On 31 October, the United Families and Friends Campaign marked its 27th anniversary with a remembrance procession. Several groups joined to support a letter delivered to the Prime Minister at 10 Downing Street.
The letter called for urgent action to protect people in state custody. That includes people in prison and in police cells. Marchers carried the message that lives matter and the state must answer for these deaths.
Three days later, the House of Commons Justice Committee held a hearing on learning from inquests. It also considered the case for a national oversight body.
Families’ evidence
The first panel heard from bereaved relatives in cases where the authorities had been found responsible for neglect. They were Richard Caseby, Jonny Santer and Dr Kate Szymankiewicz.
Mr Caseby’s son died after leaving a secure hospital, where he had been held under the Mental Health Act. Mr Santer and Dr Szymankiewicz each lost a child. Dr Szymankiewicz said poor supervision in hospital had failed her daughter.
Each family described the same frustration. They said the inquest process felt adversarial rather than a search for the truth. In their view, lawyers for state bodies focused on avoiding blame rather than finding solutions.
They said inquest papers arrived very late, and hearing dates and times changed at short notice. Some coroners, they said, appeared to discourage juries from looking at the wider background to a death.
They also described a wide gap between coroners. Some pursue issues after a hearing, while others simply record findings and send them out. The families called for a standard approach that examines causes in depth.
They told MPs that nothing would bring their loved ones back. But knowing that changes would follow to save others would have eased their pain. Instead, they said, nothing had changed, and Prevention of Future Deaths (PFD) notices had made no difference.
Campaigners’ evidence
The second panel heard from Deborah Coles, Executive Director of the charity INQUEST, and Dr Georgia Richards. Dr Richards founded and directs the Preventable Deaths Tracker and is an academic senior fellow at King’s College London.
Dr Richards welcomed one change. The Chief Coroner’s office now publishes lists of PFD notices that have gone unanswered. But she said recent changes to ease work pressures delay publication of the notices. That makes it harder to see who has responded, and harder to learn from inquests.
Ms Coles and Dr Richards said inquests often cite inadequate care plans for people at risk, yet the problem persists. So do failures by staff to carry out proper checks on vulnerable prisoners.
The Justice Committee reported on the Coroner Service in 2021. It called the lack of a system to follow up PFD reports a ‘missed opportunity’. A follow-up inquiry began in 2023. The then-Chair later wrote to the Ministry of Justice about PFD reports and the poor use of coronial data. The committee expects to report later this year.
The United Families and Friends Campaign also held a demonstration in Scotland. One participant, Sharon Cowan, said campaigners want Scotland to scrap its Fatal Accident Inquiry system. Critics have called it unfit for purpose. They also want more support for families of prisoners who die, including immediate legal representation and funding.
MPs in England also heard that families need legal representation at inquests to get justice.
