INQUEST is calling for urgent and effective action to ensure access to justice for bereaved families, to improve prison safety, invest in community-based alternatives and reduce the prison population.


"The fact that the jury have confirmed she might still be with us if the level and nature of observations had been different is painful to hear. I am still worried for other vulnerable prisoners, who like Nicola, might not be getting the correct treatment or support. I hope that lessons have been learnt and the prison and healthcare providers put changes in place which mean that Nicola’s life has not been lost in vain. I do not want another family to have to go through what we have been through." Christine Lawrence, mother of Nicola Jayne Lawrence who died in HMP New Hall


"Appalling inspection reports, damning inquest findings, and statistics on yet more deaths, have become so regular that those in power seem to forget these are human beings to whom the state owes a duty of care. Families continue to be traumatised, not only by the deaths, but by the failure to enact change. Deaths, self-harm, violence, impoverished regimes and conditions are the daily reality of the prison system. Despair and distress are at unprecedented levels in failing institutions within a failing system. The failure to act on warnings from inspection, monitoring, investigation bodies and inquests exposes an accountability vacuum allowing dangerous practices to continue."Deborah Coles, INQUEST Executive Director 


For almost forty years, INQUEST has worked alongside the families and lawyers of the men, women and children who have died in prison. Bereaved families have been instrumental in drawing attention to deaths in custody and the need for systemic policy change. 

INQUEST’s monitoring of investigations and inquests into prison deaths shows that many deaths are preventable and the result of neglect and systemic failings in care. This contravenes national and international human rights standards, including Article 2 of the European Convention of Human Rights which upholds the right to life.  

Action to address the persistent failure of the prison and healthcare services to rectify dangerous practices is long overdue. There is a need for urgent and effective action to ensure access to justice for bereaved families, to improve prison safety, invest in community-based alternatives and reduce the prison population.


In January 2020 INQUEST published Deaths in prison: A national scandalThis report provides unique insight into the dangers of imprisonment and makes the following recommendations to end deaths caused by unsafe systems of custody and detention: 

  1. Commit to an immediate reduction in the prison population, halt prison building and divert people away from the criminal justice system.
  2. Prison staff, including healthcare staff, require improved training to meet minimum human rights standards to ensure the health, well-being and safety of prisoners.
  3. Ensure access to justice for bereaved families through the provision of automatic non-means tested legal aid funding for specialist legal representation to cover preparation and representation at the inquest and other legal processes. Funding should be equivalent to that enjoyed by state bodies/public authorities and corporate bodies represented.
  4. Establish a ‘National Oversight Mechanism’ – a new and independent body tasked with the duty to collate, analyse and monitor learning and implementation arising out of post death investigations, inquiries and inquests. This body must be accountable to parliament to ensure the advantage of parliamentary oversight and debate. It should provide a role for bereaved families and community groups to voice concerns and provide a mandate for its work.
  5. Ensure accountability for institutional failings that lead to deaths in prison. For example, full consideration should be given to prosecutions under the Corporate Manslaughter and Corporate Homicide Act, where ongoing failures are identified and the prison service and health providers have been forewarned. The reintroduction of The Public Authority (Accountability) Bill would also establish a statutory duty of candour on state authorities and officers and private entities.

Download the report


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CREDIT: The above illustration is credit of Michael Collins, as part of the These Walls Must Fall Campaign. See: detention.org.uk