27 June 2023
A new campaign No More Deaths, seeking to challenge the lack of accountability, transparency and action on recommendations arising from deaths, has launched today.
Public and corporate bodies have a duty to keep people safe from harm and protect lives. Yet every year INQUEST supports hundreds of families whose loved ones have died preventable state related deaths, often in very similar circumstances.
Public inquiries, inquests, investigations and official reviews are processes which have been crucial in shining a light on failing systems and dangerous practices. They make vital recommendations that could save lives.
These processes follow deaths of people in police custody and prisons, mental health settings, or following disasters like Grenfell and Hillsborough. As well as broader cases such as those involving NHS failures and the response to the Covid-19 pandemic.
Yet there is no framework to monitor compliance or actions taken in response. Instead, recommendations are forgotten or dismissed. This leads to yet more preventable deaths and harms.
INQUEST is calling on the government to create a National Oversight Mechanism: A new independent public body responsible for monitoring recommendations arising from inquests, inquiries, official reviews and investigations into state-related deaths.
A National Oversight Mechanism would:
  • Collate recommendations and responses in a new national database
  • Analyse responses from public bodies and issue reports
  • Follow up on progress, escalate concerns and share thematic findings
The No More Deaths campaign briefing further details the case for change. INQUEST will be launching a petition so members of the public can support. The campaign will formally launch with an event in parliament on Tuesday 27 July.
The campaign is supported by a range of organisations including Grenfell United, the Hillsborough Law Now Campaign, Covid-19 Bereaved Families for Justice, Liberty, Appeal, Justice, Mind, Runnymede, and more.
Deborah Coles, Director of INQUEST, said: “Everyone can agree that when failures lead to preventable deaths, we must ensure that action is taken to keep people safe and protect lives.

Bereaved families seek truth, accountability and meaningful change in the hope that future deaths will be avoided. The current system is not fit for purpose, betrays bereaved people and leaves us all at risk.

Inquiries, inquests and reviews can be vital tools for scrutinising deaths and recommending changes. However, the current lack of transparency and oversight on recommendations undermines their preventative potential. 
We need a National Oversight Mechanism to address this shocking accountability gap and ensure that when recommendations are made following deaths they are not lost, ignored or left to gather dust. This would do justice to bereaved families and help save lives.”
Richard Caseby, father of Matthew Caseby, said: “My son Matthew was killed after gross negligence at a Priory hospital where he was supposed to be held for his own safety. It took my family over a year to expose the truth.
Despite a devastating inquest conclusion and a Prevention of Future Deaths report setting out specific actions, we hit a cliff edge.
For example, the coroner recommended the Department for Health and Social Care establish national guidelines for fences and security in acute mental health units. Has anything been done? Despite repeated requests, I have no idea.
When failures have been publicly exposed, how long do the bereaved have to bang on doors to make change happen?
That's why an oversight body is needed. To make sure that the glib response ‘lessons will be learned’ actually translates into effective action."
The Right Reverend James Jones KBE, former Bishop of Liverpool and Chair of the Hillsborough Independent Panel said: "It is a waste of an inquest or inquiry if lessons learnt from the tragic death of a loved one are not acted upon. But there is no national mechanism to make that happen. At last the charity INQUEST has come up with a practical proposal to set one up. The Government must not ignore it."
Natasha Elcock, Chair of Grenfell United, said: Grenfell United wholeheartedly support the need for the National Oversight Mechanism. We have seen first-hand how recommendations from Grenfell have failed to be implemented. 
Six years on, we now know that every single death at Grenfell could and should have been avoided. We’ve worked tirelessly to ensure our loved ones are remembered not for the way we were treated before the fire, but for the legacy that is created post the fire. But so little has changed.
Bereaved and survivors should not have to fight to hold Government to account to ensure learning and change and that history is not repeated.”
Lobby Akinnola, on behalf of Covid-19 Families for Justice, said: “The worst has already happened to those of us who have lost loved ones to Covid-19. Nothing will bring back our lost loved ones, but we won’t rest until we know that your families will be safer in the future, and not suffer as a result of state actions as we have.
A National Oversight Mechanism will help us and all other groups campaigning to prevent state related death hold the government to account. The Covid-19 Inquiry will only be as valuable as the policy changes it will bring about.

For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]

For more information see the No More Deaths campaign briefing (embargoed to 00.01 Tuesday). The campaign webpage and petition will go live on Tuesday.

A number of bereaved families who are supporting the campaign around the UK are available for comment. Their family members died in a range of circumstances, including in police contact, mental health settings or prisons.

The Right Reverend James Jones KBE, was the Bishop of Liverpool and Chair of the Hillsborough Independent Panel. See bishopjamesjones.com

In 2017 his independent review of Hillsborough Families’ experiences was published, which included the voices of a range of bereaved families supported by INQUEST and recommended the creation of a body to follow up on recommendations on deaths.

Matthew Caseby, the son of Richard Caseby, was 23 years old when he died on 8 September 2020. He had absconded from the Priory Hospital Woodbourne in Birmingham, where he was a detained NHS funded mental health patient. See the media release on the inquest conclusions for more information.

Journalists should refer to the Samaritans Media Guidelines and guidance for reporting on inquests.

Grenfell United are a collective of survivors and bereaved families from the Grenfell Tower fire. See grenfellunited.org.uk
Covid-19 Bereaved Families for Justice is a collective of over 6,500 bereaved people. covidfamiliesforjustice.org