There are times when it feels like change is a distant prospect but last week marked a truly momentous week for INQUEST and the families we work with.  In just five days many hugely significant milestones were reached on issues INQUEST has campaigned about for decades; with the needs of bereaved families recognised in two major reports, on multiple occasions in the House of Commons, and in commitments from the government.  These achievements are a testament to our families’ unwavering fight for changes to systems that have, for many, delivered little more than defensiveness, denial and delay. So, before our usual newsletter resumes, here we take a moment to reflect on a momentous week.

First ever review on deaths in police custody supports key INQUEST recommendations and is an opportunity to save lives

INQUEST Director, Deborah Coles was Special Advisor to the Chair and INQUEST facilitated meetings for Dame Angiolini to hear directly from bereaved families, as well as from lawyers who regularly represent families. The report contains many recommendations advocated by INQUEST including: 

  • Non-means tested public funding for legal representation of families.
  • Strengthening systems and structures of accountability and holding the police to account at an individual and corporate level, such as through an office for Article 2 compliance which would monitor and report on recommendations arising from deaths.
  • An end to shocking delays, including through an aim that Article 2 cases should be dealt with in the same time scales as civilian homicide cases.
  • Recognition of the disproportionate number of deaths of people from Black, Asian and minority ethnic communities who die following the use of restraint, and the need to tackle racism and discrimination in IPCC investigations and police training
  • Phasing out of ex police officers as lead investigators within the IPCC.  
  • Better treatment of vulnerable people including through proper resourcing of healthcare facilities to divert people from police custody and an end to the use of police cells as a ‘place of safety’.

You can read more about the wide ranging recommendations in our press releasebriefing, or the full report which includes our Family Listening Day report in the annex.

To ensure the seminal report received the coverage it deserved INQUEST organised a packed press conference with Dame Angiolini, Deborah Coles, and the families of Thomas Orchard, Olaseni Lewis, Sean Rigg and James Herbert represented on the panel. You can watch a recording of the conference above. As a result there was widespread coverage including: evening news across all main national TV channels including Channel 4, a useful overview in Vice, and local coverage including on ITV Tyne Tees. Later in the week there was also BBC coverage marking the 4th anniversary of the death of Leon Briggs, whose case is illustrative of an endemic problem of delay.

The report was announced in parliament with an oral statement from Nick Hurd, the minister for policing, who gave personal thanks to INQUEST and the families who contributed. Deborah Coles met with the Minister on Tuesday, and on Wednesday the review was the main agenda item of the Ministerial board of deaths in custody, on which INQUEST is represented


The Angiolini review represents a real opportunity to address some of the worst aspects of the investigation and legal system faced by families and offers a blueprint for changes to policing, health and justice systems. So far, among other things, the recommendation for non-means tested legal representation was accepted by the government in their response. And the college of policing responded to recommendations on use of force and restraint with this training video. We await further developments and government actions. Ultimately the value of this report will be in the change it creates, and INQUEST will continue to push for these important recommendations to become practice.

‘The patronising disposition of unaccountable power’: Hillsborough review offers blueprint for public accountability after state related deaths

Two days after the Angiolini review, on Wednesday 1 November a review of the experiences of families affected by Hillsborough was published, which also calls for important changes in the response to state related deaths. As is clear in the title, ‘The patronising disposition of unaccountable power’: A report to ensure the pain and suffering of the Hillsborough families is not repeated, it echoes the experiences of many families we work with and outlines systemic changes for state and public bodies.  

The report makes 25 recommendations (summarised here) including, again, non-means tested, publicly-funded legal representation for bereaved families at any inquests at which public bodies are represented. It also calls for proportionate legal funding, meaning state bodies are not able to use public money to fund legal representation more advantageous than that which is available to families. It also supports the implementation of Hillsborough Law.
We are pleased to see the experiences of those at our family listening day, as well as issues raised in our submission, are reflected throughout. In a letter to our Director, Bishop James Jones who wrote the review said the evidence from the family listening day had influenced the report and that he had personally given a copy of the family listening day report to the Secretary of State for Justice.

The government have said they will respond ‘in due course’. As we told the Guardian and Daily Mail, “It is vital the Government acts on these recommendations to support recently bereaved families in accessing truth, justice and accountability; not least those affected by the Grenfell fire. The legacy of Hillsborough should be improvements across the inquest system to benefit families who are still coming up against many of the same hurdles that the Hillsborough families had to battle against.”

‘Seni’s Law’ passes through parliament with unanimous support

On Friday ‘Seni’s Law’, a Private Members Bill brought by Steve Reed MP formally titled the Mental Health Units (Use of Force) Bill, passed through the House of Commons with cross party support. Steve Reed brought the Bill in honour of Olaseni ‘Seni’ Lewis, a 23 year old IT graduate who died as a result of prolonged restraint by police officers whilst a voluntary inpatient at Bethlem Royal Hospital, Croydon in 2010. If enacted, changes the Bill would make include: increased oversight and management of use of force in mental health units, and a requirement that police must wear body cameras when attending these units (more info here). It will also ensure an independent investigation of any restraint related death in a mental health setting.

Seni’s family welcomed the Bill and were joined by Deborah Coles in the gallery in the House of Commons as MPs from across the House declared their support in the second reading.  Steve Reed MP thanked INQUEST for our practical support in writing the Bill, as well as the Lewis family’s lawyer Raju Bhatt, a member of the INQUEST lawyers group. MPs unanimously voted the Bill through its second reading, and it will now go through Committee stage.

And as well as all this…

  • Members of our team and INQUEST lawyers group met with the new Chief Coroner on 31 October where he provided  an overview of his first year in office and answered questions mainly around the persistent problems with the inquest process and inconsistency between Coroners.
  • Sara Ryan launched her book Justice for Laughing Boy: Connor Sparrowhawk - A Death by IndifferenceRead an extract and buy a copy here. Deborah Coles spoke at the London book launch, alongside Caoilfhionn Gallagher QC who represented the family, Helena Kennedy QC who commended INQUEST’s work, and Sara Ryan herself.
  • Meanwhile INQUEST’s casework team carried on advising on hundreds of cases of state related deaths, with over 500 ongoing cases.



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