Welcome to INQUEST’s latest E-Newsletter

There’s been quite a gap since the last newsletter as we’ve had to navigate through some difficult months and not had the resources to devote to informing you about our work. However we are now in a better position and can let you know about some of the work we have been doing in the last six months. Inevitably we can’t do justice to that work here and you can find out more on our website – latest news and press releases.
It has been an exceptionally busy and productive time with a renewed focus on some of our key areas of work. Alongside an ever-increasing demand on our specialist casework service on deaths in custody and detention we have been working on some important policy initiatives on the deaths of children and young people in prison and on the deaths of people in mental health settings. We have published two ground-breaking reports and generated some great media coverage of the issues arising from our work.  
All our work is informed by the collective experiences of families going through the investigation and inquest process and our unique overview of the legal and policy issues that arise.  We will be working hard, in the context of a new government to ensure that these concerns remain firmly on the agenda.

Policy and publications – getting the message across

A packed meeting in parliament on 11 February discussed the key findings of our new report Deaths in MentalHealthDetention: An investigation framework fit for purpose? The report calls for independent investigation of deaths in mental health settings. We co-ordinated a package, that appeared the night before the report launch, on BBC Newsnight on the deaths of children in mental health detention. It included an interview with our co-director Deborah Coles and some of the families with whom we work.  The following day Jeremy Corbyn MP referred to the report in parliament, saying: I urge the Minister to look at the report, which is very serious, well prepared and well researched.’ Its findings also informed an adjournment debate held by Charles Walker MP on 27 February. Lobbying for change to the way deaths in mental health settings are investigated is a key work stream for the organisation and will be a high priority for us to raise with the new government. 
Deborah Coles spoke again in parliament on 23 February at the launch of the report of the Equalities and Human Rights Commission inquiry into deaths of people with mental health problems in all forms of detention. INQUEST advised the Inquiry team and organised a Family Listening Day enabling those most directly affected to give direct evidence to the Commission. Its report echoed many of INQUEST’s concerns. We were particularly pleased to hear the then Minister for Mental Health, Norman Lamb MP, mention our call for improvements to the investigation of deaths in mental health detention and refer to our report launch the week before. We co-ordinated Channel 4 News coverage that included an interview with Deborah Coles and the father of 15 year old Alex Kelly who died in Cookham Wood Young Offender Institution. The inquest into his death concluded at the end of 2014 with highly critical, but sadly familiar findings.
On 2 March our report Stolen Lives and Missed Opportunities: The deaths of young adults and children in prison was launched at the Transition to Adulthood (T2A) Alliance attended by 250 policymakers, practitioners and charity representatives where Deborah Coles and Policy and Parliamentary Officer, Ayesha Carmouche presented the key findings and recommendations. The report documents how the deaths of 65 young people and children in prison are underpinned by a pattern of failures and poor practice. It shows how the use of prison is an ineffective and expensive intervention that doesn’t work and calls for a radical rethink the way in which we respond to young people in conflict with the law. In welcoming the report Joyce Moseley, Chair of the T2A Alliance commented: "they may be a small organisation but they punch well above their weight". The report was widely discussed in the media including the Observer, The Independent and Children and Young People Now.
Our work on deaths of young people in prison has also been key to our engagement with the Harris Review into the self-inflicted deaths of 18-24 year olds in prison. We have contributed to the Review in a range of ways: we submitted an evidence-based report including a focus on our work with families of the young prisoners who have died in prison; Deborah Coles was a member of the review panel in her capacity as a member of the Independent Advisory Panel on Deaths in Custody and we held two family listening days during November and December 2014, bringing families together with panel members to inform their findings and recommendations. The review aims to influence key Ministers and practitioners and its report has been delivered to the Ministers. We are waiting to hear when it will be published alongside the reports of the Family Listening Events.

Black Lives Matter

Following the shooting of unarmed black man, Michael Brown, in Ferguson in the United States, our co-director, Deborah Coles spoke alongside campaigners and families whose relatives have died in custody, at two events in London addressed by Patrisse Cullors, founder of Black Lives Matter.  The first was a well-attended parliamentary event on 26 January, which was chaired by John McDonnell MP and included speakers Diane Abbott MP, Becky Shah from the Hillsborough Justice Campaign and bereaved families including Marcia Rigg and Stephanie Lightfoot-Bennett from the United Friends and Families Campaign (UFFC).

The second event was a meeting organised by the Police Action Lawyers Group at Doughty Street Chambers on 30 January. Other speakers at this event included, Leslie Thomas QC, barrister and INQUEST Lawyers Group member who represented the families of Sean Rigg, Azelle Rodney, and Mark Duggan. 

Deborah spoke about INQUEST’s work to ensure that the voices of bereaved families are heard during investigations into deaths in custody and about our work in monitoring and documenting the disproportionate number of deaths of black people in custody following the use of force by state agents. She also highlighted the many instances of deaths in custody which often slipped under the radar, arguing that these deaths are ‘part of a continuum of violence and oppressive treatment’ and that these feed into wider concerns about impunity for powerful state institutions. The meetings were important in highlighting how deaths in custody and how we hold the state to account are a global human rights issue. 
January saw the long awaited inquest into the death of Habib ‘Paps’ Ulah following contact with police in High Wycombe. The family, supported by the Justice 4 Paps campaign finally had the opportunity to ask their question at a full inquest hearing nearly eight years after his death in July 2008. The jury returned a highly critical misadventure and narrative conclusion about the circumstances of his death following inappropriate and dangerous police restraint.

Deborah Coles also spoke at the launch of the Institute of Race Relations publication Dying for Justice to which she contributed an article. This excellent report looks at the pattern of deaths of people from BAME, refugee and migrant communities who have died between 1991-2014 in circumstances involving the police, prison authorities or immigration detention officers.  
The disturbing evidence that emerged at the inquest in Birmingham into the death of Kingsley Burrell following contact with police and mental health services in May 2011 is a shocking reminder of the need to keep the pressure on for justice and accountability. After a six week inquest the jury returned a highly critical conclusion of neglect and found that prolonged restraint and a failure to provide basic medical attention had caused his death. It found systemic failings by police, mental health and ambulance services.
We have also been advising the lawyer acting for Sheku Bayoh, a 31 year old black man who died in Fife in Scotland on 3 May 2015 following the use of restraint by police officers and have called for a robust and independent investigation. Although the investigation system in Scotland is different we can draw on and share our experience of working on restraint related deaths in England and Wales. You can read more about it here and here.
On 18 May, the inquest concluded into the death of immigration detainee Rubel Ahmed at Morton Hall Immigration Removal Centre. Rubel was discovered hanging in his cell on 5 September 2014, a few days after being informed of the decision to remove him to Bangladesh.  He was detained in this former prison despite concerns expressed by parliamentarians and HM Inspectorate of Prisons about immigration detainees being held in prison-like conditions, regimes known to exacerbate mental and physical ill health. . The jury returned a critical narrative conclusion and found “inadequate” communication between multi-disciplinary teams was one of the factors that contributed to his death following the service of removal directions on him. Staff did not know who detainees were, had not been trained in resuscitation techniques and emergency procedures and could not remember much of their training on working with immigration detainees as opposed to prisoners. A key recommendation from a previous inspection about not locking detainees in their rooms in the evenings and overnight had not been implemented. The Coroner confirmed he would be writing a prevention of future deaths report to the Home Office.

Deaths in Mental Health Detention

In November 2014 a jury found that multiple failures led to the death of 18-year-old Rebecca Louise Overy on 24th June 2013 in an adult secure unit in Nottingham. She was moved from adolescent into adult mental health care without proper transitional arrangements. She was a detained patient at the time of her death and had been in a secure adolescent psychiatric unit from the age of 13 where she had an established network of support and friends of her own age. Her doctors were very encouraging and led her to believe that she had a future. Rebecca believed that she would be returning back home after she turned 18. Instead a day after she turned 18 she was moved to an adult mental health facility. The jury found that her self-harming escalated after her speedy transition to adult mental health care without proper planning, cancellation of visits and tight restrictions. 
Rebecca’s death is a shocking reminder that there needs to be an urgent improvement and investment in the care of children and young people by mental health and social services.  Rebecca was failed by the very services that should have provided her with care and treatment at a most critical time in her life. 
In April 2015 a coroner concluded that lack of mental health beds was a contributory factor in death of 17 year-old Sara Green an inpatient in a privately run Priory Group hospital. When she died Sara had been an in-patient for 9 months despite having been considered ready for discharge within 3 months of admission due to a lack of NHS placement and a failure to manage her discharge. The Coroner concluded that this was a contributory factor to the act of self-harm that ended her life. The hospital was 100 miles from her family home despite the fact that she benefitted from close family ties and that her anxiety was worsened by not being in a community or an alternative psychiatric institution closer to her home.

The inquest revealed that the hospital had no coherent policy on how or how regularly observation should be conducted, the staff were conducting observations in breach of the Priory’s own national policy, correct observation policy was not taught at induction training and confusion as to the meaning and frequency of observation levels is widespread nationally.
The Priory’s internal investigation did not identify the failings found by the Coroner in this inquest, underlining the need for more independent investigation and effective scrutiny of deaths in mental health settings to identify learning in order to safeguard lives in the future. INQUEST will be lobbying the new government to make these changes and to address the dangerous inadequacies exposed in our system of mental health care for children and young people.

In the first four months of 2015 the casework team have provided specialist advice on 127 new cases of deaths in custody and detention in addition to on-going open cases. In comparing the last two years April 2013 – May 2015 we have seen a 39% overall increase in specialist casework. Fig 1 shows the increase in new cases each year and Fig 2 shows the overall cases worked on each year including on-going open cases.

Deaths in prison

There have been 66 deaths in prison in England and Wales in the period January-April 2015: 18 of those were self-inflicted, two were homicides; there have been 3 BAME deaths in prison (2 of which were self-inflicted); 4 self-inflicted deaths of prisoners aged 18-24; and one death of a woman in prison, which is awaiting classification.

Deaths following police contact  

There have been six deaths in
England and Wales in the period
January-April 2015 following police contact: three of those were in custody and three involving police vehicles.

Stronger Voices, Better Outcomes: strengthening family engagement after deaths in detention

In December as part of our work on our project funded by the Big Lottery Fund families from across England came together for a successful meeting of our Family Reference Group to share their experiences and thoughts. Over the next two years, this group will be working closely with us as we develop our on and offline advice and support resources like our Handbook and Skills Toolkit  and roll out our training programme to improve the family experience.  After months of planning this was a cracking start to this part of the project and we are really grateful to everyone for their expertise and enthusiasm on the day.

Funding legal representation at inquests

Improving family access to public funding for legal representation at inquests into deaths in custody, detention and care settings remains one of our  key priorities. We  have joined with others to protect the important advances made over a decade ago that saw families able to apply for exceptional funding for representation at death in custody inquests and to improve access to justice for bereaved people. This inequality of arms between the state and private companies and families was highlighted on Radio 4 You and Yours. Deborah Coles and Rosie Reed, whose 23 year old son Nico died a preventable death in a home for adults with learning disabilities drew attention to the myth perpetuated by government that 
inquests are informal hearings and yet the State invariably instructs lawyers to represent its interests.

Taking this issue forward at a policy level we were really pleased to havsubmitted a supporting witness statement in the High Court challenge to the Lord Chancellor’s Guidance on legal aid funding by Joanna Letts, who was not granted legal aid for her brother’s inquest at which the hospital, doctors and social worker
sconcerned were all due to be legally represented. The judgment of the High Court made on 5 February found that the Guidance is unlawful.
We also lent our support to the Justice Alliance protest held outside parliament where Deborah Coles spoke alongside Marcia Rigg, sister of Sean Rigg and Deputy Chair of the United Families and Friends Campaign about the importance of properly funded legal representation in holding the state to account after deaths in custody.

Don't forget: links to INQUEST's media coverage are available on our website here where you can also read our press releases

Supporting INQUEST

“What can I say? A group of people who are dedicated, passionate, experienced and committed, bringing a shed load of expertise, networks, ideas and action. In the background, INQUEST. A remarkable organisation. Unobtrusive, non-intrusive and quietly and efficiently effective. A perfect mix for the recently shell-shocked.”

Mother of an 18 year old Connor Sparrowhawk who died in a specialist NHS unit.
People regularly express surprise that INQUEST is such a small organisation  thinking we are a larger and well resourced organisation.  The opposite is true – we have five full time and three part time staff and 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.

Fundraising thanks 

We are really grateful to everyone who makes donations and to all our supporters who have been making great efforts to raise money for us. Although this newsletter focuses on the first four months of 2015 we particularly want to thank those who’ve been making special fundraising efforts for us since the end of the summer last year. We include huge thanks to:
  • The family and friends of Thomas Orchard, who died in police custody in October 2012, raised over £2,500 for us in the Great West Run on October 18th 2014.
  • Our Co-Director Helen Shaw ran 5km in Richmond Park and raised over £1000 on October 19th 2014.
  • Everyone who contributed to and attended the annual INQUEST Lawyers Group Festive Quiz in December organised by Claire Hilder from Hodge Jones Allen solicitors that raised nearly £5,000.
  • Lara Pawson who asked her friends to donate to INQUEST instead of giving her birthday presents and raised a wonderful £700 in February.
  • To everyone who attended and support the first INQUEST Lawyers Group Quiz Up North in Manchester on 18 March that raised over £3,000
  • The two students, Lucy Bowden and Emma Coles, from Edinburgh University who raised over £1,000 on a sponsored hitch hike to Paris.
  • To In the City: Mod and Ska Night who raised £170 for us in April.
  • To Anna Thwaites and Gemma Vine for their amazing achievement  of running the Brighton Marathon on 12th April raising over £1,400.        
  • Finally to everyone who has made donations – there are too many of you to name but your generosity helps us to help others and to make a difference.

Future Fundraising events

  • Avalon Ffooks will be walking the South Downs Way in the week beginning 5th July with four friends in memory of her cousin Clemmie Nicholson who died of Meningococcal Septicaemia three days before her 18th birthday in May 2009.

If you'd like to organise a fundraising activity for us please go ahead and let us know. Setting up a fundraising page on Justgiving is easy - just follow the link here.

We have been really encouraged by recent responses by funders to out work - in particular to their commitment to long-term engagement with us that means we have a sustainable platform from which to develop our work.