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INQUEST conducts policy work and research on issues relating to deaths in custody. We aim to raise public awareness, improve the investigation processes following contentious deaths and increase accountability of state officials in order to prevent future avoidable deaths.
Through our casework over more than 25 years, INQUEST has a unique overview of how the inquest system operates from the perspective of bereaved families and their advisers. We extract policy issues arising from contentious deaths and their investigation and campaign with and on behalf of bereaved families for changes in practice to prevent deaths. Our policy and research work is widely used by parliamentarians, lawyers, academics, policy makers, the media and the general public.
Between 1997 and 2007 INQUEST's casework and monitoring service has highlighted over 2,500 deaths in prison and in police custody in England & Wales. Many of these deaths have raised serious issues of negligence, systemic failures to care for the vulnerable, institutional violence, racism, inhumane treatment and abuse of human rights.
Our monitoring and casework has revealed serious shortcomings in the existing mechanisms of legal and democratic accountability following a death in custody. There are no mechanisms for monitoring, auditing or publishing investigations and inquest findings and no statutory requirement to act on the findings of these investigations. There is also a pattern of institutionalised reluctance to approach deaths in custody as potential homicides even where there have been systemic failings and gross negligence has occurred. There has not been a successful homicide prosecution for a death in custody for over 30 years.
INQUEST regularly submits written and oral evidence to parliament and statutory agencies on issues arising from deaths in custody and their investigation. We lobby to change policies and practice relating to deaths in custody and for increased accountability following contentious deaths.
Our book Unlocking the Truth describes the experiences of families bereaved by deaths in custody from the time of death to the conclusion of the investigation and inquest and situates them within the political, recent historical and legal context.
In November 2008 INQUEST had a meeting with the Council of Europe's Committee for the Prevention of Torture and briefed them on our concerns arising from our work on deaths in custody.
In the 10 year period between 1997 and 2007 there have been over 530 deaths in police custody in England & Wales, as a result of police shootings or following contact with the police, and more than 320 deaths in police vehicle incidents.
INQUEST has identified patterns of deaths occurring in police custody such as:
• deaths which raise issues about standards of care such as deaths due to self injury, alleged drunkenness or drug intoxication, or poor medical care;
• excessive use of force by police officers;
• disproportionate numbers of deaths following the use of force against people from Black and Minority Ethnicity communities;
• fatal shootings - there have been 32 police shootings since 1997.
INQUEST believes that deaths in prison cannot be looked at separately from examining harsh and impoverished prison conditions, the use of segregation, poor medical care and prison overcrowding - all of which have implications for people's mental and physical health. Until there is a fundamental review of the overuse of prison for the most vulnerable and marginalised, prison deaths will continue.
The growing prison population has resulted in the rise self-inflicted deaths in prison (over 900 out of more than 1,700 deaths in prison in England & Wales in the years 1997-2007) and the record number of women taking their own lives. Suicide prevention and prison overcrowding are incompatible and this dismal record should be a matter of national shame and prompt urgent reform.
INQUEST sits on the Ministerial Group for Suicides and works with the Prisons and Probations Ombudsman to raise thematic issues arising from our casework to ensure lessons are learnt from deaths in prison.
INQUEST's monitoring has revealed that a disproportionate number of Black people and those from minority ethnic groups have died as a result of excessive force, restraint or serious medical neglect. We believe this is indicative of institutional racism in the criminal justice system.
Black deaths in custody must be seen in the context of the disproportionate overuse of prison for black people, the plight of immigration detainees, the treatment they receive and the overuse of control and restraint techniques and segregation. While the number of restraint related deaths are a small minority of the total numbers of deaths they have been the most controversial because of what they have revealed about the excessive use of force by functionaries of the state.
In 2007 alone Black and Minority Ethnic deaths made up 25% of self-inflicted deaths, and 19% of all deaths in prison.
INQUEST has been involved in supporting the families in a high number of cases of black deaths in custody such as the restraint-related deaths of Roger Sylvester and Rocky Bennett and are continuing to closely monitor such deaths.
Between January 1996 and December 2006 there were 77 self-inflicted deaths of women in prison. Our monitoring of women's deaths in prison has shown that women are continuing to die in an unprecedented number. Although the number of deaths corresponds with an increase in the numbers of women being sent to prison, it is still disproportionately high.
INQUEST is extremely critical of the failure of the prison service and government to address the questions about the overuse of prison for women. A large percentage of women in prison are primary carers whose imprisonment has far-reaching consequences their families and society in general.
In March 2007, the government published the Corston Report which looked at the treatment of women in the criminal justice system. INQUEST was represented on the report's panel. The report recommended a radical overhaul of the way women are treated in the criminal justice system and INQUEST is urging the government to implement its findings at the earliest opportunity.
INQUEST published a major report Dying on the Inside: Examining women's deaths in prison in April 2008.
The report is the first analysis of all self-inflicted deaths of women in prison between 1990 and 2007 in England & Wales and identifies trends and patterns arising from the deaths presenting a shameful picture of preventable tragedy. The recommendations in the report focus on a departure from current thought and practice, with the key recommendation being the abolition of prison for women as the central criminal justice response and investment in radical community-based alternatives.
Child and youth deaths in prison
Between January 1997 and December 2007 there were 144 self-inflicted deaths of young people and children in prison and secure training centres. This figure includes 18 self-inflicted deaths of children aged 14-17 in custody.
INQUEST believes that for many young people, prison is an inappropriate place where their experience of imprisonment can contribute directly to their death. We believe there needs to be a proper understanding of how vulnerable children should be treated in the criminal justice system and are calling for a properly-resourced public inquiry into the deaths of the 30 children who have died in state custody since 1990 in the hope that proper lessons can be learnt from these tragic deaths.
INQUEST has particular concerns about the high levels of restraint used on children in custody. We have produced case briefings on the restraint related deaths in 2004 of 14 year old Adam Rickwood, who took his own life in Hassockfield Secure Training Centre shortly after being restrained by staff, and 15 year old Gareth Myatt who died following the use of a controversial method of physical control at Rainsbrook STC.
INQUEST published a groundbreaking book In the Care of the State? on the subject of child deaths in custody in 2005. We are currently working with the NSPCC and the Child Rights Alliance for England on a joint campaign to end the use of pain compliance restraint techniques against children in custody.
The Coroners & Justice Act 2009
On 12 November 2009 Royal Assent was given to the new Coroners and Justice Act signalling significant changes in the way contentious deaths are investigated in England and Wales. INQUEST has long argued for reform of the inquest system. It has worked closely with MPs and peers to improve the Bill to address the problems of the inquest system which is hampered by delay, inconsistency of approach, lack of resources and the inability to properly fulfil its vital function of preventing unnecessary deaths. INQUEST will continue to work to ensure that the concerns of the families with whom the organisation works are addressed during the consultation on the secondary legislation and during implementation.
An inquest is the only automatic public investigation of a contentious death that takes place in a court of law. Therefore the need for it to be effective in deaths which involve issues of state or corporate accountability is crucial.
In the Queen's Speech on 3 December 2008 the government signalled its intention to introduce a Coroners and Justice Bill, which was then published early in 2009. The government stated that:
"[the] Coroners and Justice Bill will ensure that victims are at the heart of the criminal justice system. It will significantly improve the service bereaved families receive from a reformed coroner system, and introduce a more consistent and transparent sentencing framework.
The purpose of the Bill is to... reform the justice and coroners systems to deliver a more effective, transparent and responsive service to the public. "
INQUEST engaged with the process as the Bill made its passage through parliament and had some success in ensuring that the needs of bereaved people were at the forefront of parliamentarians' minds so that measures were introduced that would:
• tackle delays in the inquest system;
• address the problems with public funding for families' legal representation;
• record and monitor inquest findings;
• make recommendations to relevant statutory bodies following inquest findings;
• and ensure action is taken following these recommendations.
Measures proposed in clauses 11-12 of the Coroners and Justice Bill which would have allowed some inquests to be held partly in secret (as previously dropped from the Counter Terrorism Bill 2008) were eventually removed from the Bill after concerted campaigning by INQUEST and others. However, the Justice Secretary instead proposed such inquests would come under the Inquiries Act 2005, a solution which was in many ways even less satisfactory.
Despite last-minute campaigning for them to be amended or removed, the Coroners and Justice Act 2009 received Royal Assent on 12 November 2009 with the controversial secret inquiries measures intact.
(PDF281KB) (Hansard is the transcript reports of proceedings in both the House of Lords and the House of Commons)
The government sought to give the Secretary of State powers to issue certificates to hold 'secret' inquests in any case where he or she believes that material will be revealed which is contrary to the public interest. The unexpected proposals were contained in the Counter Terrorism Bill published in January 2008 and would have amended the Coroner's Act. The proposed amendments would have enabled some inquests to be conducted at least partly in private, with government-vetted coroners and government-approved counsel overseeing the 'sensitive material'. Bereaved families and their legal representatives - as well as the public at large and the media - would be excluded from the process.
INQUEST believes the proposals amounted to a attack on the independence and transparency of the coronial system in England and Wales. They were fundamentally flawed; unsupported by evidence; disconnected from legal principles; and were devised without any consultation with stakeholders. We were particularly alarmed that the proposals should be contained in proposed Counter Terrorism legislation as this implies that there have been real issues that have arisen in relation to inquests that have involved questions of 'counter terrorism'. We are at a loss to identify any such circumstances and lobbied hard to have these clauses removed from the Bill.
Concerted campaigning by INQUEST (with the support of a broad coalition including Liberty, JUSTICE, the Royal British Legion, Northern Ireland Human Rights Commission) resulted in cross-party parliamentary opposition to the proposal, including from the Joint Committee on Human Rights and the Justice Committee. It was announced on 14 October that the controversial clauses had been dropped from the bill, though the government eventually re-introduced the same proposals in the Coroners and Justice Bill when it was published in January 2009.
In July 2007 the government finally passed the long-awaited Corporate Manslaughter and Corporate Homicide Act 2007. This Act is a victory for the bereaved families who have campaigned tirelessly for accountability following the death of loved one at work. It means that for the first time in UK law, corporations can be held accountable for grossly negligent acts that cause a death at work.
The Act is also a victory for deaths in custody campaigners. After extensive lobbying by INQUEST, working with Peers and a coalition of penal reform and human rights NGOs, the remit of the Act has been extended to cover prison and police cell deaths. The government resisted this extension heavily but was defeated by the House of Lords on five occasions and eventually forced to concede. The Act gives a three year delay period for the law covering deaths in custody to come into force. INQUEST will be monitoring the provisions being put in place to deal with the legislation.
Ministerial Council on Deaths in Custody
The creation of a new three-tier Ministerial Council on Deaths in Custody was announced by the Ministry of Justice in July 2008 , following publication of the Fulton Review and replaces the Ministerial Roundtable on Suicide and the Forum for Preventing Deaths in Custody . It is jointly funded by the Ministry of Justice, Department of Health and the Home Office.
The first-tier consists of a Ministerial Board on Deaths in Custody , which has replaced the Roundtable and has wider terms of reference to include all types of death in state custody (prison; approved premises; police; revenue and customs; immigration; psychiatric hospitals) . INQUEST is an independent member of the Board and at its first meeting held in June raised its concerns about the ongoing problems faced by families both in delays to inquests being held and in obtaining public funding for their legal representation.
The second tier of the Council is the Independent Advisory Panel (IAP) whose role is to provide independent advice and expertise to the Board. The IAP will be supported by a broadly-based group representing practitioners and stakeholders to be formed on an ad hoc basis . The appointment of the six members of the IAP was announced in June, and includes Deborah Coles.
NQUEST has campaigned for a properly resourced, independent standing commission on deaths in custody and will be closely monitoring the new structure and its impact.
