In this edition:


General election demands 

In the lead up to the General Election, INQUEST have released a set of Manifesto Demands covering access to justice, and our policy recommendations on prisons, policing, mental health and learning disability and Grenfell.
We need your help to call on all parliamentary candidates to support the legal aid campaign: 
  1. If you haven’t already, please sign and share the #LegalAidforInquests petition
  2. Ask your local candidates to support the petition and campaign – use this list to see who is standing in your constituency
  3. Share on Twitter and Facebook to spread the word
Together our voices are stronger, and it is only through collective, collaborative campaigning that we can bring about social change.

Grenfell inquiry report
The public inquiry into the Grenfell Tower fire published the report of the first phase of the inquiry. The recommendations made were chillingly familiar. Following the Lakanal House tower block fire in 2009 where six people died, the coroner made recommendations including on reviewing the ‘stay put’ policy and building regulations, due to the spread of the fire on the exterior of the building. When the Grenfell Tower fire happened, these recommendations had still not been actioned.
Deborah Coles told the Today Programme on BBC Radio 4, the recommendations from Lakanal House "were left to gather dust".
INQUEST produced a briefing to inform parliamentary debates on the Grenfell Tower inquiry in the House of Commons and the House Lords. Joanna Cherry MP, Andy McDonald MP and Baroness Kidron spoke about the important recommendations made by INQUEST, including the need for a national oversight mechanism and for the reintroduction of the Public Authority (Accountability) Bill.

Working with families
INQUEST held a family forum at the beginning of November. It was an emotional but also empowering day for many who attended. The day ended with an interactive session on family involvement in INQUEST campaign and policy work.
Aji Lewis and INQUEST’s Mo Mansfield, gave a presentation on INQUEST Family Participation and the Mental Health (Use of Force) Act (Seni's Law) at the Restraint Reduction Network Conference in Bristol. Seni died following police restraint whilst healthcare staff looked on. Aji and Conrad, Seni's parents, were given surprise awards for outstanding contributions to the reducing restraint sector.
Melanie Leahy, mother of Matthew who died in a mental health unit in Essex, and Mo attended a parliamentary committee evidence hearing on the Public Health Services Ombudsman report Missed Opportunities which lessons can be learned from failings at the North Essex Partnership University NHS Foundation Trust.
Melanie's lack of trust in the investigation processes has led her to call for a public inquiry, and through sheer determination and a massive twitter campaign her parliamentary petition was has been signed by over 100,000 people, which should be considered by the new Government. 
The Family Reference Group met at the end of October, we hope to have a family's newsletter out soon. If you would like to write something for this please contact Mo on [email protected].
The United Families and Friends Campaign annual march in memory of all those who have died in state care and custody took place at the end of October. INQUEST walked alongside families in solidarity. As ever those who spoke did their loved ones proud, and sadly new families were welcomed into the fold as the fight for justice continues.

Deaths in custody in Scotland

INQUEST is working on a project looking at the systems for responding to deaths in Scotland. As part of this, we have been working with the lawyer Aamer Anwar and families of Sheku Bayoh and Katie Allan who he represents; sharing expertise and experience from our work in England and Wales.

Humza Yousaf, Cabinet Secretary for Justice in Scotland, announced an independent public inquiry into the death of Sheku Bayoh. The announcement follows a meeting in Scottish Parliament with the First Minister of Scotland Nicola Sturgeon, Humza Yousaf and Sheku’s family, their lawyer Aamer Anwar, and Deborah Coles the Director of INQUEST. Sheku Bayoh’s family spoke to the Sunday Post.

Deborah Coles (INQUEST), Kadi Johnson (sister), Nicola Sturgeon (First Minister), Aminata Bayoh (mother) & Ade Johnson (brother in law), Aamer Anwar (lawyer)

Learn more

Humza Yousaf has also ordered an independent review of deaths in Scottish prisons, following the deaths of Katie Allan, William Lindsay, Allan Marshall and others. This is a huge step forwards in terms of ensuring greater transparency of deaths in Scottish prisons.

Mental health

Duncan Lawrence has been sentenced to four months in prison after failing to attend and disclose crucial evidence at the inquest into the death of Sophie Bennett. INQUEST believes this is the first time a witness at an inquest has been criminally charged for a failure to participate.

Sophie’s father, Ben, was quoted in the Guardian The extent of his disrespect to us by not taking part in the process is extraordinary. There was evidence we wanted to be included. The whole inquest process was meant to be when you find out the truth of what happened.”

A coroner has highlighted the effects of anti-psychotic medication Clozapine on physical health, and the lack of effective national weight gain monitoring programme for mental health inpatients, at the inquest into the death of Kate Stamp. Kate, 30, was one of three women to die at The Dene in less than a year.

Her family told the BBC they were pleased the coroner sought to raise awareness of the "potentially life-threatening physical effects of Clozapine”.
A coroner found that a failure by Camden and Islington NHS Trust contributed to the self-inflicted death of 19 year old Osman Ahmednur. His death was the third of four self-inflicted deaths of young Eritrean refugees from the same friendship group. His family were quoted in the Guardian.

Deaths of people after release from prison

A new report on the deaths of people following release from prison has been published this week showing that self inflicted deaths have increased six fold since 2010. Written by Rebecca Roberts, head of policy at INQUEST, and Dr Jake Phillips of Sheffield Hallam University, they highlight the lack of visibility and policy attention given to this growing problem and call for immediate action to ensure greater scrutiny, learning and prevention. 

Deborah Coles was quoted in the Guardian“The figures are deeply disturbing and require urgent scrutiny, due to the current lack of independent investigation into these deaths. What is clear however is that people are being released into failing support systems, poverty, homelessness and an absence of services for mental health and addictions. This is state abandonment.”

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Challenges to police impunity and anonymity

Anonymity orders have typically been granted for police officers following fatal shootings. However, INQUEST has observed a recent trend of anonymity applications being made and granted to police officers in other circumstances, such as where the death involved police restraint. This is disproportionately the case where the person who died is racialized as black. This has been successfully challenged in the following cases.

The Crown Prosecution Service have announced that criminal charges will be brought against two officers involved in the death of Dalian Atkinson. One officer has been charged with murder and manslaughter and the second officer with actual bodily harm. Dalian died in August 2016 aged 48, following use of force by officers of West Mercia police, including restraint and Taser. The judge lifted the anonymity of the officers after it was challenged by media organisations.

A coroner’s decision allowing 16 police officers to be screened from public view during an inquest into the death of Andrew Hall, 43, has been overturned following judicial review. Andrew was subject to a period of restraint by officers at Huddersfield Police station, after being arrested in Huddersfield Royal Infirmary where he had been very unwell in September 2016. We told the Guardian “Anonymity goes against the spirit of an open and transparent investigation and hinders scrutiny of public officials.”

Prison and immigration detention

The Ministry of Justice released the latest statistics on deaths and self harm in prison showing historically high levels of self-inflicted deaths as seen over the past six years and record high levels of self harm. INQUEST were quoted in the Independent.

“These statistics are more than numbers. They represent real people in extreme distress, leading to preventable deaths and traumatic bereavement for families. The lack of accountability for these deaths, and the abject failure of the system to prevent them, is a moral and political disgrace.” 

A new joint report by the Prison Reform Trust, INQUEST and Pact (the Prison Advice and Care Trust) reveals that most prisons in England and Wales are failing in their duty to ensure that emergency phone lines are in place for families to share urgent concerns about self-harm and suicide risks of relatives in prison. INQUEST were quoted in the Daily Mail.

Learn more

Jury highlights a series of failures that contributed to the self-inflicted death of Darren Williams, 39, at HMP Woodhill in January 2019. INQUEST caseworker Selen Cavcav was quoted in Northampton Chronical “It is chilling that the circumstances and failures of Darren’s death are so familiar. How many more people must lose their life as a result of these deplorable failures in the prison’s duty of care?”

Darren Williams and Carlington Spencer

Carlington Spencer was an immigration detainee at Morton Hall Immigration Removal Centre. The inquest jury found that he died on 3 October 2017 as a consequence of a stroke, and identified series of failings which possibly contributed to his death, including that staff dismissed detainee’s concerns that he was suffering a stroke, instead believing he was reacting to spice. INQUEST was quoted in the Independent.

Learning disabilities and autism

Sally Lewis, 55, had learning disabilities and was in supported living accommodation when she died after faeces blocked her bowel in 2017. Her death was initially classified as natural causes and her family have had to fight for a full inquest. Her family spoke to the BBC. Please support their crowd funder.

The Joint Committee on Human Rights has echoed INQUEST’s key demands by recommending legal aid for inquests and independent investigations following deaths in their report on the detention of young people with learning disabilities &/or autism.

In other news

  • On the 30th anniversary of the UN Convention on the Rights of the Child, INQUEST has joined a range of supporters of children's rights in signing this letter urging all political parties to commit to incorporating the convention into UK Law. #UNCRC30
  • INQUEST were shocked and saddened to hear of 39 deaths of people in a lorry in Essex, understood to have been trafficked to the UK. Deborah Coles told the Guardian This is a shameful and avoidable loss of life. Both the individual deaths and the broader social and political context must be subject to the most searching scrutiny in a process which enables the bereaved families to participate.”
  • Lucy McKay, Policy and Communications officer at INQUEST spoke at the Independent Custody Visitors Association Conference about dignity of detainees in police custody and the work of INQUEST to ensure changes in policy and practice to prevent deaths
  • Deborah Coles spoke at the Manchester Law Society Inquest conference about ensuring the essential voice and participation of the family in post death investigation processes.
  • Rebecca Roberts and Deborah Coles presented at the Independent Advisory Panel for Deaths in Custody conference hosted by the Royal College of Nursing on ‘Natural’ Deaths in Custody.
  • Deborah Coles gave a presentation at Essex University on the work of INQUEST, speaking truth to power and campaigning for truth, justice and accountability after state related deaths.

24 November 2019 – Rebecca Roberts is speaking at the RebLaw conference on a panel on Tough on crime? Evidence based approaches to prison reform. Tickets are available on Eventbrite.

Thank you…

We are very grateful to Isla and Ellie who have smashed their fundraising target after running a half marathon for INQUEST.

Huge congratulations also to Rachel for running Rugby half marathon for INQUEST and in memory of Sean Fitzgerald.

National Mikey Powell Memorial Fund

INQUEST is proud to be a partner of the National Mikey Powell Memorial Family Fund. This fund will make a real difference for families and their campaign groups that need financial support during the often long struggles for justice lasting for decades in many cases. Find out more about the fund and how to set up a regular donation online.