Welcome to the Spring edition of the INQUEST E-Newsletter

The last two months have been extremely busy both in terms of casework and at a strategic policy level.  It has also marked two significant moments for our small team including the broadcasting of a BBC Panorama programme on deaths of children in mental health settings and the conclusions of the Hillsborough inquests.  
We are now recruiting for a Research and Policy Officer and a Communications Officer to continue to build momentum and help support the team in its significant work.  If you are interested in working for INQUEST, download the job descriptions here.

On April 11th BBC Panorama ‘‘I’m Broken Inside: Sara’s story’ featured the story of Sara Green, a 17 year old child who died whilst in the care of a private child mental health setting. INQUEST had supported Sara’s family through the investigation and inquest into her death and worked closely with Sara’s family and Panorama. Central to the programme was INQUEST’s extensive research which uncovered the lack of any coherent system to record or monitor deaths of child inpatient deaths in mental health settings; a gap which means that not one government department (Health or otherwise) is able to identify the number of children who have died. This is compounded by the lack of an independent mechanism to investigate these deaths. The programme generated significant social media interest and touched the hearts of many and we received emails from people expressing concerns about the current mental health crisis affecting children and young people. It also generated parliamentary debate and prompted a meeting between INQUEST and the Minister for Community and Social Care, Alistair Burt at which he committed to addressing our concerns. INQUEST is conducting significant policy work on this area, and supporting other families whose children have died, including the family of Amy El-Keria, a 14 year old who died in another private child mental health setting in 2012 and whose inquest is on-going.

On 26th of April, the Hillsborough inquests concluded, with jury findings that were a powerful expose of state and corporate failings. An inquest jury of ordinary men and women confirmed the truth about what happened; the 96 football fans who died in the 1989 Hillsborough disaster were unlawfully killed, and the fans were exonerated of any blame.

Our Director Deborah Coles was in court with the families and described their courage and 27 year campaign for the truth against a backdrop of institutional denial and injustice as inspirational. This was the righting of an historical wrong and their campaign has given a powerful boost to other families fighting for truth, justice and accountability where their loved ones have died in the care of the state.   We have worked closely with the family lawyers, all of whom are members of the Inquest Lawyers Group; our advisory group member, Raju Bhatt, was a member of the Hillsborough Independent Panel, along with a founding member of INQUEST Professor Phil Scraton whose in-depth research and commitment was pivotal to the truth emerging.

Sadly the experiences of the Hillsborough families are not isolated and we see too regularly how the state fails bereaved people. Public bodies routinely try to avoid meaningful investigations, to evade responsibility, to blame the deceased and deny families the necessary resources, financial, legal and emotional. That the Hillsborough conclusions are impacting on the current debate on how police related deaths are investigated is welcome and is a debate INQUEST is feeding into. Shadow Home Secretary Andy Burnham has launched a cross-party campaign to reform inquests, the handling of police misconduct and the relationship between police forces and the media. One of the proposals includes the legal right for bereaved families to receive equal funding for legal representation at inquests – non means tested public funding was vital for the families to play an effective role at the Hillsborough inquests - an issue that INQUEST has been campaigning on for many years.

Another important policy development was the announcement by the Care Quality Commission of their review into how NHS Trusts investigate and learn from deaths. This announcement followed the publication of the Mazars review which revealed that Southern Health NHS failed to investigate hundreds of unexpected deaths of mental health and learning disability patients. The CQC recently issued a warning to the Southern NHS Foundation Trust following an inspection in January 2016. No other health trust has faced such scrutiny and their failure to act on recommendations from inquests, investigations and inspections is unacceptable and highlights an accountability gap at a corporate level.  INQUEST has been working very closely with the family of Connor Sparrowhawk who have been behind the campaign to push for real change in the way people with learning disabilities are treated. We have also run a persistent campaign on the need for deaths of mental health patients to be independently investigated.

Increasing number of self inflicted deaths, self harm and homicides in prisons continued to have an impact on our caseload.  MOJ statistics published in April showed that self inflicted deaths up to March 2016 were almost double the number in 2013 and homicides were at an all time high. See INQUEST’s response to these statistics and Deborah Coles and INQUEST Trustee Joe Sim’s open letter to the Guardian: Inescapable realities that face UK prisons.

Also in this period, restraint of children in custody became a focus again following a report by Ministry of Justice revealing that the G4S run Rainsbrook secure training centre, where 15 year old Gareth Myatt died twelve years ago, had the highest number of restraints being used. See our Deborah Coles' comments in relation to these disturbing findings.

A big thank you to everyone who donated to the London Legal Walk.  We have so far raised £9,487.50.  We have been overwhelmed by the positive messages of support and the generosity of everybody who has donated.  We received donations from our friends, the families that we support, the lawyers we work with, and wider supporters, and we are grateful to all of you.  For INQUEST staff the day was not only an opportunity to raise money, but also so to walk in solidarity with the 10,000 other walkers from the legal profession to raise money for much needed services.  There is still time to sponsor us at the LONDON LEGAL WALK 

For all details of INQUEST’s other recent work see also latest news and press releases, as well as updates on our facebook page and twitter account.

Other Policy in brief:

  • INQUEST responds to EHRC's one year report, Preventing Deaths in Detention of Adults with Mental Health Conditions.
  • INQUEST responds to HMIP report on Woodhill Prison.
  • INQUEST responds to IPCC report on Police use of force.
  • INQUEST calls for evidence to include in the Independent Review into Deaths in Police Custody.
INQUEST responded to the Bach Commission on Legal Aid, highlighting the inequality of arms experienced by bereaved people at inquests into deaths in custody and detention. It will go on our website shortly.

Case Work Updates

INQUEST's casework team opened 55 new custody cases from March 2016 to 10 May 2016.   Of these, 23 were deaths in prison, 20 were deaths in psychiatric settings, and 12 were deaths in police custody. Some of the inquests which concluded in this period were Philmore Mills, Hannah Evans, Shalane Blackwood, Istiak Yusuf,  Lloyd SkeltonMartine Brandon and Jack Susianta.

INQUEST monitors all inquest outcomes concerning our casework and uses the evidence arising to inform our policy and parliamentary work to try and prevent future deaths.   

This period also marked a very concerning rise of self inflicted deaths of women in prison.  There have been 5 deaths of women so far this year including the death of a 21 year old, the total number of such deaths in 2016.   

Thomas Orchard
On March 21st, the jury in the Thomas Orchard trial was discharged for legal reasons. There will be a re-trial starting 27 January 2017.

Jean Charles De Menezes
European Court of Human Rights gave its judgment in the case brought by the family of Jean Charles de Menezes. This is a disappointing ruling that further undermines confidence of bereaved families in the processes for holding police to account.  

Anthony Grainger
A Public inquiry has been ordered into the fatal shooting by police of Anthony Grainger.


Inquest Law 32
We are delighted that edition 32 of Inquest Law magazine is out now.  The journal is packed with essential information including case law update, case notes and many articles including one by Lord Toby Harris on the Harris Review.  If you are a member of Inquest Lawyers Group, you will automatically receive a copy.  If you would like to subscribe to the magazine you can do so here.
Inquest Skills and Support Toolkit
The updated version, funded by the Big Lottery is now online.  The toolkit is a useful practical guide for any family facing an investigation and Inquest process following a death.  One family member has fed back:

"The toolkit has a simple and easy format that is extremely informative, and gives a clear honest outline of the lengthy legal process, obstacles and practical tips during what will be an emotive and difficult time for all the family."

The Inquest Handbook
Watch out for the updated version of the Inquest Handbook which will be released in the next few weeks.  This is a guide for bereaved families, friends and their advisers. The publication has been developed in collaboration with other specialist advice agencies and bereaved people who have been through the difficult circumstances of a death involving a coroner’s inquest.


See our website for up to date statistics on deaths in custody on the INQUEST website here. These figures are based on INQUEST's casework and monitoring and may be revised in light of updated information.

Organisational News
Raji Hunjan has started in her role as our new Operations Director and we warmly welcome her to the team at INQUEST. We also say a sad goodbye to our Policy and Parliamentary Officer Ayesha Carmouche who has left the organisation to pursue some international work - we wish her all the best in her future endeavours.
We are recruiting!
We are looking for two new members of out team who want to make their mark working within a complex and politically sensitive environment. 

Communications Officer: you will be responsible for maximising INQUEST’s ability to influence policy and practice change, communicate our work to a variety of different audiences, and maintain a strong network of supporters.

Policy Officer:  you will be responsible for the delivery of INQUEST’s policy and parliamentary work, ensuring that its evidence based work is taken up by parliamentarians, policy makers and practitioners. 
Both posts require self-starters with excellent writing skills who will thrive on working in a highly pressurised environment at a time when there are increasing demands on INQUEST for our input.

Click here to find out more

Supporting INQUEST

“After we tragically lost Sara, INQUEST was and continues to be a much needed supportive element in our lives. Our involvement with INQUEST has meant that we have access to invaluable advice, without which we wouldn't have even known where to begin with the legal process.

The amount of respect and gratitude we have for INQUEST, in particular our caseworker; is immeasurable.

As a family we can genuinely, honestly say that without the support of INQUEST we would have been totally isolated and alone. They go 'above and beyond' to help families. For us; that help is something we will be eternally grateful for.”

      - Mother and siblings of 17 year old Sara Green, who died in a mental health setting
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 and three part time staff and 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.
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.