Page 36 - When Things Go Wrong

or unnatural death; the cause of death is unknown; or the deceased died while
in custody or otherwise in State detention. However, the duty to investigate
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does not extend to those cases which do not give rise to such suspicion, but
which form part of a series of deaths that when looked at longitudinally is
suggestive of systemic failure.

2.49 Examples of such a series cited to us in the course of our work include the (at
least) 69 suicides over a six year period linked to the handling of benefit claims
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by the Department for Work and Pensions and the 63 deaths across six care
homes in South Wales investigated for abusive practice in the early 2000s.
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There are further examples where individual inquests were opened into deaths
in custody or otherwise in State detention, but a single inquest might have been
beneficial in exploring the commonality of issues. A graphic example is the
series of fatalities at HMP & YOI Styal, where six women died in the 12
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months between August 2002 and August 2003.

2.50 None of the examples in the above paragraph have led to the establishment of
a public inquiry. As outlined at para 2.2, this is a political decision entirely
within the discretion of the relevant Minister. However, it is unsatisfactory that
in the absence of sufficient political pressure, deaths such as these are not
investigated in context, and without scrutiny of underlying systemic causes.

Jurisdiction and scope

2.51 In order that systemic failures causative of death are investigated in context
and are investigated as efficiently and humanely as possible, we recommend

91 Coroners and Justice Act 2009, s. 1.
92 National Audit Office, Information held by the Department for Work & Pensions on deaths by suicide
of benefit claimants (HC 79, Session 2019-20).
93 See Margaret Flynn, In Search of Accountability: A review of the neglect of older people living in care
homes investigated as Operation Jasmine – Executive Summary (2015).
94 See INQUEST, Learning from Death in Custody Inquests: A New Framework for Action and
Accountability (2012), p. 11. The report notes that “at the conclusion of an inquest into a previous death
in Styal prison in 2001 the coroner made a rule 43 report about the need to set up a detoxification regime
for women withdrawing from drugs. This was not implemented until after the sixth death had occurred,
which was over two years after his report was issued”.

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