Welcome to the April/May edition of the INQUEST E-Newsletter

Olaseni Lewis: calls for CPS prosecution in light of damning inquest findings

It was poignant that almost seven years on from his death, during Mental Health Awareness Week, the Olaseni ‘Seni’ Lewis inquest concluded after 10 long weeks for his family. A catalogue of failures and delay by the IPCC and other investigative bodies had meant the inquest could not be heard before this time. 

Having heard 29 days of evidence, the jury’s highly critical narrative unanimously condemned police and healthcare staff actions in relation to the 23 year old’s death as a result of a prolonged restraint by MPS officers at Bethlem Royal Hospital on 31 August 2010.

Their damning criticisms included:

  • Multiple failures at multiple levels within Bethlem Royal Hospital meant that the hospital staff had to call upon the assistance of the police when Seni became unwell.
  • The force used by the police officers over two successive periods of prolonged restraint of Seni – including the use of mechanical restraints - was excessive, unreasonable, unnecessary and disproportionate, and contributed to Seni’s death.
  • The failure by hospital staff and the police officers alike to provide basic life support when Seni collapsed under restraint also contributed to his death.

The family have called for the CPS to reconsider the case for criminal prosecutions against the officers involved: “In light of the evidence we have heard, we consider that the prolonged restraint that resulted in Seni’s death was not and cannot be justified, and we now look to the Crown Prosecution Service to reconsider the case, so that the officers involved in the restraint may be brought to answer for their actions before a criminal court.  This is necessary, not just in the interests of justice for Seni, but also in the public interest, so that the police are seen to be accountable to the rule of law”.

Media coverage was extensive and Seni’s parents and Deborah Coles gave powerful interviews to Channel 4 newsITV news, BBC London News, the Victoria Derbyshire show and BBC Radio London. Press coverage included the GuardianEvening StandardIndependentCroydon GuardianCroydon Advertiser, the Voice and BBC Online.

Since Seni’s death in 2010, INQUEST’s casework and monitoring statistics have identified a further 27 deaths in custody where police restraint was a feature.

Our press release can be found here, which also outlines our concerns surrounding the prevalence of mental health and race as factors in police-restraint related death and the failures of mechanisms for accountability and learning from previous deaths.

INQUEST has criticised Government for the failure to publish the Independent Review, now delayed again due to the general election. The review - chaired by Dame Elish Angiolini - was set up in direct response to disquiet over the deaths of Seni Lewis, Sean Rigg and others and the protracted legal process. The review was anchored in the experiences of bereaved families.

How the media is helping to bring justice and systemic change a step closer

INQUEST continues to see an increase in our casework, having registered almost 200 new cases already this year. Our work with the bereaved families and friends can extend over many years, with some of our longest running cases receiving considerable media interest, most recently Thomas Orchard and Olaseni Lewis (above).

High profile media coverage of specific cases gives INQUEST a platform from which to raise awareness of the broader issues running throughout our casework. This publicity also drives an increase in self-referrals to INQUEST, when isolated families realise they are not alone in their experiences and that there is somewhere to go for help.

Disappointingly some cases do not receive the media coverage they deserve, despite our best efforts. For those cases which do, INQUEST is there to represent the voices of all the other families bereaved in similar circumstances, ensuring these are not reported as ‘one-off’ deaths. Each family statement read outside court, each critical jury narrative, each Prevention of Future Deaths report is holding the state to account and a collective step closer to change and justice for all the bereaved people we work with.

Serious concerns over legal aid funding of families at Article 2 inquests

The inequality of arms and resources faced by families following a death in state care or detention is brought into stark contrast by our work. INQUEST has given prominence to this issue in our evidence to the Angiolini Independent Review into Deaths in Police Custody and more recently in our evidence to the post-Hillsborough Bishops Review, emphasising again our call for automatic, non-means tested public funding for families at state related inquests. At INQUEST, we are now seeing grieving families facing greater uncertainty and delay over legal funding following a dramatic change in approach by the Legal Aid Agency.

The recent case of Nadja Ensink-Teich being a prime example. Her husband Jeroen Ensink, 41, was killed in December 2015 by young student who had paranoid schizophrenia, and just days earlier had knife and as
sault charges against him dropped. Nadja has been denied legal aid to be legally represented at his inquest, which is set to explore the actions of police, prosecutors and mental health professionals leading up to his death. The police and CPS have their legal representation paid for by the state; the police by a QC.

Nadja is currently crowd-funding to raise funds to cover her legal fees at the inquest. She has just 9 days left to raise the money needed – if you are able to support her, please do so here

Failings in the care of a 15 year old Pip McManus contributed to her suicide 

Pip suffered from Anorexia and during the inquest, the Priory accepted hers was one of the most severe cases they had seen. This month, a jury found that her death was a suicide, with the following contributory factors:
   - Inadequate community care and specialist post-discharge support for Pip and her family.
   - Failure to implement a timely care plan and lack of cohesiveness amongst agencies.
   - Inadequate communication of enhanced risk of suicide on discharge.
The coroner will be issuing a Prevention of Future Deaths report.

Deborah Coles, Director of INQUEST said:
“Pip’s death has exposed a mental health system which pushed through the discharge of a highly vulnerable child without any of the support or care in place to make sure she would be safe. Her terrified family knew there was huge risk. Their concerns were dismissed and minimised throughout”.

Poor quality and overstretched mental health services feature frequently across our specialist casework. Pip’s story reinforces INQUEST's serious and ongoing concerns over the lack of scrutiny and oversight of deaths of children and young people occurring in mental health settings like the Priory. 

  • There currently remains no pre-inquest system of independent investigation into the deaths of children who die as mental health in-patients.
  • With private providers now publicly funded to provide 47% of all in-patient Child and Adolescent Mental Health Services, Government must ensure adequate safeguards and controls are in place.

This was another case attracting extensive media interest throughout the inquest with coverage on the BBC News, ITV and Channel 5 and press coverage in the Sun, Metro, Daily Mail, Manchester Evening News and the Guardian.

HMP Woodhill – INQUEST calls for a corporate manslaughter investigation 

As we await the imminent decision on the HMP Woodhill Judicial Review, highly critical jury conclusions have been made at the inquests of Danny Dunkley and Michael Cameron, 2 of the 18 prisoners who have died at the prison in the last 4 years.

The prison service is facing calls for a corporate manslaughter investigation after a litany of failures resulting in an “unbroken pattern of deaths”. Deborah Coles told the Guardian the death of 35-year-old Daniel Dunkley, who killed himself in July last year, showed warnings had been ignored and raised serious questions for senior managers at the site.

“The unbroken pattern of Woodhill deaths reveals a systematic failure at a local and national level to act in response to critical inquest findings and recommendations for action. The prison service must be held accountable for failures to implement recommendations and this litany of failures. They have clearly ignored warnings about the risks to health and safety of prisoners and the necessary sanctions should be enacted against those responsible.

“When any organisation fails to act on repeated warnings and this failure leads to the shocking death toll witnessed at Woodhill, it demands nothing less than a corporate manslaughter investigation.”

Another avoidable young death at HMP YOI Cookham Wood – is this how we want to treat our children? 

A coroner at a hearing last month into the death of a 16 year old epileptic Daniel Adewole at HMP YOI Cookham Wood, concluded that prison officers should have entered his cell much sooner.  Officers waited 38 minutes, after they first received no response at Daniel’s cell door, before opening his door. They went for a cigarette before checking his safety.

Daniel is the second boy to die at Cookham Wood since 2012. In the investigation into the previous death, Alex Kelly there were also concerns that staff delayed going into the boy’s cell during the night.

Deborah Coles, Director of INQUEST said:
“Daniel was vulnerable, both because he was a child and he suffered from epilepsy. The inquest into his death raises the question, why was this boy in prison in the first place? At 16 years old Daniel was left to die alone on the floor of a prison cell, all for the sake of a 6 month sentence. Only two years previously, a PPO investigation also identified that staff had failed to open cell doors and had a delayed response to a child in danger. The prison said they would review procedures and ensure there is no delay when there is potential risk to the life of a child. However, lessons clearly were not learned”.

Last month’s report by the Council of Europe’s Committee for the Prevention of Torture and Inhuman and Degrading Treatment or Punishment (CPT) reflects some of the ongoing concerns of INQUEST on issues in UK places of detention. The CPT visited adult and youth prisons, police custody, immigration detention and psychiatric institutions in England between March and April 2016, including Cookham Wood.

INQUEST made a detailed submission to the CPT based on the issues arising from our casework and policy work and met with the CPT team on their recent return visit, prompted by their serious concerns. They identified multiple systematic failings, to the extent that in the case of prisons, none of the establishments they visited could be considered safe. Find our summary and response here

Joint Committee on Human Rights adopts INQUEST recommendations

The lack of action in response to repeated prison deaths was a thematic issue raised in our evidence presented to the JCHR in March. By ensuring the families of Dean Saunders and Diane Waplington gave evidence alongside us, INQUEST placed family voices at the heart of the process. This directly impacted on the JCHR’s adoption of our key recommendation for a national oversight mechanism and their recognition of the importance of family evidence.

Click here to read their interim report, published 2 May 2017. Our response with links to our oral and written submissions can be found here

INQUEST has called for politicians to take urgent action to address this failing prison system, as the numbers of people dying in its care continues to rise.

The latest MoJ statistics published on 27 April showed the rate of self-inflicted deaths has more than doubled since 2013, and the number of incidents of self-harm has reached a record high. There were 113 self-inflicted deaths in the 12 months to March 2017, 10 of which were in the female estate.

You can find INQUEST’s response to the figures here

Other updates in brief: 

  • Southern Health NHS Foundation Trust will finally face charges over the death of Connor Sparrowhawk, with prosecution being brought by the Health and Safety Executive after the trust admitted responsibility. Without doubt, this is thanks to the relentless campaigning of Connor's family, for never giving up in their struggle for truth and justice despite all the push back. 
  • INQUEST are advising the family and lawyers involved in the Sheku Bayoh case. Sheku died in police custody in Kirkaldy, Scotland on 3 May 2015. The family are still waiting for the investigation to conclude, two years on.

"In the six and a half years since Seni's death, INQUEST has been with us every step of the way, giving us the strength that we needed to persevere and find out what happened to Seni.

Like other families before us, we have found that INQUEST has been there for us in our time of need, to cope with all the challenges that we never thought we would have to face and we do not know what we would have done without this small but effective organisation. So, thank you, INQUEST: love and respect!" 

- Aji Lewis, mother of Olaseni Lewis


This year so far, INQUEST has registered almost 200 new cases, alongside the bereaved families we already provide ongoing support and guidance to.

That's why we're walking the London Legal Walk to raise money to fund our specialist casework service and to enable us to campaign and influence policymakers to effect real change. We receive no government funding and are entirely reliant on grants and donations.

Please donate what you can here and share the link to help us reach our target!

This week we gratefully received a donation from Joan Meredith in memory of a wonderful friend and supporter of INQUEST, Pauline Campbell. Pauline was a relentless campaigner against women’s prison deaths after the death of her own daughter, Sarah, in Styal Prison.