Latest news at INQUEST

Welcome back to the INQUEST newsletter. Despite the newsletter taking a summer break, INQUEST has continued to be as busy as ever. This issue covers our work with families influencing parliament on the coronial system, COVID-19 and the protection of human rights, recent news on policing, Grenfell, prison and mental health and new platforms for families to connect online.

In this edition:

  • Influencing parliament:
    • Coroners Service inquiry
    • COVID-19 and human rights
    • JUSTICE report ‘when things go wrong’
    • Urgency of Seni’s Law
  • Recent news:
    • Policing
    • Grenfell
    • Prison
    • Mental health, learning disabilities and autism
  • Family campaigns:
  • Connecting families:
  • Upcoming events:

Influencing parliament

The coronial system is failing in its role to prevent future deaths and struggling to ensure bereaved families have access to justice. INQUEST evidenced these failings as part of our submission to the Justice Committee Inquiry on the Coroners Service. In a separate submission, INQUEST brought together evidence from 51 bereaved families who shared their experiences with us. Families' testimonies offer the most powerful example of what changes to the Coroners Service are needed and we are very grateful to all families involved. This will be published on the Justice Committee website in due course. 

INQUEST Director, Deborah Coles and Andy McCulloch, father of Colette McCulloch, who died whilst in the care of mental health services, gave oral evidence to the Justice Committee as part of their inquiry. Deborah Coles highlighted that now more than ever, as coroners struggle to respond to the high number of deaths arising from COVID-19, change is urgently needed.

INQUEST tells committee change is urgently needed

INQUEST were concerned by the language of by Andre Rebello, the Senior Coroner Liverpool and Wirral Area and Secretary to The Coroners' Society of England and Wales, in the previous evidence session, referring to the “dark arts” of lawyers at inquests. We reject his comments implying efforts to widen the scope of investigations to “trawl for additional information that is not necessarily part of the means of arriving at the cause of death” are inappropriate and his suggestion that as a response to COVID-19 jury inquests could be suspended.

In our submission to the Joint Committee on Human Rights inquiry on The Government’s response to COVID-19: human rights implications, we exposed the retrogressive steps taken across detention settings justified by the need to contain the spread of COVID-19 and how the government has failed to live up to human rights obligations. In their final report from the inquiry, the committee puts forward recommendations on policing, prisons and mental health detention, drawing from INQUEST’s evidence, and repeating our concern that prison conditions amounted to solitary confinement. They also call for a ‘swift review’ and concluded that it is ‘very likely’ that a public inquiry will be needed in order to fulfil the State’s obligations under Article 2.

Deborah Coles responded to the committee report, saying 

The government remains reluctant to answer difficult questions about its approach to the pandemic so far, or set up any form of review or inquiry. This is a dangerous approach which, if continued, misses the opportunity to learn important lessons which could save lives and better protect human rights."

INQUEST supports the legal challenge by over 1,600 COVID-19 bereaved families for an independent public inquiry. At a time when they are grieving, they have been forced to litigate to try and force the government to act. They deserve answers as to whether the deaths of their loved ones could and should have been prevented. The inquiry call is in all of our interests. Find out more about the campaign group COVID-19 Bereaved Families for Justice UK

A major and timely review by a groups of experts in the post death investigation, inquest and inquiry processes has been published, When Things Go Wrong: the response of the justice system. Deborah Coles was part of the JUSTICE Working Party chaired by Robert Owen QC, which also included Dr Sara Ryan, members of the INQUEST Lawyers Group and the former chief coroner. It sat for a year and Deborah chaired a sub group on public engagement and the needs and experiences of bereaved people were central to the work. The report put forward 54 recommendations directed at remedying shortcomings of the present system of inquests and public inquiries. Such recommendations include INQUEST’s longstanding calls for a national oversight mechanism, and non means tested legal aid for bereaved families.

INQUEST has signed a letter written to Nadine Dorries, calling for Seni’s Law to be enacted immediately. It is unacceptable that despite the Mental Health Units (Use of Force) Act being passed in 2018, it has yet to be commenced. The Act will provide greater transparency and accountability on the use of force and restraint in mental health settings, requiring mental healthcare providers to keep records of their use of force. Within the context of increased use of restraint in inpatient settings since COVID-19 (see news below), the commencement of this Law must be an urgent priority.

Recent news:

INQUEST and the families we work alongside are continuing to draw attention to the unacceptable and disproportionate number of deaths of Black people in police custody in the UK following the use of lethal force and neglect.
A powerful new music video by Kano showed the harsh reality of police violence against black communities in the UK. It is an important recognition of those who have died and shines a spotlight on state violence and structural racism and the lack of justice and accountability for their families.

Watch the video

The inquest into the death of Kevin Clarke, who died after being restrained by nine police officers in Lewisham, has openedMy brother was love, his sister Tellecia told Channel 4 News whilst INQUEST Director Deborah Coles told ITV London “I think the elephant in the room is institutional racism”.

mural has been unveiled opposite Lewisham Police Station in south-east London, commemorating Kevin’s life. His mother told BBC London “As we go through the inquest into Kevin's death, it is a fitting tribute to moments in his life".


Marcia Rigg, Justice campaigner and sister of Sean Rigg, and Deborah Coles spoke to The 100 Types of Human podcast about state violence, racism, deaths in custody and families’ struggles for justice and change in the UK. Marcia speaks powerfully not only about Sean’s death but about turning her grief, pain and anger into a positive weapon, campaigning for justice with other families.

Listen now

On the three year anniversary since the death of Rashan Charles who was restrained by police in Hackney, his great uncle and ex met police chief, Rod Charles, spoke to the Guardian about the increasing gulf between the police and the black community.

An analysis by the Institute of Race Relations find that Tasers are being disproportionately deployed against the black population, Tasers have long-term permanent consequences and that Taser usage is rapidly increasing. 

Lisa Cole, sister of Marc Cole and INQUEST spoke to IRR to condemn the government decision to allocate £10 million to a Taser roll out scheme rather than using the investment into communities.

A month later, a new Taser model, said to increase risk of internal injury and inflict greater pain on people has been approved by the Home Office. “This further weaponisation of the police with potentially lethal Tasers is dangerous and deeply concerning” Deborah Coles told The Times.

Deborah Coles was pleased to contribute to ‘Justice Matters: essays from the pandemic’, published by Legal Action Group. Deborah writes about how the Black Lives Matter protests and murder of George Floyd have provided the impetus for renewed debates about state violence and structural racism, police accountability and defunding the police and investing in community services rather than the criminal justice system. Check out a free preview and order your copy.


In August, INQUEST wrote to the Grenfell Inquiry Chair to ensure Phase One recommendations are acted upon given the worrying history of recommendations disappearing into the ether. One month later, it was shameful to see that 308 MPs, including the constituency MP for Kensington Felicity Buchan, voted to not implement recommendations. This decision is failing bereaved families and survivors; it is failing those who continue to feel unsafe in their homes.


New statistics from the Ministry of Justice on 'safety in custody' show the number of deaths of people in prison remains at a historically high level and that self-harm has reached record numbers. According to INQUEST's analysis every five days a person in prison takes their life and incidents of self-harm are up 11 percent compared to last year, equivalent to 177 incidents per day.

The annual report by the IMB Chair raises concerns about high numbers of prisoners spending prolonged periods in segregation prior to COVID lockdowns. This concern only increased during COVID with prisoners across the estate held in prolonged solitary confinement, as noted in the report on short scrutiny visits by HM Chief Inspector of Prisons. Our casework and monitoring shows there have been at least 140 deaths in prison since 24 March, 37 of which have been self-inflicted.

Director Deborah Coles and INQUEST trustee Joe Sim feature in the new Prison Radio UK Podcast, the Secret Life of Prisons, talking about what’s happened in the 30 years since the Strangeways riots and asking fundamental questions about what prison is for. Listen here.

Mental health, learning disabilities and autism

New statistics by NHS digital and analysed by Professor Chris Hatton show sharply increasing use of severe physical restraint, chemical restraint and seclusion on people with learning disabilities and autistic people in inpatient services. This is not just concerning but foreseeable and preventable.
In March INQUEST raised concerns about the indirect impact of COVID-19 including the use of restraint, medication and seclusion. We reminded the government of the importance of upholding and protecting the human rights of people in inpatient settings.
Our monitoring from July showed that between 1 March and 5 June there were over four times as many COVID-related deaths of people detained under the Mental Health Act (78) as COVID-related deaths in prisons (19), which hold around four times as many people as those detained under the MHA.

The annual Learning Disabilities Mortality Review (LeDeR) has been published. It is shocking that less than half of the deaths reported to LeDeR had been subject to a review (45%) and only 6% had received a full multi-agency review. Deaths of people with learning disabilities must receive full scrutiny, learning and accountability.

The parents of Natasha Abrahart, who died whilst she was a student at the University of Bristol, have launched legal action which claims she was a victim of negligence and disability discrimination. “How will the university prevent the same mistakes that we believe occurred from happening again? We will continue to campaign to ensure that other students don’t endure the suffering Natasha did" they told the Guardian.

Our senior caseworker Selen Cavcav joined Melanie Leahy, who gave evidence to the petitions committee on her call for a public inquiry into her son’s death, following a petition which gained over 100,000 signatures. Matthew Leahy, 20, was found hanging at the Linden Centre, Chelmsford where he was an inpatient in 2012. INQUEST has now joined forces with Melanie and a team of London lawyers to escalate that call to investigate deaths in mental health settings across the whole of Essex.

Following a pre inquest review into the death of Gaia Pope, her cousin, Marienna, writes for the Independent about her family’s journey fighting for Justice for Gaia. “The paperwork says she died of hypothermia but I call it a death by indifference. Almost three years later no one has been held accountable for any of this and that is a matter not just of our private grief but of public concern.” INQUEST highlighted that proper scrutiny of Gaia’s death is vital not least at a time of increasing concern about mental health of young people and lack of specialist services for women.

Family campaigns

The National Mikey Powell Memorial Family Fund allocated £8,350 in grants to 19 families and campaigns in the first round of grants! The fund is the first permanent national resource of its kind to provide practical assistance to families affected by deaths of people in custody. The next round will open on the 7 December, watch this space!

Learn more and donate to the initiative

Lee Lawrence, son of Cherry Groce who was shot by police in 1985 which sparked the Brixton uprising, speaks to Simon Hattenstone of the Guardian of the lifelong aftershocks of police violence. ‘The Louder I will Sing’ is a powerful memoir written by Lee Lawrence of the personal and legal battles that followed. Order your copy. Lee is a member of the INQUEST Family Reference Group.

In August bereaved families from across Essex gathered together for a memorial service for their loved ones who were failed by mental health services in Essex. The peaceful memorial was to both remember loved ones and join forces in a call for changes across the entire county. More here.

Darren Cumberbatch died in police custody in 2017. The inquest jury concluded that he died following ‘considerable restraint’ by police. Black Conscious Coventry and #Justice4Daz campaign is calling for a ban on police Tasers. Sign the petition.

The family of Winston Augustine, who was found dead in Wormwood Scrubs prison, held a peaceful protest on the second anniversary of his death. His family told BBC London that they are dismayed at the delays in uncovering what led to his death.

Connecting families

The families joining the INQUEST Facebook community is growing, and it’s inspiring to see families share their support and solidarity with each other on that platform. If you would like to join please follow this link Families@INQUEST Facebook Group.

We held our second Connection Café which was a lovely, welcoming and connected space facilitated by some of our Family Reference Group members. As they welcome newer families it is a powerful and caring environment where people can share their experiences of the grief, frustrations, and things that help them to cope with the long road towards the inquest and beyond.

Kathryn, who attended the previous Connection Cafe, said: "I found it supremely helpful, comforting and supportive so thank you to everyone who was instrumental in making these happen.” 

Our next Connection Café will be on Wednesday 21 October 11am-1pm. You can register your interest by emailing [email protected]

Upcoming events:

  • 31 October - United Families and Friends Campaign (UFFC) are holding their annual memorial march in memory of all those who have died in state care or custody in London. We hope to see you there.
  • 7 December - The second application round for families to apply for financial grants from the National Memorial Family Fund opens. You must register your campaign prior to applying for funds. Further information.

In other news:

  • INQUEST published Issue 41 of Inquest Law. The magazine is a vital resource for anyone working on the investigation of sudden deaths, and this issue features article on the investigation of COVID-19 deaths of frontline workers and the death of George Floyd, plus case law updates, case notes and more.
  • INQUEST’s Grenfell Project Coordinator Natasha Thompson spoke to Young Lawyers Making Change event about the importance of campaign work when the law can’t or doesn’t work.
  • Christian Weaver, a pupil barrister at Garden Court North, and who previously worked at INQUEST as caseworker assistant, has released a book Know Your Rights: The Law in 60 Seconds. The book follows Christians’ YouTube series were he sought to inform people of their rights and make the law accessible. Check it out.

National Memorial Family Fund

Tru Powell is running a half marathon in memory of Mikey Powell, who died in police custody in 2003, and to raise money for the National Memorial Family Fund to support other families in their long battles for justice.

Please show your support and solidarity to Tru and sponsor him if you are able to!

Sponsor Tru