In this edition:

  • Seni's law, a fitting legacy
  • UFFC, 20 years of united families
  • No death is natural in prison
  • Short term fixes not working
  • Child imprisonment is wrong, let’s end it
  • Police picking up the pieces?
  • Autism and learning disabilities
  • Immigration detention
  • Mental health
  • Legal aid for inquests
  • Global campaigns
  • Also this month…
  • Upcoming events

Seni’s law, a fitting legacy

The Mental Health (Use of Force) Bill received Royal Assent in Parliament. Known as Seni’s Law, the Act will increase protections and oversight on use of force in mental health settings. The Lewis family have fought tirelessly for eight years to ensure that no one else dies in such horrific circumstances. They have been the driving force behind this bill.

INQUEST is proud to have been part of this momentous step forward, alongside the family, Steve Reed MP and many great organisations. We were cosignatories to this letter to the Guardian, welcoming this new law.

UFFC 20 years of united families


The United Friends and Family Campaign held a conference to mark their 20th anniversary. The conference heard powerful contributions from families and allies including Tippa Naphtali, Lisa Cole, Janet Alder, Aji Lewis and Marcia Rigg.

Akala, opened the conference: “Even if you feel like you might not get the justice you deserve, the fruit of your labour is there. Because the fight of people like you”.

INQUEST staff and volunteers joined families at the 20th anniversary UFFC annual procession in central London.

No death is natural in prison

The Health and Social Care committee echoed INQUEST’s concerns in their report into prison healthcare, acknowledging that ‘so-called natural cause deaths too often reflect serious lapses in care’. Head of Policy, Rebecca Roberts, was quoted in the Independent.

INQUEST has long running concerns about the oversight, regulation and accountability of prison and health services and the persistent failure to rectify dangerous practices. In the lead up to the Committee’s report, we spoke to the Observer.

Recommendations from the Committee’s report, if acted upon, could save lives. These include an independent review of implementation of inspection recommendations, improved health screenings and access to appointments, quicker transfers to mental health settings, and clarity on measures to improve standards of healthcare more generally. This is also the first time a committee has made recommendations to address the alarming number of deaths of people after release from prison.

Short term fixes not working

New Ministry of Justice statistics show a rise in deaths and self-harm in prison custody and of deaths of people shortly after release from prison. Speaking to the Guardian, we said “Short-term fixes are not working. Ministerial focus on violence ignores the shocking death toll in our prisons and the need for a radical overhaul. We need to tackle sentencing policy, reduce the prison population and redirect resources to community services”.

Mark Saunders, father of Dean who died in HMP Chelmsford in 2016 spoke alongside Deborah Coles to LBC. Mark said: 'Dean would help anyone & everyone, when he needed help, people turned their back on him'.

The inquest into the death of Jessica Whitchurch at HMP Eastwood Park concluded that “deeply inadequate” levels of care contributed to her death. Jess’ sister Emma told the Independent:  “After a painful two and a half year wait and seven days of extremely distressing evidence the jury has finally confirmed what we have known all along, that Jess’ care in the hours before her death was inadequate and that her death was avoidable

Selen Cavcav, INQUEST caseworker, was quoted in the Guardian; "This country criminalises women for their own suffering, imprisoning them in places that cannot possibly end the cycle of harm or keep them safe.”

The inquest into the death of Tommy Nicol, found that he had 'lost hope' whilst on an IPP sentence. Tommy’s sister, Donna, told the Watford Observer“My brother was jailed for a minimum term of four years yet two years after he had completed his tariff he was still in jail. Tommy became more and more desperate, but nobody would listen to him. The prison authorities didn’t even carry out a mental health assessment despite his very high risk of self-harm and suicide.

Child imprisonment is wrong, let’s end it

INQUEST is one of the founding members of a new campaign to end child imprisonment. 

Liz Hardy, mother of Jake Hardy who died aged 17 in HMYOI Hindley in January 2012 spoke at the launch in the House of Lords. “I was shocked when he was sent to prison. I thought he would be looked after. I thought he would get the basics. He was only a child.” Liz was interviewed for Byline.

You can read about the campaign in this letter to the Guardian and sign up to support the campaign.

Police picking up the pieces?

INQUEST responded to a new report by HM Inspectorate of Constabulary on Policing and Mental Health. Marcia Rigg, sister of Sean who died in police custody in 2008 was on the Victoria Derbyshire programme. 

"This report is nothing new. What we need is implementation and action, not another report... Deaths in police custody are still happening. What we need is care.”

In an in-depth piece in the New Statesman, (‘What police ‘picking up the pieces of mental health services don’t tell you’), INQUEST’s Victoria McNally, said the police need to treat people in crisis as “patients with health needs, not applying a criminal justice response”.

The inquest concluded into the death of Adrian McDonald finding that he died as a result of stress following an incident involving police dog bites and Taser use combined with the effects of cocaine. Wayne, Adrian’s brother, spoke to Channel 4 News. WARNING: GRAPHIC FOOTAGE.

The police misconduct hearing in relation to the death of Kingsley Burrell is ongoing. The family welcome support and invite the public to attend the hearing. Find out more information on this Event or by following the Justice4Kingsley Campaign page on Facebook.

New police tactics around police pursuit will "cause far more harm than they prevent and make everyone less safe" Lucy McKay, Policy and Communications Officer told Children and Young People Now.

Autism and learning disabilities

The inquest concluded into the self-inflicted death of Billie Lord, who absconded whilst an inpatient at the Campbell Centre in Milton Keynes. The inquest heard how placing Billie in a shared dormitory would have been an added stressor because of his autism, which the coroner is addressing in a Prevention of Future Deaths report.

Too many people with Autism and learning disabilities are detained (sometimes indefinitely) in Assessment and Treatment Units, with reports of inhumane and degrading treatment. You can help raise this issue in parliament by supporting this petition.

Immigration detention

The Crown Prosecution Service reversed their prosecution decision on the 6th anniversary of the death of Prince Fosu in immigration detention. Deborah Coles was quoted in the Guardian and the Justice Gap

The jury at the inquest into the death of Branko Zdravkovic at The Verne detention centre returned a conclusion of ‘suicide’. Nicola Sanderson, Branko’s partner and Natasha Thompson, INQUEST caseworker spoke to the Guardian.

Mental health

The inquest into the self-inflicted death of Ellie Brabant in a mental health unit run by Southern Health concluded, with the coroner finding that the lack of a clear care plan, and the decision to discharge Ellie from Section 3 of the Mental Health Act contributed to her death.

On the anniversary of her disappearance, Gaia Pope's family appealed to the public to come forward with any relevant information. They have also launched an art project in her memory.

Speaking to the Guardian, Deborah Coles said, “There is a clear link between the trauma of rape and mental ill-health. The longer the delay in identifying any systemic failings, the greater the risk of more young women like Gaia dying.”

Legal aid for inquests

Andy Slaughter MP pressed the government on the important issue of legal aid for inquests at a parliamentary debate. INQUEST’s briefing for MPs highlights the current situation and why urgent change is needed.

This urgency remains ever prevalent, as demonstrated by the CrowdJustice campaigns being launched by bereaved families to obtain legal funding.

We spoke to the Guardian, “Inquests provide an opportunity for families to ask questions and establish the truth. Unrepresented families face a huge disadvantage given that state bodies and private providers are almost always legally represented”.

Tim McComb died on 26 August 2016 whilst in supported accommodation and the family have been denied legal aid for the inquest. They say "we can’t face the inquest alone unrepresented". Please support the CrowdJustice fundraiser.

Libby Rose suffered from an eating disorder and died aged 16. The coroner has said her death was from ‘natural causes’. Her family are crowdfunding for legal representation to help them argue for an inquest to be opened.

Global campaigns

Deborah Coles was invited to address the Women of the World Festival (Festival Mulheres do Mundo) in Rio de Janerio, the first time it has been held in Latin America. She spoke on two panels specifically focusing on the incarceration of women in the UK and Brazil and the social and political context of racism, sexism, poverty and inequality.

She then met with a community organisation the Redes da Maré in the Maré favela and spoke with the mothers of those who died as a result of state violence. This included the mother of Marielle Franco, who was an outspoken Brazilian politician, feminist, and human rights activist who was assassinated earlier this year. They discussed sharing best practice, global campaigns and strategies against state related deaths and the importance of this work particularly in light of the election of Bolsanaro.

Deborah also presented a paper via video link opening the University of Sydney Critical Death Investigation Lab conference in Australia.

Also this month:

  • The latest issue of INQUEST Law has been published with a specific focus on the deaths of women. Find out more about subscribing on our website.
  • RebLaw UK 2018 conference: Deborah Coles spoke alongside Una Morris of Garden Court chambers, Dr Sara Ryan, mother of Connor Sparrowhawk and Stephanie Lightfoot-Bennett, sister of Leon Patterson.
  • London Forum on Children & Policing: Rebecca Roberts spoke about INQUEST’s concerns about deaths of children and young people following police contact, and discussed the Angiolini Review.
  • Deaths on probation: Rebecca spoke at event as part of the Festival of the Social Sciences on the neglected issue of people who die whilst under probation supervision.
  • Lockdown podcast: Deborah spoke to the Lockdown about deaths in state custody and the work of INQUEST.

Upcoming events

15 December – INQUEST Family Social Gathering. INQUEST invites all families we have worked with for a social gathering on Saturday 15th December. There are still some tickets left. BOOK HERE.

17 December - The Incarcerated Workers Organising Committee are screening the 2001 film Injustice. The event is free to register and is raising donations for the National Memorial Family Fund which will be the first national resource of its kind to provide financial support for families affected by deaths in state custody and detention.