It’s hard to know how to contact or potentially influence His Majesty’s Coroners without writing to them all individually, which then means you’re either writing in very general terms or your writing to them about cases for which you inevitably don’t know the full details. But I nevertheless think there’s something emerging in my mind about inquests in to mental health police contact deaths which is academically interesting, but practically a little concerning.
Given my PhD topic is focussed on examining Preventing Future Death reports from HM Coroners, I’m increasingly interested in the part the individual coroners play in issuing such notices and in particular, what I might call the inconsistency of their approach. Let me give some examples so you see what I’m going to increasingly bang on about, over the next five years or so!
Let’s imagine one person dies and it emerges during inquest the police force concerned admitted their training wasn’t up to scratch – it’s happened several times with MH-PCDs. Forces attending the inquests might turn up and admit the problems, offer evidence that either have been addressed or will be soon after the inquest and the Coroner is then reassured so chooses not to issue a PFD to try to force the improvement they think is necessary to avoid further serious incidents. It doesn’t have to just be about training, it could be a joint protocol between agencies was flagged as problematic (or as non-existent!) and the force or mental health trust gives evidence to show that has been or will be sorted.
But what about other areas where the same problem may exist?!
LESSONS LEARNED
Whenever there is an untoward tragedy which makes headlines, we often and quite understandably see families and friends of someone who died campaigning to ensure “that no other family has to go through this and that lessons are learned.” Whenever proceedings end with an adverse finding involving a particular agency, we often see senior people standing up, offering an apology and promising to “learn lessons” by incorporating learning from PFDs in to policies and procedures – so it seems everyone wants lessons learned, doesn’t it?!
So why aren’t they learned? … my own experience is that they’re not, that seems to be what hundreds of PFDs are telling us. Why not?!
Well, it seems to me one reason is the need for learning is largely focussed on the police force or mental health trust which was relevant to the death. We’ve seen in recent times inquests for Martin Waite, Christian Parker and Ricki Gillatt which did not lead to a PFD, which I would argue fails to consider whether the issues identified by those coroners in those cases, could also lead to future deaths in other police force areas who may well have had (and I would argue who do) face the same difficulties.
Training for RCRP, for example, was initially conceived by Humberside Police for their area, but it was shared via the College of Policing with all police forces for their use. Sof if HM Coroners in West Yorkshire and West Mercia were worried about training matters for those forces, as reported, might it not be prudent to think about a PFD for the College of Policing to ensure any other forces with similar training didn’t end up with the same kind of problem. Indeed, if a PFD for West Yorkshire had been issued and other areas had learned that lesson well, might latter incidents occur at all?
We don’t know – and it can’t be anything more than speculation on my part, but that’s the kind of thing you might hope should happen. It’s literally the idea of PFD notices, at least in principle. Learning from a disaster in Area A should not only be learning for them, it should be learning for Area B if they have the same kind of structural risk in their policies, procedures and protocols but we need a way of getting the learning “out there”.
HM CORONERS
I find myself reading a lot and writing about the PFD process for my PhD, as much as writing about the MH specific PCDs which I’m aiming to research because across the 265 deaths since 2000 which I’ve identified so far, there is an obvious congruence between many of them in various areas of the country.
We often find areas don’t have proper joint protocols between agencies – especially problematic because such protocols are required by the Mental Health Codes of Practice in both England and Wales. We find sometimes the protocols do exist, but they’re not up to standard or they’re not known about and properly disseminated across relevant staff. We find training is sub-standard or non-existent in too many instances or we find communication channels are sub-optimal.
The charity Inquest has long since called for a “National Oversight Mechanism” to make sure recommendations from public inquiries, investigations or inquests are collated and learned, including more widely than by the individual agency involved in a specific disaster. Everything I’m outlining here and learning in my research means something along those lines has to be right because, as Director of Inquest Deborah Coles pointed out –
“You’re not just guilty of failing to learn lessons, you’re repeatedly guilty of failing to learn repeated lessons.”
His Majesty’s Coroners, it would seem, could be doing a little more to help us with that, if they were pushing beyond the particular agencies involved in the specific case they’re hearing.
Awarded the President’s Medal, by
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2025
I am not a police officer.
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
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