In this issue:

We will be following up with a further newsletter next week to update you with developments on the legal aid campaign, deaths in prison, probation failings and our ongoing work with families. 


In the past month, multiple inquests have concluded into the deaths of people in, or following, police custody where drug swallowing or secreting packages was a factor. Many of these cases raise issues with the police's recognition of, and response to, medical emergencies. 

INQUEST is concerned about the hostile environments frequently created at these inquests through the defensive and combative tactics of police lawyers. This was particularly prominent at the inquest into Edir (Edson) da Costa where lawyers representing the police sought to narrow lines of inquiry and divert attention away from the circumstances that resulted in his death

An inquest jury found that failing to take Carl Maynard, 29, directly to hospital after suspected drug swallowing represented a ‘missed opportunity to increase Carl’s chance of survival’. They also rejected the Kent Police officers’ initial justifications for entering his property, which did not meet the legal standards required. 

Police officers failed to adequately carry out constant observations which provided an opportunity for Leroy 'Junior'  Medford to ingest drugs, a jury found. Evidence was heard that timely medical treatment would have made it "very, very likely" that Junior would have survived.

The jury found that the cause of death of Adam Harris, 34, was cocaine and alcohol toxicity. He was held by Greater Manchester Police in a van dock area outside the custody suite for 54 minutes where he demonstrated increasingly bizarre and concerning behaviour. Adam was then in the custody suite for an hour before receiving medical attention.

Edir (Edson) da Costa, Adam Harris, Carl Maynard, Leroy 'Junior' Medford, Darren Cumberbatch (left to right)

A jury returned a majority ruling at the inquest into the death of Edson da Costa that he died by ‘misadventure’ after his airway was obstructed by a plastic bag containing drugs. His father was quoted in the Independent “Edir did not deserve to die in the way that he did and we will forever feel that if things had been done differently his life may have been saved.”

Restraint by Warwickshire Police contributed to the death of Darren Cumberbatch, a jury found. He died as a result of cocaine use in association with restraint and related physical exertion. Deborah Coles, Director of INQUEST, was quoted in HeartThere is no justification for the brutal use of force Warwickshire police deployed against Darren. He was struck by batons, Tasered, sprayed with an incapacitant, punched, stamped on and restrained. Such violence is no way to respond to a man experiencing a mental health crisis, agitated, paranoid and afraid.”

The jury at inquest into the death of Joshua Blackham, a Surrey police officer, found that he was under considerable stress which is likely to have contributed to his self-inflicted death. The welfare system within Surrey police was inadequate and information sharing was insufficient to meet Joshua’s needs. Failures in process at the NHS also meant he did not receive the mental health support his GP referred him for.


14 June marked two years since the Grenfell Tower fire in 2017. At INQUEST we paused to reflect and remember the 72 people who needlessly lost their lives.

These families continue to show great courage, defiance and strength as they selflessly and tirelessly fight for the truth and campaign for the safety of us all. We attended the Grenfell silent walk alongside many others to show solidarity and support the Grenfell community.

“Two years after a public inquiry into Grenfell was announced, not a single recommendation has been made to prevent future deaths. This is failing the families and survivors who placed their trust in this inquiry. It is failing those who continue to feel unsafe in their homes. Grenfell families have put their trust in the Inquiry.” Deborah Coles wrote in the Guardian.

Emma Dent Coad MP brought a debate in the House of Commons on the response to the Grenfell Tower Fire. INQUEST's parliamentary briefing, sent to MPs in advance of the debate, draws on our recent evidence based report, Family reflections on Grenfell: No voice left unheard.

Through their lived experience, families made practical and insightful suggestions for change to establish best practice for this Inquiry, and for future disasters.

Lawyers for two US law firms announced that they had filed of a lawsuit against US manufacturers on behalf of the families of 69 people that died and 177 that survived the fire at Grenfell Tower, in a bid for corporate accountability. INQUEST was quoted in ITV.

INQUEST's Grenfell Project Coordinator Remy Mohamed wrote a blog for The Law Society about Grenfell 2 years on. She writes “The bereaved and survivors inspire me daily with their dignity, defiance and commitment to preventing future disasters.”

Immigration detention

2017 saw 11 deaths of people who had been detained under immigration powers, the highest  annual number on record. Many of the inquests from this unprecedented spike are now underway. Successive inquests have highlighted fundamental failings in treatment and care of immigration detainees as well as unsafe systems and practices.

The two most recent cases both evidence a culture of disbelief by detention staff when detainees are in distress and requesting medical attention.

The jury at the inquest into the death of Amir Siman-Tov found that several missed opportunities contributed to his death. Amir was taken to hospital after he explained that he had taken an overdose of prescribed painkillers. A doctor at the hospital received a phone call from a psychiatrist working at Colnbrook Immigration Centre, who was sceptical that Amir had taken an overdose, suggesting instead that he may have taken tic tacs.

His family were quoted on RightsInfo: “The jury’s conclusions show that he did not wish to die and that if those with responsibility for his care had not failed him, he would be alive today."

At the inquest into the self-inflicted death of Marcin Gwozdzinski, the jury found ‘systemic failures’ at Healthrow IRC contributed to his death. The day before his death, Marcin telephoned London Ambulance Service (LAS) numerous times requesting assistance, asking the operator to come to the centre to save his life. The control room at the IRC told the LAS that Marcin had been making hoax calls.

The High Court has ordered a landmark public inquiry into immigration detention abuse. INQUEST welcomed the judgement in response to decades of denial and obfuscation by the Home Office. The abuse exposed at Brook House and wider harms across the detention estate highlight the human cost of UK immigration policies. Read more on Detention Action.

Mental health and learning disabilities

“How much more light can be shone on well-documented and sustained human rights abuses, deaths, dangerous restraint and practices that are endemic in institutions and enabled by the clearly deficient and failing processes of investigation, oversight and external scrutiny”.

Deborah Coles, Dr Sara Ryan and Mark Neary’s joint letter to the 

The Parliamentary Health Service Ombudsman highlighted the systemic failure of former NHS Trust to tackle repeated failings following the deaths of two young men. The Leahy family have launched a parliamentary petition calling for a full public inquiry, which now has 9,000 signatures.

Melanie and Michael Leahy were quoted on EssexLive"Patients continue to die. More paper shuffling just delays necessary changes to be made sooner. Continued failings have eroded public confidence in services and a public inquiry is the only way to bring it back.”

Alison St James died in 1991 whilst she was a mental health inpatient. Alison's siblings, Tom and Sarah, are seeking a new inquest into her death so the truth about what happened can be uncovered and made public. To do this they must raise £8,000. Please support their Crowdfunder.

Probation failings

There have been a number of inquests into the deaths of women killed by someone under probation supervision. These inquests have performed a vital function in scrutinising the actions and inactions of the state, in the hope that future deaths can be prevented. 

These are not isolated cases and until violence against women is taken seriously by authorities the deaths will continue.

The inquest into the homicide of Quyen Ngoc Nguyen exposed a ‘dysfunctional’ system for public protection and concluded that she was unlawfully killed.

Failures of West Midlands Police and National Probation Service contributed to homicide of Lisa Skidmore, the inquest into her death found. The perpetrator had alerted the services to his increasing risk but no action was taken.

The Advisory Council on Misuse of Drugs have released their report on Custody-Community Transitions. Drawing on INQUEST’s submission, the Committee has called for systemic changes to reduce deaths of people following release from prison and police custody.

Other news...

  • Senior Caseworker Selen Cavcav delivered training to coroner’s officers together with Tony Herbert (father of James Herbert) to inform them about the experiences of families facing a state related inquest. Selen stressed the importance of early advice and sign posting. Direct referrals from coroner’s officers have increased since our participation to these training events.
  • Deborah Coles spoke at the British Society of Criminology conference in Lincoln alongside Marcia Rigg, Shelia Coleman and David Scott about the importance of activists and academics speaking truth to power.

  • Our caseworkers delivered training to Saint Joseph Hospice Volunteers which covered the impact of inquest and investigation processes on bereavement.
  • Deborah Coles joined Sonali Naik QC to shine a light on the many injustices faced by women in the criminal justice system to mark the 40th anniversary or Clean Break. 

Thank you

The INQUEST team completed the 10km London Legal Walk. It is the fourth time we have participated to raise money to continue our work. Huge thank you to everyone who sponsored us.