In this edition:


LEGAL AID FOR INQUESTS – we need your views

After many years of campaigning, there is now widespread understanding about the urgent need for reform of legal aid funding at inquests.
The Ministry of Justice have launched a call for evidence inviting bereaved families, lawyers and organisations to answer specific questions on the inquest system. The call for evidence follows recommendations by both the Angiolini review and the Bishops review on the need for non-means tested public funding at inquests.
The responses will help to inform new guidelines which will then be put out to public consultation. This is a major opportunity to influence the support available for families. The deadline is 31 August 2018.
We encourage all families to submit evidence based on their experiences and views. There is a tight deadline and the questionnaire is technical in places. INQUEST is happy to facilitate and help with evidence from bereaved families. Please contact Ayesha Carmouche for further information.
Testimonies from families will be the most powerful in bringing about the necessary change and an end to the current inequality of arms.
The INQUEST Lawyers Group steering committee are coordinating responses from ILG members.


The Joint Committee on Human Rights backed INQUEST’s call for better access to justice for bereaved families in their report published earlier this month, recommending that families have access to non-means tested public funding for legal representation at inquests. We were quoted in the Guardian and The Times highlighting the inequalities bereaved families experience at inquests.
It is clear that family evidence really impacted on the Inquiry’s recommendations; “We wish to single out for special mention bereaved family members: Richard Huggins, Sara Ryan and Louise and Simon Rowland, who shared with us their experiences of seeking justice for their loved ones through the inquest process - we are deeply indebted to them.”


INQUEST responded to Independent Office for Police Conduct (IOPC) annual statistics, which showed the highest number of deaths in and following police custody in over a decade.
INQUEST Director, Director Coles, was quoted on the front page of the Guardian; "Until you have investment in frontline mental health services, the police will be the first point of contact for people in crisis… Many of these preventable deaths illustrate the impact of austerity and the historic underfunding of health and community services."
INQUEST also highlighted the disproportionate number of fatalities of black people following restraint and the role racial stereotyping plays in custodial deaths in the Independent and the Guardian.
The record-breaking count of deaths in custody does not include at least three high profile cases, as reported by OpenDemocracy.
INQUEST’s Policy and Communications Officer, Lucy McKay, wrote for The Metro asking: if we don’t hold police responsible for deaths in their custody, how can we make sure they’re not repeated?
The inquest into the death of Terry Smith concluded that neglect contributed to his death, which involved excessive restraint by Surrey Police. Terry’s family spoke to Channel 4 News about their relief at the critical conclusion (please note: the link contains graphic footage of restraint from the start).


A huge thank you to all those who responded to our requests to lobby your MP on Seni’s law – the Mental Health (Use of Force) Bill. The Bill, which will help strengthen protections against dangerous use of force in mental health settings, passed through the third reading in the House of Commons with unanimous support.

It will now go through the House of Lords, where there will be a second reading in Autumn, followed by a third reading and then (hopefully) Royal Assent (when a Bill becomes Law).

(Photo above: Seni’s parents Aji and Conrad Lewis, with Steve Reed, Labour MPs and assistants, Marcia Rigg and Lucy from INQUEST).


This month three inquests have highlighted ongoing concerns about the deaths of women in mental health settings.
The inquest into the self-inflicted death of Zoe Watts who died aged 19, in the care of Oxford mental health services, found serious issues with risk recording and management, and communication with family.
The inquest into the death of Deirdre ‘Dee’ Harvey, who died aged 53, concluded that her death in Royal Glamorgan hospital was accidental, contributed to by neglect. Her death came after the Healthcare Inspectorate Wales highlighted issues with ligature points in the hospital, but no actions were taken to address this risk.
Risk management was also found to be an issue at the inquest into the self-inflicted death of Sophie Payne, who died aged 22 at Queen Mary Hospital in Roehampton. The jury found failures in care planning, follow up after incidents, and failure to remove items which posed a risk.
As discussed in the Guardian, INQUEST are increasingly concerned about these repeated patterns of failure of vulnerable women in secure mental health care. We are currently undertaking policy work in this area and will update subscribers on this soon.


Dexter Bristol died following a year of being rejected as a British citizen and struggling to prove to the Home Office his right to live in the UK. Deborah Coles told the Independent that the unique and exceptional circumstances of the case justifies a broader inquiry into the impact of the Windrush scandal on people’s physical and mental health.

Dexter’s mother, Sentina Bristol, spoke to the Independent and is fighting to secure a wide ranging inquest for her son Dexter. Support her CrowdJustice fundraiser for legal funding.


Deborah Coles and the family of Osvaldas Pagirys, who died aged 18 in HMP Wandsworth, spoke to the Today programme on BBC Radio 4. Osvaldas was found on five separate occasions with a ligature. On 14 November 2016, his emergency cell bell was ignored for 37 minutes. Peter Clarke, Chief Inspector of Prisons, agreed with Deborah Coles that cell bells going unanswered is a systemic issue - listen again here (at 1 hour 31 minutes).

The Chief Inspector of Prisons annual report condemned the ‘totally inadequate’ response of prisons to inspection recommendations. INQUEST commented in the Independent.
INQUEST responded to the latest Ministry of Justice safety in custody statistics on prisons. In the Independent we highlighted that the number of deaths awaiting classification over the period had more than doubled, with the majority of people found unresponsive in their cells.


INQUEST is launching its buddy-up programme and inviting families to participate in peer-to-peer training. The scheme will enable families with experience of an inquest, policy or campaigning to support other newly bereaved families dealing with a traumatic death.
We are organising our first round of training for families who want to become buddies on Saturday 1 September. If you would like to receive training, get in touch with our family participation officer, Ayesha Carmouche.


  • The IOPC launched a new investigation into how Dorset Police handled the rape case brought by Gaia Pope two years before her death in November 2017.  Commenting in the Independent, we pointed to the clear link between the trauma of rape and mental ill health and the failure of statutory agencies.
  • Mustafa Darwood died during a Home Officer immigration raid. Natasha Thompson, INQUEST caseworker, spoke to the Guardian; ‘the current approach to asylum seekers in the UK which allows for raids like this is a cause for concern and shame. We hope that Mustafa’s death is looked at in the wider context of the current hostile environment, the influence of which cannot be ignored.’
  • INQUEST ran a family listening day, for the London NHS Clinical Network to hear directly from families bereaved by deaths in prison which involved issues with healthcare. The report is coming soon.
  • For all of our latest media coverage, take a look on our website.

Supporting INQUEST 

John O'Neill, 63, has been training exceptionally hard in preparation for the London triathlon this Sunday, as you can see from the updates posted on the JustGiving page by Tony Herbert. John said:

'I feel so motivated to complete this triathlon to honour the memory of all of them and to raise money to help INQUEST save lives. Love to all the families.'

He broke his shoulder two years ago, but that has not stopped him in his tracks. Please help him reach his £10,000 target for INQUEST by donating online
Thank you to everyone who sponsored Rachel Rumbol in her first 10k on 15 July. She raised £780 for INQUEST.