Page 48 - When Things Go Wrong

Coordination of investigations and evidence gathering

Delay

3.6 An unexpected death may trigger investigation by a wide range of
investigators, such as: the police; coroners and their officers; the Health and
Safety Executive (HSE); the Independent Office for Police Complaints
(IOPC); the Care Quality Commission; the Air Accident Investigation Branch
(AAIB); the Marine Accident Investigation Branch (MAIB); the Rail Accident
Investigation Branch; and the Prisons and Probation Ombudsman (PPO),
alongside agencies conducting internal institutional reviews.

3.7 The Angiolini Review found inadequate coordination between investigating
agencies to be a significant cause of delay in death in custody cases. Citing
submissions from INQUEST, the Review highlighted the case of Olaseni
Lewis who died in 2010 following prolonged restraint by police officers whilst
in psychiatric detention:

The HSE did not extend its investigation to the police force because of the
IPCC 123 investigation. In 2015 it emerged that since 2012 the HSE had
been in communication with the MPS, IPCC and CPS regarding
corporate manslaughter by the NHS Trust, without any single agency
taking responsibility for that matter. Later that year Devon and Cornwall
Police began to undertake such an investigation. In the meantime the
IPCC referred their investigation to the CPS in relation to the actions of
individual officers, but not the MPS as a corporate body. The inquest has
now been scheduled to commence in January 2017, over six years on from
the death. 124

3.8 We have heard conflicting accounts as to the effectiveness of existing
arrangements between the police and other investigators. One consultee
suggested that the situation is improving: while there has been tension between
agencies historically, the number of terrorist attacks in the United Kingdom in

123 The Independent Police Complaints Commission, the predecessor of the Independent Office for
Police Conduct until January 2018.

124 Angiolini, supra note 15, para 14.43.
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