1. Preventing deaths in police custody The role of the custody visitor Deborah Coles co-director INQUEST

2. About INQUEST Advice Casework Policy and research Campaigning

3. Police custody deaths in numbers 269 deaths in police custody in last 10 years (to October 2013) 47 black and minority ethnic deaths INQUEST has worked on 206 police custody deaths in the last 10 years

4. Case study: Andrzej Rymarzak Alcohol intoxication Failure to follow procedure including: Failure to conduct rousing checks Failure to provide adequate medical care and treatment

5. Case study: Thomas Orchard Mental health Restraint Use of Emergency Response Belt (ERM) Taken to police custody Adequacy of medical care

6. Key issues arising from INQUEST casework on deaths in police custody Mental health Restraint (incl. Taser use) Drug and alcohol intoxication Drug swallowing Medical care and role of FME Self harm and self-inflicted deaths

7. Cont’d… Communication problems Training Record keeping/monitoring Cell design/Risk Assessments/Custodial Health & Safety

8. HMIP/HMIC inspections of police custody Poor recording and analysis of use of force Authorisation and incidence of strip searches and use of force – use of strip clothing Too many mental health detainees in police custody Unsatisfactory risk management

9. Regulation 28 Prevention of Future Deaths reports (previously Rule 43 reports) and narrative conclusions/verdicts Learning tool to prevent future fatalities More meaningful outcome for bereaved families Current limitations: Lack of detailed monitoring, analysis or follow up

10. Learning from deaths in custody The need for a more co-ordinated role on post- inquest learning from regulation, inspection and monitoring bodies Integration of investigation and inquest findings and follow-up Incorporate post inquest learning in Custody visitor role

11. About INQUEST Learning from Death in Custody Inquests http://www.inquest.org.uk/publications/learning-from-death-in-custody- inquests ‘Inquest Law’ magazine – subscribe: http://www.inquest.org.uk/ilg/inquest-law-magazine inquest@inquest.org.uk www.inquest.org.uk