The Jimmy Mubenga Inquest: how much can it really achieve?

His death on a deportation flight Heathrow in October 2010 provided the "impetus for a broader enquiry into the use of the rules governing enforced removals from the UK, and in 

particular the role of the UK Border Agency in overseeing the contractors acting on its
behalf in escorting those being removed." This week, the inquest into what exactly happened to Jimmy Mubenga and who was responsible for it opened at Iselworth Crown Court. However, the limits on the powers of the coroner are such that in cases such as this, an inquest only ever provides partial justice.

The inquest represents an opportunity for a "full, fair and fearless investigation" that they were denied in July 2012, when the CPS decided that there was insufficient evidence to support bringing criminal proceedings against the guards who applied the forcible restraint that eventually led to his death; a decision that Deborah Coles of Inquest described as "shameful". With a list of witnesses numbering 100, there is every reason to anticipate a detailed and considered investigation and outcome in around 2 months' time.

But just what options are available to an inquest? What might such an outcome look like? The Corners' Rules make it clear that the purpose of an inquest is to:

" directed solely [at] ascertaining .......—
(a)who the deceased was;
(b)how, when and where the deceased came by his death;
(c)[other procedural details concerning the death]

Furthermore:

"(2) Neither the coroner nor the jury shall express any opinion on any other matters."

And, for the avoidance of doubt, Rule 42 makes clear that:

"No verdict shall be framed in such a way as to appear to determine any question of—

(a)criminal liability on the part of a named person, or
(b)civil liability."

By definition then, the scope of any outcome will be limited. That is not to say that it will be unimportant. The potential for a jury to deliver narrative verdicts, detailed accounts of the facts and circumstances leading to a person's death, together with the power of a coroner to make  recommendations intended to prevent future deaths, "Rule 43 Recommendations" - has produced some important results. This has been most recently demonstrated by the recommendations that followed the death of Melanie Beswick. Indeed, those recommendations are given further force by the fact that public authorities against whom such recommendations are made are now legally obliged to respond them.

Nevertheless, as Inquest pointed out in their "Learning from Deaths in Custody: A new framework for action and accountability" report, Rule 43 is still in need of fundamental reform for two key reasons. Firstly, there is no obligation on a coroner to make recommendations. Secondly, whilst Rule 43 has facilitated the development of a "rich seam of data" that is essential in the prevention of future deaths:

"that input is being undermined, as there are no established mechanisms for monitoring compliance with and or action taken in response to failings identified in narrative verdicts or in response to rule 43 reports."

Furthermore:

"learning is lost by: the inconsistent approach by coroners to the use of their powers to report matters of concern to the relevant authorities; the lack of analysis, publication and dissemination of the reports or narrative verdicts across custodial sectors and the lack of transparency and accountability of the detaining agencies about action taken to rectify identified and dangerous systemic problems."

I will be watching developments in the inquest with interest. It will doubtless help to sustain the focus on issues around the use of restraint techniques and the treatment of immigration detainees more generally that have dogged the authorities. However, whatever the findings, the absence of any co-ordinated oversight over the outcomes of inquests makes it incredibly difficult, if not impossible, to achieve the kind of much needed reform that is still unquestionably needed in order to address the alarming rate and repetition of entirely preventable deaths in custody.