Emergency response time - how long is too long?

I am currently employed by the firm of solicitors that represented Mr Sarjantson. I write in an entirely personal capacity. As such, nothing in this post should be deemed to reflect the view(s) of the firm.

Sarjantson v Humberside Police

In a deceptively short ruling, the Court of Appeal has said that there is an arguable case against the police for taking too long to respond to a 999 call contrary to their obligations under Articles 2 and 3 of the European Convention of Human Rights.This was the first case of its kind, one that raised issues of such importance that the judgment was given by the Master of the Rolls. However, the impact of this decision will extend beyond the police. It has important consequences for all emergency services but also represents a re-assuring outcome for members of the public, who would be surprised not to have the protection of the Convention in the stark circumstances of this case.

The facts

Sarjantson was attacked by a group of young men armed with baseball bats, in the early hours of 9 September 2012, and suffered serious head injuries which caused short and long-term memory loss.The police received 3 separate 999 calls within three minutes from terrified local residents as a gang ran amock in Grimsby, vandalising properties and assaulting other victims before launching the most vociferous attack on the claimant. He was not specifically identified until seven minutes into the second of those phone calls and the extent of the assault and the need for an ambulance came after 8 minutes. That third caller  told the police:

"there's a big gang of them down there….can you send the riot van, we're running upstairs now". "Fucking hell, stop it. Stop it. Fucking leave it. I'm sorry Chris, fucking hell you evil bastards". 

The perpetrators of the attack were convicted of causing grievous bodily harm and of causing violent disorder and are currently serving lengthy prison sentences.

An internal police investigation was critical of the police. It found that there had been an 11 minute delay before the police officers were deployed to the scene. This meant that they did not arrive until almost half and hour after the first 999 call was made, almost twice the target response time of 15 minutes. This was all the more significant because, consistent with their procedure, the ambulance service refused to attend without a police escort.

The first ruling

It had been argued for the Claimant that this failure was a breach of the duty imposed upon the police to take measures to avert a real and immediate risks to life and to avert a real and immediate risk of injury as required by Articles 2 (the right to life) and 3 (the prohibition on inhuman and degrading treatment.

The police initially succeeded in an application for summary judgment as the claim was struck out as having no reasonable prospect of success. The claim against the police was unarguable. The judge reached that conclusion for two reasons. Firstly, she held that, according to the case law of the European Court of Human Rights, a duty could only arise in this context under Art 2 ECHR where the immediate risk to life is posed to is to an identified person(s) i.e. 7/8 minutes into the second phone call. Second and relatedley:

"even if a duty could arise in relation to an unidentified person(s), it could not arise on the acts of this case because there was insufficient time between the first call and the time of the assault for the police to attend the incident."  

 A third, new, argument advanced in the Court of Appeal was that the duty of the state to protect against an imminent risk to life could not arise where that risk had already materialised. Once the risk has materialised the duty of the police in this context ceased.

The Court of Appeal's Judgment
Is it a condition that there is a real and immediate risk to an identified or indentfiable person?

The Claimant appealed successfully that each three of these reasons was wrong in law. The leading authority comes from the Grand Chamber judgment in Osman v United Kingdom, which held that the duty  to take preventative operational measures to protect an individual whose life is at risk from the criminal acts of another individual arose when:

" the authorities knew or ought to have known at the time of the existence of a real and immediate risk to the life of an identified individual or individuals from the criminal acts of a third party and that they failed to take measures within the scope of their powers which, judged reasonably, might have been expected to avoid that risk"

Whilst there is a reference to "identified individual or individuals" it would be wrong to view this as delimiting the scope of the duty. The Grand Chamber also emphasised that Article 2 is drafted in broad terms. It was for that reason they rejected an argument that the failure to offer sufficient protection must amount to gross negligence:

"Such a rigid standard must be considered to be incompatible with the requirements of Article 1 of the Convention and the obligations of Contracting States under that Article to secure the practical and effective protection of the rights and freedoms laid down therein, including Article 2."

For that reason:

" it is sufficient for an applicant to show that the authorities did not do all that could be reasonably expected of them to avoid a real and immediate risk to life of which they have or ought to have knowledge."  

As counsel for the claimant demonstrated by reference to several subsequent cases that applied the "Osman Duty" (as to which, see paras [15] - [23]), it is for this broader proposition that Osman is the authority. It is not a condition of the duty under Article 2 that the person at risk be identified, only identifiable.

Was there no breach of the duty because there was insufficient time for the police to attend the incident?

The judge's second ground for striking out the claim was also wrong. The fact that the police response would have made no difference is not relevant to liability. In Kilic v Turkey (2000) 33 EHRR 58 for example, the court found a violation of Art 2 ECHR in a case where the applicant's brother complained that his brother had been killed by or with the complicity of the State security forces because they failed to take preventative steps that would have "assisted in minimising the risk". As the court here noted:

"It is noteworth that there was no consideration of whether the steps that should have been taken would in fact have saved the brother's life"

Can the duty arise once the risk has materialised?

Counsel for the police argued that the Osman duty was confined to taking measures that stopped a risk/threat from materialising. This was dismissed very shortly (see para [30]) on the basis that in this case, the authorities were dealing with an ongoing incident. Therefore, there was still a duty to prevent further violence.

Comment

The Osman duty takes account of:

 "the unpredictability of human conduct and the operational choices which must be made in terms of priorities and resources"

And further that:

"such an obligation must be interpreted in a way which does not impose an impossible or disproportionate burden on the authorities. [So that] not every claimed risk to life can entail for the authorities a Convention requirement to take operational measures to prevent that risk from materialising. 

Even so, there is no doubt that the existence of a duty in this context will add to the operational workload of the police. Counsel for the police doubtlessly had this in mind in resisting the appeal and particularly in attempting to argue (however hopelessly) that no duty existed where a risk had arisen that could not have been avoided, even where a risk was continuing and the police would be called upon to take further actions.

To that extent, it is fair to say that this case does indeed raise issues of considerable importance for the police, but many practitioners feel the impact of the decision is broader still. There is no reason why an Osman duty could no arise in comparable circumstances against other emergency services who unreasonably fail to respond promptly to an emergency call. Tweak the facts of this case for example, where a delayed response from the ambulance service was not justified . And what about dilatory fire services responding to an arson attack? Moving beyond the traditional emergency services, this judgment will have consequences for child-protection services, mental health services and a range of other public services that have responsibility for responding to may-day calls.There is much more to come from this judgment and not just for the police.

The NMP - 33 and still Keeping the Fight Alive

My return to the blogsphere this week, coincided with the 33 anniversary of arguably the most successful community organisations in recent memory. On Friday, I was honoured to have been invited to D'GAF in Stratford, to mark an occasion that drew together founders Gulshun Rehman, Ilona Aronovsky and Herby Boudier, current staff and new volunteers like myself for the premier of "Keeping the Fight Alive" - an independent short film by Rayna Nadeem charting NMP's more than 3 decades on the frontline against racism and inequality, for social justice and accountability of the state.

33 probably seems like an odd year for which to commission a film but, as vetran campaigner Cilius Victor observed, for an organisation that has set itself against the complacency of the status quo, it was perfectly fitting. Indeed, as Nadeem said, when she embarked on her latest project, it was conceived as a 5-minute promotional film that grew into something four times as long. The NMP grew out of the racist murder of Akhtar Ali Baig. Stabbed in the heart in broad daylight, outside East Ham station, Baig's murder became the rallying call for a community led push-back against racial violence and the complicity of the police and politicians in it; whether through indifference or active participation.

The result of that indifference was their abandonment of vulnerable communities who were forced to fend and defend themselves and yet when they did so, they found themselves in the dock. After the police did nothing to stop the harassment and violence against pupils going to and from school by National Front thugs, the community organised chaperones. One day, they arrived at the school to find a car of what turned out to be plain-clothed police officers. National Front members were not far behind a fight broke out and whilst the fascists were let go, the men who had been defending local children were arrested. The Newham 7 was born. Their acquittal at the Old Bailey, met by hundreds who had come from across the country under the NMP banner to lend their support was a seminal moment in British history. For the first time the law recognised that when a community is abandoned by those charged with their care and protection, self-defence is no offence. Nevertheless, the Newham 8 came shortly afterwards, in very similar circumstances, charged with rioting. The NMP again swung into action and again, the result was the same: no guilty on all charges.  

Come the 90s and the NMP was continuing to expand rapidly. Its ambitions were undiminished and it began to tackle the difficult issue of deaths in police custody. The Project rallied behind the families, first, of Shiji Lapite and then Ibrahima Sey both two of the first victims of positional asphixia, being suffocated by being restrained in a prone position in which they could not breath properly. This was the last violent act of police brutality. Lapite had been dragged to the ground in a neck hold and kicked in the head after police claimed he had been "acting suspiciously". Sey had been arrested after a domestic dispute. He complied fully with the police to the extent that he was not even handcuffed until he arrived in the custody suite of Illford Police Station. Sey had acute mental health needs and so, until then, he had been accompanied by a friend. Once in custody he was told that his friend had to leave. This made him anxious. His agitated state prompted officers to handcuff him with his hands behind his back before being sprayed in the face with pepper spray and held face down for 15 mins. By that time he had fallen silent and limp. Help was called but it was too late, Sey was the first person to die in custody having been sprayed with CS gas. In what would become an all too familiar story, both the Police Complaints Authority (now the IPCC) and the Crown Prosecution Service refused to take any further action. It was left to the coroner's court to deliver any semblance of the justice that the campaign which had followed his death demanded. His verdict: unlawful killing.

The defining case of that decade was, of course, the murder of Stephen Lawrence and its exposure of institutional racism an outcome that validated the experience of BME communities from Newham to Newcastle. The NMP's support of the Lawrence family was led by Gilly Singh Mundy, who died unexpectedly in 2007. His absence was remarked upon several times on Friday evening and even to a new volunteer, it was clear that the power of his presence still resonates strongly in the Project's work. 

As well as defending the rights of others the NMP have had to negotiate their own challenges. A fire destroyed their original offices, necessitating their move to Stratford, albeit via make shift offices in the home of another veteran campaigner, Kevin Blowe. When they dared to say that the police had killed Ibrahima Sey, Newham Council, who had funded them up to that point, withdrew that money. Current director, Estelle Du Boulay openly acknowledged that, for a short time at least, the future of the NMP was in doubt. It was down to just one full-time staff member. How could it possibly survive? Securing funding from the National Lottery was necessary by holding on it grass-roots up rather than top-down ethos it did not matter how bad things got because, as Asad Rehman, current chair of the NMP explained, “The NMP is and always will be about people”. With only a handful of permanent staff members it depends on volunteers to manage its workload but it can rely on that support because, unlike other campaign initiatives, it does not just raise an issue and then leave the community to deal with the backlash, it is there throughout. It is the product of the community that it serves.

Importantly though, its work transcends both racial and geographical boundaries.* Back in the late 80s, Lee Dray, a 17 year old white boy who had been harassed by police in Canning Town for several months until, one day, he was viciously assaulted by a police officer. The NMP successfully co-ordinated a campaign that resulted in a successful action against the office responsible. However, not without Dray being charged later with assault and disturbing the peace. This was highlighted as an example of what Boudier described as the quiet criminalisation of young people identified as social undesirables, whether they were young Black youths or the poor white working-class. And this was the key point, Black or White, there was a commonality of experience that was bigger than any racial differences, the maintenance of which only served to benefit the divisive politics of the Right.   

More recently, there have been the campaigns for justice for the families of Jean Charles De Menezes and Ian Tomlinson. To that you can add Mohammed Abdulkahar, and his brother Abul Koyair, the first of whom was shot before they were both arrested in a shambolic terror raid in Forest Gate in 2006, for which there was no evidence to bear out the purported “specific intelligence”  on which the police were acting against two innocent men. “Back in the day, the thugs were out on the streets, it was easy to spot a skinhead”.” “Now, we’re fighting something you can’t always see.” This was a reference to the “War on Terror”. That fear and paranoia that is exploited to justify an increasingly draconian approach to policing and public order, of which the mass surveillance of the sort that saw the Met Police attempt to “infiltrate” the NMP or the mass arrest of anti-fascist activists resisting the continuing threat of the National Front’s progeny, the EDL, provides just two recent examples.

To this, add the impact of the first round of legal aid cuts in the Legal Aid and Sentencing Act 2012, the further isolation of vulnerable communities as designed in the latest legal aid proposals and the desolation that will result from the government’s austerity programme. The demands on its services will be all the greater as these policies start to bite. I don’t know how exactly the NMP will navigate these challenges but, one way or another they will, of that I am sure. If the utopia of post-racialism continues to allude us then let’s hope for 33 more years of this inspirational community project. Here's to keeping the fight alive.

Nadeem’s film will be available online via the NMP website within the next few weeks. I will add a link as soon as I can. In the meantime, there will be local showings to mark Black History month.

*In producing this post, I also consulted an interview that Asad Rehaman gave to Black Flag magazine in the early 2000s.

The Smiley Culture Verdict: a peculiar conception of justice

More than 2 years after his death, an inquest jury has finally delivered a verdict on the death of cult reggae star David "Smiley Culture" Emmanuel. It is one that will offer little comfort to his family or those, like myself, who rallied behind the "Campaign4Justice for Smiley Culture" in the wake of yet another unquestionably avoidable death, contributed to by basic failings by the authorities.

Smiley died shortly after 4 police officers attended his home to execute a search warrant. Despite being under arrest, he was able to escape the supervision of these officers, make his way to the kitchen, take a knife from the drawer and inflict a single, fatal blow to his heart. The verdict: suicide.

The implication of the jury's verdict on these "tragic events" is that Smiley  resorted to this desperate act to avoid the prospect of a long prison sentence for drugs offences with which he had been charged and bailed, pending a trial just days before his death. That is certainly the simplest, most convenient explanation. Not least because 3 of his co-accused were later convicted and sentenced to lengthy custodial sentences. But there are some who have gone a step further and suggested that this renders the circumstances of Smiley's death as unworthy of concern. It is a narrative that characterised the death of Mark Duggan as that of a gun-toting drug dealer, who, one way or another, got what was coming to him, as did Azelle Rodney, if only for travelling in a car where other passengers may have had guns. The (subconcious?) public receptivity to this idea was well understood by the Met Taskforce intent on smearing the Lawrence Campaign.

Whilst the hang 'em and flog 'em brigade, members of which dismissed the outcry at Smiley's death as "a lot of fuss" might not have any truck with the presumption of innocence for "them", as opposed to "us" . These were men who died innocent of any crime. The farcical misinformation that followed in the wake of Duggan's death, to which even the IPCC contributed, was quickly exposed. The events leading to the death of Azelle Rodney remain the subject of a public inquiry that is due to report this Friday. Whilst we will never know what Smiley was or was not involved in, it does not matter.

Equally as fundamental as the presumption of innocence, is the Rule of Law. Even if a person is/was guilty of a crime,  we are subject to a standing police force not mob rule. The idea that justice is only for people who are "really" innocent is comfort to a fool and must be rejected without hesitation. As Smiley's nephew, Merlin, who set up the justice campaign has put it:

"My gripe with my uncle's death is not if he was an angel or demon but how he died.. It was most peculiar to say the least. If any other person's family member had died under such peculiar circumstances, of course, by default, there would be an understandable concern."

However, straight-forward the outcome may have been to some, it did not convince everyone on the jury. After 12 hours of indecisive deliberations, the coroner accepted a majority verdict.

Even if (and it remains, in my view a big "if") the prospect of prison suffices to explain why Smiley might have done what he did, ask yourself this. Just how is a man, now in the custody of no less than 4 officers, allowed to find himself in a situation where he can get hold of knife and take his own life? According to the police account, up until his very last few moments, Smiley had been calm. One of the officers attending was known to Smiley and described him as being "courteous, respectful, and compliant". So much so, he was able to stand:

"[u]nobserved... from his chair and obtained the knife
from an unknown location. The severity of the injury meant that, despite the officers
best endeavours and paramedic attendance, Mr Emmanuel could not be saved."

What trigged a sudden change in mood that saw him apparently become aggressive? Threatening officers before turning the knife on himself?
 
That Met supervision, or more accurately the lack of it, was a contributing factor in his death, was so evident that it is little wonder that the jury were able to agree on this point. How is it that trained officers allowed this to happen? The decision to make the one of the officers responsible for supervising Smiley and the search was accepted as a contributing factor. In addition, according to the chambers of Leslie Thomas, who represented the family:

[t]he inquest has also highlighted serious failings in the Independent Police Complaints Commission's investigation, including a failure to attend the scene until some four hours after the event, a failure to secure all relevant evidence, and a failure to critically analyse opinions expressed by the expert witnesses.

Although, these observations do not appear on the verdict itself.

Yet again however, there will be no further opportunity to examine the officers concerned. The Coroner will write to the Met to highlight the failings but the IPCC are standing by their decision not to pursue misconduct proceedings. Perplexingly, this is despite recognising that:

"[t]he ongoing assessments made by officers were left wanting. Four experienced officers felt it appropriate to detain a suspect in the kitchen, potentially the most dangerous room in the house and afforded him a level of freedom not normally associated with an operation of this kind."

The promises of a more robust Commission, endowed with more potent investigative powers in the wake of Hillsborough revelations and its shambolic handling of the investigation into the death of Sean Rigg are, as I expected already exposed as bitterly hollow.

The verdict has been met with consternation by Smiley's family. It is hard to argue with the feelings of his daughter Shenice McConnachie that, in truth, the verdict brings us "no closer to the truth". There are simply too many unanswered questions. Without them, there can be no justice.  

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.

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.