Newsletter June/July

It has been an extremely busy month, as ever, which reflects an intensely busy year so far. In 2017 we have opened over 160 new cases and carried over around 500 cases from previous years. As such we are recruiting a Senior Administration Officer; please spread the word (deadline 7 August). This newsletter covers the deeply concerning spate of deaths of black men following police contact in the last few weeks, updates on the Angiolini review and IPCC statistics on police deaths, yet more evidence of the ongoing crisis in prisons, as well as notes on our work following the tragic fire at Grenfell tower, recent inquest conclusions and more.

Image by Sarah Reed Campaign for Justice

The inquest concluded but the question remains: why was Sarah Reed ever sent to prison?

Sarah Reed was a 32 year old black woman with mental ill health. She died as a result of institutional racism, neglect and indifference. The jury at her inquest concluded that unacceptable delays in psychiatric assessment and failures in care contributed to her death (full info). Even before she was failed by the system meant to protect her she had been a victim of state violence after being assaulted by a police officer in 2012, a harrowing ordeal caught on CCTV. She was remanded in custody at HMP Holloway solely for the completion of two psychiatric assessments to determine whether she was fit to plead.
Following the conclusion, Deborah Coles said that Sarah Reed should never have been imprisoned:
“Serious mental health problems are endemic in women’s prisons, with deaths last year at an all-time high. They continue because of the failure of the governments to act. The legacy of her death and the inhumane and degrading treatment she was subjected to must result in an end to the use of prison for women. The state’s responsibility for these deaths goes beyond the prison walls and extends to the failure to implement the Corston review, tackle sentencing policy and invest in alternatives to custody and specialist mental health services for women.”
INQUEST caseworker Selen Cavcav supported Sarah’s family with the post death processes, and helped them find appropriate legal representation. Marylin, Sarah’s mother thanked Selen during her witness statement. She told the Observer“It’s not just a question of lessons learned, or individuals blamed. It’s the whole system that has to change so that other young women don’t die.”
Sarah was the last person to die in Holloway before the prison, which was the largest women’s prison in Europe, closed its doors six months later. The site is likely to be turned into flats, however campaigners such as Reclaim Holloway are pushing for a community led plan including urgently needed women’s support centres, such as domestic violence and mental health services. Sisters Uncut occupied the Holloway visitor’s centre in May with one activist, Aisha Streetson saying, “We are reclaiming the former prison, a site of violence, to demand that public land is used for public good. Prisons are an inhumane response to social problems faced by vulnerable women – the government should provide a better answer”
In 2017 there have been 4 deaths in women’s prisons, after last year saw a record high number of deaths. Kirsty Walker died in HMP Bronzefield in 2015. Her inquest was scheduled for the start of this month, but was adjourned on the day is was due to begin. This caused serious distress for the family, as well as frustration and concern for INQUEST as we were notified that the second death this year occurred in the same prison just days before. Her caseworker Selen commented on troubling findings at recent inquests in iNews.

Assurances finally given that publication of the Independent Review into deaths in custody is imminent, as we learn of a spate of concerning deaths
This month, INQUEST and 36 other organisations joined forces, publishing a letter in the Guardian questioning the continued and unexplained delays in publishing the outcome of the independent review into deaths in police custody. It has since been confirmed that the report will be published after the parliamentary recess.
The IPCC published their latest annual statistics on deaths during or following police contact this week, underlining ongoing concerns about the treatment of the most vulnerable members of our society by police, as they revealed the vast proportion of those who die in or following police contact are experiencing mental ill health. The 2016/17 figures also showed that the year saw the highest number of police shootings since the IPCC began, and a rising number of police pursuit related road traffic accidents. Our full response can be found here, which was quoted in the Guardian and Independent.
IPCC also reported the first death we are aware of involving a police issued spit hood (referred to as a ‘contamination hood’), which is deeply troubling as we see the roll out of these implements across many forces.
Protests were sparked following the deaths of three black men in the last five weeks, all of which occurred after restraint by police. Edir Frederico Da Costa, 25, was left in critical condition and died six days after being restrained in Stratford, London. Darren Cumberbatch, 32, died following police contact in Nuneaton, Coventry. And Rashan Jermaine Charles, 20, died in Hackney, London following restraint by officers which was captured in harrowing CCTV footage that circulated on social media in the hours after his death. Deborah Coles spoke to Dazed magazine about our concerns.
The funeral of Leroy Medford took place this month, 3 months after he died April this year having been taken into custody at Loddon Valley police station. His sister spoke to the ITV News about the family’s experience of the investigation process to date. 
This month came the disappointing and all too familiar CPS decision not to prosecute any officers from Avon and Somerset police for the death of James Herbert in 2016. INQUEST caseworker, Victoria McNally spoke to Somerset live about the disappointing decision.
INQUEST trustee, Rebecca Roberts, wrote a powerful article in the Independent article this month questioning the promises of greater police numbers and asking why are politicians not looking at more creative alternatives when it comes to protecting the public?

How INQUEST is supporting those affected by the Grenfell Tower fire
In the absence of effective and coordinated state run support, voluntary and community groups have been filling the void in responding to the tragic fire at Grenfell tower last month.
From the outset INQUEST were concerned about misleading information and confusion, including on the purpose and scope of inquest’s and inquiries following disasters of this nature. We issued a statement welcoming the establishment of a judicial public inquiry. We wrote to the Prime Minister in early July to push for the establishment of an inclusive and transparent process, after which a consultation on the Terms of Reference was announced.
We have put in a detailed submission to the consultation to try and ensure the inquiry is:
  • a wide ranging process that will robustly scrutinise how and why this fire was able to happen, and ensure accountability of those responsible.
  • involves an audit of all coroners’ recommendations in respect to previous fires, to ascertain the response from the relevant authorities.
  • examines events before and after the fire to consider how those affected have been treated at a local and national level. 

We were also concerned about the lack of advice and support for bereaved people.  We wanted to ensure bereaved people and survivors had advice and information about the legal processes, how they could play a meaningful role and where they could go for independent advice and support. We produced translated information leaflets in 18 languages (with more to come) and a flyer outlining our relevant experience and how we can help. Find these resources and more here.

Comedian Mark Thomas has organised a show at the Edinburgh festival, fundraising for INQUEST and North Kensington Law Centre to support those affected by Grenfell. You can buy tickets here

The crisis in prisons rages on
This month the crisis in prisons in England and Wales was again confirmed, first by the publication of the Prison and Probation Ombudsman’s annual report, then in a bleak annual report by HM Inspectorate of Prisons, and again in the latest statistics on safety in custody from the ministry of justice. INQUEST co-wrote a letter to the Timesresponded to the statistics and appeared on BBC World at One (from 14:40), calling for the government to stop tried and tested failing policy responses and pursue a radical change of direction: invest in mental health and social services, tackle sentencing policy and promote alternatives to custody which will better protect everyone, including the victims of crime.
HMP Woodhill remains in the headlines, with the BBC News once again highlighting HMP Woodhill’s failings, this time in their care of Tom Morris whose inquest concluded this month. Tom, 31, was serving a short sentence for shoplifting when he died in June 2016. His father Ralph wrote to the prison in April 2016 warning his son was suffering from paranoid schizophrenia, yet the prison decided to move him to a single cell which proved fatal. The coroner who oversaw Tom’s inquest said government intervention was required at the prison.
Last week, the inquest concluded that Ned O’Donnell’s death at HMP Liverpool was accidental and contributed to by neglect by the prison. The jury highlighted multiple failings in his care and communication between staff, including failure to respond to Ned telling them he would kill himself. They also found his cell conditions in segregation were not fit for purpose. In May last year, an inquest on another death at the prison came to a similar conclusion. Since 2015 there have been 14 deaths at HMP Liverpool. The coroner has issued a Report to Prevent Future Deaths raising concerns that important information in assessing risk could be missed if action is not taken to remedy issues with communication and assessment.

INQUEST caseworker, Anita Sharma told the Guardian “the litany of gross failures to respond to O’Donnell’s fears, mental illness and vulnerabilities resulted in the avoidable death of yet another young man at Liverpool prison. We repeat our call to government to show a demonstrable commitment to stem the tide of avoidable deaths”.

Two inquests in a month raise serious patient safety concerns at Sussex Partnership NHS Trust
An inquest jury has concluded that gross failures in providing basic care, amounting to neglect, contributed to the death of Sabrina (‘Sabby’) Walsh, 32. She died in October 2016 after less than 4 hours in the care of the Sussex Partnership NHS Foundation Trust. No formal risk assessment was carried out, there was a failure to effectively consider Sabby’s needs and to put her on one to one observations (as per the Trust’s admission’s policy). These findings came just a few weeks after equally damning jury findings at Janet Fuller’s inquest at the same NHS trust. 

INQUEST caseworker, Shona Crallan was interviewed about the death on BBC Sussex said in response: “This highly critical conclusion reaffirms ongoing concerns about the inadequacy of mental health provision nationally. We are particularly concerned by the repeated failures in care found in relation to Sussex Partnership NHS Foundation Trust. There is clearly a need for an urgent independent review into mental health care by this Trust.”

In other news…
  • INQUEST casework staff and members of the Inquest Lawyers Group recently met with the Legal Aid Agency to discuss the mounting crisis in legal aid funding for inquests. We will be establishing a working group with the LLA and Ministry of Justice to try and address this.
  • The latest issue of Proof Magazine on why legal aid matters is out now. It features a roundtable discussion including Deborah Coles called 'Be afraid without legal aid'. 
  • Deborah Coles met with the new Chief Coroner, Mark Lucraft QC this month. He plans to meet with INQUEST Lawyers group in Autumn. 
  • Thank you to James who raised money for INQUEST by running from Manchester to Stockport in memory of his friend Jordan Begley, who died 4 years ago. If you wish to make a donation, you can still do so here.
  • The latest edition of INQUEST Law Magazine has been sent to print. This month the focus is on deaths in prison. You can subscribe here
  • We are recruiting a Senior Administration Support Officer. Deadline 7 August. Please share with your networks. 


With so few staff and so much work, we are always grateful for the generous donations we receive to help us fight alongside families for truth, justice and accountability. 

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.