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Deaths in Custody: The impact of Coroners’ Rule 43 reports on organisational learning

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Deaths in Custody: The Impact of Coroners’ Rule 43 Reports on Organisational Learning (PDF, 228.2 KB)

Mendas Review: The impact of Coroners’ Rule 43 Reports on Organisational Learning

The Independent Advisory Panel on Deaths in Custody1 (IAP) commissioned Mendas to:

  • Identify the action that has been taken by the individual custodial sector in response to (Coroner) Rule 43 reports
  • Determine the impact Rule 43 reports are having in terms of sharing learning and contributing to the prevention of future deaths
  • The purpose of this report is to provide suggestions for improvement for the IAP. The IAP will in turn take forward those suggestions it chooses to pursue by making recommendations to the Ministerial Board.