Our thoughts and solidarity are with all those involved in the distressing events of the last month: terrorist attacks in Manchester, London Bridge and Finsbury Park and the Grenfell Tower fire.

Grenfell Tower: INQUEST’s role in ensuring truth, justice and accountability

INQUEST are deeply shocked by the tragic fire at Grenfell tower and have seen first-hand the devastating impact on the affected communities. This has been exacerbated by the insensitive and inadequate response by both national and local Government.

There is rightly acute public concern about how this disaster will be investigated and we issued a statement to outline our view that a judicial public inquiry needed to be set up urgently. Inquests are limited in scope, do not allow for survivors (that are not themselves bereaved) or those with a wider interest an independent voice and cannot deal directly with the complex far reaching questions. For the inquiry to have the trust and confidence of survivors and bereaved they must be consulted with meaningfully on its terms of reference, to include the context, circumstances and aftermath of the tragedy.

Bereaved and survivors must have access to non-means tested public funding for legal representation on an equal footing to that of public authorities and private bodies. No stone must be left unturned, the truth about this tragedy exposed and those responsible brought to account.

We now have a dedicated section on our website here to support those directly affected.


The CPS today confirmed that six people, including two former senior police officers, have been charged with criminal offences over the deaths of 96 people at the Hillsborough disaster and the alleged police cover-up that followed.

We need the proposed @HillsboroughLaw enacted so families in future will not have to wait 28 years for news like todays #Hillsborough #JFT96

HMP Woodhill Judicial Review – 18 dead but ‘no evidence of systemic failings’?

Last month, the High Court rejected the claim that the Governor of the prison and the Secretary of State for Justice had acted unlawfully by failing to take appropriate steps to reduce the rate of suicide and an order requiring them to take action to try and prevent further suicides. This was on the basis that the evidence demonstrated a series of distinct but separate operational mistakes in suicide prevention at the prison. As different mistakes were made in specific factual circumstances, the Court said that the evidence did not demonstrate a systemic failure.

INQUEST intervened in this judicial review because of ongoing concerns about the lack of a national oversight mechanism to monitor, audit and follow up actions taken in response to recommendations by the investigation, inspectorate and monitoring boards and inquests.  

HMP Woodhill is the most deadly prison as exposed by the stark fact that 18 men have taken their own lives there since May 2013 (the highest number in the prison estate): 5 in 2015 and 7 in 2016:

  • Michael Cameron’s inquest was held the week before the High Court’s decision. This was yet another damning inquest, where a jury found further failures in the management of a vulnerable prisoner.
  • At Danny Dunnley’s inquest in April, it was accepted by the Governor in an open court that, had the previous recommendations been implemented, the chances are that Danny would have been alive today.
  • The inquest into the death of Thomas Morris, the 4th of 7 deaths in 2016, began this week. 

“The current system is not fit for purpose, does not result in lesson learning and puts prisoners lives at risk by failing to make meaningful changes to dangerous practices and systems” Deborah Coles said in response to the judgment. 

INQUEST’s media release can be found here.

Extensive national and local media coverage was secured, with family members and Deborah Coles giving interviews to national media including BBC News at Ten, ITV, BBC online, Guardian and Radio 4.  

Our next edition of INQUEST LAW magazine features articles analysing the judgment and what needs to happen next. You can purchase a copy at inquest.org.uk or call 0207 263 1111.

Inquests continue to highlight failures across an unsafe and ever deteriorating prison system

It was extremely disappointing not to see any mention of the crisis in our prisons mentioned in the Queens speech last week. An open letter on prison reform was published by the new Justice Secretary, David Lidington, reinforcing his commitment “to building on the essential reforms that are already under way to make prisons places of safety and reform”. Increasing the number of prison officers was cited in order to reduce “the currently unacceptable levels of assaults, self-harm and suicides”.

The future of the Government’s reform prisons has also been thrown into doubt after Wandsworth prison, seen as the flagship of the scheme, lost its status and has reverted back to a normal prison.

Week on week, the inquests we attend and critical reports from inspection and monitoring boards continue to find multi agency failings leading to the avoidable deaths of prisoners. Recent inquests have shown how staff are unable to implement even the most basic training and policies intended to protect vulnerable and at risk prisoners:

  • Caroline Hunt – was one of four women to die in HMP Foston Hall in 2015. The coroner took the unusual step of writing to the Governor to warn that a prison officer who gave evidence at the inquest risked endangering the lives of current prisoners and issued a prevention of future deaths report – usually sent after an inquest has concluded – during the inquest. The Independent and Guardian covered the conclusion.
  • Callum Smith – the inquest into the death of Callum who died at HMP Bristol highlighted another person urgently in need of mental health care and support who ended up in the criminal justice system. That Callum’s family had to call on the police for help after being unable to access the appropriate healthcare is an indictment of community mental health provision.
  • Last month, a jury concluded that the treatment of Vikki Thompson, a 21 year old transgender woman by HMP Leeds and community healthcare services were inadequate. Following her death, the Government implemented a new policy on the care and management of transgender prisoners, but INQUEST is not convinced this would have prevented her death. The Guardian covered the case.
  • Next month (4 July) the inquest into the death of Sarah Reed at HMP Holloway begins. Sarah was found dead in her cell in January 2016: she had been the victim of a notorious police brutality case in 2012 and suffered mental health issues know to the prison officers, doctors, social workers, lawyers and police. It is a serious concern that a woman with such serious mental health issues was held in a prison setting, which proved once again unable to keep vulnerable women safe. Her inquest will explore issues around her medication, use of segregation and punishment for behaviour, suicide and self harm risk assessment, delay in obtaining fitness to plead assessments and the mechanisms and circumstances of her death.

Prison inspections continue to further evidence our growing prison crisis:

  • This month a 3rd HMIP report found HMP Pentonville was still not safe. There have been five more self-inflicted deaths since 2015. Where is the learning?
  • damning Ofsted report at Medway Secure Training Centre (STC) in Kent rated the safety of young people, effectiveness of leaders and managers and the promoting of positive behaviour at the STC as inadequate. The centre was the subject of an undercover BBC Panorama programme last year showing abuse and mistreatment of youngsters. Kent Police charged a number of staff employed at the time.

    Deborah Coles told the Metro: "This report exposes the failure of Government to act on previous concerns about child protection, safeguarding and dangerous restraint. STCs are a flawed model incapable of reform and need closing down. We need to reinvest in child-focused therapeutic local authority children’s homes. It is a shocking indictment of our justice system that it is deemed acceptable to subject children to such ill treatment and failings in care".

An increasingly armed police force must be accountable for its actions

Following the recent terrorist attacks, there are more armed police than ever on our streets to protect the public. Whilst public safety in these difficult times is of paramount importance, INQUEST has concerns at the ongoing failures to ensure transparent investigations and to hold the police to account when fatalities occur. Nik Wood, long term supporter of INQUEST, wrote this letter in the Guardian this month highlighting that the pattern of IPCC and CPS failures to hold to account police officers involved in shootings causes much concern.

INQUEST was extremely disappointed by a recent BBC documentary, where police officers apparently sought to discredit the family of Henry Hicks, who died following a dangerous police pursuit. In 2016, an inquest jury rejected the version of events given by police officers involved in the chase. The family’s response can be found here.

Continuing concerns in the care of people with mental ill health

State failures to effectively diagnose, treat and care for those with mental ill health, as well as failures of the inspection and regulation bodies, continue to dominate our casework.

  • The Linden Centre, run by the North Essex NHS Trust is finally under investigation, following 20 deaths at the centre. Melanie Leahy and Lisa Morris whose sons both died in their care, were interviewed alongside Deborah Coles on the Victoria Derbyshire Show about the repeated failures to learn from these deaths. The Guardian also covered the story.

    Deborah Coles told them “The fact that mental health unit deaths are not independently investigated shows a shocking lack of accountability.“

    Melanie and Lisa attended our CQC Family Listening Day last year alongside other families bereaved in a healthcare setting, where they were able to voice their concerns to CQC staff. 

  • Janet Muller’s death was one of a number of concerning recent deaths of sectioned inpatients on the Mill View hospital ward, which is run by Sussex Partnership NHS Foundation Trust. The inquest this month uncovered that failures in Janet’s care were not isolated incidents. The same trust has suffered serious criticism before in relation to previous deaths, which begs the question had they acted on previous recommendations would Janet still be alive today? Janet’s family had to fight to secure Article 2 funding and to ensure an inquest took place. The state focus was on the criminal prosecution following her murder and not on the hospital failings which allowed a vulnerable, mentally ill young woman to leave the hospital grounds in the first place.
  • INQUEST has worked extensively with the Marie and Jim McManus whose 15 year old daughter died in the care of the Priory. They spoke to the Guardian this month about how failings in her medical care, which were exposed at her inquest, failed Pip.  Marie said “We’ll never know if her death [she was hit by the train] could have been prevented for the simple reason that no one ever really tried to prevent it”.

New Government, old priorities

INQUEST will continue to speak truth to power, whoever that may be over the coming months. We will continue to exert our influence to ensure the crisis in places of detention and barriers to truth, justice and accountability for bereaved families are not forgotten by the new Government. 

Now the election is behind us, we will continue to push hard for ‘Hillsborough Law’ which we were involved in the drafting of and calls for non-means tested public-funding for families representation at state related inquests. We will also continue to push for the long awaited publication of various reviews with which we have been involved, including the Farmer Review and the Bishop's post-Hillsborough Review.

We have been informed by the Home Office that the publication of the 
Angiolini Review is a priority and we await when this will finally take place. It is unacceptable that this has been with Government since January this year given ongoing disquiet around police related deaths, although we are told that work has already begun on some of its many recommendations. 

Other INQUEST updates in brief...

  • INQUEST is delighted (and relieved!) to have secured Big Lottery Funding for the next three years! With this, we can put family participation at the heart of our work. 
  • Deborah Coles attended a National Preventative Mechanism meeting with the inspection and monitoring boards of places of detention across the UK where she discussed how there could be greater dissemination of the learning and recommendations from deaths in custody and detention. She reiterated INQUEST’s call for a national oversight mechanism of all recommendations arising from inquests. 
  • INQUEST trustee and lawyers group member Dexter Dias QC, has published a book called Ten Types of Human which he was inspired to write when working with us on the inquest of 15 year old Gareth Myatt who was fatally restrained by officers in a child prison. Gareth's mother asked what kind of person could do that to a child? This book is his attempt at finding the answer. INQUEST is one of three charities promoted in the book and DC was invited to talk about our work ‘giving a voice to the voiceless’. Dexter’s interview on BBC Radio 4 can be heard here.

Supporting INQUEST

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 11 members of staff (many of whom are part time) and rely on a team of committed volunteers to cope with our growing workload. 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.