Dear Friends of INQUEST,

As the year draws to a close, along with the team at INQUEST, I would like to thank all the wonderful families, supporters, and lawyers who have contributed to significant development and change in 2018.

I would particularly like to pay tribute to the many families we have worked with this year. Too many preventable state related deaths occur because of abuses of power, neglect and ill treatment. In the absence of adequate mechanisms for learning and accountability, it is bereaved families who have helped to raise public and political awareness of individual deaths and the broader social and political context in which they occur.
This ongoing struggle often comes at great physical and emotional cost to families. We have been deeply saddened this year to hear of the untimely deaths of numerous bereaved family members that we have worked with over the years, whose mental and physical health was profoundly affected by the death of their relative in state care, and the trauma of the legal processes which followed.

The unwavering commitment of families working to prevent future deaths is something we must all be grateful for. At INQUEST it is those families who inspire and energise us to continue pushing for truth, justice and accountability.
Next year we will continue to work hard to drive the systemic change that is so needed at local and national levels. Our expertise on state related deaths is in ever increasing demand, with our team working hard to ensure families have access to specialist legal, practical and emotional support. 

INQUEST relies entirely on grants and donations to continue this vital work. Our independence from government is fundamentally important for our integrity and our uncompromising position in holding the state to account. Recent examples of the co-opting and silencing of charities and organisations has been a further reminder as to why an independent and critical voice is so important.  
Please consider supporting our work by donating online if you can, and getting involved in our campaigns in the new year.

Thank you for standing with us in speaking truth to power. This can be a difficult time for many families and we are thinking of you and hope you have a peaceful festive period. We look forward to working with you in the New Year.

Deborah Coles, Executive Director of INQUEST
Please note that INQUEST will close for the Christmas and New Year period on Friday 21 and will re-open on Wednesday 2 January.

In this edition:

  • Bringing families together
  • Legal aid for inquests
  • Grenfell Inquiry
  • Use of force by police officers
  • Police
  • Widespread neglect in mental health settings
  • Prisons
  • Influencing policy

Bringing families together

The collective experiences and voices of families inform all INQUEST’s campaign and policy work. We have re-established  the INQUEST Family Reference Group, to bring together families to directly advise on and shape our work. The group have helped us to set up a new Buddy Up programme which will enable newly bereaved families to be supported and advised by families who have already been through the inquest and investigation process.

Thank you to those who attended the end-of-year social gathering for families, an event which our Family Reference Group asked us to organise, at a time of the year which many find very difficult. A special thanks goes out to Tania for sourcing the raffle gifts, Merlin for the music, Anna for organising the fantastic jazz set by Jesse and Joe, and everybody who brought delicious food and drinks along, and made the night so special.

Legal aid for inquests

Keep an eye out for the Family Legal Aid for Inquests Campaign which will be officially launched early in 2019. After many years of campaigning from bereaved families and INQUEST, there is now widespread understanding about the urgent need for change to legal aid funding at inquests. The latest voice backing our call for non-means tested legal aid was the Independent review of the Mental Health Act, published in December. INQUEST submitted evidence to this and met with the review team.

This month INQUEST told the Law Gazette that access to justice is essential to enable accountability and learning from deaths. INQUEST lawyers group member Merry Varney wrote for OpenDemocracy on why grieving families need legal representation at an inquest. Our Director also wrote to The Times on the necessity of coronial reforms, and the imperative for bereaved people to have automatic non-means-tested public funding for representation at inquests. This would ensure a level playing field with state lawyers funded from the public purse.

There is a real chance that together we can bring change. Please get in touch with our family participation Ayesha Carmouche for regular updates and if you are interested in working with us on the campaign.

Grenfell inquiry

The first phase of the Grenfell Inquiry has now come to a close. Our Grenfell Project Co-ordinator Remy and members of the team have been in regular attendance. The Inquiry opened in May 2018 with pen portraits which humanised those who died and brought their voices into the Inquiry.

However, INQUEST voiced concerns that the processes which followed did not continue in the same essence. We wrote to the Inquiry team about ongoing concerns on the venue, disclosure of evidence and the importance of ensuring meaningful participation of bereaved families, survivors and residents.

Phase 2 is expected to be begin in late 2019. In the meantime, the Chair will be working on his report and interim recommendations. “There has been the most compelling evidence at the Grenfell Inquiry about systemic and gross failings that led to 72 preventable deaths”, Deborah Coles told the Guardian. 

It is anticipated that the venue for Phase 2 will be more suitable and local to West London. The change of venue is welcome news and a testament to the bereaved, survivors, residents and their supporters, who have pushed for this change since the Inquiry began.


Gross misconduct charges were proven against one West Midlands Police officer following the 2011 death of Kingsley Burrell. PC Paul Adey has been dismissed for providing dishonest accounts. However, it is incomprehensible that the excessive use of force by all three officers was ‘not proven’.

Our director took part in a new BBC Scotland documentary on the death of Sheku Bayoh, who died following restraint by police officers in Fife. The film also heard from his family, lawyer Aamer Anwar, and other experts, drawing additional attention to the need for a public inquiry.

Speaking to the BBC, we commented“We can’t ignore the role that race may have played in Sheku Bayoh’s death, considering the immediate resort to the use of force by police. We see a pattern of the state narrative demonising those who die to deflect from actions of officers.”

The inquest into the death of Jimmy Quinn has concluded that failures by Northumbria Police & North East Ambulance Service meant he died from otherwise survivable injuries. Jimmy waited 55 minutes for emergency help.

Use of force by police officers

The Home Office published the first ever national statistics on the use of force by police. Deborah Coles was quoted in the Daily Mail saying, “Officers report most commonly using force not because of prior knowledge or possession of a weapon, but because of alcohol and drugs, the ‘size, gender or build’ of the subject, or mental ill health. These figures beg questions about discriminatory assumptions and attitudes towards certain groups of people.”

The Metropolitan Police have pushed ahead with armed patrols in London. This could not be further away from a public health approach to addressing violence and will only further undermine trust and confidence in the police.

Responding to figures indicating that the Metropolitan police use Tasers and restraints more often against black people, Deborah commented in the Guardian that, Racial stereotypes woven into police culture and practice can lead to disproportionate and fatal use of force. Our cases show a disturbing picture of violence, racism and inhumane attitudes.”

Widespread neglect in mental health settings

We are increasingly concerned about the repeated patterns of failure and neglect in mental health settings, particularly in Trusts where there have been numerous deaths.

Neglect in a Leicestershire Partnership trust run mental health unit contributed to the death of Amanda Briley, an inquest jury has found. Amanda was 20 when she died, after returning to the controversial Bradgate Mental Health unit from Christmas leave. Victoria McNally was quoted in the Leicester Mercury:

“The jury's findings are a shaming condemnation of this trust's systems and practises in the operation of basic safeguarding standards and in the dangers to which Amanda was exposed in being forced to remain in a unit so unsuited to someone with autism."

Neglect by a mental health assessment team in Leicestershire Partnership NHS Trust contributed to the death of David Stacey, an inquest jury has found. Despite good practice and positive actions of the police meaning David could have been kept safe, he was left alone in distress by an NHS mental health team who believed he should be taken to hospital, but wrongly thought there were no beds available.

Neglect at South London and Maudsley NHS Trust run Bethlem Royal Hospital contributed to the death of Catherine Horton, an inquest jury has found. This was on the part of the medical and nursing team responsible for her care. She died of self-inflicted injuries at her home in Croydon, two weeks after absconding from the mental health ward.

Emma Butler’s death was the third self-inflicted death in just 15 months at the Whiteleaf Centre in Ayelsbury. The jury was critical of the care and decision making which allowed her unsupervised leave, despite evidence of her risk of self-harm. INQUEST spoke to the Independent:

We must question the systems of learning that have allowed three deaths at the same unit within a 15 month period, exposing such similar, basic patterns of failure.”

INQUEST have consistently called for a national oversight mechanism on state related deaths to monitor, audit and follow up on action taken in response to recommendations arising from investigations and inquests. The independent review of the Mental Health Act published this month endorsed this call.  


The permanent state of crisis which is inherent to the prison system is causing ever greater harm. This year has seen a series of Urgent Notifications issued by HM Inspectorate of Prisons documenting some of the ‘worst conditions ever seen’.

INQUEST responded to the inspection report on HMP Birmingham following the Urgent Notification in August. Natasha Thompson, INQUEST caseworker said, “That inspectors are still finding a dangerous and deteriorating prison is reprehensible”.

Neglect and serious medical failures in a Sodexo run women’s prison contributed to death of Natasha Chin. She died less than 36 hours after entering prison from the effects of vomiting, alongside chronic alcohol and drug dependence. Natasha’s sister, Marsha was told the Independent, “As a family we have been shocked to learn of the inadequacies of the care provided to her and the fact that prison staff and management could have prevented her untimely death”. 

Deborah Coles said: “Sodexo and the Ministry of Justice must be held to account for their failure to act upon repeated warnings about unsafe healthcare practices in Bronzefield. Natasha’s death was a result of this indifference and neglect. It is shameful that women continue to die such needless deaths in prison.

The Home Office deleted records about the death of immigration detainee Michal Netyks in prison, to avoid responsibility, an inquest has highlighted. We told the Independent“Michal's death was a preventable consequence of a cruel and inhumane immigration process.”

The deaths of Katie Allan, 21 and William Lindsay, 16, at HM YOI Polmont in Scotland this year has reignited calls for Scottish Courts to dramatically reduce the number of people being sent to prison. INQUEST is working with the family of Katie Allan and their lawyer.

In a conversation with The Ferret, Deborah Coles said that reducing prison numbers is key to saving lives. She backed the family’s call for an independent review of these deaths.

Influencing policy

  • INQUEST has responded to the Ministry of Justice consultation on establishing an Independent Public Advocate (IPA). We have serious concerns about the current proposals which risk further diluting the voices and power of bereaved families and survivors.
  • INQUEST submitted evidence to the Joint Committee on Human rights inquiry into immigration detention, flagging the unprecedented and dramatic rise in immigration deaths in 2017 and calling for greater transparency within the Home Office.
  • INQUEST is one of the founding organisations of a new campaign, End Child Imprisonment. At the November launch, Liz Hardy, mother of Jake who died in Hindley Young Offenders Institution spoke about her experiences. Read her powerful words in Byline. You can support the campaign here.
  • Deborah Coles spoke at the All Party Parliamentary Group on Penal Affairs, chaired by Lord David Ramsbotham, alongside the new Prison and Probation Ombudsman, Sue McAllister, and chair of the Independent Advisory Panel on deaths in custody, Juliet Lyon, about learning from deaths in custody, the importance of inquests and the role of families in shining a light on system failures, and the need for a national oversight mechanism.

Supporting INQUEST

  • We are so grateful to Hodge Jones and Allen for hosting another successful Christmas quiz, and to generous sponsors Doughty Street Chambers, Matrix Chambers and Garden Court Chambers. It was a wonderful evening and raised over £7,800 to fund our vital work. This was the 10th year HJA has held the quiz in aid of INQUEST, bringing together the community of lawyers who work with and supporting us.
  • And a big thanks to the Jessica Mathers Trust for their generous donation. 

If you’d like to donate to INQUEST you can give a one off or regular donation on our website

Thank you.