The Sean Rigg Independent Review: a family victory

The death in custody of Sean Rigg is something that I have blogged about extensively both on this blog and others. It was/is a tragedy unique not for its subject-matter but for the sense that it would come to embody an impetus for the reform of our approach to deaths in custody rarely seen more than once in a generation. And so it continues to prove. That is to the eternal credit of the Rigg Family and their dogged campaign for justice that led an independent panel reviewing the death to call on the Independent Police Complaints Commission (IPCC) - who conducted the initial investigation and cleared the officers involved of any wrongdoing - to reconsider the failure to bring misconduct proceedings and fundamentally reform their approach to conducting investigations in future.

It also condemned collusion between officers and their Federation representatives in responding to the investigation, a failure of local mental health services and inadequate training of officers in dealing with persons with mental health problems. The independent panel: Dr Silvia Casale, Martin John Corfe and James Lewis QC, also found "a malaise" in dealing with the obvious racial issues in this case ( a point that I will consider in a separate post). By taking a comprehensive, broad-based analysis of this case these conclusions have the potential to save lives and mark out the campaign that has struck a blow to the heart of the establishment.

The Terms of Reference

The Review’s broad terms of reference were

• to examine the IPCC investigation in light of both the evidence given at the Coroner’s Inquest and the verdict of the Inquest;
• to consider whether any further investigation is required, with a view to misconduct or criminal proceedings against any member of the police service;
• to identify any lessons to be learnt or broader issues for both the IPCC and the overall
• system for investigating deaths following police contact;
• to take account of the Rigg family’s concerns; and
   
• to take account of parallel reviews relating to policing, mental health and deaths in custody.

The IPCC's approach and Police Misconduct 

The challenge for the IPCC was (i) to examine all the surrounding circumstances, (ii) to consider which of these might have been causal to Mr Rigg’s death, and (iii) to explore whether the conduct of, or acts of omission by, any of the people involved contributed to his death and, if so, to what extent. 

This must also be read against the special remit of the IPCC enjoys as a result of our obligations under Art 2 ECHR. The Convention requires it to be proactive in investigating deaths in custody, the investigation should (i) be set up by the State of its own accord (without requiring any complaint or allegation), (ii) be independent practically and hierarchically, (iii) be effective in the sense of capable both of determining the legality of the State’s actions or omissions and of leading to the accountability of those responsible (including by criminal prosecution), (iv) be prompt and reasonably expeditious, (v) have sufficient public scrutiny to ensure effective accountability in practice as well as in theory, and (vi) should have sufficient involvement of the next of kin to ensure their legitimate interests

The IPCC failed that challenge. In part, and in summary, this was because of things that are beyond the Commission's control - they are reliant on officers, as the first at the scene, to maintain the integrity of potential evidence, which did not happen in this case. They are entitled to expect the co-operation of officers. Instead, they were met with the undue interference of union representatives from the Police Federation who interrupted questioning and officers who had been left  by investigators from Professional Standards (the authority with the primary duty to investigate police misconduct) to discuss the content of their statements before being interviewed.

So far as the IPCC is concerned, the Review "noted that the Commissioner in charge of the investigation into the death of Mr Rigg was the only member of the IPCC team on the case who was not located in London, [which] had implications for the effective oversight of the investigation." IPCC investigators most obviously failed to subject the account of police officers and other involved, to forensic scrutiny In particular:

"(i) the position adopted by the officers that they were not aware that Mr Rigg might be suffering from mental health problems was open to question on the grounds of improbability, given the clear indications of mental illness enumerated in the report;

(ii) if the police officers did not suspect that Mr Rigg was mentally ill, it was open to question whether they were observing him carefully enough and assessing him on an on-going basis; and

(iii) the omissions and/or failures of the police officers in relation to identifying Mr Rigg as a person with mental health issues were indicative of a lack of care towards Mr Rigg as a person in their custody."

This lack of diligence is one reason for the paucity of charging and prosecutions that follow a death in custody. The combined effect of the over-readiness of IPCC investigators to accept the accounts they received from the officers, who they did not interview for themselves until 6 months after the event left the such a "scant" body of  evidence on which, the review accepts, criminal charges could not be based. Instead, it was left  to the inquest to revive questions of police misconduct that must surely now be reconsidered.

The IPCC's critical lack of analysis is also shown by its failure to pursue pertinent issues that it identified for itself early on. In particular, the Review identified, concerns regarding mental health and restraint. At the time of the arrest, Sean had his own (expired) passport in his pocket. Curiously, the officers assumed it to be stolen and accordingly failed to identify him. This meant that they did not call for a criminal record check. Had they done so, markers of his mental health issues and a related history of violent offending that would have explained his erratic behaviour and would have steered officers to police policy on dealing with people suffering from mental health issues - which highlights the priority of prompt medical care. It also contributed to the fact that the police took 3 hours to respond to calls for help. This was indicative of police police performance at an early stage and was again something that was not given sufficient importance.

Sean was restrained, handcuffed, face-down on the ground by arresting officers for 8 minutes. He was under the control of those officers within just a few minutes. This was a breach of policing guidelines, which required a detained person to be returned to a sitting or standing position as soon as s/he had succumbed to arrest. Those handcuffs were not removed until some hours later, after he collapsed. Despite video evidence from a local resident who recorded to the initial arrest on their mobile phone, it was left to the coroner to identify and question these timing issues, even though the IPCC had commissioned a photographic expert for other aspects of the investigation. Importantly:

"Since the Coroner does not have the power to direct misconduct proceedings, it falls to the IPCC, as the only body with that power, to look again at its determination in the light of all the evidence available since the inquest."

That subsequent evidence includes footage that made a lie of the assertion that the custody Sergeant checked Sean whilst he was in the police van left in the car park of the police station. This is an assertion that goes to the heart of the question of whether or not officers properly discharged their duty of care. The IPCC had access to that CCTV material but were cursory by comparison in their analysis of it. The lie was only brought to light because of the "intensive scrutiny of the Rigg Family."

The Rigg Family

The Review considered that:

"the family are fellow travellers in the search for the truth. The perspective of the family must be recognised as important."

Lamentably, the IPCC treated them with the contempt of fare dodgers. The initial IPCC press release was issued without consultation with the family and worse still was fundamentally inaccurate suggesting, for example, that Sean died in hospital. To add insult to injury, the Metropolitan Police disclosed criminal record checks to the IPCC on two members of the family, despite only ever being asked to provide a check for the main witness to the assault. In a perverse turn of events, two people who should have been treated akin to victims were being treated as if they had something to hide. The suggestion that the material was relevant to the disclosability of CCTV evidence to the family was, as the Review found, nonsense,

Instead of returning those files unopened as irrelevant, they were viewed by a senior investigator. Fortunately, this did not affect disclosure but did amount to a further breach of the confidence that the family should have enjoyed in the authorities.

That breach was, of course, insignificant in comparison to everything that preceded and indeed followed it. Grief can be crippling at any time but the family refused to be crushed by the weight of the establishment mounted against them. The Review was in no doubt about the debt it owed to them:

"The Rigg family were determined to see that a thorough investigation took place. Their considerable and sustained efforts resulted in the emergence of information that might otherwise not have seen the light of day. The Rigg family are to be commended for their tenacity and commitment in this regard. This Review has benefited significantly from the input of members of the Rigg family and their solicitors."

Community Mental Health Services

"[T]here is a different requirement in terms of the scope of such investigations than holds for other IPCC investigations. When a death in custody occurs, the public has an interest not only in knowing whether any crime or misconduct has occurred, but also in understanding what has happened and why. This is especially important when there are lessons to be learnt to prevent further tragedies."

An IPCC investigation of a death in custody is broader than the inquistorial role of a criminal investigation. Their job is not only to establish what happened but to prevent it happening again. Identifying "gaps and practical shortcomings in individual cases" and extrapolating "patterns of systematic weakness across cases... [in order] to recommend changes to policy and operations. That demands "a more holistic approach". In that context:

"more emphasis might have been placed, in the IPCC investigation, on key features of the community mental health care provided to Mr Rigg."

This is a reference to the South London and Maudsley (SLaM) NHS Trust, whose inept management of Sean's care was also admonished by the inquest jury. Indeed, some of the issues were identified by the IPCC such as, the absence of a medical risk assessment during the relapse of Sean's schizophrenia .The Review echoed that criticism but identified other points that should have been considered. For example, there was no advance planning for relapse. The hostel that Sean was living in was also a residence where all the occupants were suffering from mental health problems, something that was neither notified to or recorded by the police (something which Lambeth council have since commited to addressing). The IPCC should have highlighted these "missed opportunities to provide care before crisis involvement with the police". This emphasises the point that

"[a] report from the IPCC must be expected to raise questions to be addressed by others, such as the Coroner, and to draw robust conclusions not only as to whether misconduct or criminal behaviour occurred, but also as to whether there was poor practice or major omissions in the duty of care constituting at least poor practice and possibly amounting to a breach of the duty of care." 

This would have brought attention to the need for greater co-ordination between and community mental health services.

Where now?

Earlier in the week, I questioned how much an inquest could achieve. The arguments I made there remain valid but the significance of this review cannot be underestimated. It has forced the IPCC to concede that it can no longer stand by its earlier report, which it will now reconsider. Channel 4 News also reported that the IPCC will review all of its investigations into deaths in custody. The IPCC's response actually identifies this as just one of the recommendations in the review but if it were accepted, it would surely cement this significance of this campaign alongside those of the Lawrence Family 20 years on from from the acknowledgement of institutional racism in the Metropolitan or the exposure of endemic police corruption by the family of the 96 people who died at the Hillsborough.

The Review has set out a template for more robust investigations by the IPCC. It has also called on the Commission to "articulate clear expectations and independent criteria for assessing police conduct." It has also increased the pressure on the officers, some of who are currently under investigation for perjury and perverting the course of justice, who now face the possibility of misconduct and potentially (more importantly) criminal proceedings.

The emphasis on the failings of mental health care and the need for improved training and greater coherence across community agencies, including the police is another one of many key outcomes. However, it is imperative that this review is not left to gather dust and that the impetus it has created is fully harnessed.

Whilst the authorities fatally missed numerous opportunities to save Sean's life, the Rigg Family seized upon their chance to hold them to account. They will be the first to acknowledge that they did not and could not have done it on their own. They secured the fearless support of lawyers like Daniel Machover and Helen Stone and Leslie Thomas. They have also been aided by the incomparable expertise and resources of INQUEST. Theirs is a journey that many have and will continue to travel, from the families of Jimmy Mubenga  Azelle Rodney, Kingsley Burrell and Smiley Culture; Daniel Morgan to Andrei Litvenenko. This review has such resonance not because the Rigg Family's quest is unique but because their fight against institutional corruption and a dogged pursuit of justice in the face of many slammed doors is well known to so many, particularly to those who have lost loved ones in custody.

 The Review is indeed a watershed for the IPCC. It marks a higher water-mark in the tide of criticism that has been growing ever since the IPCC was set up in 2002, replacing the similarly beleaguered Police Complaints Authority.  However, that cannot obscure the reforms that must be made of all the agencies that so badly failed Sean Rigg and countless others.The response to the review must be as robust and holistic as the IPCC should have been. We have not reached the last leg of this journey just yet.