INQUEST is committed to developing and providing effective support for the bereaved families we work with. A key aspect of this is gathering and responding to feedback. This is essential for ensuring our future work reflects family’s needs. It also illustrates to potential funders how and why our work is beneficial and thus is vital in helping us access and maintain funding streams.

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In this edition:
  • Mental health
  • Legal aid for inquests
  • Prison
  • Family campaigns
  • Police
  • In other news...
  • Upcoming events

Note to those engaged with INQUEST's casework team: We have experienced a significant rise in caseload in recent months. As a result, we are having to restrict our remit. Providing much needed advice and support to bereaved families continues to be our number one priority and we are in the process of recruiting to increase our casework capacity.

Mental health

Steve Reed MP supported INQUEST's calls for independent investigations into deaths in mental health settings and #LegalAidforInquests in a Westminster Hall debate on Mental Health Act reform.

INQUEST prepared a briefing for parliamentarians in advance of the debate, describing why the current system of investigations and oversight following deaths in mental health settings is insufficient for identifying and implementing necessary changes to prevent future deaths. Read more.

The inquest into the death of Kenan Canalp, 27 concluded finding neglect and failures by South London and Maudsley NHS Foundation Trust 
contributed to his death.

Anita Sharma, Senior Caseworker at INQUEST said: This is not an isolated incident involving this NHS Trust. Whilst we welcome their admission of multiple failures at the inquest, the real test lies in the implementation of changes across SLaM mental health services."

Legal aid for inquests

This month marked the 70th anniversary of legal aid. At a time when they are grieving and at their most vulnerable, bereaved families face complex and demanding legal funding application processes. Some are lucky to get legal aid, but many do not or face paying large sums towards legal costs. Legal aid for inquests is a lifeline for bereaved people which is why we continue to campaign for non means tested public funding for inquests

Marcia Rigg, justice campaigner and sister of Sean Rigg, and INQUEST director Deborah Coles spoke at a Justice Alliance parliamentary event marking 70th anniversary of legal aid, explaining how vital it is for families to have #LegalAidforInquests.

Deborah Coles was quoted in The Justice Gap Every review considering #LegalAidForInquests over the past 20 years has recommended this injustice be addressed. Government has failed spectacularly to confront the reality of the uneven playing field that exists.”

Ben Bennett, whose 19 year old daughter Sophie died in mental healthcare, spoke to ITV about the ‘crass and cruel’ application process for legal aid funding. He told the Morning Star, “Thank goodness we had legal representation. I can’t even contemplate how the inquest would have been if we didn’t have a barrister.”

Family members of the 22 people killed in the Manchester Arena bombing have been struggling to access legal aid, despite multiple lawyers representing government agencies being paid from the public purse. Deborah Coles told the Observer “The treatment of terrorist victims is cruel and inhumane and is symptomatic of the dysfunctional and unfair process for funding family representation at inquests.”

Families bereaved from the London Bridge attack had their legal aid applications denied on ‘public interest’ grounds until the last week of the hearings. James Hodder, partner of Kirsty Boden who was killed during the attack, spoke to the IndependentIt doesn’t make any sense … authorities will happily fund their own representation, which is the real hypocrisy of this whole situation.” His petition calling for legal aid for families at inquests into terror attacks has received over 250,000 signatures. Sign it here.

Bob and Maggie Abrahart, parents of Natasha Abrahart who died whilst at Bristol University, had to crowdfund for their legal representation at the inquest into her death. They spoke to Channel 5 News.


The Ministry of Justice released the latest statistics on ‘Safety in Custody’ highlighting an increase in self-inflicted deaths and self-harm. This continues the historically high level of deaths in prison, seen in the past six years.

Commenting on the figures, we told the Guardian and  Independent, Deaths, self-harm, violence, impoverished regimes and conditions are the daily reality of the prison system. Despair and distress are at unprecedented levels in failing institutions within a failing system. The failure to act on warnings from inspection, monitoring, investigation bodies and inquests exposes an accountability vacuum allowing dangerous practices to continue.  

The new Justice Secretary must act upon what are clear solutions - tackle sentencing policy, reduce the prison population and redirect resources to community health and welfare services. This however requires bold and decisive action at a political and institutional level, not more empty words”

In light of the recent ministerial reshuffle, INQUEST will be convening meetings with new ministers covering the key areas of our work.
Jordan Hullock, was just 19 years old when he died in June 2015. He was remanded to HMP Doncaster on 1 June 2015 and soon began complaining of feeling unwell at the prison. From 12 June, he developed headaches and was soon unable to get out of bed, eat, or drink without assistance. 

Jordan looked severely unwell, but no action was taken by healthcare staff until he was urgently transferred to hospital on the 24 June and put into an induced coma. He died six days later.

An inquest jury concluded that there were serious failures in staff’s response to his condition. The grandfather of Jordan told ITV Calendar "We still feel he'd be with us if he had got the care he deserved to get."

Family campaigns

A properly conducted inquest should interrogate any failings in the systems and practices intended to keep people safe. Inquests are a vital way of exposing unsafe practices in state care and holding public services to account and can save lives.
       The below family campaigns are seeking full and thorough inquests into the circumstances of the deaths of their relatives, in the pursuit of truth and accountability. Please consider supporting the crowd funders if you are able to.
The family of Alison Bell, who died in 1991 whilst she was a mental health patient, are raising money to seek a new inquest into her death, after new evidence of sexual relations with a member of healthcare staff was revealed.

Alongside the family, Deborah Coles told ITV 'This death raises important questions about safeguarding and exploitation of vulnerable people in receipt of mental health services that need to be answered.' See the CrowdJustice appeal, for more information and to donate.

Susan Nicholson was murdered by her partner in 2011. Her family are calling for a full and proper inquest to examine whether the police could have prevented her death. Ensuring this case receives proper scrutiny is important for the protection of all victims of domestic violence.

The family are raising funds to bring a judicial review to challenge the coroner’s decision that Susan’s death does not qualify for a full Article 2 inquest. The CrowdJustice appeal only has a few days left to reach the goal.
Alison Bell (left) and Susan Nicholson (right)


Recent inquests have highlighted failures or delays in police responding to dangerous situations as medical emergencies. Too often this is based on a suspicion of people feigning illness, particularly those from black and minority ethnic groups. There is no harm in police taking people to hospital to be checked and receive care. However, the cost of overlooking warning signs is immeasurable.

Nuno Cardoso died following arrest by Thames Valley Police in 2017. The jury reached an uncritical narrative conclusion, despite the troubling evidence heard. Nuno was one of five black men to die following use of force by police in 2017, the majority of which relate to the police response to drug swallowing or consumption. His family spoke to Oxford Mail.

Shine Reports on Open Democracy have published a series of articles about the death of Rashan Charles following police restraint in 2017. Rebecca Omonira-Oyekanmi revisited the medical evidence provided at the inquest. Rod Charles, a retired Chief Inspector of the Metropolitan Police and Rashan’s great Uncle, challenged the official claims of the circumstances surrounding his death.

Other news:

  • 'When Things Go Wrong' is a JUSTICE working party which aims to make informed recommendations on institutional responses to deaths or serious incidents where a systemic pattern of failure is evident. Deborah Coles has been invited as a member. More here.
  • INQUEST gave evidence to the UN Committee Against Torture earlier this year, as part of their periodic review of the UK’s compliance with the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. Our evidence is a detailed dossier on deaths and ill treatment in prisons, mental health settings and police custody in the past six years. It is now available in full on our website.
  • The Home Office have been refused permission to appeal against a High Court judgement to allow an investigation into human rights abuses at Brook House Immigration Centre. The decision comes nearly two years after BBC’s Panorama exposed abuse against detained persons at Brook House. INQUEST provided a supporting statement about the importance of ensuring proper scrutiny of ill-treatment and abuse. Read more on Deighton Pierce Glynn .

Upcoming events:

31 August – Winston Augustine died in HMP Wormwood Scrubs in 2018. Show your solidarity with his family and friends outside the prison on 31 August at 2pm to mark 1 year since his death.

21-24 September - The World Transformed a 4-day festival of politics, arts and music that runs alongside The Labour Party Conference in Brighton. INQUEST will be involved in sessions looking at how we need to imagine social justice responses rather than continue our reliance on criminal justice approaches. Further information is available online

26 September – Deborah Coles is joining Carl Cattermole in conversation on his book ‘The Survival Guide’ at the Wansteadtap in London. Reserve your tickets online.

Supporting INQUEST

Ellie and Isla are running Oxford Half Marathon for INQUEST. We wish them the best of luck. Please sponsor them by donating online.