The United Families and Friends Campaign annual rally is taking place TOMORROW. Show your solidarity by joining the procession and walking alongside the families and friends of those who have died in state care or custody. Meet at 12 noon at Trafalgar Square in central London. More info.

If you can not attend but still want to show families bereaved by state related deaths your support, please donate to the National Family Memorial Fund. 

In this edition:

Deaths in prison

The Prison and Probation Ombudsman, who investigate deaths of people in prison, on probation and in immigration detention, released their annual report which highlights a 23 percent increase in the number of self-inflicted deaths in prison on last year.

INQUEST told the Independent "recommendations made are ultimately only as good as their implementation. Yet there exists a shocking accountability gap that allows lifesaving recommendations to disappear into the ether."

Marc Maltby, Anthony Solomon and Jamal Hussein.

The inquest into the death of Marc Maltby, 23, at Nottingham prison, found that the placing of a table tennis table in front of his cell door and the subsequent actions of staff were “inadequate”. Sharon, Marc’s mother, spoke to the BBC.

Jamal Hussein, 32, feared for his life in Manchester prison and died in September 2016, 11 days after being found with a ligature in his cell. The inquest heard that a series of threats were directed at Jamal whilst in prison. His family spoke to Manchester Evening News.

The jury at the inquest into Anthony Solomon concluded that his death was caused by the toxic effects of synthetic cannabinoids. The jury highlighted a failure to answer the cell bell sooner and the prevalence of drugs in Nottingham prison at the time of this death. Read more on Hucknall Dispatch.

Deaths in women's prisons

Following the news of a death of a 26 year old at Foston Hall, 109 women have now died in prison since the Corston review into women’s experiences in the criminal justice system was published in 2007. We told the Guardian “So many deaths are the result of neglect and a criminal justice system that continues to incarcerate people in unsafe prisons. Until we abolish prisons the deaths and harms will continue.”

Check out this important long read article in the Independent on the life and talent of Charlotte Nokes, the inhumanity of IPP sentences and the urgent need to redirect resources from criminal justice to welfare, health, housing and social care. Featuring Charlotte’s family, Donna Mooney (sister of Tommy Nicol who died on an IPP sentence in prison), Deborah Coles, Women in Prison and more.

The death of a new born baby in Bronzefield prison after a women gave birth alone in a cell this month illustrates the utter inhumanity of the prison system.

Our Director Deborah Coles spoke to BBC Radio 4's Woman's Hour about the importance of robust scrutiny on how the death was allowed to happen. Listen again on BBC Sounds.

Human cost of government policies

There have been a series of deaths that have sadly illustrated the human cost of government policies. Whether it is the major changes to probation services under the ‘Transforming Rehabilitation’ reforms, the enforcement of the hostile environment, or cuts to welfare support, these policies have had a devastating and, in these cases, fatal impact, particularly on those most in need of care and support. 

The National Audit Office is to investigate the Department for Work and Pensions monitoring of suicides after ministers refused to provide figures on how many people in welfare system have taken their own lives. Deborah Coles told the Independent “That people have been so desperate to take their own lives as a result of the punitive and cruel benefits system is a serious concern that requires much greater scrutiny".

The inquest into the death of Alex Malcolm, 5, has concluded finding numerous failures by the National Probation Service and system defects following ‘Transforming Rehabilitation’ reforms contributed to his murder. Senior Caseworker Selen Cavcav was quoted in the Guardian.

The second inquest into the death of Dexter Bristol concluded with the coroner finding he had died of natural causes. The coroner did not find that the Home Office’s hostile environment was a contributory factor in his death, despite his family’s serious concerns.

In the 18 months prior to his death, Dexter’s family say he was placed under unbearable stress by the Home Office as he was required to prove his settled status, despite residing in the UK for 50 years. His mother, Sentina D’Artagnan, told the Guardian “Justice has not been done. Dexter was going through a lot of stress because of the Home Office and I believe it was those stresses that brought on his collapse and death.”

Mental health

Lauren Finch, 23, died seven days after she was found with a ligature. The jury identified a series of critical failings by mental health services and highlighted the impact of police restraint on Lauren's state of mind. Deborah Coles was quoted in Manchester Evening News and Leigh Journal.

Isaac Eastwood was receiving mental health care in the community when he died aged 21. In the two months prior to his death, his family had requested that he be admitted to hospital three times. At the inquest conclusion his family said we feel we have honoured the memory of our beloved 21 year old son and feel the inquest process has allowed the issues to be heard and allowed us to share some of the pain and trauma we have experienced.”

At the conclusion of the inquest into the death of Liverpool student Ceara Thacker, 19, her father told ITV that universities must have "proper systems for identifying students at risk and communicating effectively with healthcare services and where appropriate, families." As the high number of students taking their own lives at university continues, the findings of this inquest must be considered by universities across the country.

Lauren Finch, Isaac Eastwood and Ceara Thacker

Earlier this year, an inquest found inadequate observations contributed to the death of Alex Blake, 36, who died from a drug overdose whilst at Lambeth Hospital. The senior coroner has issued a prevention of future deaths report on the basis that three witnesses potentially falsified evidence at court. We told Southwark News “It is essential that key witnesses exercise candour to ensure a full and fair inquest hearing, and to uncover any failings within the case.”


The police watchdog has found no case to answer for misconduct by Essex police, after officers took almost three hours to answer 999 call. Suzanne Brown, 33, died after being stabbed by her partner, who was experiencing a severe episode of mental ill health. Deborah Coles told the Guardian “It is difficult to reconcile the weak outcome of this investigation with the complacent response to a series of emergency calls."

Gaia Pope died aged 19 after she was reported missing on 7 November 2017. Her body was found 11 days after her disappearance within a mile of where she was last seen. Gaia's family have learned that inquest proceedings will be postponed again, due to further delays in the IOPC's investigations into Dorset Police's handling of her rape allegation and later disappearance. Her family said: "Every deadline the IOPC has given our family has been broken with little explanation, while decisions are made without us behind closed doors.”

The parents of Douglas Oak, 35, who died hours after being restrained by police have spoken out following the conclusion of an inquest which highlighted a need for improvements in training for ambulance staff and police officers. More in the BBC and Guardian.

The Independent Office for Police Conduct (IOPC) informed the family of Thomas Orchard of their decision to withdraw directions for gross misconduct proceedings against two Detention Officers. His family were quoted in the Guardian and on the BBC As a family we are completely unable to comprehend how people who were charged with manslaughter can now be allowed to face absolutely no scrutiny for their work practices in relation to Thomas’ death.”

The US company behind Taser visited the UK to demonstrate their new 'safer' technology to police forces in the UK, which they are recommending for use on those with mental ill health. INQUEST told the Guardian about the serious concerns of new restraint devices and the need for police to recognise that all restraint has the potential to cause death.

Grenfell Inquiry news

The Grenfell Inquiry will release the Phase 1 report on the 30 October, despite calls for the publication date to be brought forward to avoid Brexit overshadowing its findings. The public hearings for Phase 2 of the Inquiry are set to begin at the end of January 2020

Work at INQUEST 

Applications for a role as Senior Caseworker close on Friday 1 November. This is an opportunity to join the INQUEST casework team, providing essential advice and support to families bereaved as a result of statutory failure or neglect. Please note, the application deadline has been extended by a week. See more about the role and how to apply on ouwebsite.

In other news:

Family Reference Group members, Aji Lewis, Anna Susianta, Marcia Rigg, Tania El-Keria and Family Participation Officer Mo Mansfield met with the Department of Health regarding the implementation of the Mental Health Units (Use of Force) Act 2018, known as Seni’s Law. The guidance will go out to public consultation in November. 

INQUEST have held a number of policy meetings with INQUEST Lawyers Group, including with the Chief Coroner, Mark Lucraft QC, and the Prison and Probation Ombudsman.

Deborah Coles was in discussion with Carl Cattermole on his new book, Prison: A Survival Guide, alongside Lisa Selby who spoke about her experiences of supporting loved ones inside. 

Upcoming events:

11 October 2019 – 30 November 2019: [BLANK] is a new play by Clean Break which explores the impact of the criminal justice system on women and their families. Book your tickets online.

26 October: Join the United Families and Friends campaign on their march in memory of those who have died in state care or custody. See more.

27 October: Rachel is running the Ruby Half Marathon in memory of Sean Fitzgerald, and to raise money for INQUEST. Sean was fatally shot by police earlier this year. The run takes place on 27 October, which would have been his 32nd birthday. Show your support and donate on JustGiving.

Supporting INQUEST

Huge congratulations to Isla for running the Oxford Half Marathon at the weekend. Due to an injury, Ellie is running later next month. We admire the dedication! There is still time to donate to their fundraising page if you are able to.