On 2 March our report Stolen Lives and Missed Opportunities: The deaths of young adults and children in prison
at the Transition to Adulthood (T2A) Alliance attended by 250 policymakers, practitioners and charity representatives where Deborah Coles and Policy and Parliamentary Officer, Ayesha Carmouche presented the key findings and recommendations. The report
documents how the deaths of 65 young people and children in prison are underpinned by a pattern of failures and poor practice. It shows how the use of prison is an ineffective and expensive intervention that doesn’t work and calls for a radical rethink the way in which we respond to young people in conflict with the law. In welcoming the report Joyce Moseley, Chair of the T2A Alliance commented: "they may be a small organisation but they punch well above their weight"
. The report was widely discussed in the media including the Observer
, The Independent
and Children and Young People Now
Our work on deaths of young people in prison has also been key to our engagement with the Harris Review
into the self-inflicted deaths of 18-24 year olds in prison. We have contributed to the Review in a range of ways: we submitted an evidence-based report including a focus on our work with families of the young prisoners who have died in prison; Deborah Coles was a member of the review panel in her capacity as a member of the Independent Advisory Panel on Deaths in Custody and we held two family listening days during November and December 2014, bringing families together with panel members to inform their findings and recommendations. The review aims to influence key Ministers and practitioners and its report has been delivered to the Ministers. We are waiting to hear when it will be published alongside the reports of the Family Listening Events.
Following the shooting of unarmed black man, Michael Brown, in Ferguson in the United States, our co-director, Deborah Coles spoke alongside campaigners and families whose relatives have died in custody, at two events in London addressed by Patrisse Cullors, founder of Black Lives Matter. The first was a well-attended parliamentary event on 26 January, which was chaired by John McDonnell MP and included speakers Diane Abbott MP, Becky Shah from the Hillsborough Justice Campaign and bereaved families including Marcia Rigg and Stephanie Lightfoot-Bennett from the United Friends and Families Campaign (UFFC).
The second event was a meeting organised by the Police Action Lawyers Group at Doughty Street Chambers on 30 January. Other speakers at this event included, Leslie Thomas QC, barrister and INQUEST Lawyers Group member who represented the families of Sean Rigg, Azelle Rodney, and Mark Duggan.
January saw the long awaited inquest into the death of Habib ‘Paps’ Ulah following contact with police in High Wycombe. The family, supported by the Justice 4 Paps campaign finally had the opportunity to ask their question at a full inquest hearing nearly eight years after his death in July 2008. The jury returned a highly critical misadventure and narrative conclusion
about the circumstances of his death following inappropriate and dangerous police restraint.
Deborah Coles also spoke at the launch of the Institute of Race Relations publication Dying for Justice
to which she contributed an article. This excellent report looks at the pattern of deaths of people from BAME, refugee and migrant communities who have died between 1991-2014 in circumstances involving the police, prison authorities or immigration detention officers.
The disturbing evidence that emerged at the inquest in Birmingham into the death of Kingsley Burrell
following contact with police and mental health services in May 2011 is a shocking reminder of the need to keep the pressure on for justice and accountability. After a six week inquest the jury returned a highly critical conclusion of neglect
and found that prolonged restraint and a failure to provide basic medical attention had caused his death. It found systemic failings
by police, mental health and ambulance services.
We have also been advising the lawyer acting for Sheku Bayoh, a 31 year old black man who died in Fife in Scotland on 3 May 2015 following the use of restraint by police officers and have called for a robust and independent investigation
. Although the investigation system in Scotland is different we can draw on and share our experience of working on restraint related deaths in England and Wales. You can read more about it here
On 18 May, the inquest concluded
into the death of immigration detainee Rubel Ahmed at Morton Hall Immigration Removal Centre. Rubel was discovered hanging in his cell on 5 September 2014, a few days after being informed of the decision to remove him to Bangladesh. He was detained in this former prison despite concerns expressed by parliamentarians and HM Inspectorate of Prisons about immigration detainees being held in prison-like conditions, regimes known to exacerbate mental and physical ill health. . The jury returned a critical narrative conclusion and found “inadequate” communication between multi-disciplinary teams was one of the factors that contributed to his death following the service of removal directions on him. Staff did not know who detainees were, had not been trained in resuscitation techniques and emergency procedures and could not remember much of their training on working with immigration detainees as opposed to prisoners. A key recommendation from a previous inspection about not locking detainees in their rooms in the evenings and overnight had not been implemented. The Coroner confirmed he would be writing a prevention of future deaths report to the Home Office.
Deaths in Mental Health Detention
In November 2014 a jury found that multiple failures led to the death of 18-year-old Rebecca Louise Overy
on 24th June 2013 in an adult secure unit in Nottingham. She was moved from adolescent into adult mental health care without proper transitional arrangements. She was a detained patient at the time of her death and had been in a secure adolescent psychiatric unit from the age of 13 where she had an established network of support and friends of her own age. Her doctors were very encouraging and led her to believe that she had a future. Rebecca believed that she would be returning back home after she turned 18. Instead a day after she turned 18 she was moved to an adult mental health facility. The jury found that her self-harming escalated after her speedy transition to adult mental health care without proper planning, cancellation of visits and tight restrictions.
Rebecca’s death is a shocking reminder that there needs to be an urgent improvement and investment in the care of children and young people by mental health and social services. Rebecca was failed by the very services that should have provided her with care and treatment at a most critical time in her life.
In April 2015 a coroner concluded that lack of mental health beds was a contributory factor in death of 17 year-old Sara Green
an inpatient in a privately run Priory Group hospital. When she died Sara had been an in-patient for 9 months despite having been considered ready for discharge within 3 months of admission due to a lack of NHS placement and a failure to manage her discharge. The Coroner concluded that this was a contributory factor to the act of self-harm that ended her life. The hospital was 100 miles from her family home despite the fact that she benefitted from close family ties and that her anxiety was worsened by not being in a community or an alternative psychiatric institution closer to her home.
The inquest revealed that the hospital had no coherent policy on how or how regularly observation should be conducted, the staff were conducting observations in breach of the Priory’s own national policy, correct observation policy was not taught at induction training and confusion as to the meaning and frequency of observation levels is widespread nationally.
The Priory’s internal investigation did not identify the failings found by the Coroner in this inquest, underlining the need for more independent investigation and effective scrutiny of deaths in mental health settings to identify learning in order to safeguard lives in the future. INQUEST will be lobbying the new government to make these changes and to address the dangerous inadequacies exposed in our system of mental health care for children and young people.
In the first four months of 2015 the casework team have provided specialist advice on 127 new cases of deaths in custody and detention in addition to on-going open cases. In comparing the last two years April 2013 – May 2015 we have seen a 39% overall increase in specialist casework. Fig 1 shows the increase in new cases each year and Fig 2 shows the overall cases worked on each year including on-going open cases.
Fig 1 Fig 2
Deaths in prison
There have been 66 deaths in prison in England and Wales in the period January-April 2015: 18 of those were self-inflicted, two were homicides; there have been 3 BAME deaths in prison (2 of which were self-inflicted); 4 self-inflicted deaths of prisoners aged 18-24; and one death of a woman in prison, which is awaiting classification.
Deaths following police contact
There have been six deaths in
England and Wales in the period
January-April 2015 following police contact: three of those were in custody and three involving police vehicles.
Stronger Voices, Better Outcomes: strengthening family engagement after deaths in detention
Family Reference Group members at work
In December as part of our work on our project funded by the Big Lottery Fund families from across England came together for a successful meeting
of our Family Reference Group to share their experiences and thoughts. Over the next two years, this group will be working closely with us as we develop our on and offline advice and support resources like our Handbook
and Skills Toolkit
and roll out our training programme to improve the family experience. After months of planning this was a cracking start to this part of the project and we are really grateful to everyone for their expertise and enthusiasm on the day.
Funding legal representation at inquests
Improving family access to public funding for legal representation at inquests into deaths in custody, detention and care settings remains one of our key priorities. We have joined with others to protect the important advances made over a decade ago that saw families able to apply for exceptional funding for representation at death in custody inquests and to improve access to justice for bereaved people. This inequality of arms between the state and private companies and families was highlighted on Radio 4 You and Yours
. Deborah Coles and Rosie Reed, whose 23 year old son Nico died a preventable death in a home for adults with learning disabilities drew attention to the myth perpetuated by government that inquests are informal hearings and yet the State invariably instructs lawyers to represent its interests.
Taking this issue forward at a policy level we were really pleased to have submitted a supporting witness statement in the High Court challenge to the Lord Chancellor’s Guidance on legal aid funding by Joanna Letts, who was not granted legal aid for her brother’s inquest at which the hospital, doctors and social worker