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Article 2 Compliant Investigations

This project has been building upon the work undertaken by the Forum for Preventing Deaths in Custody, which examined whether the current arrangements for investigating deaths in custody complied with Article 2 of the European Convention on Human Rights. Professor Philip Leach is leading this work.

Philip reported his findings and recommendations to the Ministerial Board in June 2011. Recommendations focused around four main areas: (1) deaths of those detained under the Mental Health Act (MHA); (2) deaths in prison; (3) children who die in (or in transfer to or from) secure children’s homes (SCHs); and (4) inquests. Professor Leach is undertaking further work to progress these recommendations with a range of stakeholders and will report back to the Ministerial Board in due course.

In 2015 the Minister for Children & Families agreed to include provisions in the forthcoming children’s home regulations (due to be put before Parliament during the current session) that would put the PPO’s remit in SCH’s on a statutory footing. These changes include the following:

  • An amendment which adds the PPO to the list of existing bodies (such as the LA, LSCB and Ofsted) who must be notified when a child dies in a SCH; and
  • A new regulation, which requires an SCH to invite the PPO to investigate the death of a child in a SCH. This includes access to the premises; access to documents and records relating to the child as the PPO requires and; the ability to interview, with consent, the children accommodated there and other relevant persons (i.e. parents, relatives and people working at the home)

The Children’s Home (England) Regulations came into force in April 2015.

The Panel raised delays to inquests with the Ministry of Justice, Coroners’ Society and more recently the Chief Coroner. The Chief Coroner keeps a register of inquests taking longer than 12 months to complete and reports on this to Parliament.

The Panel has raised concerns that independent investigations are not being commissioned into deaths of detained patients. They worked with the Care Quality Commission (CQC) to obtain access to a small sample of serious untoward incident reports completed by NHS Trusts following deaths of detained patients, and produced an analysis of these in a paper to the Ministerial Board in June 2013. The Panel highlighted the variation in quality and scope of the investigations and recommended that NHS England should produce guidance for mental health trusts on how they should undertake investigations which should include guidance on how to ensure investigations are Article 2 –compliant, where relevant. This recommendation was accepted and the Panel continues to liaise with NHS England on the production of updated guidance.

Terms of Reference

The working group considering the issue of Article 2 compliant investigations include:

1. Carry out a short review to identify the research that has been undertaken in this area.

2. Review the recommendations contained within the Forum for Preventing Deaths in Custody’s report, which examined whether the current arrangements for investigating deaths in custody complied with Article 2 of the European Convention on Human Rights.

3. Undertake a series of meetings with key stakeholders to identify and discuss the priorities in relation to Article 2 compliant investigations from a policing/prisons, mental health and coronial perspective.

4. Aim to identify any gaps in knowledge, practice or policy within the different custodial sectors.

5. Highlight some case studies to illustrate any gaps in processes or examples of good practice, which could be shared.

6. Use the findings of this work to feed into the development of cross sector guidance on the principles of Article 2, which will be taken forward as part of the IAP’s longer-term work programme.


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