End of year newsletter 2019

Dear friends of INQUEST,

I would like to extend a huge thank you to everyone who has worked alongside us this year. Particular thanks to all the wonderful families we work with, 
our funders, members of the INQUEST Lawyers group and the phenomenal INQUEST staff team.

From families bereaved after deaths in custody and detention, Hillsborough and Grenfell, it is their passion and determination, standing together in solidarity and building a community in the pursuit of accountability and meaningful change, that has led us through this busy and challenging year.

INQUEST have worked tirelessly to transform and politicise the investigation of contentious deaths and uphold the rights of bereaved people in the pursuit of truth, justice and accountability. Now more than ever, we will stand strong defending human rights and access to justice and against the politics of othering, the demonising of minorities and the hostile environment.
In the coming year, INQUEST will continue to give a voice to those who the state would rather silence. We will fight for a society that protects the human rights of all its citizens, particularly the most powerless and marginalised and for a more just and humane world.
INQUEST will continue to campaign for 
our key demands, #LegalAidforInquests, an independent public body to audit, monitor and follow up action taken in response to recommendations from inquests and inquiries, and the implementation of Hillsborough Law, alongside our policy recommendations on prisons, policing, mental health, learning disability and Grenfell.
We have a number of exciting and innovative projects with our growing network of family campaigners, led by the Family Reference Group. We will also be planning for 2021 when INQUEST will be celebrating our 40th anniversary.

Our independence from government is vitally important to us. Our core work is supported by trusts, foundations and donations. Please continue to support our work in whatever way you are able to and help us continue to support hundreds of families bereaved by state related deaths each year.

We know this time of year can be particularly difficult for people who have experienced the death of a loved one. Please look after yourselves. On behalf of the INQUEST team we wish you all a peaceful time over this holiday period.

Deborah Coles, Executive Director of INQUEST

Please note: festive period opening times
INQUEST are running a reduced casework service between Monday 23 December and Monday 6 January. If you have an urgent issue requiring a response, such as an upcoming hearing date, please leave your name, number and details. All non-urgent enquiries will be responded to from 6 January.
A year in casework

Over this year, our casework team of eight have supported more families than ever before. Since the beginning of 2019, the total number of cases we have worked on is 1,407. This includes 850 cases carried into the year due to the length of time it requires to get through the investigation and inquest processes. This constitutes a 25 percent increase in our overall caseload compared to the previous year.

This rise in demand has been particularly evident in our strategic casework with 447 mental health cases, 390 in prison settings, 197 after police contact and 26 deaths in learning disability settings.


Following the historic unlawful killing conclusions from the longest jury inquest in legal history, the question still remains as to who is responsible. The not guilty verdict in the trial of the former police chief superintendent David Duckenfield, who was in command at Hillsborough has been received with anger and disappointment by families still seeking accountability 30 years later.
The lasting legacy of Hillsborough must be the public authority accountability bill (Hillsborough law), enforcing a duty of candour and equality of arms. This could help a move from defensiveness to transparency and change the legal landscape following contentious deaths, making it fairer, just and more equal” writes INQUEST Director Deborah Coles and INQUEST Grenfell Project Coordinator Remy Mohamed in the Guardian.

Volunteer at INQUEST
We are seeking two new volunteers to join INQUEST in our London office, for two days a week in early 2020, to support our policy and communications team, or our family participation projects. Applications close on 20 January. More information on how to apply is available online. Please share with your networks.

Mental health
Despite sometimes being a painful process, part of the reason families go through inquests and investigations is to help ensure that no one has to live through the same experience. However, many inquests expose similar failings time and time again. There is an urgent need to create an independent national oversight body to monitor action taken in response to recommendations from post death processes. This is vital in order to prevent future deaths.
An inquest jury found a sequence of serious failures relating to staffing, leadership and safeguarding processes on the Caburn Ward probably contributed to the death of Bethany Tenquist, 26. INQUEST caseworker Selen Cavcav told ITV that the unit did not keep Beth safe. Beth’s siblings told the Independent: “The more you think about it, the more you realise that this is what 10 years of austerity does. Why was an NHS hospital relying on bank staff, with zero-hour contracts, to care for such complex patients?”

There was a ‘gross failure’ in the medical care of Callie Lewis, 24, an inquest found. The jury also identified a direct link between her death and the lack of autism awareness. INQUEST was quoted in BBC News.

Christopher Laskaris, 24, who had mental ill health and a diagnosis of autism, died after being stabbed in his flat in November 2016. His family have raised concerns that the police left him at risk by not making sure his flat was secured after officers smashed in his front door days before he died however the inquest was limited in scope and failed to examine the broader circumstances of his death.  
A coroner has concluded that the self-inflicted death of John Ashley, 57, was contributed to by neglect. He was under the care of the Community Mental Health Team in Sussex Partnership NHS Trust when he started experiencing hallucinations and attended his GP asking for help. We told the Argus this is one of a series of damning inquest conclusions involving this trust.
Bethany Tenquist, Callie Lewis, Suzanne Roberts, John Ashley, Christopher Laskaris
A culture of poor care at The Dene mental health hospital has been exposed, following a series of inquests into the deaths of three women in nine months at the privately run facility. The inquests follow a criminal investigation into the deaths and other incidents, which was closed despite concerns that there was still a significant amount of missing evidence. 
Suzanne Roberts, 33, died on 18 October 2015 whilst a patient at The Dene. The inquest found her death was caused by an injury and kidney infection, and she was experiencing chronic dehydration. Suzanne had been inappropriately discharged from general hospital back to The Dene three days before her death, despite being extremely unwell. The inquest jury found The Dene failed to adequately assess and meet her physical health needs, which probably contributed to her death.
The inquest into the death of Katherine Stamp at The Dene on March 2015 concluded last month (see previous newsletter), and also highlighted failures to meet her physical health needs.
Naomi Scott, 27, died in general hospital on 1 February, 2016, after receiving care at The Dene. Naomi did not have any family to represent her at the inquest into her death, which concluded her death was ‘misadventure’ and that she did not intend to end her life in an act of self-harm which led to her death.

Learning disabilities
The jury at the inquest into the death of Ryan Mason concluded that he died of natural causes, as a consequence of epilepsy, contributed to by neglect. There was no formal training, written guidelines or risk assessments of the epilepsy monitoring watch for Ryan’s support staff employed by Imagine, Act and Succeed. The watch was out of charge on the night Ryan died.
Deborah Coles said: “The premature deaths of people with learning disabilities are all too common. This wide-ranging inquest has provided important scrutiny upon the circumstances of Ryan’s death, with damning findings which must now be used to inform urgent change for all those with learning disabilities and epilepsy.”


The 14 December marked two and a half years since the fire. Hundreds of people gathered for the Grenfell silent walk which took a poignant route through Kensington. The walk ended at the base of the tower where there was a 72 second silence and speeches from Karim Mussilhy and Lowkey.
Phase two of the Inquiry will begin on 27 January 2020. INQUEST will continue to keep a watching brief and support the families affected to ensure their voices are heard.
The Grenfell Tower cladding manufacturer, Arconic, has spent £30m on lawyers and advisers defending its role in the disaster. Deborah Coles told the Guardian “This goes to the heart of the issue about equality of arms for those most affected. Justice must not be undermined by those with deep pockets.”

Custody deaths

A jury concluded that Mzee Mohammed-Daley’s death, following restraint and arrest by security staff and Merseyside police, was a death by ‘natural causes’.  Following the inquest, caseworker Selen Cavcav said: "There is nothing 'natural' about this death. It is difficult to reconcile this outcome with the harrowing footage of Mzee lying unconscious on the floor, hands cuffed behind his back as police and security staff watched on."

Mark Needham’s death in Northumbria Police custody was contributed to by "serious errors, omissions and a gross failure to provide basic medical attention", an inquest found. His family spoke to Chronical live for changes to how vulnerable people are treated in custody.

Cameron Whelan, 26, was pursued by Warwickshire police when he entered a river. His body was found four days later. The inquest concluded finding his death was ‘misadventure’ caused by drowning, with no critical findings, despite concerns of the family.

A jury identified a series of failures by prison and healthcare staff at HMP Woodhill at the inquest into the death of Chris Carpenter. Concerns were raised about his mental ill health due to a recent bereavement but no meaningful safeguards were put in place.

Cameron Whelan, Mark Needham, Mzee Mohammed-Daley, Chris Carpenter

Bereaved family represents peers at inquest
The inquest into the death of Stephen Berry has concluded finding he died from the effects of alcohol withdrawal after being held in Northumbria police custody. The jury found symptoms of Stephen’s physical ill health should have been treated as a medical emergency and that had medical care been provided then his death may have been prevented. Shocking evidence on the behaviour of police officers was also heard at the inquest, at which the family were represented by another bereaved family member.
His family were represented at the inquest not by lawyers but by another bereaved family member, after being unable to get through the protracted and painful application process for legal aid funding. Tracey McCourt and Stephen’s daughter, Gemma, connected online. Tracey supported Stephen’s family through the inquest and was recognised by the coroner as the family representative. She and the family were supported by INQUEST Head of Casework, Anita Sharma. Gemma, Stephen’s daughter spoke to ITV News Tyne Tees.

In other news
A huge thank you to Hodge Jones and Allen for putting on the annual Christmas Quiz to raise money to support the work of INQUEST. Thanks also to all our Lawyers Group who attended and well done to Matrix Chambers who knocked Garden Court off the top spot!
On the 30th anniversary of the UN Convention on the Rights of the Child, INQUEST joined a range of supporters of children's rights in signing this letter in the Times urging all political parties to commit to incorporating the convention into UK Law.
Rebecca Roberts, Head of Policy spoke at the RebLaw conference on a panel on Tough on crime? Evidence based approached to prison reform.
On International Human Rights Day we joined a coalition of organisations calling on all party leaders to protect human rights, including those of people in state care of custody.
Deborah Coles spoke at Sheffield University as part of their Student Union’s 16 days of action on gendered violence on the work of INQUEST.
INQUEST staff attended a meeting in Tottenham about Mark Duggan and the work of research based organisation Forensic Architecture whose virtual model of the shooting undermines the finding of the police investigation. The use of this digital technology and investigation could be important for the future of police accountability.

National Memorial Family Fund

INQUEST is proud to be a partner of the National Memorial Family Fund. This fund will make a real difference for families and their campaign groups that need financial support during their struggles for justice. Read more about the National Memorial Family Fund and how to donate.