The Commission’s Inquiry makes recommendations in four key areas. They are addressed at government, regulators and inspectorates and the leaders and managers of individual institutions including:

• Learning lessons and creating rigorous systems and processes 
• A stronger focus on meeting basic responsibilities to keep detainees safe
• Greater transparency and robust investigations
• The Equality  Human Rights Framework should be adopted and used as a practical tool in all three settings  

Inquiry Reports

• Preventing Deaths in Detention of Adults with Mental Health Conditions (Full Report)
• Preventing Deaths in Detention of Adults with Mental Health Conditions (Executive Summary)
• Human Rights Framework for Adults in Detention
• Glossary (PDF | Word)
• Recommendations (PDF | Word)
• Terms of reference (PDF | Word)