In this edition:
  • Access to justice
  • Priory prosecuted
  • Police custody
  • Care settings
  • Prisons and immigration detention
  • Launch of INQUEST Library Online
  • International work
  • 40 years on, the death of Blair Peach
  • New INQUEST Staff

Access to justice

At a debate on legal aid for inquests in parliament, MPs discussed INQUEST’s campaign and the need for automatic funding for bereaved families following state related deaths. They highlighted the unacceptable inequality of arms faced by families, criticised the recent review of legal aid for inquests and challenged the Minister, Lucy Frazer QC, MP on the government’s refusal to grant automatic legal aid.

Marie Rimmer, MP said, “at present the Government can spend money on the legal equivalent of tanks, helicopters, fleets and so on, while the families of the bereaved are left with the legal equivalent of a stick”.

Stephanie Peacock MP brought the debate. Watch a short clip of her opening speech:

Stephanie Peacock closed the debate with the following remarks; “I thank the Minister for her comments, but they simply do not go far enough. Families do not choose to be part of the process. She has given no real explanation for the disappointing consultation.

I will conclude by quoting INQUEST, which states: 'Specialist legal representation and input from families is crucial to ensuring robust post-death investigations and inquests. Inquests must shine a light on any state failings'. I implore the Minister: please listen to INQUEST.”

See the Law GazetteChannel 4 News and the INQUEST twitter thread for more coverage.

Read the transcript 

Figures released by INQUEST indicate that the Ministry of Justice spent £4.2million on Prison and Probation Service legal representation at prison inquestswhile granting just £92k in legal aid to bereaved families through the Exceptional Case Funding scheme in 2017.

Rebecca Roberts, Head of Policy at INQUEST was quoted in the Independent and Guardian:"These are truly shocking figures and it’s no wonder that families feel that the system is stacked against them. The Ministry of Justice must act now to introduce fair legal funding for bereaved families to ensure a level playing field at inquests.”  

To support INQUEST’s campaign, please add your name to our petition. It has already gathered more than 36,000 supporters.

Priory prosecuted 

The Priory Group were convicted of a breach of health and safety law and fined £300k following death of Amy El-Keria. Pictured: Tania El-Keria and sister Debbie at the BBC for interviews following the prosecution.

Amy, who was 14 years old and had multiple mental health diagnoses, died whilst an NHS funded patient in a specialist children’s unit at a private mental health hospital run by the Priory Group.This is understood to be the first prosecution of its kind and is a historic moment in terms of accountability following deaths of children in private mental health settings.

Tania El-Keria, Amy’s mother, spoke to Channel 4 News “What this prosecution and this guilty plea has done is maybe saved a life, and maybe future lives. And that’s what I want to do in Amy’s name."

Tania was also interviewed by Heart News, Radio 4 Today and BBC Breakfast.

Victoria McNally of INQUEST was quoted in the BBC"Allowing the Priory to investigate their own actions, meant it took six-and-a-half years for their criminally unsafe practises to be exposed.”

A documentary on ITV ‘The Priory: Teenage Mental Health Uncovered’ revealed evidence of serious failures of care for teenage patients at the Priory high dependency mental health unit where Amy died.

Police custody

INQUEST continue to push for implementation of recommendations from the landmark Angiolini review on deaths and serious incidents in police custody. We joined the families of Sean Rigg and Seni Lewis at a meeting with Nick Hurd, Minister of State at the Home Office, to discuss next steps.

Devon and Cornwall Police were found not guilty of causing the death of Thomas Orchard as the prosecution into health and safety breaches continues. Speaking outside court, his family said they were "dismayed" by the judge's ruling. "We still think that Thomas's death was a needless one caused by sloppy and dangerous practices”. More in the Guardian.

A jury concluded that neglect contributed to death of Duncan Tomlin following police restraint in 2014. The inquest found that he died due to cardiorespiratory failure due to both restraint in a prone position and the effects of a combination of drugs.

Paul Tomlin, father of Duncan said: "As a family we feel the finding of neglect by the jury is a damning assessment of the police’s behaviour”. The family told the Guardian they were required by the Legal Aid Agency to pay over £7,000 as a contribution towards their legal representation at the inquest.

The family of Raymond Knight have been left with unanswered questions as the inquest into his death in Essex police custody concluded. The jury returned a short form conclusion and were not left instructions by the coroner to determine further issues.

An inquest concluded into the death of James Lockett, whose medical cause of death was recorded as 'unascertained'. The inquest heard that an officer had concerns about James and the possibility that his mental health was deteriorating but this was not communicated with the Community Mental Health Team.

Care settings

Inquest into the death of Colette McCulloch found multiple failures in her care and raised serious concerns about the treatment of women with mental ill health and autism. 

Colette's parents spoke to the Victoria Derbyshire programme with coverage in The Times and GuardianINQUEST continues to push for better monitoring and oversight of private providers of mental health services.

The Charity Commission have opened a statutory inquiry into Richmond Psychosocial Foundation International following the findings of the inquest into the self-inflicted death of Sophie Bennett.

The family of Claire Greaves, a young mental health campaigner who died in a private mental health hospital spoke to BBC Wales Live, demanding change.

Prisons and immigration detention

An inquest found that serious failures at Sodexo run HMP Peterborough contributed to the death of Annabella Landsberg. Her sister Sandra spoke to Channel 4 News and was quoted in the Guardian“I don’t know how these people keep on doing this to other people. I think it’s not right and no one deserves to be treated that way.”

Writing for the Guardian, Deborah Coles highlighted the dehumanising treatment black women face in prison. Distress is too often disbelieved and viewed as a discipline and control problem, as was the case in the deaths of Annabella Landsberg, Natasha Chin and Sarah Reed.

People in prison with mental ill health are waiting up to six months to be transferred to hospital for treatment. INQUEST told the Guardian“The prolonged delay in transferring people from prison to mental health settings, when they are recognised to be in crisis, is deplorable and is costing lives.”

Dean Saunders, 25, and Sarah Reed, 32, both died in prison whilst awaiting transfer to a mental health hospital. Dean’s partner told the Guardian that being in prison “made his symptoms worse. He was isolated from any sense of normalcy.”

The Justice Committee released their Prison Population report. Drawing on INQUEST's evidence, the committee highlighted that "social problems cannot be meaningfully addressed through the criminal justice system" and supported our call for public health approaches.

INQUEST joined a united call for the immediate closure of harmful child prisons. "The focus of any government with children’s interests in mind must be investment in and expansion of community support services, not detention and criminal justice systems." Eric Allison and Simon Hattenstone wrote in the Guardian in support of the campaign.

INQUEST urged for bold action as deaths in prison have risen and recorded levels of self harm broke new records. The government's focus on violence has distracted from the dismal reality of prisons where every four days a prisoner takes their own life. INQUEST was quoted in the Guardian, describing the perilous state of prisons as a 'national scandal'. 

An inquest jury found failings in the immigration detention system contributed to the killing of Tarek Chowdhury at Colnbrook IRC. His family were quoted in the Guardian “These proceedings have shown us that the systems are broken and that it is time for agencies to do some soul searching.”

The family of Katie Allan, a 21 year old who self-inflicted death in Polmont youth prison in Scotland, have launched a CrowdJustice funder. They need funding in the next stage of their legal campaign to present to Government ministers, academics and society the stark reality of what is happening in Scottish prisons.

International work

Deborah Coles was in New York this month as part of our international work, scoping how different jurisdictions investigate state related deaths. She met with the UN special rapporteur on torture, academics, activitsts and NGO's including the American Civil Liberties Union to share knowledge and discuss deaths at the hands of the police, racial profiling and systemic issues of impunity within failing accountability mechanisms. She also met with women fighting against injustice for incarcerated women and for prison abolition.

Boneta-Marie Mabo, Debbie Kilroy, Angela Davis, Deborah Coles and Kim Pate in New York

Launch of INQUEST Library Online

INQUEST has launched its ground-breaking project, the INQUEST Library Online (ILO). ILO is web-based searchable database of jury narrative conclusions and prevention of future deaths reports, collated and maintained by INQUEST. It also provides case law notes relating to inquests following a contentious death.

40 years on, the death of Blair Peach 

INQUEST's Victoria McNally and Deborah Coles went to Southall to remember Blair Peach, an anti-fascist protester who died after being hit on the head by police 40 years ago, and Gurdip Chagger, a school boy who was killed by racists in the same area.

They joined other members of the community standing up against fascism, racism and state violence, including Celia Stubbs, partner of Blair Peach and initial founder of INQUEST.

Deborah also spoke at Liverpool John Moores University, reflecting on the events at Southall 40 years ago and the family campaigns that ignited the emergence of INQUEST.

New INQUEST staff: Family participation officer

In March, we said goodbye to Ayesha Carmouche, our Family Participation Officer, who left INQUEST on to pursue her interest in parliamentary work. In April, we were delighted to welcome Mo Mansfield as the new Family Participation Officer. Mo is a community organiser, advocate and feminist campaigner for prison abolition. She has more than 15 years experience working in the voluntary sector in organisations including Women In Prison. You can get in touch with Mo by emailing her on [email protected]

In other news….

  • The new National Memorial Family Fund website is now live.  The fund will make small grants available for families affected by deaths in custody across the UK, to provide practical domestic assistance and further the work of their own campaigns. 
  • INQUEST’s Grenfell Project Coordinator, Remy Mohamed, spoke at a Young Legal Aid Lawyers event about the importance of families bereaved by the Grenfell Tower fire securing truth, justice and accountability.
  • Clean Break have launched a podcast! The mini-series has been created and recorded by Clean Break members. Listen here.
  • Jodey Whiting died just 15 days after her disability benefits were stopped when she missed a Work Capability Assessment due to serious illness. INQUEST are supporting her family, who are calling on the government to commission an inquiry into deaths linked to the Department for Work and Pensions. Sign the petition.


Deborah is speaking at WOW festival on 28 May, alongside Sara Ryan and Mark Neary, discussing Justice and Campaigning for Human Rights in the Care System. Book here.

Hannah and Lisa are running the Hackney Marathon in May for INQUEST! Please donate through JustGiving.

Rachel Wykes is running the Rugby Half Marathon in memory of Sean Fitzgerald who was fatally shot by West Midlands Police on 4 January 2019. To read a beautiful tribute and show Rachel your support, please visit the JustGiving page.

Supporting INQUEST

 The INQUEST team is taking part in the annual London Legal Walk in June. We are keen to raise as much money as we can to support families bereaved as a result of a death in statutory settings, whether it is in detention, in mental health settings, or as a result of multi-agency failings, such as with Grenfell Tower.

Please sponsor us by donating online.