In this issue:

  • Grenfell: No voice left unheard
  • Evidencing truth to power
  • Legal aid campaign
  • Mental health
  • Learning disabilities and autism
  • Prison
  • INQUEST out and about
  • Funding

Grenfell: No voice left unheard

INQUEST released Family reflections on Grenfell: No voice left unheard
. This evidence-based report is filled with first-hand testimonies of bereaved families, brought together as part of a family consultation day, held by INQUEST. 

Families reflected on their experiences of the aftermath of the disaster and the inquiry process and made insightful and practical recommendations for change. 

Grenfell United said: “This is the first time bereaved families have been brought together to document the impact of Grenfell in the harrowing days immediately after the fire. The report is a compelling piece of work we hope will contribute to much needed and lasting change to how we deal with disasters and disaster management.”

INQUEST conducted significant media work and was quoted widely “It is high time the inquiry team and the government listened to these voices and provide an inclusive and truthful inquiry that delivers structural change and accountability.”

Sadik Kelbeto, who lost five family members, spoke to London Live: "my words need to be heard, the government has an obligation to hear it."

The Inquiry subsequently announced that the report for the first phase of the Inquiry, which was initially due in ‘spring’, was now delayed until October. INQUEST were again widely quoted in HuffPostThe Times, and MyLondon that Uncertainty around timeframes is causing grief, anguish and anger in the community.” 

Evidencing truth to power

Evidencing Truth to Power, The Work and Impact of INQUEST – 2016 to 2018 outlines the key activities and impact of our work in a period that has been a truly momentous time for INQUEST and the families we work with, with a policy landscape presenting formidable opportunities in the pursuit of our campaigning and advocacy aims.

Thank you to Hudgell Solicitors for sponsoring the report launch.

Legal aid campaign

Our #LegalAidforInquests campaign has remained on the political agenda thanks to the support of determined families, lawyers, parliamentarians and the public. 30,000 people signed our petition in just a week, bringing the total number of supporters to more than 67,000. Please continue to share amongst your networks.

In April, MPs took part in a 90 minute parliamentary debate on legal aid for inquests in which our work was commended and Stephanie Peacock MP ending the debate with a challenge: ‘I implore the Minister: please listen to INQUEST’. INQUEST will be setting up an urgent meeting with the new minister for legal aid, Paul Maynard MP, to discuss this injustice.

Bob Neill MP, chair of the Justice Committee has written to the Secretary of State for Justice, David Gauke, urging him to reconsider the government’s position on legal aid for inquests. Read more in The Law Society Gazette.

The mother of Taylor Alice Williams, 17, who was the first child to die in a secure children's home in 20 years, has been asked by the Legal Aid Agency to pay thousands towards legal costs for the inquest despite being unable to work. INQUEST Director Deborah Coles told the Guardian:

“This is a death that needs the most searching scrutiny. That her disabled mother has been asked to contribute to funding while three state organisations are represented from the public purse is deplorable and exemplifies the cruelty and unfairness of the funding system.”
Rachel Hammerton, sister of Charlie Nokes, who died whilst in prison on a long IPP sentence, has written about her family's three year struggle for answers and the importance of legal aid for bereaved families, alongside specialist support like INQUEST's in this blog for the Metro. Rachel writes:

“Both the prison and the NHS trust responsible for healthcare in HMP Peterborough will be represented by a professional legal team, the cost of which will be met by the taxpayer. As Charlie’s family – and many other families whose loved ones have died in custody – we are not automatically afforded this privilege.”
Rachel also spoke to Buzzfeed about having to crowdfund for Charlie’s inquest. Please donate to the crowdjustice page if you are able to.

Learning disabilities and autism

INQUEST responded to the annual Learning Disabilities Mortality Review (LeDeR) and the Care Quality Commission’s review of restraint, prolonged seclusion and segregation for people with a mental health problem, a learning disability or autism. The reports reveal preventable deaths and unsafe care of people with learning disabilities and autism.

Deborah Coles said: “The findings of LeDeR and the CQC today add to the growing evidence of inadequate care, human rights abuses and needless incarceration of people with learning disabilities and autism. Yet we still see an unconscionable lack of political will and leadership to ensure action and systemic change."

Sara Ryan, campaigner on the rights of people with learning disabilities and autism, said: “These reports underline the barbaric and inhumane way people with learning disabilities and/or autism continue to be treated in this country. It is utterly shameful and the government needs to stop hiding behind reports, consultations and inquiries and actually act.”

Deborah and Sara were part of panel discussion on justice and human rights for people with mental ill health, learning disabilities and autism in the care system, alongside leading campaigner Mark Neary, and Jonathan Hurley from Advance SS as part of Writing on the Wall festival in Liverpool.

Legal challenges

INQUEST provided a supporting statement for the landmark High Court challenge concerning Brook House immigration detention centre abuse. In our view, a public inquiry is the most effective way to scrutinise inhuman and degrading abuses of power experienced by immigration detainees at Brook House and elsewhere. Read more on Detention Action.

The Court of Appeal have held that the standard of proof for a suicide conclusion should be at the lower civil standard at inquests. Therefore, coroners and juries have only to be satisfied that it was ‘more probable than not’ that a self-inflicted death was a deliberate act. Previously this was at the higher criminal standard of ‘beyond reasonable doubt’. There is a wider impact on the standard of proof for unlawful killing. The ruling follows an appeal brought by James Maughan’s family against a suicide conclusion. James was found hanging in a cell at HMP Bullingdon. INQUEST intervened to ensure the perspective of bereaved families were considered. The Court of Appeal has granted permission to appeal to the Supreme Court.


Monuments to injustice: The latest issue of Proof Magazine includes an article from INQUEST’s Head of Policy Rebecca Roberts on the prison crisis and deaths in custody. “Across the political spectrum the current ‘crisis’ facing prisons has been articulated as one of understaffing, underfunding, violence and drugs. However, these so called ‘problems’ are better understood as symptoms of the overuse of imprisonment and punishment to tackle issues of poverty, inequality and mental illness, alongside a failure to treat prisoners with humanity, dignity and compassion. Prisons are not just ‘in crisis’, they are places of crisis.”
INQUEST trustee Joe Sim has written about the latest Ministry of Justice safety in custody statistics and draws concern that “the abject response from political parties means questions about prison safety, and the shuddering failure of penal policy more generally, are never asked.”
The inquest into the death of Daniel Davey at HMP Bullingdon concluded that he deliberately took an overdose of prescribed drugs with the intention of suicide. The jury found that the prison failed to adequately train staff in suicide and self harm management, assessment and review processes. Daniel was one of three self-inflicted deaths in 4 months at the prison.
The House of Commons Welsh Affairs Committee have published their report of their inquiry on prison provision. INQUEST submitted evidence on deaths in Welsh prisons and the committee shared our concerns around safety, delays to investigations and inquests and provision for women. Read our evidence.

Mental health

The inquest into the death of Sasha Forster, 20, resulted in three critical reports from the coroner to prevent future deaths. Sasha was autistic and had confirmed diagnoses of Obsessive Compulsive Disorder and Post Traumatic Stress Disorder. The inquest was reported in the Guardian and was tweeted by George Julian @SashaInquest.

A jury concluded that neglect contributed to the death of Norman Dunwell in a mental health unit after observation records were falsified. INQUEST caseworker Natasha Thompson said it is essential that key witnesses exercise candour.

At an unprecedented hearing a coroner has imposed a fine on a key witness for failing to attend and disclose evidence at the inquest into the death of Sophie Bennett. The Care and Quality Commission have also announced that they will prosecute the charity involved in her care. Three years after the death of Sophie Bennett, her family have welcomed the decision.

An investigation by CorporateWatch raises serious questions about the profits of the Priory group, who were fined less than two days profit following the death of 14 year old Amy El-Keria in their care. Tania El-Keria spoke to Sky News and was quoted in the Observer “Our Amy died in what we now know to be a criminally unsafe hospital being run by the Priory. To me the Priory are a morally bankrupt company. They continue to take large sums of public money, allowing our children to suffer by placing profit over safety. This cannot be allowed to continue, and I will not stop fighting until this stops.”
Deborah Coles said: “We know there have been other child deaths involving the Priory. The damning evidence about systemic failings in care begs the question as to whether the Priory’s contract should be withdrawn and reinvested into specialist NHS services.”

INQUEST and Tania El-Keria met with Jackie Doyle-Price MP, the minister for mental health, outlining our concerns about Amy’s death and the lack of public monitoring and scrutiny of child deaths in mental health settings.

The inquest into the death of Bristol University student, Natasha Abrahart, found that neglect by mental health trust contributed to her death. Natasha was the 10th of 12 suspected self-inflicted deaths at the university since September 2016. INQUEST became involved having noted the high number of deaths and concerns over systemic issues requiring proper scrutiny. The coroner has written to the health secretary highlighting the failure of the University GPs to follow guidelines. Watch the documentary Dying for a Degree on BBC 1 Thursday 30 May.
The family of 23 year old Reece Baker welcomed changes in Somerset NHS Trust Dual Diagnosis policy at the conclusion of his inquest. Reece had been considered more appropriate for treatment by drug and alcohol services despite also having mental ill health. Remy Mohamed, Grenfell Project Coordinator said that INQUEST is increasingly contacted in relation to deaths of people with multiple needs who are falling through the gaps between services.

INQUEST out and about

  • Deborah Coles and Tony Herbert, father of James - who died following police restraint in 2010 - delivered training to coroners’ officers on best practice and how to meet the needs of bereaved families during the inquest and investigation processes following a police related death.
  • Deborah Coles and Rebecca Roberts met with Bambos Charalambous MP to discuss our campaign on #LegalAidforInquests and Shadow Minister for Justice, Imran Hussain MP to highlight the historically high numbers of deaths in prisons and the need for bold and decisive action.


A huge thank you to City Bridge Trust, Wates Foundation and AB Charitable Trust for awarding us grants to support casework in London, our Scotland work and our core policy work respectively. 

INQUEST is independent of government and entirely reliant on grants and donations, without which we could not continue our vital work. You can view our funders on our website. 

Well done to Hannah and Lisa who completed the Hackney Half Marathon and raised £250 for INQUEST.

Supporting INQUEST

The INQUEST team are taking part in the London Legal Walk next month! Please consider donating to support our work here.