Welcome to the latest edition of our newsletter.

Are the NHS learning from deaths in their care?

Last month, INQUEST director Deborah Coles spoke at the ‘Learning from Deaths conference’ organised by NHS Improvement and attended by over 450 senior NHS leaders. She followed a powerful presentation by Scott Morrish about his battle with the NHS to get the truth about how his son Sam died. INQUEST's presence brought to life the lamentable experiences of many bereaved families following state-related deaths and the work of INQUEST in trying to ensure the meaningful engagement of bereaved people in the investigation process, greater accountability and learning.
Aldyth Smith, mother of Bethan who died in NHS care and who attended our CQC Family Listening Day last year (and the above event) talks here about the need for Trusts to listen to families and the vital support INQUEST provided in their fight for justice. This extract below from her story shows the enormous impact ‘real listening’ and a long-awaited apology from the NHS Trust has had on her family: 

“Quite astonishingly the Trust wrote to us to say that our story was to be looked at again with fresh eyes and the first meeting was in January [2017]. My healing began as soon as Diane said 'Tell me about Beth'. The difference that real listening makes is immense. At last Beth was at the centre of things, right there with us in that room and we knew exactly why we had fought so hard for the truth…

Yesterday we met again with the Trust which now has a new Chief Executive. She offered us an unreserved apology for the way we have been treated. It was powerful and we knew that the days of writing angry but careful letters where you have to make sure that every statement is balanced by fact were over…. We know that there would have been no change at all without [INQUEST’s] Family Listening Day and the opportunities it offered. This little victory is for all of us, for you at INQUEST and for those who have no voice or strength to fight. The Trust has plans for a new initiative based on what they pledge to families when someone dies. For us at least this will be always be known as Beth's Pledge”.

Thomas Orchard - how can we reconcile a ‘not guilty’ verdict in light of the disturbing evidence heard?

Last month, a custody sergeant and two detention officers were acquitted of manslaughter relating to the death of Thomas Orchard in October 2012. A Home Office pathologist, Dr Delaney, identified that Thomas’ death resulted from a struggle and period of physical restraint including a prolonged period in the prone position and the application of an Emergency Response Belt across the face resulting in asphyxia.

Deborah Coles made the following statement in response to the verdict:

“It is difficult to reconcile this verdict with the disturbing evidence which has emerged during this trial. Thomas’ death is amongst the most horrific that INQUEST has ever seen.
Thomas was in mental health crisis and should have been taken to hospital. Instead, he was bound and gagged with a restraint belt across his face in what must have been a terrifying ordeal. Those who should have protected a vulnerable man lost sight of him as a human being. Mental ill health affects so many of us and this could have been any one of us. At a time when police are calling for more equipment, including spit hoods and tasers, we need to question priorities. Surely the first and most urgent need must be to train officers to respond safely and humanely to those in mental health crisis”.

We secured some strong, sympathetic media coverage for Thomas Orchard’s family following the verdict. This included the Daily Mail, a BBC Breakfast interview alongside Deborah Coles (broadcast on 12 April) and an invitation to the Orchard family to guest edit a BBC Five Live broadcast as part of a series on mental health (to broadcast on 26 April).

INQUEST calls for robust scrutiny and monitoring of child deaths in privately run, mental health settings

The inquest into the death of 15 year old Pip McManus whilst under the care of a privately run, Priory mental health unit is expected to conclude at the end of April. We have long campaigned for greater monitoring, reporting and independent scrutiny of child deaths in mental health settings and concerns about the secrecy surrounding private providers. INQUEST has called for an independent review into child and adolescent mental health services, in light of a disturbing pattern of cases we are working on which raise concerns about the quality of care in private and NHS settings.

Deborah Coles said at the inquest’s opening this week: 

“The case of 15 year old Pip McManus reinforces INQUEST's serious and ongoing concerns over the lack of scrutiny and oversight of young deaths occurring in mental health settings like the Priory.  There currently remains no pre-inquest system of independent investigation into the deaths of children who die as mental health in-patients. We are aware of the deaths of several other children receiving mental health care in Priory hospitals. With private providers now publicly funded to provide 47% of all in-patient Child and Adolescent Mental Health Services, we need to know that adequate safeguards and controls are in place.”

Hillsborough Law – a step closer to ‘equality of arms’?

On 26 March 2017, the Public Authority Accountability Bill, the historic ‘Hillsborough Law’ was presented to Parliament by Andy Burnham MP. INQUEST director Deborah Coles attended, alongside some of the Hillsborough families and other justice campaigners.
Drafted by lawyers who represented the Hillsborough families in the recent inquests it seeks to fundamentally rebalance the legal and coronial system in favour of ordinary families and to prevent any other bereaved families going through the same experience as the Hillsborough families and experiencing a similar miscarriage of justice.The Bill aims to make it a legal duty for public authorities and public servants to tell the truth and act with candour.

If successful, this Bill will:

  • Rebalance the legal system by giving bereaved families equal funding at inquests,
  • Require police and public servants to be open and truthful in legal proceedings or face imprisonment,
  • Make deliberate attempts to mislead the media a criminal offence.

Deborah Coles made this statement - “INQUEST sees first-hand the institutional culture of defensiveness following state-related deaths, as well as the inherent inequality of arms and resources for bereaved people compared to the unlimited resources available to public authorities. Hopefully, the learning from the Hillsborough inquests will be a catalyst for legal and cultural change and imbalance once and for all, so public bodies in all state-related deaths are required to act openly and honestly from the outset of investigations and at inquests to ensure their focus is on reducing the risks of similar deaths in future. Any justice system must ensure equal access to justice – otherwise, the state remains unaccountable.”

In Parliament, Andy Burnham asked Bishop James Jones (appointed by Theresa May to report on the experience of the Hillsborough families) to adopt the Bill's proposals. Just a week earlier, INQUEST had organised a Family Listening Day for the Bishop, where he heard directly from families who had experienced a state related  inquest and who spoke openly about the inequality of arms and the wider impact of the inquest process. We are extremely grateful to the families who participated and to the Bishop for listening with such compassion. The report of the day and INQUEST’s submission to the review will be published shortly.

Police-related deaths

On 30 March, INQUEST held a Family Listening Day commissioned by the IPCC. This was a follow up to the IPCC review conducted in 2013 into their investigations following a death in custody. Attendees from the IPCC included the Chair, Dame Anne Owers and other senior management. They heard directly from families who spoke candidly of their positive and negative experiences during the investigation process. We hope this will lead to improved IPCC practices.  Thank you once again to the families who attended. A report of the day will be published in due course.

There have been some significant updates in some of our longest running police cases:

  • The Grainger public inquiry - The police firearms officer Q9 gave evidence anonymously, disclosing that he had subsequently met with the police firearms officers responsible for the deaths of Azelle Rodney in 2005 and Mark Duggan in 2011, reported in the Manchester Evening News. The private meeting with the officer who shot dead Mr Duggan, known as V53, took place five days after Anthony Grainger’s death to "discuss welfare". The BBC reported witness evidence that no warning was issued before shots were fired.
  • In March, the Court of Appeal ruled against Mark Duggan’s family, who appealed to have the inquest jury finding of ‘lawful killing’ quashed, following the evidence that Mark was unarmed at the time of his death. The family and legal team are considering the judgement.

A concerning trend of young prisoner deaths

We’ve attended a number of inquests into the deaths of young men with mental health issues in prison and immigration centres over the past month:

  • Daryl Hargrave – a jury found neglect contributed to 22 year old Daryl’s death at HMP Winchester.  Daryl had a history of mental health problems and had been on remand for six days before his death. The jury found there was a failure to provide treatment for psychosis and a decision not to put him under constant supervision also contributed to his death. BBC coverage of the case was secured. His was one of three self-inflicted deaths at HMP Winchester in a two month period during 2015.
  • Chris Beardshaw – the Ministry of Justice has accepted there were significant failings in the care given to 37 year old Chris, who took his own life while in segregation. The jury returned a highly critical narrative conclusion and the coroner advised he would be making a Prevention of Future Deaths report due to concerns in this case around the absence of guidance on placing someone in segregation under exceptional circumstances. Yorkshire Evening Post covered the story. Chris’s death came just five months after Matthew Stubbs' who also died in the segregation unit. Since Chris’s death in December 2013, there have been 10 self-inflicted deaths in HMP Leeds, the second highest rate in any prison in England and Wales.
  • Ondrej Suha – an inquest found that the 19 year old took his own life in prison, just hours after receiving a letter from the Home Office telling him he was liable to be deported to Slovakia following his sentence (despite him having lived in the UK since the age of four). The Independent covered the story highlighting that prior to his death, Mr Suha had been discovered with ligatures around his neck on two occasions and had told staff he wanted to kill himself. He had also witnessed his cellmate try to hang himself four days earlier.
  • Deborah Coles said: “This is a desperately sad case. There was a complete disregard for the vulnerability of Ondrej Suha, not least given the delivery of such significant news before night time lockup. This left the 19 year old isolated and alone after being told he faced deportation from his home. The jury found failings in both the protection of a prisoner at risk of suicide and in the emergency response; issues we hear time and time again. It is clear that NOMS is not acting on serious health and safety concerns in prisons across the country, and staff are ill-equipped to care for vulnerable prisoners.”
  • Prince Kwabena Fosu - the CPS have authorised criminal charges against GEO Group UK Ltd and Nestor Primecare Services Ltd, who were running Harmondsworth Immigration Removal Centre in 2012, following the death of Prince.

    Deborah Coles was interviewed by the Guardian and highlighted the need to shine a spotlight on the closed world of immigration detention, the treatment and standards of care of detainees, staff training and culture. It will also afford much-needed scrutiny on the privatisation of detention services and how multinational companies are held to account when people die in their care.”

HMP Woodhill Judicial Review

INQUEST attended court on the 7 April with some of the families at the hugely significant Judicial Review into the high rates of self-inflicted deaths at HMP Woodhill. Our media release can be found hereA total of 18 self-inflicted deaths have taken place in Woodhill since early 2013, when concerns were first raised. The 18th death took place just one month after the High Court granted permission for this claim to be heard, last November. 

Deborah Coles gave the following response: "The deplorable situation at HMP Woodhill is just one stark example of a much wider national problem. Deaths occur time and again, as a result of repeated failings. Families are told that lessons will be learned but nothing changes. The reality is that the Ministry of Justice has wholly failed to address the unacceptable rise in self-inflicted deaths. It is therefore vital that the Court intervenes to protect vulnerable prisoners and their families and to stop more and more preventable deaths from occurring."
INQUEST intervened in the Judicial Review and put in a detailed statement about the failure to act on repeated recommendations arising from investigations and inquests. A response can be expected up to 28 days from the hearing – we will update you as soon as we know more.

Jury find unlawful force by prison officers led to John Ahmed’s death
Concerns about the unlawful and inappropriate restraint of a prisoner were raised by an inquest jury last month. It is extremely rare for restraint deaths to occur in prison and the conclusion from the jury is significant in highlighting deeply concerning failings. The jury rejected some of the officers’ evidence that had presented a particular narrative about John and the coroner announced he would refer this evidence to the police. The case attracted national and regional press interest, including the Independent and the Guardian.

10 years on from Corston: the human stories behind the growing number of preventable, women’s prison deaths

INQUEST and families secured some very sensitive media coverage highlighting the human stories behind the shocking women’s prison deaths statistics, on the BBC NewsiNews and the Guardian.

Last month we asked (yet again) how many women have to die on the inside before Government takes Action? following the launch of two publications - a learning lessons bulletin on self-inflicted deaths among female prisoners by the Prisons and Probation Ombudsman (PPO) and the Independent Advisory Panel on Deaths in Custody (IAP) working paper ‘Preventing the deaths of women in prison’'.

INQUEST speaks about deaths in UK immigration detention

Senior Caseworker, Selen Cavcav, attended the Detention Monitoring Group’s monthly meeting as a guest speaker to talk about deaths in UK immigration detention and the role of NGOs.  The focus was on what can the groups do in the aftermath of a death in an Immigration Removal Centre and INQUEST has agreed to feed into a guide being produced by the Association of Visitors to Immigration Detainees (AVID). Selen’s contribution was tragically timely given there have already been 3 deaths in immigration detention since December 2016.

Fundraising news 
INQUEST staff and volunteers will be taking part in this year’s London Legal Walk on the 22 May. All funds raised will go straight to INQUEST (with no deduction) and will fund future casework, campaigning and policy work. Last year we raised £8,400 – we’d LOVE to reach £10k this year.  Please support by donating here and sharing the link. 

We are so appreciative to all the families who fundraise for us – this month, Jack Portland’s family raised £580 for INQUEST. Trusts and foundations are key funders of the services we provide and we were delighted to recently receive a renewal of our funding from the Joseph Rowntree Charitable Trust.

Staffing news
Last month we said goodbye and thank you to Laura Smith and welcomed Lucy McKay as INQUEST’s new Policy and Communications Assistant. Formerly a journalist, Lucy has a degree in Sociology and Politics and was an editor and organiser of the radical print publication STRIKE! Magazine. It was through a 2014 STRIKE! campaign on policing that Lucy came across INQUEST. Lucy joins us having previously been a policy officer at HM Inspectorate of Prisons and co-ordination assistant of the UK National Preventive Mechanism.

Supporting INQUEST

People regularly express surprise that INQUEST is such a small organisation, believing we are a larger and well resourced organisation. The opposite is true – we have seven full time, three part time staff and volunteers. We need every penny to keep the organisation going. We are really grateful to all our donors and grant givers and your support can make a really significant difference to the work we do and the impact we have.

Follow us on Twitter and Facebook to keep up to speed on developments in our casework, policy and parliamentary work.
If you can, please make a donation or become a regular giver - any gift, no matter how small, contributes to securing INQUEST’s future. It's easy and secure to do via our JustGiving page or via CAF online. If you are a tax payer and you Gift Aid your donation, the government will give us 25p for every pound you donate – at no extra cost to you. Thank you.

You may also be interested in subscribing to INQUEST LAW, the journal of the Inquest Lawyers Group. Published three times a year, this magazine keeps lawyers, coroners, academics, policy makers and other interested parties informed of legal developments relating to the inquest process and the investigation of sudden deaths.