Welcome to our first newsletter of 2017 – the first of our monthly updates to engage our supporters in our casework, policy & campaigning work. 

How long before Government addresses the root causes of the prison crisis?

It was a grim start to the year with the 2016 Ministry of Justice ‘Safety in Custody’ figures revealing the highest number of self-inflicted deaths on record and highlighting many extremely disturbing findings:

  • Deaths up 38% overall, self-inflicted up 32% (total of 354 deaths, 119 of which were self-inflicted – over double the number seen in 2012)

  • Self-harm incidents up 23% (37,784)

  • Assault incidents up 31% (25,000 - a record high)

  • Prisoner on prisoner assaults up 28% (18,510)

  • Assaults on staff up 40% (6,430)

INQUEST’s formal response to these figures demonstrates the need for urgent action and accountability. There has been a long term failure of successive governments to act on recommendations arising from investigations, inquest conclusions, inspectorate and monitoring bodies and independent reviews. Underpinning all this is the need for a drastic reduction in the prison population. 

Prior to the release of these MoJ statistics, the human stories behind these statistics were reflected in the damning  neglect conclusion returned at the inquest into Dean Saunders death at HMP Chelmsford. This case highlighted serious failings in care by privately run Care UK, the fact that Dean should never have been in prison in the first place and that his death was entirely preventable.

We secured significant media and parliamentary coverage of these issues:

  • Dean Saunders family and INQUEST gave numerous TV and press interviews including the BBC News (6/10pm), BBC EssexChannel 4 news and several articles in the Guardianthis one with Dean's family was particularly strong (a donation made by an unknown supporter was attributed directly to this article).

  • Jake Foxall’s mother Mary spoke out in the Guardian and in local radio interviews about her 19 year old son's death at HMP Glen Parva.

  • We briefed Luciana Berger MP prior to her parliamentary question about Dean Saunders death, which prompted parliamentary debate . We were disappointed by a further Government committment to 'review evidence'. So much evidence has been presented; when will action follow?

  • INQUEST and Dean Saunders’ family met with Luciana Berger MP following the parliamentary debate and today, alongside Dean's family, we are meeting with Justice Secretary Liz Truss and Prisons Minister, Sam Gyimah.

Highest number of women's prison deaths as we approach the ten year anniversary since the Corston Report

In response to disquiet about the number of women taking their own lives in prison, Baroness Jean Corston was asked by the Home Secretary to conduct a review of vulnerable women in the criminal justice system. Deborah Coles, director of INQUEST, was on the review panel. The Corston Report, published in March 2007, made 43 recommendations for improving the approaches, services and interventions for women in the criminal justice system and women at risk of offending. It highlighted the need to dismantle the womens prison system and to instate a radically different, woman-centred approach.

INQUEST's report Dying on the Inside had provided the first analysis of all self-inflicted deaths of women in prison in England and Wales between 1990 and 2007, bringing into the discussion the largely unheard voices of bereaved families. A further INQUEST report in 2013: Preventing the deaths of women in prisons: the need for an alternative approach called for a radical overhaul of the way women in conflict with the law are treated.

Yet ten years on, 2016 saw a record number of self inflicted deaths in prison, 12 of which were women, the highest number since 2004. Many had life experiences of domestic violence, abuse, addiction, homelessness and/or mental ill health; the very women Corston argued should not have been imprisoned in the first place. What they needed was treatment in a women-centred service, not prison.

In response to the issues raised in our specialist casework and the increasing death toll in our prisons, INQUEST will be publishing a spring briefing paper on women's deaths in prison.

INQUEST to give evidence to Parliamentary Joint Committee on Human Rights Inquiry on Mental Health and Deaths in Prison

The ongoing concerns about the deaths of people with mental ill health in prison is also the subject of an inquiry by the Parliamentary Joint Committee on Human Rights.

INQUEST will be giving oral and written evidence based on the issues raised by our work.

Inquiry begins into fatal police shooting of Anthony Grainger 

The 2nd January saw the first fatal police shooting of 2017 when Yasser Yaqub was shot dead during a pre-planned operation on the M62.

Two weeks later, a public inquiry into the fatal shooting by Greater Manchester Police of Anthony Grainger in 2012 began. Anthony was shot by a police officer whilst he was sitting in the driver’s seat of his car, he was unarmed and no guns were found in his car. Significantly, this is only the second time in England that an inquiry has been set up to establish how a person came to their death, replacing the role of an inquest.

"There is a pressing need for public accountability at the moment, not least in the context of five fatal shootings by police officers in the last nine months alone and the increased arming of the police" said Deborah Coles, director of INQUEST at the inquiry opening.

You can find more information on the case and our response at the inquiry opening here.

The ‘public’ inquiry did close its doors on the family and the public for two weeks whilst ‘secret evidence’ was heard. Another example of families being excluded from the process, having waited over five years for answers.

We secured ITV news coverage for the start of the inquiry and continue to work closely with the media to ensure coverage of this case, which is critical in light of a recent poll by MPS officers revealing 43% of officers support having more armed police. 

Background information produced by INQUEST on this case over the past five years can be found here
The official transcripts and updates from the inquiry can be found here

Police restraint related deaths – will the families of Olaseni Lewis and Thomas Orchard finally get to the truth? 

As we await the imminent publication of the Angiolini Independent Review into deaths in police custody, two of our longest running family campaigns have reached landmark points in their battle for the truth about how their loved ones came to die. 

Olaseni Lewis and Thomas Orchard, both in mental health crisis when they came into contact with the police, died as a result of a prolonged police restraint. 

Olaseni Lewis – the family have waited six and a half years for this public inquest, delayed as a result of protracted processes and investigations into his shocking and contentious death whilst under the care of Bethlem Royal Hospital in Sept 2012. How did a physically healthy young black man, with no previous history of mental illness, come to die within hours of his admission for urgent mental health care? Strong ITV, national and local press was secured for the family at the inquest opening.

Thomas Orchard – The prosecution of a custody sergeant and two detention officers, charged with manslaughter began in January, five years after Thomas’s death. Thomas had a history of serious mental ill health and was detained in Exeter City Centre, then transported to Heavitree Road police station where an Emergency Restraint Belt was used as a ‘spit hood’ and placed around his face. Hours later, he was taken by ambulance to hospital where he was subsequently pronounced dead. National and regional media coverage was secured at the trial opening. The jury are expected to begin deliberations at the end of this month.

It seemed timely that the College of Policing launched national guidelines on the use of police restraint in healthcare settings in January – see INQUEST’s formal response to these here. We reiterate that healthcare, not criminal justice responses are needed in such cases. 

Please follow us on Twitter and Facebook where we will keep you up to date on these cases.

What can we expect following the CQC’s report into mental health and learning disabled patient deaths in the NHS?

“Learning, candour and accountability: a review of the way NHS trusts review and investigate the deaths of patients in England”  (Care Quality Commission, Dec 2016)

INQUEST responded to the CQC’s report last year and was disappointed to see our call for an independent investigation framework to tackle longstanding, dangerous systems & practices to prevent future deaths was not one of the recommendations. 

The CQC’s key findings were: 

  • The NHS is missing opportunities to learn from patient deaths 
  • A radical change in culture and approach from all parts of the system is needed 
  • Significant concerns over the quality of investigation processes led by trusts 
  • Too many families are not being included or listened to when an investigation happens. 

None of this was news to the hundreds of families we’ve campaigned with over the years, whose relatives died whilst under the care of the NHS, particularly those with learning disabilities and mental ill health. 

Read our Family Listening Day report, an event INQUEST were commissioned to organise by the CQC so they could hear firsthand the family voices and experiences. Families talked candidly about resistance to their participation and the need for truly independent investigations. 

“As soon as we started asking questions it was like we were interfering and that they were the professionals, not us. They became antagonistic”. 

“All we wanted was the truth – the worst had already happened. Independence is key”. 

We await an announcement from the CQC and NHS England as to how they will move forward with implementation. 

A recent Panorama documentary highlighted the dramatic increase in mental health related deaths in the NHS – a worrying trend which INQUEST has seen reflected in the increasing number of families contacting us.

Last month, Surrey and Borders Partnership NHS Trust pleaded guilty to breaches of Health & Safety legislation in the wake of the death of Adam Withers in 2014, aged 20, who suffered from an acute psychotic illness. Another entirely preventable death.  

Child & adolescent deaths in mental health units continue to go unmonitored

INQUEST has long called for stringent monitoring and greater public and parliamentary scrutiny of child and adolescent deaths in state and privately run mental health settings. We remain concerned about the level of transparency around the numbers and circumstances of children who die in receipt of mental health services and in mental health settings, particularly those involving private providers.

In December last year, a coroner alerted the Secretary of State for Health to the case of 14 year old Amy El-Keria who died at a high dependency mental health unit run by the Priory Group. We work with a number of bereaved families whose children have died in similar circumstances to Amy's case.

We are working closely with MPs and Lords to raise the profile of these deaths - In January a written statement was heard in both houses that failed to address adequately the concerns we raised to ministers last year. We continue to campaign for independent investigations to be held into to death of any child in receipt of mental health services.

Last month we secured robust coverage of the issues, Government failings and INQUEST's commitment to secure independent investigations for all such deaths in the Independent.

Hillsborough Law –  please show your support now!

Will you show your support for the proposed Hillsborough Law, to ensure such injustices cannot happen in the future? Click here to find out more and to register your support.

INQUEST has been working with the lawyers who represent the families at the Hillsborough inquests in support of Hillsborough Law. It is clear from our specialist casework on state related deaths that the experiences of the Hillsborough families are not an isolated example. We see the struggles and campaigns of bereaved people against a background of institutional denial and defensiveness as they seek the truth and accountability.

This was the subject of discussion at the Justice Summit in Parliament arranged by Andy Burnham MP at which Deborah Coles, director of INQUEST and Marcia Rigg spoke.  

The December 2016 edition of INQUEST LAW magazine (produced by the Inquest Lawyers Group) was dedicated to Hillsborough and hears from some of the lawyers involved with their reflections on the inquests and lessons for future inquest reform. Click here to buy a copy of the magazine or call Robert Styles at INQUEST on 0207 263 1111.

Supporting INQUEST

“Absolutely brilliant people. They have helped with everything. They've answered questions, supported me at the inquest and after. There is no other organisation like INQUEST”.

This is a quote from just one of the thousands of families we work with.


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 a staff team of 9, many part-time, and we rely heavily on volunteers. 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.