Angiolini review – work still to be done on serious incidents and deaths in custody

The independent review into serious incidents and deaths in custody by Dame Elish Angiolini has now been published. This seminal report has been long in gestation and reiterates some of the findings of previous reports covering deaths in police custody.

When Theresa May was Home Secretary she commissioned this report in part due to the death of Olaseni Lewis. One of the principal aims was to examine the procedures and processes surrounding deaths and serious incidents in police custody, including the lead up to such incidents, the immediate aftermath, through to the conclusion of official investigations.

Angiolini’s report is insightful, measured and challenging – she makes 110 recommendations, summarised in Chapter 18. These extend wider than the police service to cover health and the justice and coronial systems. They are a blueprint for change. The recommendations aim to minimise the risks of such incidents occurring in the future and “ensure that when such incidents do occur the procedures in place are efficient, effective, humane, and command public confidence.”

The report covers 18 chapters but the chapters of most interest to those working in the health and care sector are:

  • Chapter: 11 NHS investigations
  • Chapter: 16 The coronial system
  • Chapter: 17 Sustained learning

Recommendations are grouped thematically in the report but of the 110 recommendations, 15 recommendations stand out and will be of interest to readers. We set out those issues below.

Health and wellbeing (Recommendations 20 – 32)

  • Healthcare professionals should take primary responsibility for the conduct of safe management of restraint of patients in any healthcare setting. The police may have to intervene with some form of restraint but its use should be strictly limited and subject to robust monitoring and training. (Recommendation 20)
  • Independent investigations should always be held for all Article 2 related cases on NHS premises where there has been police involvement, or where someone died after contact with the police. (Recommendation 30)

Funding for families and family support (Recommendations 33 – 45)

  • The Coroner and Independent Police Complaints Commission (IPCC) staff should tell families immediately following the death of their loved one of the right to independent free specialist legal advice, the benefit of securing advice from the earliest possible stage and the right to representation of a pathologist at the post mortem or to request a second post-mortem. (Recommendation 35)
  • Consideration should be given to the mandatory video and audio recording of post-mortem examinations in contentious Article 2 deaths, with strict respect given to the control, storage and disclosure of recorded images. Wherever possible, such examinations should not take place until the family’s chosen pathologist is in attendance. The video would serve as a record of the post-mortem but should not be used as a reason not to hold a second post-mortem examination if it is warranted. (Recommendation 37)
  • NHS Trusts should engage with families throughout their own investigations. There should be formal guidelines setting out the nature and expectations of family engagement. (Recommendation 38)
  • Where the NHS Trust is only one of a number of agencies investigating a death involving both police contact and NHS contact with the deceased there should be early, regular and formal communication and coordination with the IPCC and other agencies to minimise confusion, loss of evidence and delays. (Recommendation 39)


  • Consideration should be given to the creation of statutory time limits for the investigation by agencies unless there are to be criminal charges made and the Coroner suspends the Coroner’s investigation. It is suggested that these time limits should be set by the Coroner. (Recommendation 52)


  • The Government should consider whether there is a need for a formal independent investigatory body for NHS Trusts in England and Wales. (Recommendation 67)
  • Where an individual dies during or following restraint involving both police and health personnel, a joint independent investigation by both the IPCC and the proposed independent investigatory body for the NHS should be closely aligned and coordinated in order to investigate the full circumstances of the death, including the conduct of the health personnel. (Recommendation 68)

Coroners and inquests

  • A nationally funded National Coroner Service should be urgently considered as a means to address persistent inconsistencies of service and the inability of Coroners to pursue investigations without complete reliance on the IPCC and other agencies. (Recommendation 72)
  • A specialist cadre of ticketed and experienced Coroners should be created to preside over Article 2 inquests, under the auspices of a National Coroner Service. (Recommendation 73)
  • The 2013 Coroners (Investigations) Regulations should be amended to allow for a second post-mortem examination as of right, paid for by the state, in circumstances where no contact has been made with the family before the first post-mortem occurred, except for exceptional circumstances where all reasonable efforts were made to contact the family in advance. (Recommendation 74)
  • The Chief Coroner should consider issuing guidance on what constitutes disclosure of relevant information and, subject to the superintendence of the High Court, how Coroners should approach the issue. (Recommendation 75)
  • The Chief Coroner should issue formal guidance to Coroners to prevent inappropriate or aggressive questioning of next of kin by counsel for interested persons at Inquest hearings. Coroners should be trained to be able to identify and prevent such styles of questioning where necessary. (Recommendation 76)


  • An Office for Article 2 Compliance should oversee a coordinated, methodical and routine process around the dissemination of Coroners’ Preventing Future Deaths reports and jury findings to all stakeholders, including (but not limited to) the police force, the College of Policing, the IPCC, and healthcare professionals. (Recommendation 101)


Anglioni’s report includes a look again at a National Coroner Service. Such a service would enhance the independence of coroners and ensure that coroners are not totally reliant on third party investigations which will be welcome news for all those involved in inquests.

Since this report was published at the end of October we have had the findings of the Hillsborough review which echo similar themes on matters relating to coroners and inquests. However we will have to wait and see what changes follow!

Jill Mason, Partner and Stuart Knowles, Consultant 

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