Welcome to the Summer edition of the INQUEST E-Newsletter

In the past two and a half months INQUEST’s small team has been conducting significant specialist casework and taking forward important policy issues raised through our sustained parliamentary, media and advisory work.

  • Work has continued informing the Independent review on deaths in police custody: as well as holding two family listening days, we facilitated the opportunity for Dame Elish Angiolini to meet with other families and members of our INQUEST Lawyers Group. We also put in a very detailed submission to the consultation drawing on our expertise in this area. The final report is expected to be completed late September. This review will be important particularly in view of the recent IPCC statistics on death in or following police contact, which showed, as INQUEST Director Deborah Coles highlighted, "that too many vulnerable people with mental health, drug and alcohol problems, experience poor treatment at the hands of the police [and] are much more likely to be restrained by the police and to die in police custody."
  • We have informed various parliamentary debates on policing and criminal justice and the ongoing concerns about Southern Health NHS Foundation Trust, with direct mention of our work in both debates. We also held meetings following up on various thematic areas of work on public funding for inquests, including talks with Andy Burnham MP and Keir Starmer MP, and with David Lammy about his current review of racial bias in the criminal justice system.
  • Our work continues to generate significant media coverage, shining a light on evidence of malpractice revealed by our casework, at both a local and national level. Highlights include a feature piece and Channel 4 news interview on the death of Amy El-Keria in the privately run Priory Group hospital, and a letter published in the Guardian calling for an urgent independent review of mental health services for children and young people following her death. INQUEST Director Deborah Coles did an interview for BBC's The One Show on the death of 5 year old Zane Gbangbola following the floods in Surrey two years ago and the shameful refusal of legal aid for his family to be represented despite six legal teams being instructed and funded, publicly or privately, for every party except the family.  

INQUEST has long campaigned for non means tested public legal aid funding to be provided to families following a death involving the state. We have briefed parliamentarians on this as part of our ongoing post Hillsborough inquest work. We also submitted a response to the Bach Commission on Legal Aid reiterating the importance of legal aid for families in holding the state to account. It is significant that the Chief Coroner has recognised the inequality of arms at inquests involving the state; we welcome his comments“I have recommended in my annual report … that the lord chancellor should consider amending her exceptional funding guidance so as to provide … legal representation for the family where the state has agreed to provide representation for one or more people.”  This is an ongoing strategic policy area for INQUEST.

The number of deaths in custody and detention continues to cause concern and we have seen disturbing evidence emerging from inquests that we have been involved with over the past two months. The increasing number of self-inflicted deaths in prison points to a system in crisis which must be urgently addressed by the incoming Justice Secretary as a political priority. INQUEST sits on the Ministerial Board on deaths in custody; it is worrying to note that all three Ministers representing the Ministry of Justice, Home Office and Department of Health have recently changed and their replacements have little if any previous experience in these important areas. We will be working in the Autumn to inform them of the issues identified by our work.

CQC Review on Investigation of Deaths in NHS Care

A long standing concern arising from INQUEST’s work is the investigation of deaths in mental health settings, the closed nature of the investigation process, its lack of independence and the lack of support to bereaved families. The Care Quality Commission (CQC) is reviewing how NHS acute, community healthcare and mental health trusts identify, report, investigate and learn from deaths, particularly of those using mental health services or who are learning disabled.  This review was prompted by the death of Connor Sparrowhawk and the Mazars review and increased scrutiny and disquiet over the way deaths in NHS care are investigated.  

INQUEST’s Director Deborah Coles is on the review's Expert Advisory Group and we will be sharing with the review the issues arising from our specialist casework with bereaved families and recommendations from our work in this area, in particular from our Esmee Fairburn funded evidence-based report, Deaths in Mental Health Detention: An Investigation framework fit for purpose? We will also be holding a Family Listening Day for those involved in the review to hear directly from some of the families with whom we are working.

This review presents an opportunity to try and effect change in the way these deaths are investigated, ensure better treatment of bereaved people and the prevention of other deaths. The CQC are keen to hear from families/carers about experiences of the way an NHS trust has investigated a death to inform their review. Have your say here
For 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.

Casework Update

INQUEST caseworkers opened 34 new custody cases from mid May to July 2016. Of these 22 were in prison, 6 police related deaths and 6 in psychiatric settings.

Corroborating with the concerning trends experienced in our casework are the statistics released by the Ministry of Justice, in their report 'Safety in Custody', published 28 July 2016. In line with a worrying pattern highlighted throughout, it confirmed that in the 12 months up to June 2016 there were 321 deaths in prison custody, representing an increase of 74 (30%) compared to the same period of the previous year. There were 105 self-inflicted deaths, relative to 82 in the previous 12 month period (an increase of 28%). INQUEST Director Deborah Coles commented that the figures show a "prison system [that] has lurched from crisis to crisis contributing to a culture where often vulnerable people increasingly self harm and take their own lives. These shocking statistics belie any suggestion that the government is successfully pursuing a reform agenda."

Women’s deaths
There have been two more deaths of women in prison both in Sodexo run private prisons since the last newsletter. Since January 2015 19 women have died, at least 11 of which are self-inflicted. Many of the women were in custody for minor offences raising questions as to why these women were sentenced to prison in the first place. Deborah Coles was on the reference group to Baroness Corston's review of women with vulnerabilities in the criminal justice system which was prompted by the increase in womens' deaths in early 2000. Nearly 10 years on from that review we are seeing the very same women being imprisoned in places that cannot keep them safe. INQUEST will be supporting the families of the women who have died and raising our concerns at a policy and parliamentary level in the Autumn.

Mzee Mohammed
Just a day after the new Prime Minister Theresa May highlighted issues about race and disproportionality in the justice system, an 18 year old, Mzee Mohammed, died shortly after being detained by security staff and police at a shopping centre in Liverpool. This death of a vulnerable black teenager has rightly generated significant public concern and disquiet.  It has been deeply distressing for the family to see images of Mzee still in handcuffs, being held down by police while he appeared to be unconscious. INQUEST has called for a robust investigation into the conduct of the security staff, police and paramedics involved in this tragic death.

Henry Hicks
The jury unanimously rejected the accounts of the police officers involved in the pursuit of Henry Hicks. The jury returned a critical narrative conclusion that the police were in pursuit of Henry when he crashed on his moped, despite not having sought authorisation, and that Henry’s attempt to avoid the police contributed to his death. Four Metropolitan Police (MPS) Constables will face gross misconduct hearings. The IPCC conducted a second investigation into complaints made by Henry’s family about harassment from the police. The investigation established that Henry was subjected to a stop and search at least 71 times in a 3 year period as well as 18 stop and accounts. The Commissioner has indicated she will be making formal recommendations to the MPS.

Amy El Keria
The jury concluded that gross failings contributed to the death of 14 year old Amy in the privately run Priory Group child mental health unit Ticehurst House in East Sussex.  INQUEST worked closely with Amy’s family.  The issues arising from Amy’s death will inform our thematic work on deaths of children and young people in mental health settings and the need for more openness and transparency.

Connor Sparrowhawk
Southern Health NHS Foundation Trust has accepted full responsibility for the death of Connor Sparrowhawk and has admitted that it was negligent and violated both Connor’s and his family’s human rights.
Steven Trudgill
The inquest heard that Steven was ‘stuck’ in the system. He was serving an IPP (Imprisonment for Public Protection sentence) at HMP Highpoint and was several years past the minimum term. The inquest heard evidence that the mental health support Steven received was inadequate.  HMC Peter Dean has now issued a Prevention of Future Death report to the Prisons Minister expressing his concerns about the mental health needs of prisoners serving IPP sentences.
Bruno Dos Santos
The inquest into the death of Bruno, who died at HMP The Verne, highlights the need for a wide scope investigation following an apparent natural cause death.  During the inquest it emerged that Bruno missed a MRI scan appointment due to a succession of errors which could have led to a diagnosis, treatment and possibly avoided death.

Other inquests which concluded in this period were Lee RushtonPaul HironsIstiak Yusuf and Robert Majchrzak, the outcomes of which highlight various systemic failures around the quality of healthcare provision, inadequacy of checks and search procedures, and poor understanding and implementation of mental health access and support.

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. Further information of our work is available on our website.

Family Forum 

INQUEST’s Family Forum provides a space for mutual support for the families we work with who have experienced a relative’s death in custody or detention. The Family Forum meets twice a year and gives families the opportunity to meet other families, to share their experiences, and to feed back to INQUEST their thoughts, feelings, and ideas on a range of issues and to input into our work. If you are interested in attending a future event please let us know.

We held our most recent Family Forum on 2 July 16. 
The day was underpinned by powerful emotional testimonies of families about their experiences in relation to the death of their loved one.  The afternoon session included a question and answer sessions with Marcia Rigg-Samuel in relation to her campaign for Justice for her brother Sean Rigg and practical suggestions on how to raise concerns at a policy and campaign level. Marcia was one of a number of families involved in helping to develop our Skills and Support Toolkit.

"Thank you to all the amazing INQUEST staff and the families who shared their harrowing experiences of loss of their loved ones at the hands of the state. What an incredible event. I found this so helpful to discuss my own loss of my brother in a confidential space comprised of people with similar losses, grief and frustrations with the judicial system. Thank you, this was so cathartic”. - Jo Orchard sister of Thomas Orchard.

INQUEST out and about

George Ampomsah's film, 'The Hard Stop', which follows two friends of Mark Duggan, was screened on 30 June at Genesis cinema as part of the East End Film Festival. It was followed by a Q&A panel which was hosted by Channel 4 news presenter Krishnan Guru-Murthy and included INQUEST director Deborah Coles. You can view highlights from the panel discussion here.

With the fifth anniversary of Mark Duggan's death approaching, the relevancy of the issues raised during it are all the more pertinent. Deborah Coles said of the film:
“This is a powerful documentary focusing on the death of Mark Duggan and shows the impact on the family, friends and community of a death in the hands of the police and the broader social context in which the 2011 riots took place."
The film is now on general release with 20% of revenue generated by tickets sales being donated to INQUEST to support its casework and policy work.

Natasha Thompson attended the Justice for Kingsley Burrell march in Birmingham on Saturday 9th July.  In May 2015, a jury found Kingsley was unlawful killed. His family await a CPS decision regarding prosecution of the officers.

Caseworkers attended a number of meetings covering some key issues including children in detention, mental health in custody settings, children and policing and Capita conference on community initiatives and policing of vulnerable adults. We contributed to Medical Justice's report on Deaths in Immigration Detention and attended its launch at Doughty Street chambers. 


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.


On 16th June, INQUEST held its Northern Annual Conference of the INQUEST Lawyers’ Group, followed by a quiz night to raise funds for INQUEST.  We are very grateful to Gemma Vine from Lester Morrill for taking the lead in organising, and to Garden Court North, Lester Morrill and Stephenson for providing support. We raised £2,463.

We were genuinely overwhelmed by the generosity of our supporters who sponsored INQUEST’s London Legal Walk in May (our team is pictured here).  We raised £10,400, beating our target by £400.

We now have the fundraising bug, and are getting ready to launch our Big Give campaign.  At present we are collecting pledges and the fundraising goes live on 29th November for online donations.  All funds raised will go towards creating multi-media projects with families.

Organisational News

We welcome some brilliant new volunteers to the organisation – Marilyn Boulos, Christabel McCooey and Richard Bottomley.  All bring with them a unique set of experiences and we are so grateful for their input.

HMP Leeds

The family of Matthew Stubbs held a vigil in his memory outside HMP Leeds on the third anniversary of his death, the 29th July 2016. Further information about the vigil can be found here.

HMP Leeds has the second highest number of self-inflicted deaths in the UK.

Supporting INQUEST

"The support we received was extremely helpful at a very stressful time, shortly after our daughter's death. Every effort was made to listen and offer support and at no time did I feel we were being rushed. We were guided to the support of a solicitor with clear definition around potential cost and the possibility of legal aid.

Without the help of INQUEST I can't think how we would have possibly navigated the complex nature of an inquest with a jury in a potential high profile case. Your support and guidance has made a huge difference to our family."

Father of 22 year old Hannah Evans, 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.