Welcome to the second issue in July of the INQUEST newsletter. Last week's newsletter covered the two year anniversary of the Grenfell Tower fire, and updates on deaths in police custody, immigration detention, probation failings and more. In case you missed it, you can view it online.

In this issue:

INQUEST is recruiting

INQUEST is recruiting a caseworker. Visit our website to find out how to apply. This is an opportunity to join our casework team, and provide essential advice and support to bereaved families following state related deaths. The closing date for applications is Monday 12 August 2019, interviews the week beginning 20 August 2019.

Legal aid for inquests

Over the past month there has been further evidence of the injustice of inquest funding and the inequality of arms faced by families following state related deaths.

The support for #LegalAidforInquests continues to grow with more people backing the campaign.

Deborah Coles attended the Ministerial Board on Deaths in Custody, raising concerns about legal aid with the recently appointed minister, Paul Maynard MP, as well as ongoing issues around deaths in custody and detention.

Shadow Justice secretary Richard Burgon MP also questioned Paul Maynard MP in Parliament. He said “Families shouldn’t be forced to mount press campaigns to get the legal aid they rightly deserve. Does the Secretary of State regret his recent decision to refuse families legal aid and will he revise his decision?”

This was in response to the Legal Aid Agency requesting that the mother of Taylor Alice Williams, 17, who died in a secure children’s home, pay thousands of pounds for legal representation at the inquest, despite her being disabled and unable to work.

Avon and Wiltshire Mental Health Partnership spent almost £200,000 on legal representation for inquests last year. Becky Montacute, daughter of Julie Carter-Montacute who died following a catalogue of failures by her local mental health partnership, exposed this figure through Freedom of Information requests. Becky told Bristol Live:

 “The inquest into my mum's death found 9 failings in her care. I am certain not all of these would have been found without us spending thousands of pounds from our own pocket on a lawyer”

Angela Pownall, mother of Adrian Jennings who died after leaving a mental health unit in 2016, met with Legal Aid Minister Paul Maynard MP to highlight with him the importance of automatic non means tested legal aid for bereaved families. She spoke to ITV Granada about having to resort to loans to cover the cost of legal representation at the inquest.

The leader of the opposition, Jeremy Corbyn, reiterated that the Labour Party is committed to ensuring legal aid funding for bereaved families at inquests at Prime Ministers Questions.

INQUEST attended a parliamentary event to mark 70 years of legal aid. Pete Weatherby QC of Garden Court North and trustee of INQUEST joined Deborah Coles, and Dr Sara Ryan, mother of Connor Sparrowhawk and campaigner, at the event. 

Working alongside families

The Family Reference Group (FRG) met to discuss how they sit within INQUEST’s strategic work. We will be recruiting new FRG participants shortly.

If you are one of the families that we have worked alongside and would like to contribute to shaping our work at INQUEST, please get in touch with our Family Participation Officer, Mo Mansfield

We were delighted to hold our second #SoulsINQUEST workshop welcoming new family participants into this exciting photography project.


INQUEST published a 2019 update to our report, Still Dying on the Inside. There have been 106 deaths in women's prisons since the 2007 Corston Review and between 2010-2018, 159 women died after leaving custody.

The recent inquests into deaths in prison have exposed systemic failings in suicide and self-harm processes and failures to respond to repeated warnings from coroners and inspection and monitoring bodies to prevent future deaths. The time for change has never been so urgent and necessary.

A jury found that the lack of mental health assessment and issues with suicide and self-harm procedures possibly caused the death of Marcus McGuire. Marcus' family were quoted in the Birmingham Mail, highlighting how he was failed and criminalised, not just by HMP Birmingham, G4S, and the criminal justice system, but throughout his life.

A jury at the inquest into the self-inflicted death of Rocky Stenning found that there was a failure to adequately assess his risk of self-harm and suicide whilst he was at HMP Chelmsford. He had been transferred from a mental health setting to the prison nine days earlier. Deborah Coles told the Independent: “Ultimately, responsibility for Rocky’s death rests with the complacent and indifferent response to potentially lifesaving recommendations. Without action and accountability, nothing will change.”

The jury at the inquest into the self-inflicted death of Andrew Brown found no improvements had been made prior to his death, despite Nottingham prison being forewarned about unsafe practices by HM Inspectorate of Prisons. He was the second of five men to die at the prison in less than a month in 2017. His family were quoted in the Independent

Shane Stroughton died a self-inflicted death on the same landing, of the same wing in Nottingham prison, one day after Andrew was found. He had been in prison on an IPP sentence (imprisonment for public protection) imposed when he was just 19 years old and served in excess of six years over his original tariff. The jury found a series of failings at HMP Nottingham contributed to his death.

Shane Stroughton, Marcus McGuire and Andrew Brown all died in prison following failures in suicide and self-harm monitoring processes

Tan Dhesi MP lead a debate about the detrimental harms of Indeterminate Sentences for Public Protection  at a Westminster Hall debate, and spoke of Tommy Nicol, 37, who died in HMP the Mount. Tommy was over his tariff and had described IPP sentences as a form of ‘psychological torture.’

Rafal Sochacki, a 43 year old Polish national, died at Westminster magistrates court on 21 June 2017. He died from severe heatstroke after being kept in a transfer van and an unventilated court cell on one of the hottest days on the year. INQUEST spoke to the Guardian and BBC about the accountability gap in the inspection and monitoring of court cells and treatment of detainees.

Jordan Hullock, who died from meningitis and a heart condition, was failed by HMP Doncaster healthcare staff, an inquest has found.  His family were quoted in Yorkshire Evening Post“Not being informed of our child’s admission to hospital denied us of the chance to say goodbye.” 

Emma Lewell-Buck MP joined the call to #EndChildImprisonment at a Westminster Hall debate. She said: "Child prisons must close. The focus of any government with children’s interests in mind must be investment in and expansion of community support services, not detention and criminal justice systems.”

INQUEST joined #OPENUP Women’s Futures Mass Lobby of parliament, led by Women in Prison. Learn more about the event.

Inspections and governance

“Not only is the prison system broken, so too are the mechanisms for ensuring democratic accountability and implementing meaningful change. Mental distress, ill health and deaths in prison are a social justice emergency in need of urgent attention”, writes Head of Policy Rebecca Roberts foPROOF Magazine.

INQUEST responded to the HM Inspectorate of Prisons annual report which highlighted that out of the 28 prisons inspected, 22 were found to be unsafe. Peter Clarke said that the number of deaths in prison is a scandal and called for an independent inquiry into self-inflicted deaths.

Deborah Coles was quoted in the Independent“It is unconscionable that there is a self-inflicted death every four days in prison. The Inspectorate rightly comments on the chronic failures in the systems of accountability. Despite intense scrutiny recommendations are systematically ignored. The human cost of this is further preventable deaths.”.

INQUEST submitted evidence to the Justice Committee Inquiry into Prison Governance. Our casework and monitoring shows that current systems of governance are not fit for purpose as inquests and investigations identify repeated failures by the Ministry of Justice in their duty of care to protect the lives of people in prison.

Katie Allan, 21, and William Lindsay, 16, both died in 2018 at Polmont Youth Offenders Institution in Scotland. Their families criticised Her Majesty’s Inspector for not asking the prison service why it “failed to implement so many of the recommendations made in previous inspections”.


The deeply critical report of the Anthony Grainger Inquiry has been publishedAnthony, a 36 year old father of two, was shot dead by an armed police officer during a ‘hard stop’ operation. The Judge found that the Greater Manchester Police were “to blame” for Anthony’s death, and a catalogue of errors meant that the police operation violated Article 2 - the right to life. 

The family and Gail Hadfield Grainger, Anthony’s partner, are now calling on the CPS to review the case and charge Greater Manchester Police with Corporate Manslaughter. Gail spoke to Victoria Derbyshire (From 31 mins).

Deborah Coles told the Guardian "The failure to hold the police to account for lethal force breeds impunity. The rule of law must apply to the police, including at a corporate level, in order to prevent abuses of state power.”

Gross misconduct proceedings have been discontinued following abuse of process arguments by four Devon and Cornwall Police officers who were involved in the restraint of Thomas Orchard in October 2012. Thomas, 32, died 7 days later on 10 October.

Thomas’ family told the Guardian they "feel let down and have been failed beyond belief. It seems to have reinforced the notion that the Police can behave in ways that we see to have been grossly irresponsible, negligent and reckless … and get away with it.”

Deborah Coles was quoted in Independent: “Two months ago this force was fined for criminally unsafe restraint practises exposed by his death. That this disciplinary hearing has been stopped before it even started is simply deplorable.”

INQUEST Lawyers Group conference

Thank you to every who attended our training conference for the INQUEST Lawyers Group (ILG). Extra thanks goes to Fieldfisher for hosting, ILG Steering Group members who helped organise and the excellent speakers.

Specialist inquest practitioners covered a wide range of current key issues in inquest law, practice and procedure including: Case law updates and developments, legal aid funding update and deaths in mental health settings. Find out more about the INQUEST Lawyers Group.

Other news...

  • This year marks 70 years of Human Rights. Deborah Coles tells Clean Break about why Article 2, the right to life, is so important.
  • Dr Sara Ryan has written an article on how bereaved families experience NHS inquiries and investigations experiences, and examines whether families’ needs are met through the processes.
  • Deborah Coles signed a letter by Netpol alongside 151 other campaigners, lawyers, academics, journalists and politicians saying the police must stop categorising protect activities as ‘domestic extremism’.
  • Lucy McKay, Policy and Communications Officer, met with the Council of Europe's Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) alongside other NGO’s during an ad hoc visit to the UK to examine prison conditions.