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Cross Sector Learning

Timeliness and learning from inquests

In 2011, the Panel collected data from coroners about delays on inquests into deaths in custody, which have a significant impact on both families and the quality and timeliness of learning. Recommendations about how to address the problem of inquest delays were presented to the Board in October 2011. The IAP has been working with the Chief Coroner’s office, the PPO and the IPCC to progress these recommendations. The IPCC recently reported that the CPS had now created a central expert team to deal with deaths in custody and anecdotal evidence showed improvements in decision times. The PPO has set deadlines for completion of cases which were exceeded in both years 12/13 and 13/14.

The Panel was pleased to note that by summer 2014 the Chief Coroner’s Office had started to publish Preventing Future Death (PFD) reports and responses on its website. The Chief Coroner’s Office did not have sufficient resources, however, to conduct an ongoing analysis of common themes arising from the PFD reports. The Panel commenced scoping activity as to how it might fulfil that role, but work stalled pending discussions at the Ministerial Board about how organisations should work together to identify cross sector learning.


Learning Lessons

Deborah Coles presented a paper to the Ministerial Board in October 2010 detailing early work which focused on identifying how different custodial organisations capture and share learning in relation to deaths in custody, how this learning was used to inform policy and training, and how it was fed back to operational staff and communicated to bereaved families.

In February 2015, Lord Harris gained the Board’s approval to coordinate a meeting of those with responsibility for learning lessons in each of the services and regulatory bodies to identify how cross-sector learning might be identified. IAP hosted a working group meeting in May 2015. The meeting was attended by a range of stakeholders and delegates were asked to explore questions such as:

  • Is there a mechanism to pick up cross-sectoral issues
  • What are the practical barriers to learning
  • What is understood about any arrangements that currently work well, and
  • Are there any existing models that enable complex organisations to learn lessons?




Many of the organisations had good local arrangements but all felt that nobody had yet “cracked” the issue.


The panel will be facilitating further cross sector talks and will work up a proposal for a literature review of learning mechanisms in some national private organisations later in the year.


Terms of Reference
  • Outline the current investigative procedures undertaken following a death in state custody. This covers deaths, which occur in prisons, in or following police custody, immigration detention, the deaths of residents of approved premises and those detained under the Mental Health Act (MHA).
  • Identify how the relevant investigative and regulatory bodies capture learning at the different stages prior to the completion of the investigation and inquest and explore how any early issues of concern and lessons are disseminated.
  • Collect data on the number of deaths in custody awaiting inquests, the time between death and the conclusion of the investigation and inquest and undertake a short analysis of this data to ascertain the reasons for the delays. This should take into account Article 2 obligations and the impact upon bereaved families and staff.
  • Undertake a series of meetings with stakeholders to identify and discuss the priorities in relation to cross sector learning from a policing/prisons, mental health and coronial perspective.
  • Identify the processes for the collation and dissemination of narrative verdicts and Rules 43 Reports and make recommendations to address any identified gaps.
  • Identify some case studies to illustrate any gaps in processes or examples of good practice, which could be replicated.






Last updated July 2015


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