can follow that up. And George's tracker is a good example about what what is actually possible in the context of, of PhDs. The second point would be the analysis. And I think this is particularly important. It would be able to analyse the kind of themes and patterns and issues coming out of the recommendations that are made following all these processes. But crucially, the third power would be to to follow up, and a mechanism would need those clear powers to, to follow up and report on action or inaction.
And that would be done through the ability to gain access to information and, importantly, work with other regulatory or or, for example, prosecution bodies. It would be independent of government. We think that's really, really important because, you know, inquests and inquiries involve kind of deep scrutiny into all arms of the state. So that function on an operational independence of an oversight body is, is critical to public confidence and its ability to function it effectively. The other thing that's really important, and a kind of key principle, is that the views of bereaved people, victims and affected communities should be built into the kind of governance and operation of of a nom.
And we've kind of suggested previously that this should be done through potentially an advisory board made up of those groups. And the reasons for saying that is because what you've heard thus far is how families are very often the drivers to try and affect change, and they never hear from anybody about what's actually happened. So, so that's really crucial. The the accountability to Parliament is important. And I would say as well, that also speaks to a question that the chair mentioned earlier about the role of select committees, because we would see the norm as having a very significant research function, you know, the analysis and research function.
And given it would cover quite a lot of different areas, it could produce thematic reports, you know, specialist reports on different areas. So , for example, the high number of prison deaths, it could it could analyse, do the follow up report to yourselves as a select committee in the same way as the housing committee looked at Grenfell and the fact that, you know, what preceded Grenfell was the Lakanal House fire and an inquest, and we saw the kind of contempt with which that report was treated. And then it would importantly, have a key kind of transparency role, which is to bring this information into, into the into the kind of public domain.
And that's really important because clearly, one of the issues is about, you know, the lack of transparency and accountability of those responsible for, for, for change. And I think, I mean, finally, I, I just say that, you know, I think one of the frustrations that we have is that we've been talking about these issues for many, many years now, and a lot of energy seems to be at the moment being kind of expended on who could carry out this role, which who could we give this job to? And 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, very powerful body to try and drive change.
And that, of course, cuts across so many important areas of public health and safety. So having kind of reflected at length about what would be possible, we have come to the conclusion .
So that would include inquests, statutory and non-statutory inquiries, reviews and investigations. And as I say, it would have the three main functions collating. And we can we can follow that up. And George's tracker is a good example about what what is actually possible in the context of, of PhDs. The second point would be the analysis. And I think this is particularly important. It would be able to analyse the kind of themes and patterns and issues coming out of the recommendations that are made following all these processes. But crucially, the third power would be to to follow up, and a mechanism would need those clear powers to, to follow up and report on action or inaction.
And that would be done through the ability to gain access to information and, importantly, work with other regulatory or or, for example, prosecution bodies. It would be independent of government. We think that's really, really important because, you know, inquests and inquiries involve kind of deep scrutiny into all arms of the state. So that function on an operational independence of an oversight body is, is critical to public confidence and its ability to function it effectively. The other thing that's really important, and a kind of key principle, is that the views of bereaved people, victims and affected communities should be built into the kind of governance and operation of of a nom.
And we've kind of suggested previously that this should be done through potentially an advisory board made up of those groups. And the reasons for saying that is because what you've heard thus far is how families are very often the drivers to try and affect change, and they never hear from anybody about what's actually happened. So, so that's really crucial. The the accountability to Parliament is important. And I would say as well, that also speaks to a question that the chair mentioned earlier about the role of select committees, because we would see the norm as having a very significant research function, you know, the analysis and research function.
And given it would cover quite a lot of different areas, it could produce thematic reports, you know, specialist reports on different areas. So , for example, the high number of prison deaths, it could it could analyse, do the follow up report to yourselves as a select committee in the same way as the housing committee looked at Grenfell and the fact that, you know, what preceded Grenfell was the Lakanal House fire and an inquest, and we saw the kind of contempt with which that report was treated. And then it would importantly, have a key kind of transparency role, which is to bring this information into, into the into the kind of public domain.
And that's really important because clearly, one of the issues is about, you know, the lack of transparency and accountability of those responsible for, for, for change. And I think, I mean, finally, I, I just say that, you know, I think one of the frustrations that we have is that we've been talking about these issues for many, many years now, and a lot of energy seems to be at the moment being kind of expended on who could carry out this role, which who could we give this job to? And 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, very powerful body to try and drive change.
And that, of course, cuts across so many important areas of public health and safety. So having kind of reflected at length about what would be possible, we have come to the conclusion .
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Tessa Munt
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Tessa Munt
Been working on this in terms of a new body and this type of strategy? I mean, we've been working as an organisation. We're over. We were set up in 1981. I would say that the work around the national oversight mechanism and the current iteration has probably been for for a few years now, and we've met with various governments around this. We've given evidence to all sorts of different committees. I think there is a lot of debate within government at the moment about what should happen. And obviously, the Pacac committee are hearing evidence at the moment in terms of particularly with the focus on inquiry recommendations.
But I think in our view, you know, the importance of these issues and how often they are they are interlinked. And Richard already talked about the Lampard inquiry. Now, that inquiry was set up because of the repeated nature of deaths involving Essex mental health services. And it had to be a statutory inquiry because there was a lack of cooperation of senior management with the initial review that was set up and it kind of in a way, for me it speaks to the the difficulties that we have identified in following up where what change has actually happened.
And just finally, I mean, I would just add that, you know, the the reason why we think it's so important is Johnny spoke to the fact that he subsequently found out through the benefit of, of, of George's work as well about other deaths that have occurred. And one of the things we think a nom could do is almost have that kind of alert system. So where you see these patterns, you can spot recurring dangers across different institutions and you can escalate those concerns. And it could be a vital, vital resource for parliamentarians, for coroners, for inquiry chairs, for academics.
I think, you know, that we can't wait any longer. Every time, you know, every year we have these conversations and we see avoidable deaths occurring, you know, and at great cost. Not, of course, the human cost and the trauma of these avoidable deaths, but also the cost to the public purse because death investigations are expensive, public inquiries are expensive. And why are we putting families and victims through these processes, only then to ignore the learning that can potentially.
But I think in our view, you know, the importance of these issues and how often they are they are interlinked. And Richard already talked about the Lampard inquiry. Now, that inquiry was set up because of the repeated nature of deaths involving Essex mental health services. And it had to be a statutory inquiry because there was a lack of cooperation of senior management with the initial review that was set up and it kind of in a way, for me it speaks to the the difficulties that we have identified in following up where what change has actually happened.
And just finally, I mean, I would just add that, you know, the the reason why we think it's so important is Johnny spoke to the fact that he subsequently found out through the benefit of, of, of George's work as well about other deaths that have occurred. And one of the things we think a nom could do is almost have that kind of alert system. So where you see these patterns, you can spot recurring dangers across different institutions and you can escalate those concerns. And it could be a vital, vital resource for parliamentarians, for coroners, for inquiry chairs, for academics.
I think, you know, that we can't wait any longer. Every time, you know, every year we have these conversations and we see avoidable deaths occurring, you know, and at great cost. Not, of course, the human cost and the trauma of these avoidable deaths, but also the cost to the public purse because death investigations are expensive, public inquiries are expensive. And why are we putting families and victims through these processes, only then to ignore the learning that can potentially.
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Speaker 1
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Speaker 1
Conjunction with a coronial database? Absolutely. So I would say that there can't be a mechanism without the national database, without knowing what deaths are occurring across the country. So I would see I would sort of. encourage that the the first two parts of the mechanism, which is to collect and analyze reports that should be independent from government and at an institute that has academic freedom to analyze that data in in a in a transparent way at the the Preventable Deaths Tracker already collects and analyze all PhD reports. We have lots of different types of dashboards that issue live alerts when new deaths do occur.
So we've already built the infrastructure to do that component. So we analyze every PhD that comes through. And we've produced the live alerting system for for multi-storey car parks for Johnny. So that's that infrastructure already exists and has been built, but PhDs are not enough. And so if there is a mechanism that just focuses on public. inquiries and PhDs, it's going to be a really biased system.
So it needs to look at all inquests. And the final bit is we produce live. dashboards that update in real time.
So we've already built the infrastructure to do that component. So we analyze every PhD that comes through. And we've produced the live alerting system for for multi-storey car parks for Johnny. So that's that infrastructure already exists and has been built, but PhDs are not enough. And so if there is a mechanism that just focuses on public. inquiries and PhDs, it's going to be a really biased system.
So it needs to look at all inquests. And the final bit is we produce live. dashboards that update in real time.
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Speaker 1
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Speaker 1
Often sit in. someone's shelf and gather dust. And so it's. 2026 and we have lots of digital infrastructure where we can build these live systems. So I would urge against, against an annual report and focus on a digital live reporting system like we've already built at the Preventable Deaths Tracker. The final thing to say, I know we've run out of time, but this already exists for the for children in England. So there is the National Child Mortality.
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Speaker 1
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Speaker 1
Which collects all deaths in children in England. And it already exists in many Commonwealth countries that have adopted the coroner service. So I'm from Australia originally it exists in Australia, New Zealand, Canada, the US. So this is not an innovative thing that we are explaining. A national coroner system database. exists in other countries that have coroner systems. So it's not new. Australia started in the year.
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Speaker 1
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Speaker 1
The minister, I then met with the minister straight after that meeting, which was Mike freer at the time. He was the minister. Now, what is now the minister for victims, and he just said, we will not fund this, put a paywall in. And so that's exactly what happened. At the conclusion when I got home that evening, and I still have had no funding from anyone to for the digital infrastructure, my team is now funded by a philanthropist. So I have a philanthropist who funds two team members, and we have two more joining in, in, in time.
But I still self-fund the digital infrastructure behind the tracker. It's very difficult to get. funding for building digital infrastructure in a research environment because it's research.
But I still self-fund the digital infrastructure behind the tracker. It's very difficult to get. funding for building digital infrastructure in a research environment because it's research.
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Speaker 1
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Speaker 1
And that was the triggering triggering inquiry that said made the recommendation to government that we need a national database to ensure we're counting the lives that we're that we're losing for our First Nations people. So that happened in in the late, the late 80s, early 90s. And there was several, you know, feasibility studies that went on in the 90s that brought that in 20 in the year. 2000 in Canada, it was driven by the opioid crisis, which is what my PhD was on. So I was looking at how we could prevent deaths from opioid. overdoses and the increased.
prescribing in that we were seeing in long term pain medications. And the government went to coroner's office in Canada and said, how many people are dying from opioids? And they couldn't answer that because they didn't have a national coronial database. Now that exists. That came into effect in.
prescribing in that we were seeing in long term pain medications. And the government went to coroner's office in Canada and said, how many people are dying from opioids? And they couldn't answer that because they didn't have a national coronial database. Now that exists. That came into effect in.
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Sarah Russell
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Sarah Russell
Because if I'm not here, there is no preventable death tracker. And just if there were a couple of things that you can see because you've just described other countries where they're very there was a very clear gap in the data they recognized, and they decided this was a thing. Are there obvious gaps in our data that you can see from the work that you've done already, that you .
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Speaker 1
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Speaker 1
Think this would. enable us to know? Yes. So I so the data bit. Yes, but the way that I've now decided to work is actually just follow what government. policies are are going through Parliament. So violence against women and girls, we see continuous deaths of children and, and partners in PhDs that come through road traffic accidents is another one. Suicides. The. There are so many deaths that we can't choose. And so 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 would realize that we could do this, and we needed to do this.
Usually it takes something. I was thinking a global pandemic would be enough. It clearly wasn't. So I, I really don't know what else to do, but I'm hopeful. Through the health bill, 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 I should probably say, which is.
Usually it takes something. I was thinking a global pandemic would be enough. It clearly wasn't. So I, I really don't know what else to do, but I'm hopeful. Through the health bill, 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 I should probably say, which is.
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Speaker 1
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Speaker 1
But the minister in charge, the Ministry for justice, is the worst. responder to PhDs. They respond to about 30%. They've only ever responded to 30% of all reports. And I think this committee could really take forward what's happening in. Really try and understand what's happening at the. Ministry for justice, to. understand how they are using PhDs and they should be a role model. If they came out, they should come out with. 100% of all PhDs responded to. So that I can take that to the Department of Health, to the Department of of Transport, to the Department of Education, and show them the Ministry of Justice is the leader.
They are 100%. Everyone else should follow. So I think the. Justice Department or. ministerial department could become role models, which might be a lever for change. But I could talk about lots of other deaths that are tragically happening every day across the country .
They are 100%. Everyone else should follow. So I think the. Justice Department or. ministerial department could become role models, which might be a lever for change. But I could talk about lots of other deaths that are tragically happening every day across the country .
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Vikki Slade
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Vikki Slade
I do want to ask Vicki to ask her question and and I'm modifying it because I, I was originally going to ask you about what powers and features an existing. organization might want to have, but you've been really clear that an existing organization is not the way to go. You've also covered, I think, in quite some depth, some of the features and functions. So I'm not going to go into that, but I suppose the two things that leaves me with is.
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Tessa Munt
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Tessa Munt
Cases, how would having powers actually work in those cases? I mean I think the point that's been well made is about the importance of collating inquest conclusions, because they are such an important body of evidence. And within the non proposal we talk about recommendations from investigations. Now that obviously includes inquests. But it also includes the investigations prior to an inquest being held. So the different investigations that would take place. I think the other thing to say about, you know, the narrative conclusions are jewelry findings of systemic failure. They have to be treated as important sources of learning.
So that would be the first thing I would say to that. The other thing about a national oversight mechanism, and I completely agree with with George's points about, you know, a national database and the value of having data. But I think one of the big areas that we're being failed by is the lack of follow up on all these recommendations and on the evidence that is identifying systemic failure, the actual there is nobody who is following up what happens to this evidence. How is it changing things for the better? And that's why I think the national oversight we've come up with, with with that proposal.
And there is no organization, you know, according to our knowledge anyway, that has the specified role in their governing statute or their terms of reference to look at conclusions of investigations into state related deaths. And that's where there is that real accountability gap. And there's a complete disconnect between the, the, the kind of inquest process and then learning and prevention across different government agencies. And just to the point that that George made about the Ministry of Justice, I mean, you know, given that that is the department that is responsible for for coroners, it's quite shocking that, you know, we're here in 2026 giving evidence about something that has remained a consistent theme for decades.
And there's some, you know, there's this we should be learning from, from that, we've got a point of kind of inertia here, you know, and as I said in my previous answer, unless, you know, unless we do something and we do something quickly, you will continue to hear .
So that would be the first thing I would say to that. The other thing about a national oversight mechanism, and I completely agree with with George's points about, you know, a national database and the value of having data. But I think one of the big areas that we're being failed by is the lack of follow up on all these recommendations and on the evidence that is identifying systemic failure, the actual there is nobody who is following up what happens to this evidence. How is it changing things for the better? And that's why I think the national oversight we've come up with, with with that proposal.
And there is no organization, you know, according to our knowledge anyway, that has the specified role in their governing statute or their terms of reference to look at conclusions of investigations into state related deaths. And that's where there is that real accountability gap. And there's a complete disconnect between the, the, the kind of inquest process and then learning and prevention across different government agencies. And just to the point that that George made about the Ministry of Justice, I mean, you know, given that that is the department that is responsible for for coroners, it's quite shocking that, you know, we're here in 2026 giving evidence about something that has remained a consistent theme for decades.
And there's some, you know, there's this we should be learning from, from that, we've got a point of kind of inertia here, you know, and as I said in my previous answer, unless, you know, unless we do something and we do something quickly, you will continue to hear .
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