NEWSLETTER: SPRING 2023

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4 May 2023

CONTENTS

• Souls INQUEST Exhibition
• Prisons
• Police
• Mental health
• Grenfell Tower
• Unlocking the Truth for 40 Years
• Other News
• Family section: With upcoming events and opportunities for bereaved people working with INQUEST

SOULS INQUEST EXHIBITION

This May, come along to the very first showing of our SoulsINQUEST exhibition. SoulsINQUEST uses photography and writing as a lens onto state violence, death, grief and resistance. The exhibition is an embodiment of family resistance that refuses to be silenced, misrepresented or forgotten.  

A collaboration between bereaved families, Sarah Booker, INQUEST, and curated by Languid Hands, it is a powerful act of defiance in response to decades of injustice. Open 12-28 May at 198 Contemporary Arts and Learning in Brixton. Find out more here. 
 
Follow our Instagram to stay up to date with our work and what we’re up to!

INQUEST INSTAGRAM

PRISONS

Last year, 371 people died in prison. INQUEST’s report, Deaths of racialised people in prison 2015 – 2022: Challenging racism and discrimination makes a powerful intervention as it uncovers new data and tells the stories of 22 racialised people and how they died preventable and premature deaths in prison. 

The report throws into sharp relief the fatal consequences of institutional racism in prison – an issue that has been overlooked by authorities for too long. Deborah Coles, Director, and Jessica Pandian, Policy Officer at INQUEST, wrote a piece in The Guardian about how in Britain, a jail sentence is often a death sentence.

The failure of prisons to provide a safe environment has been underlined by inquests into the deaths of Brett Lowe, Liridon Saliuka, and Alex Braund. 

The murder of Brett Lowe by his cellmate at HMP Nottingham was found to have been preventable. During the inquest, the jury found failings and systemic issues contributed to his death. 

Significant and multiple failings at HMP Belmarsh were also identified by the jury investigating the death of Liridon Saliuka. The jury found that repeated failings to consistently recognise the fact and extent of Liridon’s disability, along with an insufficient willingness to address his concerns negatively impacted on his mental health and contributed to his death. 

Alex Braund, 25, died of pneumonia at HMP Nottingham. An inquest found that neglect contributed to his death. His parents spoke to The Guardian about how the prison’s abandonment of their son will haunt them forever. 

The Justice Select Committee published a report in September on the IPP (Imprisonment for Public Protection) sentences, that recommends resentencing all those serving IPP. 

The recommendations made by the committee are in line with the suggestions made by INQUEST in the submission we made to the inquiry in November 2021. 

The Government announced plans to use 400 police cells to house male prisoners in Operation Safeguard to act as overspill sites of detention. Deborah Coles wrote to The Guardian about this crass, ad hoc and dangerous turn. 

An unprecedented corporate homicide investigation was announced in March against the Scottish Prison Service over the restraint death of Allan Marshall in HMP Edinburgh in 2015.  

On Tuesday, an inquest opened into the death of Aisha Cleary who died in HMP Bronzfield after her 18-year old mother gave birth alone in her prison cell.

Deborah Coles said: "A teenager giving birth alone in a prison cell, her calls for help ignored, is deeply shocking. This inquest must examine how she and her baby were so badly failed by multiple state agencies with responsibility for their welfare, health  and safety." 

POLICE

INQUEST, Marcia Rigg (sister of Sean Rigg) and Aisha Okorie (sister of Oladeji Omishore)
with the UN Working Group of Experts on People of African Decent

We published our report ‘I can’t breathe: Race, death and British policing’ which found that Black men are seven times more likely to die following police restraint. Despite this, the families of those who died are unable to get accountability from a system that is not “fit for purpose”. 

The report features in-depth interviews with five bereaved families who have been through the post death processes.  

Wayne McDonald, brother of Adrian McDonald, said: “George Floyd said the same thing as Adrian: ‘I can't breathe’. When Adrian says, ‘I can't breathe’, the officer's told him ‘well, you're talking aren't you?’. The whole culture has to change.”  

Carla Cumberbatch, whose brother Darren died following police restraint in 2017, spoke to Channel 4 about the lack of accountability and failure of the police watchdog to consider the role of racism in his death. 

A police officer involved in the death Dalian Atkinson in 2016 was found guilty of gross misconduct in a police disciplinary hearing. The family welcomed the panel’s decision but expressed grave concerns that the police officer will continue to serve in the force. 

Following their visit to the UK, the United Nations warned that ‘the UK is institutionally racist’ and urged ministers to act. INQUEST met with the UN Working Group of Experts on People of African Descent alongside the families of Oladeji Omishore and Sean Rigg.  

Deborah Coles said: “INQUEST sees the impact of structural racism across the breadth of our work, from deaths in custody and detention to [the] Grenfell Tower fire. We view these deaths within the broader context of policing, imprisonment, immigration, health and legal systems in maintaining and exacerbating racial inequalities and discrimination against Black people.” 

Baroness Casey’s review of the Metropolitan police following the death of Sarah Everard found that the force was institutionally racist, misogynistic, and homophobic. INQUEST responded by drawing attention to the meaningful structural change that bereaved families want, and have consistently called for.  

The ongoing inquiry into the death of Sheku Bayoh heard how his family were prevented from saying their final goodbyes due to a police watchdog error. Deborah Coles spoke alongside Sheku’s family on The Ferret podcast about the inquiry. 

The family of Chris Kaba responded to the Independent Office for Police Conduct’s (IOPC) decision to refer the homicide investigation into Chris’ death to the Crown Prosecution Service. 

“Our family, alongside the community who have supported us over the past seven months, have been consistent in our call for accountability. 

This step forward is necessary and welcome. We urge the Crown Prosecution Service to do their bit and provide their advice to the IOPC urgently. 

We very much hope that the CPS advise in favour of a prosecution and that the truth will emerge, without delay, through criminal proceedings. Our family and community cannot continue waiting for answers. 

Chris was so loved by our family and all his friends. He had a bright future ahead of him before his life was cut short. We must see justice for Chris.” 

Less than a year after the death of Oladeji Omishore, who fell from Chelsea Bridge after being Tasered by Metropolitan police, a man died in a London Taser incident after falling from a balcony. 

Deborah Coles, speaking to the Guardian said: “Once again we see the fatal consequences of the police being first responders to people in mental health crisis and the use of force against Black men. It is clear from previous deaths that the use of Tasers and force is prioritised over the care and compassion needed.” 

This year marked 34 years since the Hillsborough disaster. Earlier this year, police chiefs apologised for failures that led to 97 people dying. Alongside the bereaved families, INQUEST continues to campaign for Hillsborough Law to create a new legal duty of candour on public authorities to tell the truth and to ensure victims of disasters are entitled to parity of legal representation during inquests and inquiries. Follow the campaign here.

MENTAL HEALTH

From left to right: Christi Harnett, Emily Moore and Nadia Sharif

Last week, we published a new report highlighting the persistent challenges bereaved families are facing following the death of their loved one in mental health services. 

The report, written in consultation with 14 families, shows that families face numerous hurdles during investigations and inquests into their loved ones’ deaths, and the processes are not delivering the change required. They are instead shrouded in delay, secrecy and animosity towards families, who simply wanted active participation and a truthful account of what caused their relatives’ deaths. 

Speaking anonymously to INQUEST, one bereaved family member said: “The death wounded me, dealing with mental health services has broken me. Everything is a fight when you have the least fight in you. Nothing can bring your child back. All we can do is help them ensure it doesn’t happen again.” 

Bereaved families, alongside INQUEST, have been campaigning for a statutory public inquiry into mental health deaths in Essex. 

A parliamentary debate earlier this year heard about the impact of the limited legal powers of the current inquiry. Out of the 14,000 NHS staff contacted for evidence, only 11 have come forward. This followed a public statement by the chair of the inquiry, Geraldine Strathdee, stating that the inquiry was not fit for purpose. 

Chris Nota, a teenager with autism, was under the care of the trust when he died in 2020 after falling from a height in Southend. An inquest found that multiple significant failures by the trust contributed to his death. 

We saw several other critical inquest conclusions into the deaths of young people with autism including Stefan Kluibenschadl and Leo Toze, highlighting the urgent need for appropriate child-centred, autism-focused mental health support. 

A critical governance report found catastrophic leadership failures following the deaths of three young women in the care of Tees, Esk and Wear Valley NHS Trust.  

It follows the publication of three damning independent investigation reports into the deaths of Christie Harnett, Emily Moore, 18,  and their friend Nadia Sharif, 17. The trust is now being prosecuted by the Care Quality Commission (CQC). 

We also saw how repeated multi-agency failures led to the deaths of vulnerable young people including Ben Nelson-Roux and Samuel Howes. 

Ben Nelson-Roux, 16, died at an adult homeless hostel in 2020. Ben had ADHD and was later recognised as a child victim of criminal exploitation. His parents spoke to ITV News about how Ben was failed and their pleas for help ignored. 

Samuel Howes, 17, died after jumping in front of a train in Croydon on 2 September 2020, just one month before his 18th birthday. The inquest found a series of failures by various agencies, including police, mental health and social services, possibly contributed to his death by suicide.  

His mother Suzanne has been sharing resources and insights into life after loss in her blog. She also spoke to the BBC about how her concerns were repeatedly ignored by authorities.

GRENFELL TOWER

Grenfell United annual silent walk