24 February 2022


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Announcing new chairs of the INQUEST Board

INQUEST are pleased to announce a new Chair and Vice Chair on our Board of Trustees, Diane Newton and Steve Tombs. We share more details on the new leadership, and reflect on the work of the chair over the past decade, Daniel Machover.



We are recruiting for an exciting new role of Project Coordinator – 40 Years of INQUEST (Heritage Project)

40 Years of INQUEST is a heritage project launching this Spring which aims to archive and celebrate the ground-breaking work of the charity in the past four decades, through the marking of the 40th anniversary with new archives, events, and creative outputs.

This is an opportunity to project manage that work, collaborating with INQUEST staff, the families we work with, photographers, oral and physical archivists, and much more.

Learn more by reading the full recruitment pack and apply via our website. The deadline is Wednesday 16 March at 1pm.


The Ministry of Justice released the latest statistics on deaths and self-harm in prison.

In the 12 months to December 2021 there were a total of 371 deaths of people in prison in England and Wales, representing the highest annual number and rate of deaths ever recorded, with more than one death a day.

The longer-term data shows that, even without including Covid-19 related deaths, this year and the past five years have seen the highest ever numbers and rates of deaths in prison. 

We told The Independent, the pandemic alone cannot explain away this record level of deaths. In the short-term urgent action is needed to ensure people in prison have access to healthcare and adequate support. In the long term, we need a dramatic reduction of the prison population and more investment in radical community alternatives.

The Government are consulting on a new Prison Strategy White Paper. INQUEST has responded highlighting serious concerns with their approach, which focuses on prison expansion. It is a significant missed opportunity to develop an alternative set of prison policies which would reduce crime, protect the public, ensure the safety of prisoners and staff, and reduce victimisation.

So called ‘natural cause’ deaths in prison continue to rise, but our cases demonstrate that these deaths are often preventable. The inquest into the death of Eshea Nile Dillon, a 22 year old Black man, demonstrates this. He had severe asthma and had called for help as he was locked in his cell and struggling to breathe. The inquest jury found missed opportunities.

Six of the deaths in 2021 were in women’s prisons. In February, prison inspectors published a damning report on an inspection of HMP Foston Hall in Derbyshire, alongside a very concerning briefing paper on women’s prisons more broadly. We raised concerns about the inhumane and unjust treatment of women in prison in The Guardian.

Inspectors also highlighted ‘rife’ violence and self-harm in HMP Chelmsford, a prison long known for contentious deaths and harms. The family of a man who was sent there whilst in mental health crisis spoke anonymously to Channel 4 News alongside INQUEST Director, Deborah Coles.

Immigration detainees continue to be at risk in prisons, due to a disparity of advice available and ineffective communication between prisons and the Home Office, a coroner has highlighted. This report to prevent future deaths followed the critical inquest into the death of Keethswaren Kunarathnam, an immigration detainee who died by suicide in Wormwood Scrubs in February 2018.

Indeterminate sentences known as IPP continue to be challenged by campaigners, including family campaigner Donna Mooney who runs UNGRIPP and recently gave powerful evidence to an ongoing parliamentary inquiry on the harms of these sentences. Watch it here and read INQUEST’s recently published written evidence to the inquiry here.


The Care Quality Commission this week published concerning new data on mental health detention in England. In 2020/21 they recorded 363 people’s deaths, which is a third higher than the total number of deaths in the year before.

The majority (268) relate to ‘natural causes’, including 114 which related to Covid-19. We recently spoke to the BBC alongside the family of Charlie Millers, raising concerns about the impact of the pandemic on both the mental and physical health of patients.

The cause of 62 deaths is currently undetermined, and 33 were ‘unnatural causes’ which includes self-inflicted deaths. Half of the unnatural deaths were of people under 30, while a disproportionate number of deaths overall (61) were of people categorised as having a ‘Black, Asian or Minority Ethnic background’.

INQUEST highlighted high numbers of deaths and concerns in three mental health trusts.

We joined the family of Bethany Tenquist in calling for action following an investigation into Sussex Partnership NHS Trust in The Telegraph finding high numbers of contentious deaths of patients.

We continue to stand with families raising concerns about Tees, Esk and Wear Valley NHS Trust, who spoke out in local media as yet another inquest critical of the Trust’s services concluded.

INQUEST is involved in three recent cases involving the deaths of young patients in Prestwich Hospital, run by Greater Manchester Mental Health Trust. Alongside their families we continue to raise concerns about the Trust and call for action from the regulator.

Recent inquests have raised concerns about private providers of mental healthcare. The families of Nadia Shah, 16, and Leon Tasi, 19, spoke to the Mirror following the inquests into their deaths in the care of private Elysium services.

Gary Mavin died a self-inflicted death whilst an NHS patient at a Priory run hospital. The coroner said, “Gary’s case is one of the worst examples of care provided to a vulnerable, mentally ill patient” and that the care he received was “seriously flawed”. His wife Lea Mavin spoke to BBC News.

The inquests into the deaths of children and young people in mental health services repeatedly highlight similar failings.

As well as Leon and Nadia (above), the recent inquest on the death of Zoe Wilson highlighted serious failings by Bristol mental health services. Zoe was 22 when she died a self-inflicted death whilst a voluntary mental health patient. The Guardian reported on her family’s continued fight for justice.

A critical inquest also concluded on the death of 24 year old Sam Copestick. It found his self-inflicted death was contributed to by neglect of Pennine Care NHS Foundation Trust. His death followed that of his brother, Matthew Copestick, 21, which also related to failures in health services in Rochdale.

Marshall Metcalfe was 17 when he died a self-inflicted death whilst under the care of Lancashire and South Cumbria NHS Foundation Trust in Blackpool. His mother, Jane Ireland, 44, was also in the care of these services when she died one month later. A joint inquest into their deaths was held and found a range of serious failings. Sister and daughter, Holly Ireland, has started Marshall’s Movement to challenge failing mental health services in their names.


Inquests continue to highlight poor standards of care and support for people with learning disabilities, autism and/or care needs, both from mental and physical healthcare and social services.

The inquest on the death of 13 year old Sammy Alban-Stanley, during the first lockdown, has concluded that he died as a consequence of injuries sustained during an episode of high-risk behaviour related to Prader Willi Syndrome, on a background of inadequate support from the local authority and mental health services.

Sammy’s mother, Patricia Alban Stanley, wrote a powerful blog about the impossible game that families of people with care needs face when trying to access potentially lifesaving support.

Coco Rose Bradford, a six-year-old girl with autism, was taken to hospital in Cornwall and died unexpectedly on 31 July 2017. An inquest found it was a death by natural causes, a finding the family continues to dispute. The accompanying narrative conclusion paints a picture of multiple failings during Coco’s care at the Royal Cornwall Hospital.


Lawyers representing the bereaved, survivors and residents (BSRs) of Grenfell Tower have told the inquiry they need to support INQUEST's call for a national oversight mechanism to ensure recommendations from inquests and inquiries are followed up and enacted. The Mayor of London also supported this. 

BSR representatives also highlighted the need for a statutory duty of candour. This would be made possible through the enactment of Hillsborough Law. See Inside Housing reports. INQUEST has long campaigned for a national oversight mechanism and Hillsborough Law and is lobbying for their implementation. 

The inquiry continues and is now examining the actions of the state more directly. Karim Mussilhy, bereaved family member and member of Grenfell United, told The Guardian podcast that politicians must be held accountable.  


We recently emailed you with an update on our Legal Aid for Inquests campaign, reporting the removal of the means test on some legal aid funding for bereaved people from 12 January this year. While we celebrated this success in the campaign, we also noted: the fight is not over.

If you haven’t seen it yet, we’d encourage you to watch and share our latest campaign video by The Law in 60 Seconds, made in collaboration with Young Legal Aid Lawyers

We’ve been lobbying for these changes to be enacted through the Judicial Review and Courts Bill, which is currently being debated in the House of Lords. We’ve also been highlighting issues with the Bill which affect inquests and bereaved people, and recommending changes required. Read our latest joint briefing on the Bill, made in collaboration with JUSTICE.


Seni’s Law, which aims to prevent dangerous use of force against mental health patients, will finally fully come into force at the end of March. Formally known as the Mental Health Units (Use of Force) Act 2018, the law is named after Seni Lewis, who died following excessive restraint by police whilst a mental health patient.

Over three years on from the Act passing, in November we joined Seni’s parents Aji and Conrad Lewis, and the Minister for Mental Health, Gillian Keegan, to celebrate this progress and the publication of long awaited guidance on the Act. Learn more.

Police officers accused of misconduct are using “defensive tactics” to avoid accountability, report The Independent. INQUEST discussed continued concerns with police misconduct processes, including increasing anger and suspicion arising from anonymity and a lack of candour by police.

Where gross misconduct proceedings for police do take place, many lead to little action. The BBC investigated finding that, of 118 cases where the standards breach was proven by force disciplinary panels, 55 led to the officer losing their job. INQUEST responded highlighting the importance of action and transparency to ensure police are not above the law.


(Pictured from left to right)

Trevor Alton Smith, a 52 year old Black man, was fatally shot by police officers on 15 March 2019. He had been experiencing mental ill health. An inquest concluded finding his death was a ‘lawful killing’, with no criticism of the operation. The family are now raising serious concerns about the findings.

Shane Bryant, a 29 year old Black man, died following restraint by Leicestershire police and members of the public on 13 July 2017. An inquest found that aspects of the force used to restrain him were unreasonable and contributed to his death. They also found missed opportunities by the off duty police officer in managing the ongoing restraint which contributed to his death.

Abdul Hamid, a 26 year old Asian man, died in contact with West Midlands police on 1 May 2020. He was restrained face down by members of the public, then a police officer intervened. The officer did not assess Abdul’s consciousness, but joined in the restraint including with his knee and handcuffs before Abdul became unresponsive. Despite clear issues, the inquest jury made no critical findings.

Lamont Roper, a 23 year old Black man, drowned in the River Lea in Tottenham following a police pursuit on 7 October 2020. An inquest concluded with the jury highlighting the inadequacy of resources for water rescue along the canal and lock, the lack of sufficient police resources, and the lack of a specialised on-call dive rescue team.

Andrew Brown, a 23 year old White man, was crossing the road outside Hounslow station in West London when he was struck by a marked police car on 1 November 2019. PC Daniel Francis was given a suspended jail sentence after pleading guilty to causing death by careless driving.

Steven O'Neill, a 28 year old White man, drowned in the River Ouse in York following police contact on 20 April 2019. An inquest has concluded finding his death was misadventure (an accidental death), despite serious concerns raised by the family around actions of the police involved.


There have been multiple recent inquests on preventable restraint related deaths involving security staff. Many concluded the death was an unlawful killing or highlighted serious failings. Yet, as we told The Independent, there is not yet any accountability, despite the duty of care these staff and the companies employing them have.

Urgent action from the Security Industry Authority is required to ensure other licensed staff are reminded of the risks of prone restraint and their responsibilities. While police and authorities must ensure action is taken to hold those responsible for deaths to account.


Gavin Brown, a 29 year old Black Caribbean man, died on 20 April 2019, eight days after he was restrained by members of the public and a door supervisor for over six minutes outside a pub. Greater Manchester police officers arrived on the scene, handcuffing and placing him under arrest whilst he was unconscious. A jury inquest has concluded that he was unlawfully killed.

Jason Lennon, 37 year old Black Caribbean man, was experiencing a mental health crisis when he was subject to restraint by security guards on 31 July 2019. The inquest concluded making wide ranging criticisms of East London mental health services engaged in Jason’s care prior to the incident, and of the ‘excessive’ and ‘unreasonable’ restraint used by licensed security guards.

Michael Thorley, a 41 year old White man, died on 22 December 2017, following a period of restraint by a security guard at Wythenshawe Hospital in Manchester, where he was a patient. He had been experiencing delirium, relating to issues in the medical treatment. The inquest into his death concluded with the jury finding that he was unlawfully killed.

These recent inquest conclusions follow that of another similar case last year, when the inquest into the death of Jack Barnes, who died following restraint by public transport staff acting partially in a security role, concluded his death was an unlawful killing.


  • The death of Alex Tekle, 18, is one of a series of deaths of young Eritrean asylum seekers highlighted by Da’aro Youth Project. A critical inquest concluded last month highlighting serious issues which affected his life. Da’aro continue to campaign to prevent future deaths of young asylum seekers.
  • INQUEST joined Fair Trails and 60+ signatories in calling for an urgent review of all Covid-related fines and prosecutions.
  • INQUEST joined Zahid Mubarek Trust and a range of orgs as signatories to this important letter to justice minister Dominic Raab on racial disparity in the criminal justice system.
  • A new study looking at Fatal Accident Inquiries in Scotland (which are the equivalent of inquests) following deaths in Scottish prisons highlighted a widespread lack of action. Researchers included the family of Katie Allan, a young woman who died in a Scottish prison. The family recently spoke to the Guardian about their continued campaign for justice and change.
  • The Justice for Gaia campaign, run by the family of Gaia Pope, have launched a manifesto for change ahead of the upcoming inquest into her death. Read and support it here.


This section is for families working with INQUEST, and includes opportunities and upcoming events which may be of interest.

Mind, Body Skills Workshops  

Our third Mind, Body Skills Workshops will be starting on Tuesday evenings shortly. Grounded in practical, evidence based skills for self-care, nutrition, self-awareness, & group support, the Centre for Mind-Body Medicine approach works to heal individual trauma & builds community-wide resilience. 

For families interested in joining the next round of workshops starting soon, please email [email protected] 

Connection Cafes

There are now two Connection Cafes a month, which bring families together in a mutually supportive space. Any bereaved family working with INQUEST is welcome:

  • Morning - Second Wednesday of every month (11am-1pm) Next session 9thMarch  
  • Evening– Fourth Wednesday of every month (6:30pm-8pm) - Next session 23rd February  

Here’s what one attendee said about the space: “The Connection Café and INQUEST has been a godsend for me in terms of support. Emotionally and practically. It dissipates the isolation. The sharing of experiences has been invaluable.”

To register for reminders and joining details please fill in this form.

Listen at lunch: untangling loss

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

The event will be structured as more of a webinar space, than a sharing space although there will be some time to do some practice/activities yourselves during the sessions. The first half of the sessions will be recorded so that those who cannot make the time can benefit from the learning.  

These will take place 1pm-2pm on the Last Friday of every month. The upcoming events are:

  • 25 February 2022 - Understanding Traumatic Bereavement
  • 25 March 2022 - Talking to children and teenagers about death

Register here via Zoom

Get More Involved with INQUEST

INQUEST are excited to invite families to get more involved in various Family Engagement work shortly, from groups to consult with our policy team on various issues, to joining our Family Reference Group, to becoming a member of the INQUEST Board of Trustees.  

We will hold an evening session in March to discuss these developments and explain the application processes. Please email Mo our Family Engagement Coordinator for more details.

Film opportunity: seeking families of Black men who have died in police contact

Acme films are hoping to reach out to all families of Black men who have died in police custody or contact in Britain, recently or historically. They say:

The story of deaths of Black people at the hands of the police, and particularly their families, is one that we believe is not present enough in our national conversation. This powerful and important film aims to fill the silence and start to tell that untold story by acknowledging every one of those Black lives.

We will not interrogate, explain or justify the actions of those who died or those who killed them. Instead, through an unflinching gaze, this film will simply provide a canvas for the testimony of the families and friends of those who have lost loved ones and who have never seen justice done.

Acme is an award-winning London-based independent production company with a track record of documentaries exploring social history, including Lawful Killing: Mark Duggan, a Drama Documentary about the police shooting of Mark Duggan in Tottenham in August 2011.

They are working with director Baff Akoto, who is an artist and experimental filmmaker whose work has been exhibited at London’s Institute of Contemporary Art (ICA) and at the British Film Institute (BFI).

Some families may have already been contacted. At this stage Acme are seeking to have an initial conversation, which would be completely confidential with no obligation to take part.

If you are interested contact: [email protected]

Research invitation: Voicing Loss

The Institute for Crime & Justice Policy Research (Birkbeck, University of London) and the Centre for Death & Society (University of Bath) are conducting research into bereaved people’s experiences of inquests.

They are particularly interested in finding out to what extent, and in what ways, bereaved people feel able to participate in inquests and the wider process of coronial investigation. This is an independent study, funded by the Economic & Social Research Council.

The research team would like to talk to bereaved people who have attended an inquest since 2013. Participants will be asked to reflect on their experiences of inquests and the role of bereaved people in the coronial process. You can find out more about the project and find the details of the researchers to express your interest here.