Preventing deaths in custody and the role of family
Like many others who have followed ICPR's rigorous research on 'Voicing Loss', I have been moved by what family members say about their experience of the coronial process: in how it can help to understand what led up to a tragic death but, sadly, how often it can compound pain and grief. And, like others, I am in awe of the strength and resilience of families determined to make sure that learning from the loss of a loved one could help to prevent future deaths.
My lens is necessarily a narrow one. Much of my work has been about trying to effect prison reform and, latterly, trying to prevent deaths in custody. My experience has been largely informed by the views, and generosity to share information, of people who live or work in custody and families and friends of people detained by the state.
First it is impossible not to be struck by how much keeping in touch with family and friends means to people in prison. A bedrock of the Prison Reform Trust is its advice and information service. Responding to over 6,000 queries a year, this service provides clear, accurate information, helps to navigate, and sometimes change, bureaucratic and arcane systems and assists prisoners and their families and friends to maintain contact.
The punishment of imprisonment is loss of liberty, not loss of hope or identity, and certainly not loss of life. Families undoubtedly help to keep people safe in custody. This is underscored by, amongst others, the Harris[1] and Farmer[2] reviews, investigations by the Prisons and Probation Ombudsman and testimony to the Independent Advisory Panel on Deaths in Custody (IAPDC). One prisoner told the IAPDC: 'Families are your people - people you can be yourself with. Family is your link to the outside world.' Another wrote in response to the widescale IAPDC consultation on how to prevent the deaths of women in prison: 'Contact with family is extremely important. I am hundreds of miles from mine. My mum is my rock and I used to see her or speak to her every day outside. Now I only get to speak to her once/twice a week using a phone that crackles. I won't see my mum again until October next year as she is too ill to travel.’[3]
From the ravages of the pandemic, a major legacy is in-cell telephony expedited by the prison service across most of the prison estate. Nonetheless, families still struggle whether to book visits and arrange transport or to share information and raise important concerns with staff. In the IAPDC ‘Keeping Safe’ consultation,[4] family members from the charity Nepacs in the Northeast advised that governors and staff must ensure ‘prompt follow up from phone calls/messages from concerned family and friends – do not dismiss them as worriers, worse still, nuisances.’
Far too often in the multiple investigations and reviews that follow a death in custody, unheeded messages and warnings about risk emerge. This is particularly true when there is a death by suicide but also applies to the many so-called ‘natural’ deaths where information has not been shared, appointments missed, and diagnoses and treatment have come too late.
Throughout the justice system, families’ voices need to be heard and their knowledge and insights valued. The Voicing Loss team believe, rightly in my view, that even without structural reform or additional funding, imbuing the coronial service with consistent respect for bereaved families would change it for the better. As to implementing recommendations to prevent future deaths, now could be the time for a national oversight mechanism.
[1] The Harris Review (2015) Changing Prisons, Saving Lives: Report of the Independent Review into Self-inflicted Deaths in Custody of 18-24 year olds
[2] Lord Farmer (2017) The Importance of Strengthening Prisoners’ Family Ties to Prevent Reoffending and Reduce Intergenerational Crime