Page 49 - When Things Go Wrong

recent years has demanded greater understanding and coordination between
investigators. In several contexts, coordination does take place and is
formalised through Memoranda of Understanding (“MoU”). 125 One of our
consultees suggested that in most death in custody cases, relationships between
police, IOPC and coroners’ offices are well-established and lengthy delays
such as in the Lewis case are atypical. This would be a welcome position.
Unfortunately, however, some of us do not recognise it as the reality.
Nonetheless, that consultee drew attention to the delays caused in
investigations into deaths where the specialist accident branches are involved
and the principle of “just culture” 126 weighs against evidence sharing between
agencies. 127 Another consultee noted the further complexity caused where a
statutory review of the investigative framework runs concurrently with the
investigations themselves. 128

3.9 We appreciate that a push for rationalisation may come into tension with
operational independence. The proposal that a political office could take on a
coordinating or directorial role over investigating agencies in England and
Wales, as performed by the Scottish Lord Advocate, 129 were not well received

125 See Grenfell Tower Inquiry and Metropolitan Police Service, Memorandum of Understanding (27
September 2017).
126 Promoting “a non-punitive environment facilitating the spontaneous reporting of occurrences”. See
EU Parliament and Council Regulation 996/2010 of 20 October 2010 on the investigation and prevention
of accidents and incidents in civil aviation and repealing Directive 94/56/EC [2010] OJ L 295/35, Recital
24. Recital 25 stipulates that “the information provided by a person in the framework of a safety
investigation should not be used against that person, in full respect of constitutional principles and
national law”.
127 The issue of disclosure of materials from an Air Accident Investigation Branch (AAIB) investigation
to a coroner was considered in R (on the application of Secretary of State for Transport) v HM Senior
Coroner for Norfolk [2016] EWHC 2279 (Admin). The inquest was into the deaths of four men in a
helicopter accident in March 2014. The Court found that the effect of Reg 996/2010 (see ibid) and Civil
Aviation (Investigation of Air Accident and Incidents) Regulation 1996 (SI 1996 No 2798) was that the
coroner had no power to order the AAIB and its Chief Inspector to disclose the cockpit voice and flight
data recorder and/or a transcript of the recording. See Singh J (as he then was) at [49]: “it is important
to emphasise that there is no public interest in having unnecessary duplication of investigations or
inquiries”.
128 For example, see the Independent Review of the statutory multi-agency public protection
arrangements (MAPPA).
129 In Scotland, criminal cases are prosecuted and conducted by the Crown Office and Procurator Fiscal
Service (“COPFS”) with the Lord Advocate’s oversight. However, COPFS also receives reports from
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