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UK: National Oversight Mechanism would allow "learning, transparency and accountability" over state-related deaths

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22 July 2024

The new Labour prime minister, Keir Starmer, has been called on by a broad coalition of organisations - including Statewatch - to set up a National Oversight Mechanism to collate the findings of investigations into state-related deaths. A letter from the coalition says that inquiries, inquests and investigations - for example, into deaths in police custody or medical facilities - "can pinpoint learning for the future to stop the same thing happening again." However, there is currently no central mechanism to collate those findings or ensure recommendations are implemented. "This is a disservice to bereaved families who look to investigations for the truth, answers, and assurance that future deaths will be prevented," says the letter, which calls for the establishment of a National Oversight Mechanism: "a new, independent body with the responsibility to collate, analyse and follow up on recommendations made during inquests, public inquiries, investigations and official reviews."

Image: Bilwanath Chatterjee, CC BY 2.0

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The letter was coordinated by INQUEST as part of the No More Deaths campaign.

10 Downing Street London
SW1A 2AA

22 July 2024

Dear Prime Minister,

The need for a National Oversight Mechanism

We write to express our concern regarding a persistent deficiency in the UK’s investigatory system and urge your new Government to take immediate steps to address this gap in accountability.

The UK has a complex and advanced system set up to investigate state-related deaths. Inquiries, inquests and investigations have been crucial in bringing to light issues of concern around deaths in detention, NHS failures and other areas of public safety. Crucially, these investigations can pinpoint learning for the future to stop the same thing happening again.

This legal framework is something the UK should be proud of. However, it is clear it is not fit for purpose.

There is no central oversight of recommendations made by coroners, inquiry chairs and investigators. What monitoring does exist is fragmented and piecemeal. Many public bodies simply do not take into consideration recommendations made during post-death investigations. In fact, a large proportion of public bodies who receive recommendations from coroners do not even bother to respond. [1] This is a disservice to bereaved families who look to investigations for the truth, answers, and assurance that future deaths will be prevented.

INQUEST, who support bereaved families following a state-related death, have done extensive work to show the psychological impact of this lack of follow-up on bereaved families and the countless preventable deaths occurring because of systemic failures to enact change. INQUEST proposes a solution: the establishment of a National Oversight Mechanism, which would be a new, independent body with the responsibility to collate, analyse and follow up on recommendations made during inquests, public inquiries, investigations and official reviews. A National Oversight Mechanism would provide better learning, transparency, and accountability for bereaved families.

INQUEST’s campaign has received official endorsement from over 60 charities and NGOs as well as from victim-led organisations like Covid-19 Bereaved Families for Justice, the Hillsborough Law Now Campaign and Grenfell United. Support for a Mechanism or similar type of oversight function has also come from the Mayor of London [2] and the report on the Infected Blood Inquiry. [3]

With the formation of a new Government, there is an opportunity to bring forward legislation to create a National Oversight Mechanism and correct the regrettable complacency in taking forward the learning from deaths.

We urge you to take this step for both bereaved families and in the interest of the wider public to drive forward meaningful, lasting change.

Sincerely,

Action against Medical Accidents (AvMA)
APPEAL
Association of Visitors to Immigration Detainees (AVID)
Birth Companions
Centre for Crime and Justice Studies
Centre for Mental Health
Centre for Military Justice
Children's Rights Alliance for England, part of Just for Kids Law
Clinks
Covid-19 Bereaved Families for Justice
Disability Rights UK
End Our Cladding Scandal
Epilepsy Action
Factor 8
Gambling with Lives
Grenfell United
Hillsborough Law Now
Howard League for Penal Reform
Hundred Families
INQUEST
JENGbA
Justice4Grenfell Campaign
Learning Disability England
Liberty
Maslaha
NetPol
Pact (the Prison Advice & Care Trust)
PAPYRUS Prevention of Young Suicide
Prisoners' Advice Service
Release
Rethink Mental Illness
Rights & Security International
RMT
Southall Black Sisters
Statewatch
Stopwatch
Suicide&Co
The Flavasum Trust
The Gemini Project
The Joint Council for the Welfare of Immigrants (JCWI)
The Justice Gap
Traveller Movement
UFFC
Zahid Mubarek Trust

[1] An analysis using the Preventable Deaths Tracker developed by researchers at the University of Oxford found that only 33% of all Prevention of Future Death (PFD) reports issued by coroners had expected responses published, with 29% of responses overdue. Further, the researchers found that response rates to PFDs examined in 25 of their studies ranged only from approximately 10% - 60%, with no study resulting in an 100% response rate. Richards, GC. The Preventable Deaths Tracker: Responses to PFDs. 2023. https://preventabledeathstracker.net/database/responses/

[2] https://assets.grenfelltowerinquiry.org.uk/documents/transcript/Transcript%209%20November%2020 22.pdf

[3] https://www.infectedbloodinquiry.org.uk/sites/default/files/Volume_1.pdf

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