This report highlights the failure to learn from preventable state related deaths in the UK. It focuses on concerns around the implementation of recommendations following inquests, public inquiries, investigations and official reviews, calling for the creation of a new independent public body, a National Oversight Mechanism, to address this. The report was launched as part of the ‘No more deaths’ campaign by Inquest, an independent charity combining specialist support for bereaved people following a state related death with campaigning for justice and change.
The report states that while public and private bodies have a duty to keep us safe from harm and protect our lives, every year in the UK hundreds of people die from preventable state deaths. It highlights that despite vital recommendations being made in various inquests and public inquiries, there is currently no system in place to oversee them or ensure changes are being made. It focuses on three sources of such recommendations and incudes case studies highlight these issues:
- Inquests – recommendations from Prevention of Future Deaths reports.
- Public inquiries – statutory inquiries established under the Inquiries Act 2005.
- Investigations and official reviews – such as those done by the Prisons and Probation Ombudsman or the Independent Office for Police Conduct.
The report argues that there is an urgent need to create a mechanism to ensure proper oversight and follow-up of these important and potentially life-saving recommendations.
National Oversight Mechanism
It calls for the creation of a new independent public body responsible for collating, analysing and following-up on recommendations arising from inquests, inquiries, official reviews and investigations into state-related deaths. This would be:
- Structurally and operationally independent, accountable to Parliament.
- Accountable to bereaved families, by establishing an advisory panel compose of families and community groups.
- Required to produce an annual report on lack of follow-up to recommendations.
- Given powers to highlight concerns about a lack of follow-up to recommendations.
- Given powers to require information from relevant stakeholders.
- Underpinned by standards on combatting discrimination and racism.