1 September 2022



With the upcoming launch of our 40th anniversary uncovering a range of amazing archives from over the years, a brand refresh, and a photography project highlighting powerful images of and by the families we work with, INQUEST have decided to (finally) join Instagram to share all this, as well as to support the brilliant family campaigners using the platform.

Our new account will be the first place to see our latest archive finds, campaign stories for sharing, and new videos and projects. Please follow and share the account, and watch this space!



INQUEST is a supporting the newly formed Hillsborough Law Now Campaign, launched in July. Deborah Coles joined a  broad coalition of bereaved families and victims of public disasters, campaigners and MPs, Mayors and Bishop James Jones for a powerful launch meeting on the need for the new law.

Hillsborough Law, also known as the Public Authorities (Accountability) Bill, is the legacy project of the bereaved families and survivors of the Hillsborough disaster. The new law would:

  • Create a new legal duty of candour on public authorities and officials to tell the truth and proactively cooperate with official investigations and inquiries.
  • Ensure victims of disasters or state-related deaths are entitled to parity of legal representation during inquests and inquiries, meaning they are funded for lawyers, putting them on a level playing field with public bodies.

If you’d like to learn more and support the campaign, join us at an upcoming online training event: What is Hillsborough Law? Led by Deborah Coles and Pete Weatherby QC, on 7 September.


There are still a few days left to apply for the current opportunities to join our team at INQUEST. Please help spread the word and check them out:

  • Media and Communications Assistant
  • Administration Officer
  • 40 Years of INQUEST Heritage Project Volunteer



Karen Beadle, mother of Garry.
Photograph: Thomas Duffield/The Guardian

Hundreds of people are dying in prison whilst on remand. We worked with The Guardian to highlight the human stories behind the statistics.

Through a series of failings by the system, Garry Beadle aged 36, took his life while on remand awaiting trial. He’d been in prison for less than a week.

Dominic Noble was awaiting trial in Leeds prison after being charged with left wing terror offences whilst experiencing serious mental ill health. Following a mental health assessment, Dominic was waiting to see a psychiatrist but died before ever being offered an appointment.

These experiences are part of a far broader pattern of failures. The rate of self-inflicted deaths of remand prisoners has consistently been around three times higher than that of convicted prisoners.

INQUEST submitted evidence to the ongoing inquiry by Parliament’s Justice Committee on the role of adult custodial remand in the criminal justice system, challenging these issues and calling for action.

Failures at HMP Chelmsford have led to 14 self-inflicted deaths since 2016. The prison has long been on notice about their inability to support people in mental health crises. This has had devastating consequences for many, including David Morgan.

Yet the recommendations arising from deaths and critical inspections have been ignored, allowing deaths like Lance Clark’s, who was also on remand, to continue. INQUEST is campaigning for a national oversight mechanism on recommendations arising from state related deaths, to ensure fatal failures are not repeated.


NOTE: Video contains distressing footage from the start

The family of Oladeji Omishore have spoken publicly for the first time, in powerful interviews with The Guardian and Channel 4 News. Deji died on 4 June following contact with two Metropolitan Police Officers on Chelsea Bridge, following multiple use of Taser.

The family said: “Like many people, we were shocked and deeply distressed by the video of Deji on Chelsea Bridge. He was clearly in mental health crisis. Yet instead of deescalating and offering compassion, the police officers shouted and used force against him. Now our beloved son, brother, and friend is gone.

We cannot bring our beloved Deji back, but we will fight to ensure that this never happens again to another human being, and we’ll continue to raise awareness and campaign for police accountability for a life tragically taken from us that can never be replaced.”

Due to the persistence of his family, the IOPC have made the rare decision to reinvestigate key elements of the death of Darren Cumberbatch in 2017, after material flaws in their original investigation. This includes reconsidering 'excessive' use of police force against Darren, with Taser, teargas and restraint in a small space.

Deborah Coles, director of INQUEST, said: “Robust investigation of deaths after police contact is vital for identifying any failures, criminality or wrongdoing, and ensuring police officers are held to account. This is in the public interest, not least when deaths raise broader concerns around the disproportionate use of excessive force against Black men, and the impact of racism and discrimination in police decision making.”

The use of Taser by police on vulnerable people was again brought into sharp focus after the death of Donald Burgess, a 93 year old man living in a care home. Donald was diabetic and had dementia, a urine infection and a catheter. He also had one leg and was wheelchair bound.

He had an episode at his care home. Police were called and he was subject to serious use of force, including Taser, PAVA spray and baton strikes. He died in hospital three weeks later. We told The Guardian, this deeply disturbing death begs the question why there was a police and not a medical response to a man in such obvious distress.

The report of the Jermaine Baker Public Inquiry has identified a catalogue of the most damning failures by the Metropolitan Police Service. The inquiry fell short of expectations concluding that Jermaine was lawfully killed. Jermaine was 28 when he was fatally shot by police.

It has been revealed that the Met police strip-searched 650 children in a two-year period often without the presence of an adult during the search. The new data reveals racist and discriminatory policing and the dehumanising of black children. INQUEST told The Guardian, “this is state sanctioned child abuse”.


From left to right: George Werb, William Jordan, Eliana Hanton and Matthew Caseby. Composite image: The Times

Bereaved families, alongside INQUEST and journalists, have been challenging the ongoing failures of private mental health hospitals. Recent investigations by The Times into The Priory Group, and by The Guardian into a range of private providers, have highlighted the extent of the issues with these companies. They are putting profit over patient safety in their treatment of both NHS and private patients, with fatal consequences.

The inquest into the death of 23 year old Matthew Caseby concluded that neglect at Birmingham Priory hospital contributed. The Times investigation into the Priory Group raised concerns about the robustness and scope of the internal investigations of the company, who provide services for NHS patients, amid claims they are not accountable when serious incidents occur.

The Guardian investigated failings at Cygnet and Elysium mental health facilities, where Brooke Martin was able to take her life due to failings in managing her risk of suicide. She was 19 years old. The Guardian also revealed that the NHS is paying £2billion a year to private hospitals for mental health patients.

The inquest into the death of 29 year old Emma Pring when she was a patient in Cygnet Maidstone concluded that failings in the appropriate level of observation and care contributed to her suicide. Her mum, Caroline Sharp, has voiced concern over the lack of NHS resources and the reliance of private mental health settings.

In collaboration with INQUEST, The Guardian revealed that The Priory, Cygnet and Elysium have been criticised by coroner’s at least 37 times for mistakes and lapses in care that were involved in the deaths of patients, including several children.

Deborah Coles, director of INQUEST, said “For years inspections, inquests and investigations have repeatedly exposed neglect and harmful practices. Yet the NHS continues to commission these providers, at significant public expense.”

We responded to the first update of the ongoing independent review into mental health services in Essex. The review is looking at cases between 2000 and 2020 of people who died while they were a patient on a mental health ward, or within three months of being discharged, in Essex.

Selen Cavcav, Senior Caseworker at INQUEST, said: “We already know this inquiry will find failures, most of which will not come as a surprise to many bereaved families or survivors who have long fought for the truth. The value of this inquiry as it stands can only be judged by its impact in creating change. That change is long overdue.”

28 year old Bethany Lilley was an inpatient under the care of Essex University Partnership Trust. An inquest concluded that neglect and a range of failures by the mental health services contributed to her death. Her death is one of so many examples of the harms caused by these services.

Crisis housing with non-clinical staff is not a safe alternative to psychiatric inpatient care. Jess Durdy was 27 when she took her own life at Link House in Bristol. Having had suidcidal thoughts, Jess was sent to a crisis house with untrained staff in Bristol, rather than a mental health ward. Jess’s mum, Moira, shared her concerns about the level of training and understanding in crisis housing.

INQUEST are working with numerous families of young women with experiences of abuse and associated trauma who have been systematically failed by public services.

Gaia Kima Pope-Sutherland was 19 when a series of events led to her death, including missed opportunities to refer Gaia to mental health support services. Gaia was a survivor of rape. She is one of many young women who should have received quality specialist support but instead died a preventable death.

The family of Gaia Pope said: “Gaia was many things. A beloved daughter, sister and friend. Bright, brave, kind, creative and fiercely loyal to those she loved.  She was also a survivor of child sexual exploitation who was badly failed by the state. What we demand now is justice for those left behind. All the lives not yet lost, which are precious and worth fighting for.”

Since Gaia’s death, her family have been campaigning through Justice for Gaia to petition to demand specialist services for survivors of rape in Dorset.


Grenfell flower memorial

Marking the five year anniversary of the Grenfell Tower Fire in June, INQUEST marched with the bereaved, survivors, and the community and shared reflections on what is needed now. As end of the public inquiry nears, there must be accountability, justice, and long-lasting meaningful change, to honour the lives lost and to prevent future deaths.

Leaseholder Disability Action Group, Claddag is asking for support to take legal action against the government. Five years after Grenfell, the Home Office announced that it will not give disabled people the right to personal emergency evacuation plans (PEEPs) on the basis of “practicality, cost and proportionality.” This is a safety failure that invites avoidable risk to life.

Forty one percent of the residents that died in the Grenfell Tower fire had disabilities. Many were housed on the higher floors and were unable to self-evacuate. This discriminatory danger cannot continue.

Claddag’s GoFundMe


  • The National Memorial Family Fund, a national resource for those that are affected by deaths in custody, have issued an appeal for new monthly donors. The Fund makes small grants available for families and their campaign groups across the United Kingdom to provide practical domestic assistance, to further the work of their own campaigns or to assist them in engaging in a range of other initiatives. Support them by donating or sharing.
  • Join INQUEST and other bereavement organisations at an event to mark World Suicide Prevention Day, with the theme creating hope through action, on Friday 9 September. The panel will be discussing barriers to accessing support for people bereaved by suicide.

  • INQUEST and INQUEST Lawyers Group have responded to the proposed changes to the Human Rights Act . These changes may diminish the legal rights that allow crucial investigations to happen following deaths, or risk reducing the intensity of their scrutiny. We are now working with a wide group of organisations resisting the Government attack on Human Rights through the Bill of Rights, which is in reality the Rights Removal Bill. Learn more.


Connection Cafes  
These are regular drop in sessions for families INQUEST work with. People who join will have shared similar layers of experiences. This is a space to connect with people, chat and focus on how you are feeling. Members of the Family Reference Group, all families with experience of the inquest process and working with INQUEST, will be there to welcome you.

  • Morning - Second Wednesday of every month (11:30am-1pm) 
  • Evening – Fourth Wednesday of every month (6:30pm-8pm) 
  • To register for reminders and joining details please fill in this form.

Listen at Lunch: Untangling loss

A monthly space, we introduce Listen at Lunch: untangling loss, as an alternative space to take time to discuss some of the aspects of grief and bereavement you and your family may be dealing with.  

The event is structured as more of a workshop space than a sharing space, although we do talk about the content together.  

The first half of the sessions will be recorded so that those who cannot make the time can benefit.  

  • 1pm-2pm - the 4th Friday of every month – register via Zoom here
  • 23 Sept 2022 - Sleep & Healthy Living
  • 28 Oct 2022 – Different Models of Grief

If you would like recordings for the previous sessions, (Understanding Traumatic Bereavement; What Happens in your body; Talking to Children & Young People about Death; Self Care, what even is it?; Part 2 Self Survival Strategies) please email [email protected] 

Get More Involved with INQUEST 

INQUEST are excited to invite families to get more involved in various upcoming opportunities for families shortly, and will be opening recruitment to join our Family Reference Group to become a member of the INQUEST Board of Trustees. Please email Mo our Family Engagement Coordinator for more details or watch out for updates in the next newsletters [email protected]