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19 February 2021


  • Recent news on:
    • INQUEST casework
    • Policing and racism
    • Mental health and social care
    • Prison
    • Inquests and Inquiries
  • Work for us – new recruitment opportunities
  • Family noticeboard – updates for families working with INQUEST
  • In other news - other highlights from the period in brief

INQUEST casework

INQUEST currently has 612 ongoing cases. Since January, INQUEST has had 81 new inquiries and taken on 41 new cases.

  • 21 mental health related
  • 10 police related
  • 8 prison related
  • 2 other/to be determined

In January we were pleased to welcome Nancy Kelhar as the ninth member of the casework team.

As we continue to respond to the ever increasing need for our casework services, we are grateful for donations from those who are able to give.

Donate here

Policing and racism

“My brother is not alive today because of the colour of his skin.”

- Kadi Johnson, Sheku Bayoh’s sister

Panorama: In January the BBC aired a Panorama special titled I Can’t Breathe: Black and Dead in Custody. The programme focused on the deaths of Black people in police custody across the UK. It looked in detail at the deaths of Kevin Clarke and Sheku Bayoh, as well as new evidence in the cases, and the challenges both families have faced in seeking justice.

INQUEST supports both families and worked with the BBC on the powerful documentary, which contains harrowing scenes with footage from CCTV and police body cameras. Learn more and watch the programme here.

Event: 9 March 2021 will be the third anniversary of the death of Kevin Clarke. Alongside INQUEST, the family invite you to an online memorial event where Kevin’s sister Tellicia Strachan will speak alongside Marcia Rigg, campaigner and sister of Sean Rigg. They will discuss the circumstances and impact of Kevin’s death, the wider context of racism in policing, the international Black Lives Matter Movement, and how you can support families in their work for justice in the UK. Book here.

National scrutiny: Deborah Coles, Director of INQUEST gave oral evidence to the ongoing Police Conduct and Complaints Inquiry by the Home Affairs Committee, alongside Michael Oswald speaking for the Police Action and INQUEST Lawyers Groups. The focus was highlighting the continued barriers to accessing justice in the investigation and complaints process for families bereaved by deaths in police custody and contact. See INQUEST's written submission, or watch the hearing.

International scrutiny: INQUEST has submitted detailed evidence calling for international action on structural racism and the lack of accountability following deaths in police custody or contact in the UK and around the world. The evidence has gone to the Office of the United Nations High Commissioner for Human Rights for their report on systemic racism, violations of international human rights law against Africans and people of African descent by law enforcement agencies. Learn more and read the evidence here.

On the submission, INQUEST told The Observer, “The UK claims transparency for its law enforcement and legal processes but our work tells a different story. We see a repetition of deaths of black people in police custody, raising concerns about structural racism, state violence, neglect and impunity.”

Journal: The latest Race & Class, a journal from the UK Institute of Race Relations, has been published. It examines how race, mental health and state violence intersect. INQUEST’s director Deborah Coles and family campaigner Marcia Rigg are featured among the powerful contributions from a range of activists and academics. Learn more.

Ongoing investigations:

The ongoing inquest into the death of Leon Briggs, who died following restraint by Bedfordshire police on 4 November 2013, is expected to conclude in early March. Footage of his treatment by police has been released to the media, with reports in Channel 4 News and the BBC (note: links contain distressing footage).

The family of Anthony Grainger, whose fatal shooting in 2012 was subject to a deeply critical public inquiry, have expressed their disappointment after the Independent Office for Police Conduct (IOPC) announced they’d take no further action against an officer involved in his death. It’s reported that the IOPC have been unable to access crucial material for their investigation, which the family say was therefore “doomed from the outset”. Other aspects of the investigation are ongoing.

Protests have erupted in Ireland following the fatal police shooting of George Nkencho, a 27 year old Nigerian-Irish man, on 30 December 2020. George was experiencing a mental health crisis before he was shot by the Garda Armed Support Unit at his home in Dublin. The family have called for the Irish justice minister to support an independent public inquiry.

There are also continued protests in Wales, following the death of Mohamud Hassan on 9 January 2021, shortly after being held in police custody overnight. There are concerns about police use of force against Mohamud, and the response to his reports of feeling seriously unwell. Investigators from the Independent Office for Police Conduct have now served a misconduct notice on a South Wales Police officer as part of the investigation. See media coverage.

This week we were saddened to learn of another death in police contact Wales, just six weeks later. Moyied Bashir, 29, died on Wednesday 17 February 2021, following contact with Gwent Police. Moyied’s family report he was in mental health crisis and a large number of police officers responded to calls for help, and used force and restraints before taking Moyied to hospital where he died. See media coverage.

Mental health and social care

Essex mental health services inquiry: Jayden Booroof died in October 2020 whilst an inpatient at the Linden Centre in Essex. His mother Michelle is one of 66 families calling for a statutory public inquiry into Essex mental health services. She spoke to ITV news. A growing collective of families bereaved by deaths in Essex mental health services are asking supporters to sign their petition to help secure a statutory public inquiry, rather than the inquiry planned by government. INQUEST stands with the families in the fight for justice.

Tees Esk and Wear Valleys NHS Foundation Trust scrutiny: INQUEST has joined a number of bereaved families in calling for increased scrutiny on the high number of deaths of mental health patients under the care of TEWV. Families alongside their legal representatives are calling for a public inquiry, to run alongside the ongoing investigations into some of the deaths of young women in the now closed West Lane Hospital in Middlesbrough. See ITV coverage.

Crowdfunding for justice: The family of Luke Naish, who are hoping to challenge the uncritical inquest into his death, have launched a CrowdJustice fundraiser and campaign page ‘Voice for Luke’. The inquest in January identified no failures or points of learning for those tasked with Luke’s care under Avon and Wiltshire Mental Health Partnership NHS Trust, despite a range of critical evidence and the concerns of the family. See our media release.

Preventing NHS scrutiny: An investigation by The Telegraph has found NHS Trusts have spent £30million on ‘witness coaching’ and preparing staff for inquests. The three highest spenders were NHS mental health Trusts. Additionally, following the Morecambe Bay Inquiry, the government agreed to implement a national protocol to avoid attempts to ‘fend off’ inquests by the NHS. This never happened. Deborah Coles commented on the impact these issues are having.  

Event: This month INQUEST Director Deborah Coles took part in the Maudsley Learning webinar ‘Seni’s Law: Detention and Race Interrogated’, alongside family campaigners Aji Lewis and Marcia Rigg. Deborah highlighted the need for urgent implementation of Seni’s Law, independent investigations into deaths in mental health settings, and a national oversight mechanism to ensure potentially lifesaving recommendations following deaths are enacted.  We hope to share a recording of the event when it is published. See live tweets.

Inquest conclusions:

Left to right: Luke Naish (see info above), Keaton Burton, Ross Mackenzie, Matthew Copestick, Patrick Casey

Keaton Burton, 19, was a kind person with a love for cars and a passion for music. During a mental health crisis, he was admitted to the Tramwell Mental Health Unit in Gateshead. He was allowed to go on unescorted leave, but absconded and walked 15 miles to a family home. He was found dead the following day. The inquest found his death was a suicide, with evidence highlighting a number of issues in care. See media release.

Ross Mackenzie, 40, was a much loved man and talented guitarist. He was under the care of community mental health services in Plymouth when he died on 2 December 2018. The inquest conclusion highlighted shortcomings in his care. A recent review of 11 serious incidents by NHS Devon Clinical Commissioning Group found seven people, including Ross, had presented to the Emergency department within 72 hours of their deaths. See media coverage.

Matthew Copestick, 21, was a funny and kind-hearted person and ardent supporter of Rochdale FC. He had autism and a high level of care needs which Rochdale Borough Council were responsible for. He needed an urgent alcohol detoxification but did not gain access to a programme. The inquest found inadequacies in his care, and concluded that when Matt was taken to A&E four days prior to his death he should have been admitted for inpatient detoxification. See media release.

Patrick Casey, 41, known as ‘Wacker’ to family and friends, was a caring, kind soul. He had a high level of care needs following a serious brain injury and died in April 2019. Care staff had allowed Patrick access to foods known to be dangerous to him. The coroner found staff at the Priory Group run care home Devon House had a “limited and flawed” understanding regarding Patrick’s food, and that his death was avoidable. See media release and ITV news coverage.


Podcast: The Justice Gap spoke to family campaigner Donna Mooney and INQUEST’s Deborah Coles about the hopelessness and despair still being caused by the controversial indeterminate prison sentences known as IPP sentences in this new Unjust Podcast (available on all main podcast providers). Donna, whose brother Tommy Nicol died in prison in 2015, campaigns with UNGRIPP on behalf of the thousands of IPP prisoners still in custody, despite the sentence being banned in 2012.

Statistics: The latest official statistics on deaths in prison in England and Wales show the overall number of deaths is rising, particularly in the latest quarter (September to December 2020) when they rose by 70%. Last year saw the second highest rate of deaths since records began more than 40 years ago, and the highest ever rate of deaths recorded as ‘natural causes’. See our media release.

In the 12 months ending September 2020, there was an overall decrease in self-harm in men's prisons, down 7% from the previous year but remaining at historically high levels. However self-harm in women’s prisons continued to rise to the highest ever levels.

INQUEST told the Independent, “These statistics represent hundreds of people suffering in extreme conditions in prisons. The government ignored experts calling for large-scale early releases to protect people in prison from the impact of the pandemic. We are beginning to see the devastating impacts of that decision.”

Our monitoring shows that already in 2021 more than 45 people have died in prison. Many deaths relate to Covid-19, and there have been at least ten self-inflicted deaths of men as young as 18.

Women’s prison expansion: Despite expressing a commitment to diverting more women from custody, the government has announced 500 new prison places for women. This followed the death of 18 year old Annelise Sanderson in Styal Prison on 22 December 2020. 

We told The Justice Gap, “The more places you have, the more courts will fill them. Instead of expanding prisons, we need to act on the evidence and redirect resources to specialist women’s and community services and address inequality, health and welfare.”

Mental health in prison: Diane Coulson, whose 21 year old daughter Emily Hartley died in prison in 2016, spoke to the Guardian about the systems which failed her. This moving conversation was published alongside new research showing the number of prisoners put on suicide or self-harm watch (known as ACCT) has risen dramatically over the past decade. INQUEST commented, “Prisons generate and exacerbate mental ill-health. At a time of such restrictive and dehumanising regimes this is even more acute.”

Children’s prisons: The inspectorate of prisons’ annual report on the experiences of children in prisons exposed a grim picture of violence and self-harm and long periods locked up. The evidence shows that while the number of children in custody in England and Wales has been falling steadily, experiences of their everyday lives continue to be disturbing.

INQUEST commented, “This report is a damning indictment of the state of child prisons. This is a failing system that has proved itself incapable of reform. That only one institution was deemed safe is shameful and points to the need to stop imprisoning children and investing in child centred community services.”

Abolition: “If you had any other public institution that was failing so badly, you would probably close it down and suggest we do things differently.” Deborah Coles, INQUEST’s director, has told The London Economic in this piece asking ‘What if we got rid of prisons?’.

Inquests and inquiries

Grenfell United march in December,
three and a half years on from the Grenfell Tower Fire.

Grenfell: The Grenfell Tower Inquiry resumed in February, with evidence from Arconic revealing the company knew the cladding they provided was highly flammable 13 years before the fire. The broader cladding scandal continues, with backlash over the latest government announcements intended to address ongoing cladding safety issues in thousands of homes. A recent debate in the House of Commons looked at protecting tenants and leaseholders from this.

Accessing inquests: In January, INQUEST wrote to the Chief Coroner to raise concerns about the inconsistency in approach across coroner’s courts in managing remote hearings during the pandemic. Despite guidance which allows for remote participation via video for those involved in an inquest, and audio access for members of the media and public, practice has varied.

Some families have had issues accessing their relatives inquest at all, while members of the media have effectively been barred from accessing some inquests even via remote audio. However, there are also examples of good practice which have positively increased the overall accessibility of inquests in other areas.  

Upcoming event: INQUEST will be taking part in the upcoming All-Party Parliamentary Groups on Legal Aid event in their session on Access to Justice, discussing the ongoing campaign for legal aid for inquests on Thursday, 25 February 2021 10:00 – 12:30. Register your interest here.

Finding justice: The challenges of accessing justice in coroner's courts, the importance of Article 2 of the Human Rights Act, and the inequality of arms between bereaved people and the state are explored in this Law Society Gazette article featuring INQUEST alongside human rights lawyers.

Work for us

We are excited to announce two new opportunities to join our policy and communications team:

  • Senior Policy and Parliamentary Officer
    This role will be key to INQUEST’s work in influencing policy and pushing for change in areas relating to detention, criminal justice, mental health, accountability and human rights. We are looking for an experienced policy professional with knowledge of the policy landscape in at least some of the these areas, and quick to learn in others. They should have excellent understanding of the workings of Parliament.
    Application deadline - Monday 8 March, 1pm
  • Media and Communications Manager
    Managing media and communications across INQUEST’s work, this role is ideal for a proactive and highly organised communicator, able to balance priorities in a fast-paced environment. We are looking for a highly skilled and strategic communicator who will bring initiative, sensitivity and energy to INQUEST’s public-facing work. They will have a track record of high quality output, influencing media and building strong working relationships.
    Application deadline - Monday 8 March

Find out more and apply here.

The recruitment follows the departure of Sarah Uncles, INQUEST’s Communications and Policy Officer for the past three years. Sarah has joined our friends at Women in Prison. Sarah (pictured far left) will be hugely missed, but we look forward to seeing what she gets up to at WIP!

In other news

  • Funding news: We are delighted that the Esmee Fairbairn Foundation has once again shown support for our work, by granting us 5 years of funding dedicated to our integrated model and organisational development.
  • Congratulations: INQUEST would like to congratulate INQUEST Family Reference Group member Lee Lawrence on winning the Costa Book award for best biography. Lee's powerful memoir The Louder I Will Sing discusses the impact of his mother Cherry Groce being shot by police in 1985, and the subsequent campaign for justice. Find links to get a copy here.
  • Bearing witness: George Julian is a much loved campaigner and champion of open justice who works with bereaved families to tell the stories of their relatives, with a focus on the premature deaths of people with learning disabilities and autism. Her work has been featured on BBC News in a short film. You can donate to support her work here.
  • Family campaigning: This month at an event on searching for justice by The Association of Muslim Lawyers, Natasha Thompson from INQUEST spoke alongside Sukhdev Reel, Mother of Ricky Reel, and Attiq Malik, a lawyer who represents the family of Shukri Abdi, on the power of family campaigning and importance of public support. See more family led campaigns to support here.

Family noticeboard

  • INQUEST has a new online space on Facebook exclusively for families bereaved by state related deaths. Already it has been inspiring to see families share support, solidarity and understanding with one another. To join the private group please the visit Families@INQUEST Facebook Group and fill in the joining request.
  • The connection café for families continues to take place on the first Wednesday of every month, with the next on 3 March from 11am-1pm. For more information and to book your place email Mo the Family Participation Officer.
  • The National Mikey Powell Memorial Family Fundin collaboration with the United Families & Friends Campaign is opening a new funding stream The Crisis Family Fund, launching on 1 March 2021. Learn more and sign up for updates on their website.
  • Prior to the festive break, INQUEST’s family reference group organised an online ‘Reflections’ event to bring families together and reflect on the year passed. There were moving contributions, including poems, readings, discussion on wellbeing and more. More events are planned in future, with announcements via email and the Facebook group.