Dear friends of INQUEST,

I would like to extend a huge thank you to everyone who has worked alongside us during this difficult year. The pandemic has brought unprecedented challenges and has exacerbated the underlying structural health, racial, social and class inequalities we see in our work. 

We have continued to advise bereaved families at a time when investigations, inquests and inquiries were subject to disruption and delay. We know the impact these disruptions have had on the grieving process. We also contributed to an array of inquiries and reviews, as always grounding our evidence in family experience and our unique overview of the processes following contentious deaths.

As the country went into lockdown in March 2020, so did places of detention, operating ever more restrictive regimes and with limited external scrutiny. We highlighted concerns about the protection of human rights for people in the care of the state, the impact of long term isolation on mental and physical health and ongoing concern about high levels of restraint and seclusion.

The Grenfell Inquiry has revealed brutal evidence about the pursuit of profit over safety and the dishonesty of global companies, Arconic, Celotex and Kingspan, selling products known to pose serious fire risks. As the bereaved and survivors have known from the outset this inquiry is revealing a major corporate scandal for which those responsible need to be held to account.

The Black Lives Matter protests following George Floyd’s murder forced the issue of structural racism and state violence into the spotlight, both here in in the UK and around the world. Emergency powers introduced under COVID-19 have only exacerbated unfair, excessive and discriminatory policing. INQUEST continues to shine a light on these issues and counter attempts to downplay them with evidence from families and our casework.

Despite the challenging year, we have welcomed and encouraged many new opportunities to build connections – between families, with other activists, lawyers, academics and others across the globe. INQUEST are delighted to have been able to create new virtual spaces bringing together a supportive, inspiring and committed community of families.

2021 is an important milestone as INQUEST begins its 40th anniversary. We have exciting projects ahead so please keep an eye out for how to get involved.

A very big thank you to the dedicated INQUEST team who have adapted to new ways of working with resilience and creativity. I would also like to thank our active board of trustees, our funders and the many individuals who have donated money this year to support our work. 

We know from experience this time of year can be particularly difficult for bereaved people and we hope that you look after yourselves and provide support to each other.

Rest assured that in 2021 INQUEST will continue the fight for social justice and equality. Until then, on behalf of the INQUEST team we wish you a peaceful holiday period.

Deborah Coles, Executive Director of INQUEST

Support INQUEST 

Festive period opening times

The INQUEST office is closed to the public from Monday 21 December to Monday 4 January. In case emergencies only, such as an imminent hearing date, contact us through our website. Messages left after 24 December will not be responded to until our return in the New Year. We wish you a peaceful festive season.

In this edition:

  • Recent news
    • Deaths under care of Essex mental health services
    • Mental health care of women
    • Policing
    • Angiolini review on deaths in police custody: pressure for change three years on
    • Learning disabilities
    • Prison
    • Child prisons
    • Grenfell
    • COVID-19
  • Family noticeboard
  • Family campaigns

Recent news:

Deaths under the care of Essex mental health services

INQUEST briefed MPs in advance of a Westminster Hall debate on deaths in mental health care on 30 November. Prompted by the tireless campaigning of Melanie Leahy, and backed by over 105,000 signatures from across the country, this debate focussed much needed attention on the shameful failures in the systems of care for people with mental ill health. We highlighted our long-standing concern about the inadequacy of oversight of these settings and the absence of an independent investigation mechanism for deaths.

Families, supported by INQUEST, are calling for a statutory public inquiry into Essex mental health services, where we have seen failures repeated time and time again in the 28 cases we have worked on since 2013. Barbara Keeley MP and Catherine West MP quoted from our evidence in support of the call for a public inquiry.

It is of great disappointment that Nadine Dorries MP, Minister for Mental Health, Suicide Prevention and Patient Safety did not listen to the calls from families, and announced an inquiry of limited scope and with no statutory powers to compel witnesses. Over 2,000 bereaved families have rejected her proposed inquiry as ‘toothless’ and we await a response to a request to meet urgently with the minister.

It would set a shameful precedent for you to proceed with establishing an inquiry that does not have the trust and confidence of the families who have already been so devastatingly failed by the services that should have kept their loved ones safe. Deborah Coles

Read more

Mental health care of women

Over the past month, four inquests and a safeguarding report have highlighted widespread shortcomings in the provision of mental health care and management of risk for women, particularly those with multiple diagnoses which are seen as complex.

Sharon Kelly, 44, died whilst under the care of Essex mental health services in 2019. The jury at the inquest concluded that there was a delay in a mental health assessment taking place, the ambulance service failed to initiate a risk assessment when arriving at the scene and that there was wide spread miscommunication between all services.

Kimberley Ann Smith was 33 when she died whilst an inpatient at St Peter’s Hospital in Surrey in 2018. The inquest found that neglect contributed to her death by suicide after she was able to abscond on multiple occasions despite being at a high risk of self-harm.

The inquest into the death of Claire Lilley, 38, concluded with the jury finding there was a lack of consistent communication from the mental health trust with her family and insufficient management of risk.

The mother of Alexandra Greenway, a 23 year old transgender woman who died in 2019, told the Bristol Cable she was let down by unfit and under-pressure NHS services, and by a ‘trans-blind’ approach that leaves people’s needs unmet. Her family also spoke out about their frustrations of the uncritical nature of the inquest into her death.

A review published by the Warrington Safeguarding Adults Board concluded that the self-inflicted death of Laura Davis, 22, was facilitated by staff at the inpatient mental health facility, Arbury Court in 2017. Caseworker Selen Cavcav responded "So many people in need end up waiting for months if not years for a suitable placement. Long waiting lists and lack of suitable services is simply costing lives."

From left to right Sharon Kelly, Kimberley Ann Smith, Claire Lilley, Alexandra Greenway, Laura Davis.

From left to right Sharon Kelly, Kimberley Ann Smith, Claire Lilley, Alexandra Greenway, Laura Davis.

An investigation by Bristol Cable has found a second children’s ward at the Priory Hospital has closed meaning that currently there are no residential mental health beds available across the city. INQUEST responded saying: "Findings of poor care and management at the Priory Hospital in Bristol is appalling but regretfully not surprising. What is needed is proper investment in specialist and therapeutic NHS services to start to redress the historic neglect of children’s mental health services.”


The latest statistics on deaths in police custody showed that the number of deaths in custody remain at the same level as ten years ago. At a time of concern about disproportionate and excessive policing, particularly of racialized communities, we still see a disturbing number of restraint related deaths. Mental health and intoxication also continue to feature too heavily. Our casework on police related deaths reveals the systemic failures to safeguard vulnerable people, the excessive use of force and neglect.

A jury found serious failures by the Metropolitan police, London Ambulance Service, mental health services and assisted housing provider contributed to the death of Kevin Clarke. Kevin told officers ‘I can’t breathe’ and ‘I’m going to die’ during the restraint which lasted 33 minutes. Wendy, Kevin’s mother said “We want mental health services better funded so the first point of response is not just reliant on the police” and Head of Casework Anita Sharma said "There is an urgent need for structural and cultural change in policing, mental health and healthcare services."

Jermaine Baker, 28, died after being shot by an armed officer in 2015. The officer, known as W80, challenged the IOPC decision that he should face misconduct proceedings on the grounds that they applied the wrong test. The Court of Appeal rejected the argument. W80 will now face proceedings for gross misconduct unless he successfully appeals the decision. Margaret Smith, Jermaine’s mother was quoted in the Guardian “The Metropolitan Police Service have fought hard to avoid taking any action against him”.

From left to right Kevin Clarke and Jermaine Baker

“It’s a battle we are still fighting" said Kadi Johnson sister of Sheku, 31, who died in police custody - after watching 'Lament for Sheku Bayoh.' Kadi said the play captured the family's feelings from the past 5 years. Deborah Coles spoke alongside Kadi at the post show event with the National Theatre of Scotland. 

The inquest into the death of 4 month old Alfie Gildea, who was unlawfully killed by his father, concluded that failings by multiple agencies contributed to his death by failing to effectively assess or communicate the risk Alfie’s father posed to him and his mother based on his history as a serious and serial abuse perpetrator. 

The government’s plans to introduce new stop and search powers is disproportionate and unnecessary. INQUEST signed this letter by Stop Watch to the Home Secretary warning that the widening police powers will further increase racial disparities. 

Angiolini review on deaths in police custody: pressure for change three years on

Three years since the landmark Angiolini review into deaths and serious incidents in police custody was published, Dame Elish Angiolini QC has voiced her disappointment that key recommendations have been “kicked into the long grass”.

The family of Seni Lewis, who died aged 23 after prolonged restraint by 11 police officers on a mental health ward, were instrumental in setting up the review. Ajibola, mother of Seni, said “we are disappointed and saddened that the majority of the recommendations have not been implemented. The lack of accountability on the part of the state agencies speaks volumes.”

Our Policy and Communications Officer, Sarah Uncles, wrote for Open Democracy about the alarming lack of progress in preventing deaths in police custody and meeting the needs of bereaved families. INQUEST Director Deborah Coles, who was special advisor to the review said If the political will had existed, meaningful change would have come and avoidable deaths prevented. This is a betrayal of those who have died and their families.”

The Joint Committee on Human Rights has added pressure on the Government to implement recommendations highlighted by INQUEST as fundamental to addressing anti-Black racism and discrimination in policing.

Read more

Learning disabilities

The inquest into the death of Joanna Bailey, 36, concluded with the jury finding she died from “natural causes” as a result of Sudden Unexpected Death in Epilepsy (SUDEP). Whilst the coroner refused to permit the jury to consider Joanna’s death was contributed to by neglect, the jury found 11 failings in her care. INQUEST told the Justice Gap “Like many people with learning disabilities, Joanna’s death was avoidable.”

Thomas Rawnsley, a young man with Down Syndrome and autism spectrum disorder died in February 2015. In response to the coroner’s uncritical conclusion, Deborah Coles said “Thomas’ death is being dismissed as ‘natural causes’ is shocking when the family had raised a series of safeguarding concerns and that staff responsible for his care lacked training. Not to mention the many unanswered questions about the poor history of care and failings that were not allowed to be a part of the inquest.”

From left to right Joanna Bailey and Thomas Rawnsley


It is disturbing to see once again the rising number of deaths in prison since October, including 24 COVID-19 related deaths and 14 self-inflicted deaths. This once again reinforces the need for a drastic reduction in the prison population #Release2SaveLives. Existing resources must be reallocated so that no one is released into destitution or poverty or a lack of health and welfare support.

INQUEST has signed this letter by Women in Prison and Birth Companions calling for the government to renew their commitment to release pregnant women in prison and extend this to include mothers of children under two.

Two inquests concluded into the self-inflicted deaths of two young men in prison, both highlighting failures by the prisons to act on the clear warning signs of their deteriorating mental health. David Sparrow died age 26 at HMP Norwich and Garry Beadle died aged 36 in HMP Durham, which as seen one of the highest number of self-inflicted deaths of any prison in England and Wales over the past decade.

The inquests once again provided evidence of the urgent need to look beyond the use of prison and act upon what are clear solutions - tackling sentencing policy, reducing the prison population and redirecting resources to community, health and welfare services.

Deborah Coles was invited to speak alongside frontline activists from across the globe at a conference organised by Open Society Foundations on the rise of mandatory detention and alternative community-led solutions that centre justice, dignity, and human rights.

Child prisons

The isolation experienced in prisons is harmful to a child’s long-term wellbeing, and has worsened due to the pandemic. INQUEST has joined Article 39 and a coalition of charities calling for the closure of child prisons in a new report. We were quoted in Children and Young People Now “Reform hasn’t worked and doesn’t work. This money must instead be reinvested in child-centred community services, youth clubs and holistic provision that prioritises support rather than punishment.”


Three and a half years since the Grenfell Tower fire, INQUEST's Natasha Thompson joined Grenfell Community Support Group and other campaigners outside 10 Downing Street in calling for justice for Grenfell. 

Witnesses who worked at Arconic, the company that made the cladding, are trying to get out of appearing before the Grenfell Tower Inquiry. The cladding company shouldn't be able to escape justice. Please sign this petition.


INQUEST is proud to be supporting the inception of the Covid-19 Bereaved Families for Justice, by advising them on their work and infrastructure and by temporarily holding grant funding on their behalf.

INQUEST has also been sharing our expertise on the investigation of contentious deaths and undertaking policy work in support of their call for a statutory public inquiry. This is vital for justice truth and accountability, as well as its stated aim of using its learning to save lives. This campaign very much speaks to INQUEST’s values and charity objectives. Please sign the petition.

INQUEST joined the British Institute of Human Rights and over 100 other organisations in an open letter to the Prime Minister and political leaders, urging them to respond proportionately to COVID-19, protect people’s rights and the rule of law, and to stand by the Human Rights Act.

Family noticeboard

INQUEST’s family Facebook community is growing. This is a new online space exclusively for families bereaved following state related deaths. It is inspiring to see families share support, solidarity and understanding with one another. To join please the visit Families@INQUEST Facebook Group.

Solidarity with the United Families and Friends Campaign who were brought online this year to commemorate loved ones who have died in police custody, prison, mental health settings and in the Hillsborough disaster. Too many men, women and children are dying from state violence, neglect and indifference. Hear directly from families of their experiences and watch their powerful video.

Read more

If you have a friend or family member who has died at the hands of the state and are interested in becoming a member of the national campaign collective, UFFC are inviting people to join by completing this questionnaire.

The National Mikey Powell Memorial Family Fund is the first permanent national resource of its kind for those affected by deaths of people in custody. The fund is making grants available for families and their campaign groups across the UK. The second grant round for applications is now open. Visit website to find out how to register. Families are encouraged to speak to their INQUEST caseworker prior to submitting their application.

The Children's Christmas Gift Fund is an important initiative from UFFC administered by The National Family Memorial Fund. The fund will make a £50 gift to any child whose parent or carer has died in state custody. The application is simple and takes three minutes to complete. Find out more how to apply here.

Family campaigns

  • UNGRIPP is an important new campaign and resource campaigning for the end of the indeterminate imprisonment for public protection sentence. With thousands of people still imprisoned under IPP despite it being abolished, it was set up by families fighting for justice.
  • “Not only is this a story about racism, policy brutality and serious injustice. This is also a story about hope, about overcoming adversity and taking strength from that outcome and seeing how we can build on that momentum” Lee Lawrence spoke to This Morning about his mother, Cherry Groce, who was shot by police in 1985 and his family’s struggle for justice ever since. ‘The Louder I will Sing’ is a powerful memoir written by Lee Lawrence of the personal and legal battles that followed. Order your copy.
  • The case of Ricky Reel is an alarming tale of police indifference and institutional racism. After his death in 1997 in contentious circumstances, police spied on his family’s justice campaign rather than ensuring a thorough investigation into his death. Sign this petition calling for a new investigation.


INQUEST are incredibly grateful that 10% of the proceeds from these tops by young eco and ethical designer Camilla Bloom will be donated to INQUEST. Check out the designs here.