The Butler Inquiry (1999), formally titled the Inquiry into Crown Prosecution Service Decision-Making in Relation to Deaths in Custody and Related Matters, was a non-statutory inquiry.

It was established in 1997 by the then-Director of Public Prosecutions (DPP), Dame Barbara Mills, following significant public concern and legal challenges from the families of Shiji Lapite and Richard O'Brien. Because it was non-statutory, it did not have the legal powers to compel witnesses to give evidence or produce documents under oath—powers that would later be standardized for statutory inquiries by the Inquiries Act 2005.

Key Details of the Inquiry

• Chair: The inquiry was led by His Honour Judge Gerald Butler QC, a retired judge.

• Purpose: It was tasked with reviewing how the Crown Prosecution Service (CPS) handled cases where individuals died in police or prison custody, specifically focusing on whether the decision-making process for prosecuting involved officers was robust and transparent.

• Catalysts: The inquiry was specifically prompted by the failure to prosecute police officers in the high-profile deaths of Shiji Lapite and Richard O'Brien, despite inquest juries returning verdicts of "unlawful killing."

  
  

Findings and Impact

Although it lacked statutory teeth, the Butler Report (published in August 1999) was highly influential:

• "Fundamentally Unsound": Judge Butler described the CPS’s system for handling these cases as "inefficient and fundamentally unsound."

• Systemic Failures: The report criticized "buck-passing" within the CPS and found that critical decisions were often left to middle-ranking lawyers without sufficient seniority or specialized training.

• Recommendations: It made several key recommendations that the CPS accepted, including the creation of a specialized "pool" of senior lawyers to handle death-in-custody cases and a new requirement for the DPP to personally oversee such decisions.