LEGAL campaigners have slammed loopholes in the inquest system as a “systemic scandal” and called for an independent body to ensure recommendations are implemented.

The Inquest charity campaigns to stop deaths in custody and said coroners’ Prevention of Future Death (PFD) reports were not legally enforceable.

Richard Caseby’s 23-year-old son, Matthew, died hours after escaping over a fence at Birmingham’s Priory Hospital Woodbourne in 2020 when he was left unattended.

The inquest jury ruled the private hospital contributed to Matthew’s death by neglect.

Mr Caseby said: “The coroner at Matthew’s inquest made a clear recommendation to the Health Secretary about the height of fences in acute psychiatric units.

“I still have no idea whether anything has been done to stop this from happening to another family.”

Inquest welcomed today’s report from the Independent Advisory Panel on Deaths in Custody (IAPDC) and its recommendation that the government set up a new body to audit and follow up PFD report recommendations.

The charity said the IAPDC report finds “the preventative potential of PFD reports not currently being fully realised, with families criticising the current system as nothing more than a paper exercise.”

Inquest claims the IAPDC report also highlights that coroners’ concerns are often “only cursorily addressed by respondents, or simply not addressed at all.”

Inquest’s Deborah Coles, who is also a former IAPDC member, said: “We need to maximise the preventative potential of these reports that too often simply gather dust.

“Families go through protracted and complex inquests after deaths in detention in the hope that no other family will go through the same experience.”