Press releases 2009

CORONERThe legal official who orders a post-mortem and who is in charge of the inquest procedure. ANNOUNCES INTENTION TO MAKE A RULE 43 REPORT FOLLOWING THE DEATH OF REBECCA SMITH AT HMP BUCKLEY HALL

On 17 December 2009, the jury at the inquest held before HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Greater Manchester North, Simon Nelson, sitting at Tops Business Centre, Heywood, Lancashire, reached a unanimous verdict that “Rebecca Smith took her own life whilst she was suffering from an enduring mental health condition.”

Rebecca had a long history of mental health problems, including several attempts at suicide. Throughout her life, she found changes to her routine and environment very difficult. However, she managed to live successfully for long periods in her own home with the support of her long-standing Community Psychiatric Nurse and local mental health team.

On 18 September 2003, Rebecca set fire to a sofa in her flat in a failed suicide attempt. She was charged with arson with intent to endanger life and remanded into custody at her

local prison, Eastwood Park . Both her Community Psychiatric Nurse and family visited her regularly in HMP Eastwood Park where she spent most her time in the in-patient Health Care Centre.

After being sentenced in March 2004, Rebecca was moved to HMP Buckley Hall, a training prison 200 miles away from her home in accordance with prison regulations, Prison Service Order 0900.

HMP Buckley Hall had no in-patient Health Care Centre, despite receiving large numbers of female prisoners with serious mental health problems. Rebecca’s family and Community Psychiatric Nurse were no longer able to visit her due to the distance involved. The upheaval for Rebecca was considerable and arranged at one day’s notice.

After being transferred to HMP Buckley Hall, Rebecca had refused to take her anti – psychotic medication. She had also stated to prison staff that she would end her life by self -suffocation. Six days before her death Rebecca was moved from the induction wing to a residential wing. Four days before her death, a decision was taken to end the additional observations by prison staff used to safe guard prisoners at risk of self- harm and suicide known as F2052SH.

Within a month of the transfer, she had ended her own life by self –suffocation with a plastic bag. She was found dead in her cell by a prison officer who tried unsuccessfully (along with other prison staff) to resuscitate her. A pathologistThe medically-qualified practitioner who carries out a post–mortem examination. explained to the inquest that Rebecca was probably dead within four minutes of placing the bag over her head.

The coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. has indicated that he intends to write to the Ministry of Justice, further to rule 43 of the Coroners Rules, asking that:

1. The relevant Prison Regulations on the transfer of prisoners from one prison to another (PSO 0900 (Categorisation & Allocation)) are revisited, to ensure that greater account is taken of individual’s prisoners’ clinical and social needs (as well as the receiving prison’s ability to meet those needs).
2. Review of items, given to a prisoner who has indicated that she will self harm, in a particular manner, are undertaken, to ensure that the prisoner does not have access to objects she may use to self –harm.
3. The emergency radio codes used by prison staff to summon help to an injured prisoner or prison officer are uniformly applied across all prisons in England Wales, to enable appropriate help to be given immediately.
4. All prison officers are given resuscitation training as part of their basic first training, during their induction.

Rebecca’s family hope that the rule 43 letter will either prevent or at least substantially reduce the risk of further self-inflicted fatalities within the prison population.

Yet again, an inquest into the death of a vulnerable woman in prison raises questions about their imprisonment. INQUEST will continue to work to ensure that such women are diverted from custody, as recommended by Baroness Corston’s report on Women with Particular Vulnerabilities in the Criminal Justice System in 2007.

Rebecca Smith’s family was represented by INQUEST Lawyers Group member Anna Thwaites from Hodge Jones & Allen Solicitors and counsel Fiona Paterson from 3 Serjeant’s Inn Chambers.

JURY FIND POLICE RESTRAINT KILLED MIKEY POWELL – DAMNING NARRATIVE VERDICTA form of verdict letting a jury give a longer explanation of what they think are the main or important issues. RETURNED AT INQUEST

The jury at the inquest into the controversial death in police custody in 2003 of Michael Lloyd Powell (known as Mikey) today returned a damning narrative verdictA form of verdict letting a jury give a longer explanation of what they think are the main or important issues. and found that the way that he was restrained resulted in his death from positional asphyxia (see below).

The inquest opened on 4 November 2009, over six years after his death in September 2003 and was heard at Sutton Coldfield Town Hall before HM Assistant Deputy CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Birmingham, Stephen Campbell.

The inquest heard that Mikey Powell died after being detained by West Midlands Police on 7 September 2003. He was 38, had three children and worked as a team leader in a local metal factory and was at the time living with his mother. He had been unwell, suffering a mental ill health episode and smashed a window at their home. His mother called the police for help, assuming they would take him to hospital.

When the officers arrived they did not help. After Mikey broke a window in their car the officers then drove away and then came back driving straight at him as fast as they could. They claimed they believed he had a gun, which he did not. During the inquest his family’s legal representatives challenged the officers as the family suspected that the officers had arrived at their home with preset fears about their area and their community.

Mikey was injured but survived the collision, and a family friend held him in a bear hug to try and prevent further trouble. However the police discharged more than four times the recommended amount of CS spray on both Mikey and his friend, and hit him with a police baton. Up to eight officers held him down on the ground for at least 16 minutes. Mikey was covered in blood.

No ambulance was called. A friend told the inquest that Mikey was put onto the floor of a police van “like a dog”. He was driven to Thornhill Road police station on the floor of the van, lying between the seats. The van parked in the station yard and Mikey was kept in it for three minutes before he was carried face down 26 metres into the “drunk cell.” It was only then officers noticed that he was not breathing. CPR was commenced and paramedics were called but to no avail.

The central issue at the inquest was whether Mikey had been transported face down on the floor of the police van, and whether this had led to him dying of positional asphyxia. The police assertion was that he had been placed on his side and had died from the combined effects of his exertion against restraint and the fact that he possessed the sickle cell trait.

Despite the injuries he had sustained prior to the police’s arrival and during the collision with the police car, and despite what should have been obvious concerns about his mental health, he was taken to a police station and not to a hospital. Police stations are still routinely used as “places of safety” for those with mental health difficulties.

Mikey’s sister Sieta Lambrias said:-

At long last the truth has come out – we have worked for six years to reach this point – the jury have found that the position the police put Mikey in killed him. Hopefully this will give some encouragement to other families who have lost someone in custody.

A chilling feature of this Inquest is that Mikey died in police hands. Officer after officer told the Court that they would do the same thing again. Most expressed no regret for Mikey’s death. We are alarmed about this, and think the community should be too. We will continue to fight to secure police accountability and stop future custody deaths.

Deborah Coles, co-director of INQUEST, said:

Mikey Powell was a vulnerable man in need of help and protection. Instead the police failed to treat him as a human being and subjected him to cruel, inhuman and degrading treatment using methods of restraint known to be dangerous. The Chief Constable of West Midlands police force needs to explain why six years after this most disturbing death his officers can give evidence that they would do nothing differently if presented with a similar situation today. Have the police learned nothing from previous high profile deaths and the recommendations arising from inquests and inquiries?

Jane Deighton, the family solicitor, said:

Tribute should be paid to Mikey’s remarkable family who, devastated by Mikey’s death, have fought for six distressing years to get to the truth and to hold those responsible to account.

INQUEST has long highlighted the disproportionate number of deaths of young black men in police custody or following police contact in circumstances involving medical neglect or the use of force. In 2004 the Parliamentary Joint Committee on Human Rights endorsed many of INQUEST’s concerns about restraint, stating:

The possibility that racial stereotyping has been a contributory factor in at least some deaths in custody resulting from restraint should be taken seriously.

Following the restraint-related death of Roger Sylvester in 1999, the Metropolitan Police conducted a review and published on 30 September 2004 the Restraint and Mental Health Report which made a number of significant recommendations.

In 2006 the IPCC published a substantial report which made recommendations for the benefit of policing, drawing their attention to the importance of reviewing progress made in relation to previous inquiry reports, in particular the Stephen Lawrence Inquiry. This report also made a number of specific recommendations for policing as a whole.

The majority (8:2) jury finding was based on answers to the following questions.

•  On the balance of probabilitiesThe standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others.The standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others. what was the injury or disease causing death?

Jury finding: Positional asphyxia

•  On the balance of probabilitiesThe standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others.The standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others., how did Mr. Powell die?

Jury finding: In the Police van prior to removal from it

•  If you have found that the cause of death was either Exertional sudden death in association with Sickle Cell trait or positional asphyxia, on the balance of probabilitiesThe standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others.The standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others. did he become more vulnerable to suffering death in the way you have found as a result of one or more of the following:-

Contact with a moving vehicle?

Being sprayed with CS gas?

Being struck by a Casco baton?

Being restrained on the ground in Wilton Street whilst suffering a psychosis?

Extreme exertion?

Jury finding: Yes

•  If you have found that the cause of death was positional asphyxia (question 1), on the balance of probabilitiesThe standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others.The standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others.:-

Was the initial position in the van on his front, his side or in between?

Jury finding: His side

Was he transported between Wilton Street and Thornhill Road Police Station on his front, his side or in between?

Jury finding: In between (his front and his side)

Was he on his front, his side or in between when PS Williams saw him at the Police Station?

Jury finding: On his front

A scan of the jury’s narrative verdictA form of verdict letting a jury give a longer explanation of what they think are the main or important issues. is available here.

The Powell family was represented at the inquest by INQUEST Lawyers Group members barristers Rajiv Menon of Garden Court Chambers and Henrietta Hill of Doughty Street Chambers, instructed by Jane Deighton of Deighton Guedalla Solicitors.

INQUEST WINS THE LONGFORD PRIZE 2009

INQUEST is delighted to have won the Longford Prize 2009 which will be presented tonight at the 2009 Longford Lecture taking place at 6.30pm at Church House , Westminster . INQUEST was nominated for the prize by Dexter Dias QC and Brenda Campbell , barristers from Garden Court Chambers, London.

The commendation reads:

We award the 2009 Longford Prize to INQUEST for its remarkable perseverance, personal commitment and courage in an area too often under-investigated by the public authorities, and especially for its support of the families of those who have taken their own lives while in the care of the state.

Deborah Coles, Co-Director of INQUEST, said about the award:

INQUEST’s small dedicated staff team is delighted to receive this award for our work in upholding the human rights of bereaved people. Despite our size and limited resources INQUEST’s unique combination of casework and policy has brought political, policy and judicial attention to the experience of bereaved people, the treatment and care of people in the custody of the state, the need for improvements to the investigation and inquest system, and for greater state and corporate accountability to prevent future deaths. We hope that this important award brings wider attention to and understanding of our important work.

The Longford Prize recognises the contribution of an individual, group or organisation working in the area of penal or social reform which has shown � outstanding qualities of humanity, courage, persistence and originality � and was established as part of a trust in memory of the late Labour cabinet minister and outspoken prison reformer Lord Longford.

It is awarded annually by a prize committee on behalf of the trustees and patrons of the Frank Longford Charitable Trust.  It is sponsored by The Independent newspaper and organised in association with the Prison Reform Trust.

Notes to editors:

About Lord Longford

Frank Longford said often during his life that he would like his epitaph to be ‘the outcasts’ outcast’.  It summed up a long career as a politician , writer and campaigner on social and prison policy which was all about standing up for the unpopular , the unloved , the underdog and those on the margins of society.

INQUEST TO OPEN INTO DEATH OF REBECCA SMITH IN BUCKLEY HALL PRISON

10am Thursday 3 December 2009
Sitting before HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Greater Manchester North, Simon Nelson, at Tops Business Centre, Hind Hill Street, Heywood, Lancashire OL10 1AQ

The inquest into the death of 40 year old Rebecca Smith opens on Thursday 3 December 2009.  Rebecca Smith was found dead in her cell with a plastic bag over her head at HMP Buckley Hall on 1 June 2004.  She had recently been transferred from HMP Eastwood Park .

Rebecca was a vulnerable prisoner with a history of self harm and suicide attempts.  She also suffered from mental health difficulties.  However, she had managed to live in the community with support from local psychiatric services until her imprisonment.

The family believes Rebecca should not have been imprisoned but instead sent to a secure psychiatric setting.  They hope the inquest will examine:

•  Why Rebecca was incarcerated rather than sent to a secure psychiatric unit;
•  Rebecca’s transfer from HMP Eastwood Park to HMP Buckley Hall, a distance of 200 miles from her home which prevented her family and Community Psychiatric Nurse of 10 years standing from visiting her;
•  The assessment and management of Rebecca’s risk of suicide and self-harm at HMP Buckley Hall including the closure of the suicide prevention document (F2052SH) shortly before her death;

Rebecca’s death once again raises questions about the imprisonment of vulnerable women and the ability of the Prison Service to keep women safe in its care. In 2004 there were twelve other self-inflicted deaths of women in prison.

INQUEST has worked closely with Rebecca Smith’s family both around the disturbing circumstances of her death and also on problems they have experienced with obtaining public fundingPublic means-tested financial assistance for representation during legal proceedings. It is not available for representation at most inquests. The Lord ChancellorThe cabinet minister in the government responsible for the effective running of the legal system in England and Wales. can grant it in exceptional cases. for their legal representation. The family have had to contribute to their legal costs, unlike the Prison Service who are represented at taxpayers’ expense. INQUEST and the family spoke about these concerns at a meeting of the parliamentary All Party Group on Penal Affairs in 2008.

Rebecca’s stepfather Peter G Smith said:

Rebecca had for many years serious mental health problems which were well documented. She did not like to travel out of her home town, had set routines and felt safe with familiar things around her. Her decline into depression and self-harm, we believe, was increased by her sudden move to HMP Buckley Hall, which took her from the local support of her family and her Mental Health Team.

Vulnerable and often fragile with her long history of mental health problems, which was not properly taken into account, we believe, when she was sentenced. If she was judged to be a danger to herself or others she should have been sent to a secure psychiatric unit.

Deborah Coles, co-director of INQUEST said:

It is vital that this death is subject to robust and thorough public scrutiny to establish whether it was preventable and to ensure that the Prison Service takes every action necessary to protect vulnerable women in its care.

Rebecca Smith’s family is being represented by INQUEST Lawyers Group member Anna Thwaites from Hodge Jones & Allen Solicitors and counsel Fiona Paterson from 3 Serjeant’s Inn Chambers.

JURY RETURNS VERDICT OF MISADVENTURE CONTRIBUTED TO BY NEGLECT AT INQUEST INTO DEATH IN MIDDLESBROUGH POLICE STATION OF MOYRA STOCKILL

Today the jury returned a verdict of misadventure contributed to by neglect at the inquest into the death of 61 year old Moyra Stockill in Middlesbrough police station on 10 December 2003. The inquest has heard damning evidence about the circumstances of Mrs Stockill’s death. She was found dead in a cell just hours after being conveyed from St Luke’s Psychiatric Hospital where she had been detained under section 3 of the Mental Health Act.

The jury heard that on 10 December 2003, Moyra Stockill was failed by everyone with whom she came into contact. The nurse in charge of the High Dependency Ward at St. Luke’s Psychiatric Hospital allowed her to be removed, unlawfully, to a police station. Senior medical staff and managers had ample opportunity to alert the police, by a simple telephone call of a few seconds duration, of the risks she posed to herself. Mrs Stockill had a habit of placing things in her mouth, including tissues, which could lead to a risk of choking. She always alerted staff by pointing after this had occurred.

The Custody Sergeant who accepted Mrs Stockill into detention failed to carry out a proper risk assessment or to cause proper enquiries to be made of the hospital. She failed to pass on what information was available to a colleague who saw Mrs Stockill pointing at her throat.

Mrs Stockill’s daughter, Clare Barker, said:

This inquest has clarified the catalogue of gross failings by NHS and police staff. The devastation they have caused me and my family cannot be put into words. I am appalled by the standard of care which my mother received. I hope no other family ever has to endure the same pain and suffering, which is ongoing.

Ruth Bundey , of Harrison Bundey, solicitor for the family said:

We are really grateful to the jury for their careful consideration, over such a long period, of these tragic events.

Deborah Coles, Co-Director, of INQUEST said:

This entirely preventable death of an extremely vulnerable woman must result in decisive action to address these gross failings so we can be assured that the same kind of tragedy will not be repeated.

Moyra Stockill’s family was represented at the inquest by INQUEST Lawyers Group member Ruth Bundey of Harrison Bundey Solicitors, Leeds.

FAMILY VINDICATED BY NEGLECT VERDICT AT SECOND INQUEST INTO DEATH OF PAUL CALVERT IN HMP PENTONVILLE

The jury at the inquest into the death of 40 year old Paul Calvert in HMP Pentonville in 2004 today returned a verdict of accidental death contributed to by neglect. The inquest was held before HM Assistant Deputy CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Inner North London, Gail Elliman, at St Pancras CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure.’s Court, London.

This was the second inquest in this case. Following the first inquest into Paul’s death in March 2007, his family brought a successful legal challenge in the High CourtThe highest civil court where cases may be heard for the first time. It also hears appeals and conducts judicial reviews, and supervises magistrates and crown courts.. The original verdict was quashed in April 2009 as the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. had unlawfully failed to allow the jury to find neglect, and directed them that they could not leave judgmental narrative conclusions.

Paul Calvert was found hanging in his cell in Pentonville on 24 October 2004, less than two days after being remanded into the prison. Paul was known to have problems with drugs and alcohol and had a history of self-harm and suicide attempts.

There was evidence at the inquest to show:

•  Prison officers failed to pay proper attention to the emergency cell alarms, taking part in games of backgammon instead of answering those alarms.
•  The audible alarm for the emergency cell bells had been disabled so that it made no noise for a period of up to 18 months.
•  There were no systems for maintenance of the alarm panels.
•  There was widespread practice of officers expecting prisoners to answer the emergency cell alarms.
•  Officers failed to take adequate steps to prevent misuse of the emergency alarm system.
•  The assessment of Paul’s risk of suicide was inadequate.

A number of other issues were raised, such as the system for the retrieval of past records, staffing and training.

The coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. directed the jury that they could leave a verdict of neglect if they thought one or a combination of several failings had a clear causative link to the death.

Deborah Coles, Co-Director of INQUEST, said:

This is a vindication of Paul’s family’s determination to obtain a just verdict despite the legal setbacks they encountered. The evidence heard about the neglect of basic health and safety at HMP Pentonville must result in all prisons examining how they discharge their duty of care, especially to vulnerable prisoners.

Paul Calvert’s family was represented at the inquest by INQUEST Lawyers Group members Valentina Santambrogio of Coninghams Solicitors and barrister Adam Straw of Tooks Chambers.

SYSTEMIC FAILINGS IN THE CARE AND SUPPORT OF VULNERABLE BOY CONTRIBUTED TO DEATH IN PRISON

A jury at an inquest into the death of 15 year old Liam McManus today returned a damning verdict finding that � systemic failings� in both the prison and the community contributed to his death. These failings meant that an accurate picture of Liam was never established by the prison resulting in him never receiving the right level of support.

Liam was a troubled child who had suffered significant loss and trauma in his short life. He had been taken into care as a young child and had lived with his aunt and uncle since he was seven. He had a history of self-harm and his vulnerability was well known to both Social Services and the Young Offenders Service. Liam had also been involved with a mental health worker for over two years.

Liam had been recalled to custody for breaching the terms of his licence. He had only 23 days left to serve before release when he was found hanging from a bed sheet tied to the window of his single cell on 29 November 2007. Liam was the thirtieth child to die in state custody since 1990. This is the second inquest in less than two years into the death of a child in HMYOI Lancaster Farms.

Throughout the seven week inquest the jury heard evidence of failings by many agencies involved in Liam’s care. The jury recognised that the following factors contributed to his death:

•  A failure by the Young Offenders Service to ensure that �protective factors’ of visits from Liam’s YOS worker, mental health worker and family would be in place during his sentence and subsequent failure by all to register when they did not take place.

•  A target driven and top-down approach by the Youth Justice Board rather than a caring culture that addressed the individual needs of vulnerable children.

•  A decision by Social Services to introduce Liam to his birth mother who lived a chaotic lifestyle, yet close his file shortly afterwards due to there being insufficient staff in the team.

•  A failure by prison staff to recognise Liam’s risk level and needs. The jury noted that this included a practice by the officers of accepting Liam’s response to questions and not referring to important documentation which provided critical information about him.

•  A practice by the prison of keeping these documents in a room which was completely separate to the wings, resulting in wing officers not having immediate access to the information.

•  An inadequate induction process.

•  An ineffective interpretation of the Personal Officer policy which should have meant that Liam was given the continuing support of one officer.

•  Incomplete and inconsistent training of officers.

•  A failure by all agencies to have the same assessment criteria for vulnerability and therefore communicate effectively.

•  A failure to hold a DTO planning meeting despite guidance that this should take place within ten days. This would have given those working with Liam an opportunity to share their knowledge of him and assist prison staff in supporting him appropriately.

•  Transferring Liam to a new wing on a night when there was reduced staff levels, meaning that other prisoners had no association during the day and were restless. This lead to heightened shouting and bullying through the windows on the night of his death, including calls for him to �string up’ which the jury recognised would have been frightening and intimidating.

The jury found:

�whilst some of the defects and factors identified may appear to have had a minimal impact, collectively they contributed to systemic failings in the care and support of Liam that contributed to the actions of Liam McManus that contributed to his death.

In addition to the findings of the jury the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. reported that there were serious inadequacies in the performance of Social Services who had lost significant documents and had closed Liam’s file just before he was due to go into custody without apparent review on the assumption that Liam would be safeguarded by the prison. He also recommended that the YOS ensured that important information about young people was sent to Young Offender Institutions in a format that was readily accessible to the officers. The coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. indicated that he would be writing to the Youth Justice Board to ensure that his recommendations would be implemented.

Liam’s aunt and uncle commented:

It seems to us that Liam’s serious vulnerability was never picked up by anyone in HMYOI Lancaster Farm and we are happy that the jury have recognised this. We hope in future that prison officers will take that bit of time to read all the information that comes into prison so that vulnerable children are given the care and consideration that they need.

We also hope that those dealing with vulnerable children take on board the evidence heard at this inquest, the jury findings and recommendations of the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. so that deaths like Liam’s can be avoided in the future The most important thing now is that no other family should have to go through what we have been through in the last two years.

Deborah Coles, Co-Director of INQUEST, said:

Liam McManus was an extremely vulnerable child placed in an environment that did not have the necessary safeguards in place to keep him safe, despite his known vulnerability, by all the professionals involved with him. Yet again an inquest jury have found systemic failings resulting in a child’s death and yet despite the deaths of thirty children since 1990 lessons are not learned. The ongoing systemic failings exposed by these child deaths in custody should be looked at as part of a public inquiry into the treatment of children in conflict with the law.

Mark Scott of Bhatt Murphy, solicitors for Liam’s aunt and uncle, made the following statement:

This case raises fundamental questions about how the state treats vulnerable children who offend. It is time for there to be a public inquiry to ensure that lessons are learned.

Liam McManus’ aunt and uncle were represented at the inquest by INQUEST Lawyers Group members Mark Scott of Bhatt Murphy Solicitors and Colin Hutchinson of Garden Court Chambers.

Notes to editors:

The full text of the jury’s six page narrative verdictA form of verdict letting a jury give a longer explanation of what they think are the main or important issues. can be downloaded here (PDF, 276KB)

DAMNING JURY VERDICT FINDS SYSTEMIC FAILURES LED TO DEATH OF VULNERABLE PRISONER

The jury at the inquest into the death of a vulnerable prisoner has found that a series of system failings led to his death.

Michael Taylor was found hanging from the window bars of his cell by torn bed sheets in HMP Bedford on 17 April 2007 aged 39. He was a vulnerable prisoner suffering from significant mental health problems and long-term opiate dependency. Michael had been receiving methadone maintenance treatment in the community to stabilise his drug addiction. On 13 March 2007 he was remanded in custody and sent to HMP Wormwood Scrubs. His methadone maintenance prescription was continued by the healthcare staff there and he remained stable. Following a court appearance on 12 April 2007, Michael was unable to return to Wormwood Scrubs because of overcrowding. Under a policy somewhat ironically called Operation Safeguard he was taken to a police station where he was kept overnight. The following day he was not returned to Wormwood Scrubs as he should have been, but instead was sent to HMP Bedford.

Michael’s vulnerability and his treatment regime meant that he should never have been included in Operation Safeguard. He should certainly not have been sent to HMP Bedford where there were well-recognised problems in healthcare provision, particularly with regard to the treatment and care of substance users. A Prison Service Order had mandated that from October 2001 prisons were to have maintenance treatment regimes for those with opiate misuse. Despite this, five years later in 2006 an HM Prisons Inspectorate report concerning HMP Bedford found that �clinical management of substance users was poor or nonexistent�men who arrived on a maintenance prescription of methadone were not able to continue with it.� The Inspectorate recommended that matters should be �urgently reviewed� so that appropriate treatment could be given.

In February 2007, two months before Michael was sent to HMP Bedford, the prison medical officer Dr Croft wrote in desperation to Patricia Hewitt MP, the then Secretary of State for health, urging change. Still nothing happened, and so when Michael arrived on 13 April 2007 he was forcibly taken off his prescribed methadone maintenance treatment and subjected to detoxification. This �cold turkey� treatment was later described by Dr Croft in a letter to the Primary Care Trust as �dangerous, cruel and outmoded�. Four days later on 17 April 2007 Michael was found hanging in his cell.

Within a matter of weeks, without requiring any major refurbishment, additional resources or funding, HMP Bedford managed to put in place a system to prescribe methadone to those in Michael’s situation.

In chilling evidence on the last full day of the inquest a witness from the Population Management Unit (PMU) warned that with the current prison population at 84,000 and rising, Operation Safeguard could be re activated at any time. When asked if the safeguards in relation to vulnerable prisoners would be adhered to any better this time he admitted that even if a Prisoner Escort Record (PER) did show some medical need, whether for drug treatment or cancer, it would in the last resort be ignored. What ruled Operation Safeguard was �necessity.� Prisoners could be sent wherever there was an empty cell regardless of medical circumstances.

At the conclusion of the inquest on Friday 6 November the jury in their narrative verdictA form of verdict letting a jury give a longer explanation of what they think are the main or important issues. found that Michael Taylor did not intend to die and that the following factors contributed to his death:

•  Inadequate information provided on the Prisoner Escort Form issued by Wormwood Scrubs to Harrow Magistrates Court, firstly in the deletion and statement of no known medical risk and that although it is stated that Mr Taylor was on methadone maintenance this information is not prominent.
•  As a prisoner on a methadone maintenance regime Mr Taylor should have been excluded from Operation Safeguard as set out in Prison Service Instruction 30/2006.
•  Having been locked out under Operation Safeguard and sent to Ampthill Police Station, Michael Taylor should have been returned to a prison with a methadone maintenance programme in place.
•  Having been placed at HMP Bedford the treatment regime available was inadequate at that time.

The coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. has indicated that he will be considering matters for his rule 43 report designed to alert the relevant authorities to action that needs to be taken to prevent further deaths.

The Taylor family said:

Michael died as a result of a government failure to follow expert advice on the medical treatment of drug misusers. Prison overcrowding also led to a macabre game of �prison chess� that ignores individual needs. Most disturbing of all was the evidence that we heard at the inquest that with the prison population rising the same thing could happen again.

Mark Scott of Bhatt Murphy Solicitors, who represented the family of Michael Taylor, commented:

Michael Taylor was a prisoner but he still had an entitlement to reasonable healthcare; the inquest heard very disturbing evidence of failures to provide basic medical care to prisoners which the jury found led to Michael Taylor’s tragic death.

Deborah Coles, Co-Director of INQUEST, said:

Both the Prison Service and the PCT tried to restrict the scope of this inquest and prevent proper public scrutiny of the systemic failures that led to this death. In failing to act on the recommendation of the Prisons Inspectorate a man died. The chaos and constant movement of prisoners arising from overcrowding means that there is the ever present risk of suicide and self-harm. INQUEST will raise these concerns with Ministers as a matter of urgency.

SECOND INQUEST INTO DEATH OF VULNERABLE PRISONER IN HMP PENTONVILLE BEGINS

10am Monday 9 November 2009
Sitting before HM Assistant Deputy CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Inner North London, Ms Gail Elliman, at
St Pancras CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure.’s Court, Camley Street, London, NW1 0WP

The second inquest into the death of 40 year old Paul Calvert opens on Monday 9 November 2009, and is expected to last for five days (the court will be sitting on 9, 11, 12, 13 and 16 November 2009). Following the first inquest into Paul’s death in March 2007, his family brought a successful legal challenge to have the verdict quashed. In April 2009 the High CourtThe highest civil court where cases may be heard for the first time. It also hears appeals and conducts judicial reviews, and supervises magistrates and crown courts. ordered that a new inquest be held on the basis that the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. had significantly misdirected the jury in terms of the verdict they could return.

Paul Calvert was found hanging in his cell at HMP Pentonville on 24 October 2004, less than two days after being remanded into the prison. Paul was a vulnerable prisoner who was known to have problems with drugs and alcohol and had a history of self-harm and suicide attempts. His family has serious concerns about whether staff deliberately interfered with the cell bell system which enables prisoners to trigger an audible alarm and a light outside their cell . Paul’s body was only discovered a significant time after his death by a cleaner who was responding to his cell bell light, indicating that Paul may have activated it before his death.

The family hopes the inquest will examine:

• The assessment and management of Paul’s risk of suicide and self-harm;
• How his drug detoxification was addressed and if he received the appropriate treatment and medication;
• whether the audible cell bells had been deliberately disabled;
• and whether any delay in responding to Paul’s cell bell contributed to his death.

Paul Calvert’s family is being represented by INQUEST Lawyers Group members Valentina Santambrogio of Coninghams Solicitors and barrister Adam Straw of Tooks Chambers.

Notes to editors:

In recent months Pentonville prison has come under harsh scrutiny concerning transfers of vulnerable prisoners between HMPs Pentonville and Wandsworth during their inspections by HM Chief Inspector of Prisons (report published October 2009). In June 2006 the Chief Inspector of Prisons published a highly critical report of the prison and 14 staff were suspended on corruption allegations in August 2006.

INQUEST INTO THE DEATH IN WEST MIDLANDS POLICE CUSTODY OF MIKEY POWELL TO OPEN AFTER A SIX YEAR WAIT

10am Wednesday 4 November 2009
before HM Assistant Deputy CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Birmingham, Stephen Campbell,
sitting at Sutton Coldfield Town Hall , Upper Clifton Road , Sutton Coldfield, Birmingham , B73 6AB (close to Sutton Coldfield railway station)

The inquest into the controversial death in police custody of Michael Lloyd Powell (known as Mikey) opens on Wednesday 4 November 2009, and is expected to last for six weeks. Mikey was a cousin of the renowned poet and writer, Benjamin Zephaniah, a patron of INQUEST.

Mikey Powell was a fit and healthy 38 year old black man and a father of three young children. He had suffered several short episodes of mental illness in the past from which he had recovered. One of these episodes occurred on 7 September 2003. Police had previously dealt appropriately with Mikey and were called again on this occasion by concerned family members. During the incident in which Mikey was detained outside his mother’s house in the Lozells area of Birmingham, officers drove a police car at Mikey, hitting him, then used CS spray and a baton while restraining him. Even though Mikey was injured, rather than taking him to a hospital the officers drove him instead to Thornhill Road Police Station where he died at some point during his detention.

It has taken six years for Mikey’s case to reach a full public inquest.

In 2006, there was a three-month Crown Court trial of ten West Midlands Police officers, eight of whom faced charges of misconduct in public office and two of charges of dangerous driving. All were subsequently acquitted. The verdict was met with dismay by the family and their supporters.

After arguing successfully for a jury inquest into Mikey’s death, the inquest was further adjourned from March 2009 because of the family’s legal challenge of the failure of the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. and the investigating force (Northamptonshire Police) to provide the family with access to 4,000 documents relating to the police investigation into Mikey’s death. The High CourtThe highest civil court where cases may be heard for the first time. It also hears appeals and conducts judicial reviews, and supervises magistrates and crown courts. ordered that the family be granted access to these and the new inquest date was set.

Tippa Napthali, Mikey Powell’s cousin said:

Such deaths in custody like Mikey’s frequently fade from public interest while the grief and anguish of affected families can continue for many years. We have only ever wanted answers to the many questions as yet unanswered, and hope that this inquest will mark an important stage in our continued quest for truth and accountability for Mikey’s death.

Deborah Coles, Co-Director of INQUEST said:

The truly shocking circumstances of this death will finally be subjected to proper public scrutiny. It is profoundly disturbing that a black man in need of medical treatment and care died following contact with the police and the issues his death raises about the use of force and the care of vulnerable detainees in police stations are as pertinent today as they were six years ago.

The Powell family will be represented at the inquest by INQUEST Lawyers Group members barristers Rajiv Menon of Garden Court Chambers and Henrietta Hill of Doughty Street Chambers, instructed by Jane Deighton of Deighton Guedalla Solicitors.

Notes to editors:

The Friends of Mikey Powell Campaign for Justice was established his family and has received considerable support both nationally and from the local community. The campaign has established a website for the duration of the inquest.

HIGHLY CRITICAL EVIDENCE ABOUT FAILINGS IN MEDICAL CARE HEARD AT INQUEST INTO DEATH OF RORY KINLOCH AT HMP BRIXTON

Rory Kinloch was found dead in his cell at HMP Brixton in the early hours of 15 June 2006, a week after arriving at the prison in relation to a minor matter. He died of an especially severe pneumonia.

Rory’s family waited more than three years for the inquest into his death to conclude. At the inquest at Southwark CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure.’s Court which finished yesterday they heard damning evidence of sub-standard medical care, a shambolic prison healthcare service and numerous failed opportunities to identify that Rory was seriously ill. The family were particularly distressed to hear expert evidence that Rory could have been saved right up until the night of his death.

The inquest heard that crucial information about Rory’s medical history was said to have been mislaid at the prison and so was unavailable to those assessing him on arrival. This was the fourth death in six years at the prison where similar failures were identified.

The first GP who saw him admitted failing to provide basic medical care to Rory. This doctor cited scenes of hopeless chaos in the area he was supposed to examine patients as a contributory factor; he in fact resigned in protest some time later and told the inquest that he would �rather work in the Third World than for the Prison Service.� The prison knowingly continued to operate this system even after medical staff had complained that it was unsafe.

The next GP to have contact with Rory also conceded that he had failed to provide basic medical care to Rory. He prescribed methadone without seeing Rory or his records, on the recommendation of an untrained nurse. There was a dispute between them as to whether the nurse had ever provided him with the history she had taken from Rory, in circumstances where the doctor explained that had if she had done he would have �actively intervened� in his care.

Rory was further failed by nursing staff at the prison; none of those who saw him had received training in their specialist role. At least two nurses who saw Rory failed to spot that he was seriously ill in the day(s) leading up to his death, although expert evidence suggested it was highly unlikely that he could have appeared well at that time, and indeed other witnesses reported that he seemed very unwell. The inquest also heard that these nurses routinely see up to 80 prisoners in two hours, and the family were aware from an investigation by the Prisons and Probation Ombudsman that nurses had been observed spending just moments over their individual assessments of prisoners.

The Kinloch family hope that the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. will make robust recommendations to the Prison Service about improving the quality of medical care at HMP Brixton, but remain concerned that the system there will only ever be as good as the quality and the will of the medical staff who work within it.

Rory Kinloch’s family was represented at the inquest by INQUEST Lawyers Group members barrister Paula Sparks of Doughty Street Chambers, instructed by Carolynn Gallwey of Bhatt Murphy Solicitors.

INQUEST TO OPEN INTO THE DEATH OF VULNERABLE PRISONER RORY KINLOCH AT HMP BRIXTON

10.00am Tuesday 20 October 2009
Sitting before HM Deputy CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for London (Inner South), Andrew Walker
HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure.’s Court, Tennis Street, London SE1 1YD

Rory Kinloch was found dead in his cell in HMP Brixton in the early hours of 15 June 2006, aged 38. His cellmate had become aware that Rory was not breathing and raised the alarm. The cause of death was identified as pneumonia.

Rory, who had been remanded to the prison for failing to answer a warrant, suffered from chronic asthma and was on a Subutex detoxification programme in the community. On arrival at Brixton a week before his death, he was prescribed a methadone detoxification programme. Despite his reported history of respiratory illness Rory’s chest was not examined by a doctor and there was no follow up when he later missed a doctor’s appointment. Prison staff, including the substance misuse nurses who administered his methadone every day, claimed not to have noticed that he appeared unwell in the days leading up to his death. This is contradicted by reports from his family and from other prisoners; for example, on the day before he died a prisoner noted that he had seen him slumped on the floor by the medication dispensing hatch.

The inquest into Rory’s death has been subject to serious delay which has caused great distress to his family and frustrated the opportunity to learn lessons. Rory’s mother Madeleine commented:

At the beginning we were told we’d have the inquest in six months, which then seemed pretty awful, but we have had to wait three and a half years which has been unbearable for the family.

Rory’s family hope that the inquest will answer a number of serious concerns about Rory’s death and his treatment and care during his short time in HMP Brixton:

• Why Rory’s chest was not examined, even though he had a history of serious asthma and had told staff he had recently had pneumonia.
• The appropriateness of prescribing methadone to Rory, given his history of respiratory problems.
• The adequacy of the health care provided to Rory in prison and whether any failings in his treatment and care contributed to his death.

Rory Kinloch’s family is represented by INQUEST Lawyers Group members barrister Paula Sparks of Doughty Street Chambers, instructed by Carolynn Gallwey of Bhatt Murphy Solicitors.

INQUEST INTO DEATH OF EXTREMELY VULNERABLE WOMAN AT MIDDLESBROUGH POLICE STATION

10am Monday 19 October 2009
Before HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Teesside, Michael Sheffield
Sitting at Coroners Court, Corporation Road, Middlesbrough TS1 2DA

The inquest into the death of 61 year old Moyra Stockill opens on Monday 19 October and is expected to last for up to six weeks. Mrs Stockill was found dead in a cell at Middlesbrough police station on 10 December 2003 just hours after being conveyed from St Luke’s psychiatric hospital, where she had been detained under section 3 of the Mental Health Act.

As part of her illness, Mrs Stockill would frequently self-harm by placing objects in her mouth. She would then alert nursing staff by pointing at her throat so that the objects would be removed. On the morning of 10 December 2003 Mrs Stockill had self-harmed on nine separate occasions, eight of which involved putting objects in her mouth. Following an alleged violent incident later that morning, the police were called. Before the police arrived a male staff member impersonated a police officer in an attempt to calm her down. Following her arrest and transfer to the police station, Mrs Stockill was placed in a cell and was later seen banging on the cell door and pointing at her throat. Custody officers did not respond and she was found dead a short time later having choked.

Mrs Stockill’s daughter, Clare Barker, who has waited six years for her mother’s inquest to take place, hopes that this inquest will examine her serious concerns, including:

• Whether Mrs Stockill should ever have been removed from the hospital premises without the authorisation of her consultant, as required under s.3 MHA.
• What effect the police impersonation might have had on Mrs Stockill.
• What information about the risks Mrs Stockill posed to herself was passed to the police and was that information sufficient.
• Whether Mrs Stockill’s care and observations at the police station were adequate.
• Why custody staff did not respond to Mrs Stockill’s banging on the cell and gesturing.

Mrs Stockill’s daughter, Clare, said:

After six long years I hope that we at last find out the truth and that the outcome of the inquest has a real effect on psychiatric and custodial care in the future.

Moyra Stockill’s family is represented by INQUEST Lawyers Group member solicitor Ruth Bundey of Harrison Bundey Solicitors, Leeds.

INQUEST VERDICT INTO THE DEATH OF ALEKSEY BARANOVSKY AT HMP RYE HILL

The jury at the inquest into the death of 33 year-old Aleksey Baranovsky today reached its verdict by slamming the appalling care and conditions that led to his death at Rye Hill prison. They concluded that his death was caused by anaemia due to chronic blood loss and also by under nutrition. However, they listed seven additional failings by the prison that caused or contributed to the death.

Jocelyn Cockburn, partner at law firm Hodge Jones & Allen who is acting for Mr Baranovsky’s family, expressed relief at the verdict. She commented:

In light of the evidence that emerged throughout this long inquest, Mr Baranovsky’s family is relieved that the jury reached the correct verdict in highlighting the dreadful conditions that led to his untimely death.  Let us not forget that only a year before Aleksey’s death, HMP Rye Hill was heavily criticised by HM Chief Inspector of Prisons who stated that the prison was an unsafe and an unstable environment, both for prisoners and staff; and that Mr Baranovsky’s death was one of three controversial deaths at the privately-run prison in a fifteen month time period.

We hope that lessons have been learnt from this long and painful inquest to ensure that the appalling level of care that Mr Baranovsky received is not inflicted upon other prisoners at Rye Hill or any other prison.

The coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. added his own swingeing criticism after the jury had handed down the verdict and said that in his view Aleksey’s treatment was � appalling and unacceptable in any modern society and shameful .�

Deborah Coles, Co-Director of INQUEST, which arranged the family’s legal representation, comments:

The importance of family legal representation at inquests and robust public scrutiny of prison deaths is demonstrated by the strong jury narrative and coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure.’s comments in this case.   Government ministers must be held accountable for their failures to ensure action was taken on the clear warnings about Rye Hill prison and the fact that prisoner’s lives were at risk.  They need to inform the public about how those responsible for this death have been held to account. The three deaths that have occurred in this prison raise serious questions about the appropriateness of the privatisation of prisons and prison health care.

Jocelyn Cockburn says: �In light of these findings we invite the prison to make a formal apology to the family, something which has not been forthcoming over the last three years.�

The inquest verdict recorded the following failures at Rye Hill:

� Aleksey Baranovsky died in his cell in the healthcare unit of Rye Hill prison after a prolonged period of deliberate self harm by way of cutting himself and regularly refusing food. This was during the period from 22 April 2006 until 10 June 2006. During this time Mr Baranovsky repeatedly refused medical attention.

We find that the following factors caused or contributed to his death:

•  A failure to carry out an adequate mental health assessment

•  A failure to carry out a full and adequate health assessment on admission or at any time that he was at Rye Hill prison

•  A failure to assess healthcare needs and draw up a detailed care plan regarding Mr Baranovsky’s long term care

•  Inadequate systems and processes regarding those verbal and written communications between healthcare prison security and prison management leading to insufficient management of Mr Baranovsky’s well being

•  Insufficient training and knowledge of some prison policies resulting in poor implementation of key safeguards

•  Failure to carry out and follow agreed actions regarding care

•  Inadequate interventions at time of greatest healthcare need. �

INQUEST RESUMES INTO DEATH OF 15 YEAR OLD LIAM MCMANUS IN HMYOI LANCASTER FARMS

11.00am Tuesday 22 September 2009
Before HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Preston, North and South West Lancashire District, Dr James Adeley,
Sitting at Lancaster Shire Hall, Castle Parade, Lancaster LA1 1YJ

The inquest into the death of 15 year old Liam McManus resumes on 22 September 2009, having being adjourned for legal discussions last week, and is expected to last for seven weeks. The inquest will hear evidence on the first day from Liam’s uncle.

Liam’s family is represented by INQUEST Lawyers Group members Mark Scott of Bhatt Murphy Solicitors and barrister Colin Hutchinson of Garden Court Chambers.

LIAM MCMANUS INQUEST ADJOURNED – NEW DATE LATER THIS WEEK OR NEXT TO BE CONFIRMED

The inquest into the death of Liam McManus which was scheduled to open on Tuesday 15 September 2009 has been adjourned for legal discussions. Evidence is now expected to commence on Friday 18 or Monday 21 September 2009.

A further press release will be issued later this week when the rescheduled date has been confirmed.

INQUEST OPENS INTO DEATH OF 15 YEAR OLD BOY FOUND HANGING AT HMYOI LANCASTER FARMS

10.00am Tuesday 15 September 2009
Before HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Preston, North and South West Lancashire District, Dr James Adeley,
Sitting at Lancaster Shire Hall, Castle Parade, Lancaster , LA1 1YJ

The inquest into the death of 15 year old Liam McManus opens on 15 September 2009. It is expected to last for seven weeks. Liam was a troubled child who had experienced a significant amount of loss and trauma in his short life.

Liam was found hanging from a bed sheet tied to the window bars in a single cell on normal location in HMYOI Lancaster Farms on 29 November 2007. He had been recalled to custody for breaching the terms of his licence and was to serve the remaining 1 month and 14 days of his Detention and Training Order in prison.

Liam was the thirtieth child and the fifth 15 year old to die in state custody since 1990. At the time of Liam’s death, the inquest into the death of 16 year old Gareth Price – who also hanged himself at Lancaster Farms – was taking place; that inquest raised significant concerns about the treatment and care of vulnerable children in prisons.

Liam’s family hope that the inquest will answer a number of serious concerns about Liam’s death, including:

• The decision to recall Liam to custody;
• the decision to place Liam in a Youth Offender Institution rather than a Secure Children’s Home or Secure Training Centre, given his age and known vulnerability;
• whether Liam’s risk of self harm was properly assessed and managed in Lancaster Farms;
• the safety of the accommodation at Lancaster Farms;
• the regime at Lancaster Farms, in particular the opportunities he had to engage in meaningful activity and with outside agencies;
• whether Liam was given proper emergency care when he was found by prison staff; and
• what role, if any, bullying by other inmates played in his death.

Deborah Coles, Co-Director of INQUEST, said:

The death of a child while in the �care’ of the state is an important matter of public concern and it is vital that this death is properly scrutinised. This is a tragic case which highlights our concerns about the use of imprisonment for vulnerable children.

Liam’s family is represented by INQUEST Lawyers Group members Mark Scott of Bhatt Murphy Solicitors and barrister Colin Hutchinson of Garden Court Chambers.

INQUEST WELCOMES PARLIAMENTARY COMMITTEE’S RECOMMENDATION THAT THE CASS REPORT BE PUBLISHED IN FULL

Today the parliamentary Joint Committee on Human Rights recommended:

�that the Metropolitan Police publish the Cass report into the death of Blair Peach without redaction, to help bring some closure to the family and friends of Mr Peach and to initiate a debate about how the policing of protest has improved and can improve still further .

INQUEST welcomes the committee’s recommendation made in its report Demonstrating Respect for Rights?, published today.

Deborah Coles, Co-Director of INQUEST, said:

That the parliamentary Joint Committee on Human Rights have added their voice to the campaign for full and unfettered disclosure of the Cass report is highly significant. Given that Blair Peach died 30 years ago there is no justifiable reason for continued secrecy which is undemocratic and continues to undermine family and public confidence in the Metropolitan Police Service.

INQUEST is working with Blair Peach’s former partner Celia Stubbs and his brother Philip Peach.

JURY FIND RESTRAINT AND NEGLECT CAUSED DEATH OF BELMARSH PRISONER GODFREY MOYO

Sitting before HM Deputy CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for London (Inner South), Andrew Walker
HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure.’s Court, Tennis Street , London SE1 1YD

The inquest into the death of 25 year old Godfrey Moyo whilst on remand at HMP Belmarsh concluded today with the jury deciding that the medical cause of his death was

(a) positional asphyxia with left ventricular failure following restraint and (b) epilepsy.

In their damning narrative verdictA form of verdict letting a jury give a longer explanation of what they think are the main or important issues. the jury found that:

�On 3 January 2005 at approximately 2.50am at Belmarsh prison Mr Godfrey Moyo suffered an epileptic fit in his cell. Prison officers were alerted and together with a nurse were dispatched to the cell. Upon regaining consciousness, Mr Moyo experienced post-ictal behavioural disturbance and attacked a cellmate.

Prison officers entered the cell to bring Mr Moyo under control. A vigorous struggle ensued between Mr Moyo and five prison officers in which three officers sustained injuries.

Prison officers brought Mr Moyo to the floor on the landing outside the cell. Full control was achieved immediately. Mr Moyo was then restrained in the face down prone position for approximately 30 minutes.

During this time Mr Moyo suffered at least two further fits, followed by periods of unconsciousness in which his breathing was restricted as a result of his position.

Mr Moyo began to suffer from the effects of positional asphyxia. The first nurse on the scene failed to adequately monitor Mr Moyo’s condition during the restraint, which contributed to his death by neglect.

The prison officers also failed to recognise the signs of distress being shown by Mr Moyo during the restraint, as highlighted by their control and restraint training. At no time during the restraint by any persons present was an attempt made to move Mr Moyo off his front as per the control and restraint guidelines or place him in the recovery position during periods of unconsciousness.

Upon arrival of the second nurse, Mr Moyo was lifted from the prone position and carried to the health care centre. Throughout the move Mr Moyo was unconscious. Upon arrival to the health care centre at approximately 3.30am Mr Moyo was placed in the Intensive Care Cell in a kneeling position against the cell bed with his upper chest and head resting on the mattress. His head was resting on the mattress while in a kneeling position Mr Moyo remained under restraint.

A doctor prescribed a 2ml intra muscular dosage of Lorazepam by telephone. The second nurse administered the drug to Mr Moyo and exited the cell followed by the prison officers.

Mr Moyo died in the intensive care cell between 3.30 to 3.50am. The second nurse failed to adequately monitor Mr Moyo’s condition while he was in the intensive care cell, which directly contributed to Mr Moyo’s death by neglect. The first nurse raised concerns on her ability to monitor Mr Moyo’s condition while he was in the ICS to the second nurse. However these concerns were not acted on.

In addition insufficient communication between the two nurses prevented the seriousness of Mr Moyo’s condition being properly recognised, which meant that an ambulance was not called until too late, approximately an hour after Mr Moyo was placed in the intensive care cell.

The second nurse and prison officers re-entered the cell and discovered that Mr Moyo was not breathing.

CPR was commenced and an ambulance was called at 4.45 am. However resuscitation by staff at the prison, paramedics and hospital staff failed to revive Mr Moyo.�

Lomaculo Moyo, Godfrey’s sister, commented:

I have waited four and half years to hear what happened on 3 January 2005 in HMP Belmarsh. I have been brave enough to sit here to hear painful evidence of the appalling and inhumane way that my brother was treated by prison staff including nursing staff at HM Belmarsh.

The jury’s verdict reflects the shocking evidence of what happened on 3 January 2005.

Godfrey was failed by a system that was meant to protect him � if staff had been doing their job properly his death could have been avoided.

Deborah Coles, Co-director of INQUEST said:

Dangerous restraint methods and neglect caused Mr Moyo’s death. He was treated as a discipline and control problem rather than a human being in urgent need of medical treatment and care. The responsibility for his death rests with the Prison Service and we await their response to this damning verdict. INQUEST will be raising the serious issues in this case at a policy and parliamentary level.

When explaining why he would make a detailed report (under rule 43 of the Coroners Rules 1984) in due course to ministers about how similar deaths can be avoided in future, HM Deputy CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. said “where do I start?” and said he was concerned by the “complete lack of understanding of epilepsy among the staff including medical staff”� and “this seems to be a system that was fundamentally flawed.”

The evidence that the jury heard included the following:

• Despite the fact that Godfrey Moyo suffered seizures twice in HMP Belmarsh (July and October 2004), there was no adequate care plan in place and no risk assessment, particularly as regards post-ictal violence.
• On the evidence of one nurse, the two nurses did not speak to each other at all; from the time that the nurses were together on the landing outside Godfrey Moyo’s cell to when he was found dead in the cell in the Health Care Centre (i.e. a period of approximately 1.5 hours).
• One officer’s evidence was that Godfrey Moyo was restrained until unconscious.
• All the officers gave clear evidence that they left Godfrey Moyo in the prone position for longer than absolutely necessary.
• Godfrey Moyo had unexplained injuries to his neck which one pathologistThe medically-qualified practitioner who carries out a post–mortem examination. gave evidence were caused beyond reasonable doubtThe highest standard of proof required in legal hearings and needed for returning inquest verdicts of unlawful killing or suicide.The highest standard of proof required in legal hearings and needed for returning inquest verdicts of unlawful killing or suicide. by compression of his neck.
• The recovery position is the only safe position in which to place an unconscious person.
• That staff failed to use a trolley although it was available.
• Some of the officers who gave evidence said that they were unable to recognise trigger signs of positional asphyxia notwithstanding their training.
• That Godfrey Moyo was not given the most appropriate medicine for his condition (rectal diazepam), despite the pharmacist finding it the following day.

Godfrey Moyo’s family is represented by INQUEST Lawyers Group members, barrister Leslie Thomas of Garden Court Chambers instructed by Daniel Machover of Hickman and Rose Solicitors.

Notes to editors:

INQUEST has monitored a disproportionate number of deaths following restraint involving people from Black and Minority Ethnic communities This is the first restraint related death in prison since the deaths of three black men in prison in 1995, Dennis Stevens in Dartmoor prison on 11th October 1995, Kenneth Severin in HMP Belmarsh on 16 November 1995 and Alton Manning on 8 December 1995.

JURY RETURNS VERDICT AT INQUEST INTO THE RESTRAINT-RELATED DEATH OF FAISAL AL-ANI IN SOUTHEND

Sitting before HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Southern and South East Essex , Dr Peter Dean
Southend Civic Centre, Victoria Avenue , Southend, SS2 6ER

A jury yesterday returned a narrative verdictA form of verdict letting a jury give a longer explanation of what they think are the main or important issues. into the death in police custody on 31 July 2005 of Faisal Al-Ani. The jury found that Mr Al-Ani, who was suffering from an acute psychotic illness and cardiac dysrythmia at the time of his death, died following �prolonged energetic restraint.� Although the jury concluded that the force used was appropriate, even though some of the methods were described by a police trainer as �in contravention of all guidance,� they also found that insufficient consideration had been given to his physical health.

Mr Al-Ani’s family are extremely disappointed by the outcome given the evidence that was heard. The inquest was shown shocking CCTV images of the restraint, including Mr Al-Ani being dragged to the ground and an officer appearing to kneel on his back and neck. Police officers also gave evidence that they had punched him whilst he was in the police car which took him to the station where he was left handcuffed and face down before an ambulance was called. He had suffered a cardiac arrest and could not be revive d. The family are now left with many unanswered questions about what happened in the police car and at the station. Mr Al-Ani’s family have been concerned throughout about the quality of the IPCC investigation which they fear has impacted negatively on the inquest’s conclusions.

Carolynn Gallwey, solicitor for the sons of Faisal Al-Ani said:

This inquest has raised disturbing questions about policing priorities and the ability of Essex police officers to identify and deal appropriately with mentally ill individuals. One of the police witnesses told the jury that Mr Al-Ani probably did not even recognise that the men restraining him were police officers. The inquest jury was effectively told that securing the �control and compliance� of even those suspected of trivial offences overrides their right to be dealt with safely.

Mrs Al-Ani, Faisal’s mother said:

It is the cruellest thing in life to be told that you have lost a child. The treatment that Faisal received from the police was atrocious. They approached him without finding out the facts and acted without finding out the facts. In my opinion they were responsible for his death.

Deborah Coles, Co Director of INQUEST, commented:

It is deeply disturbing that another vulnerable man has died following a period of restraint by the police, using restraint methods outside their guidance. How often do the police have to be reminded that restraining people for long periods is dangerous and life-threatening? The apparent justification of the use of such a level of force on the basis of public order is extremely worrying.

Faisal Al-Ani’s family was represented at the inquest by INQUEST Lawyers Group members barrister Stephen Simblet of Garden Court Chambers, instructed by Carolynn Gallwey of Bhatt Murphy Solicitors.

AFTER 30 YEARS REPORT INTO THE DEATH OF BLAIR PEACH TO BE DISCLOSED

Today the Metropolitan Police Authority and the Commissioner of the Metropolitan Police conceded to the family’s request that the full report by former Commander John Cass into the death of Blair Peach in Southall in 1979 should be disclosed, subject to any legally necessary redactions. This momentous decision followed an ongoing campaign that was given added momentum following the death of Ian Tomlinson during the G20 protests and the similarities between the two fatal indicents. Prior to the MPA meeting today, INQUEST met MPA member Jenny Jones, Blair’s former partner Celia Stubbs and his brother Philip Peach to discuss the motion requesting disclosure.

Deborah Coles, Co-Director of INQUEST, said:

We welcome the lifting of the veil of secrecy surrounding this death that has undermined family and public confidence in the Metropolitan Police Service. The challenge now is to ensure that there is as full disclosure as legally possible and that reasons are given for any redactions given ongoing public concern about this process.

It was the negative experience of Blair Peach’s family and friends with the investigation and inquest system that led them to join with others to set up INQUEST in 1981. Sadly, the need for the organisation remains as urgent today. Non-disclosure of evidence has been one of the most problematic issues following deaths in custody and has seriously undermined family and public confidence in the police complaints system. The whole basis on which the Cass report has been withheld from the Peach family for 30 years has been discredited and it is accepted by government that the results of investigations into deaths following police contact are now disclosed to families.

Notes to editors:

INQUEST’s first book, Death and Disorder , published in 1986, examined deaths involving the police during – or which sparked – public disorder – Kevin Gately (who died during a protest in Red Lion Square in 1974), Blair Peach and Cynthia Jarrett, whose death during a police raid prompted the notorious Broadwater Farm disturbances in 1985 during which PC Keith Blakelock was killed. Death and Disorder looks at these three deaths in the context of others involving public disorder, from the infamous Peterloo Massacre of 1819 to the sometimes fatal use of troops and police against strikers in the first half of the twentieth century.

METROPOLITAN POLICE AUTHORITY TO DEBATE RELEASE OF THE CASS REPORT ON THE DEATH OF BLAIR PEACH

MPA full Authority
Chamber, City Hall, The Queen’s Walk, London SE1 2AA
10am Thursday 25 June 2009

INQUEST will be supporting the friends and family of Blair Peach when they lobby tomorrow’s meeting of the Metropolitan Police Authority at City Hall.

MPA member Jenny Jones has proposed a motion to be debated at the meeting calling on the Metropolitan Police Service to publish immediately the full report by former Commander John Cass into the death of Blair Peach in Southall in 1979. The report has remained secret to this day despite requests for disclosure by Blair’s family and friends. INQUEST has also written to the Metropolitan Police Commissioner supporting the family’s call for disclosure of the report and has yet to receive a reply.

Deborah Coles, Co-Director of INQUEST, said:

Public confidence in the Metropolitan Police Service continues to be undermined by the secrecy surrounding the death of Blair Peach. The whole basis on which the Cass report has been withheld from the Peach family for 30 years has been widely discredited and yet the secrecy continues . Ian Tomlinson’s death at the G20 protest and the similarities between the two cases makes the need to disclose this report even more urgent and is in both the family and public interest.

It was the negative experience of Blair Peach’s family and friends with the investigation and inquest system that led them to join with others to set up INQUEST in 1981. Sadly, the need for the organisation remains as urgent today. Non-disclosure of evidence has been one of the most problematic issues following deaths in custody and has seriously undermined family and public confidence in the police complaints system. The whole basis on which the Cass report has been withheld from the Peach family for 30 years has been discredited and it is accepted by government that the results of investigations into deaths following police contact are now disclosed to families.

Notes to editors:

Deborah Coles, Co-Director of INQUEST is attending the meeting with Blair Peach’s brother Philip Peach and his partner Celia Stubbs.

INQUEST’s first book, Death and Disorder , published in 1986, examined deaths involving the police during – or which sparked – public disorder – Kevin Gately (who died during a protest in Red Lion Square in 1974), Blair Peach and Cynthia Jarrett, whose death during a police raid prompted the notorious Broadwater Farm disturbances in 1985 during which PC Keith Blakelock was killed. Death and Disorder looks at these three deaths in the context of others involving public disorder, from the infamous Peterloo Massacre of 1819 to the sometimes fatal use of troops and police against strikers in the first half of the twentieth century.

INQUEST TO OPEN INTO RESTRAINT-RELATED DEATH OF BLACK PRISONER GODFREY MOYO AT HMP BELMARSH

10.00am Monday 22 June 2009
Sitting before HM Deputy CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for London (Inner South), Andrew Walker
HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure.’s Court, Tennis Street , London SE1 1YDThe inquest into the death of 25 year old Godfrey Moyo whilst on remand at HMP Belmarsh opens on 22 June 2009 and is expected to last for ten days.

In the early hours of 3 January 2005 Godfrey, who had a history of epilepsy, suffered a series of violent and exhausting seizures. After a lengthy period of restraint by prison officers he was carried to the healthcare unit. He was placed in the Intensive Care Suite (ICS), which was a cell which has since been decommissioned on safety grounds, and left there unsupervised. No observations of Godfrey were recorded by any officer or member of the healthcare team during the period he remained in the ICS. Some time later one of the nurses and several officers re-entered the ICS, where it was discovered that Godfrey was not breathing. He was pronounced dead at Queen Elizabeth Hospital later that morning.

The family has waited more than four years for the inquest and hope it will examine, among other things:

• the overall quality of healthcare at HMP Belmarsh;
• whether the level of force used and the duration of the restraint were justified;
• the appropriateness of the mode of carrying Godfrey to the ICS from his cell;
• the position in which Godfrey was placed in the ICS;
• whether Godfrey should have been sent to an outside hospital;
• whether the observations conducted by healthcare and discipline staff were adequate.

Deborah Coles, Co-director of INQUEST said:

The circumstances surrounding Mr Moyo’s death are extremely troubling. This case raises serious concerns about the prolonged restraint of a young black man that must be subjected to the most robust scrutiny.

Lomaculo Moyo, Godfrey’s sister, commented:

I have been really disappointed and frustrated by the long delay in waiting for my brother’s inquest. All I want now is justice for Godfrey.

Godfrey Moyo’s family is represented by INQUEST Lawyers Group members barrister Leslie Thomas of Garden Court Chambers instructed by Daniel Machover of Hickman and Rose Solicitors.

Notes to editors:

NQUEST has monitored a disproportionate number of deaths following restraint involving people from black and minority ethnic communities This is the first restraint-related death in prison since the deaths of three black men in prison in 1995: Dennis Stevens in Dartmoor prison on 11th October 1995; Kenneth Severin in HMP Belmarsh on 16 November 1995; and Alton Manning in HMP Blakenhurst on 8 December 1995.

PETER KIRKWOOD INQUEST ADJOURNED

The inquest into the death of Peter Kirkwood at HMP Chelmsford was unexpectedly adjourned on 11 June 2009 as a result of evidence that was given. No new date has been fixed.

INQUEST OPENS INTO DEATH OF BLACK PRISONER PETER KIRKWOOD AT HMP CHELMSFORD

12.45am Monday 8 June
Before HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. Mrs Caroline Beasley-Murray
Sitting at County Hall, Duke St, Chelmsford, Essex

The inquest into the death of 28 year old Peter Kirkwood at HMP Chelmsford opens on Monday 8 June and is expected to last for three weeks. Peter was found hanging on his first night in custody at HMP Chelmsford on 14 October 2006. He had a history of self-harm and mental health problems and had been subject to an open F2052SH form (suicide and self harm monitoring procedure) during a previous period at HMP Chelmsford.

Peter’s death was the first in a series of eight deaths by hanging at Chelmsford prison in a two year period.

Deborah Coles , Co-director of INQUEST said:

Peter’s death and the series of self-inflicted deaths that have followed at Chelmsford prison are extremely worrying. There must be robust investigations into these deaths so that any systemic failings, including the impact of overcrowding, are properly examined.

Peter Kirkwood’s family is represented by INQUEST Lawyers Group members barrister Colin Hutchinson of Garden Court Chambers instructed by Dan Rubinstein of Hodge Jones and Allen solicitors.

INQUEST INTO DEATH OF CALLUM MCLEAN IN POLICE CUSTODY CONCLUDES WITH AN APOLOGY FROM GREATER MANCHESTER POLICE

18-29 May 2009
Before HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for South Manchester , John Pollard
Sitting at Stockport Magistrates Court , Edward Street , Stockport , SK1 3NF .

The inquest into the death of 41 year old Callum McLean concluded on Friday 29 May with a public apology to the family from Greater Manchester Police ( GMP ) in open court. The thorough investigation and inquest were completed just over a year after Mr McLean died. Clear systemic problems were identified and the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. has used his powers under rule 43 of the Coroners Rules to write to the police, ambulance service and the General Medical Council about the case in a bid to prevent another tragedy. Disciplinary proceedings have been recommended against two custody sergeants and a custody detention officer.

Mr McLean was detained on the afternoon of 10 April 2008 and taken to Ashton under Lyne police station where it was noted he had a head injury. Later that evening he was transferred by ambulance to Tameside General Hospital. Mr McLean died when a decision was made to turn off his life support machine on 11 April 2008.

The family had hoped that the inquest would examine their serious concerns about the level of care whilst at the police station and whether any actions or failings by the police and the Forensic Medical ExaminerFormerly known as police surgeons, FMEs or police doctors examine and assess the medical needs of people detained in police custody. could have contributed to his death.

The inquest established that Callum McLean died after he was left in a cell for nearly three hours without proper medical attention. He had sustained a head injury as a consequence of either a fall or an involvement in an assault some time previously. On arrival at the police station a Forensic Medical ExaminerFormerly known as police surgeons, FMEs or police doctors examine and assess the medical needs of people detained in police custody. (FMEFormerly known as police surgeons, Forensic Medical Examiners or police doctors examine and assess the medical needs of people detained in police custody.) was contacted due to his condition but there was a substantial delay before the doctor arrived, during which time he was only visited once and then only a cursory look was made through the spy hole of the door of his cell.

The Police and Criminal Evidence Act 1984 Codes of Practice 9.3 requires that

Those suspected of being intoxicated through drink or drugs�must, subject to any clinical directions given by the appropriate health care professional� be visited and roused at least every half hour.

When the FMEFormerly known as police surgeons, Forensic Medical Examiners or police doctors examine and assess the medical needs of people detained in police custody. visited Mr McLean at just after 8pm, four hours after his arrest, he described Mr McLean as being “half dead” and left him alone in his cell while an ambulance was called. When they arrived, two ambulance technicians assessed his level of consciousness as level 6 on the Glasgow Coma Scale. When Mr McLean received a CT scan he was found to have a subdural haematoma which was irreversible by surgery. He died at 3.30pm the following day 11 April 2008.

The jury returned a detailed narrative verdictA form of verdict letting a jury give a longer explanation of what they think are the main or important issues. which exposed a catalogue of individual and systemic failings by Greater Manchester Police and the ambulance service including:

That there were no reasonable grounds for the custody office to downgrade him from a medium risk to a low risk during the booking in process;

• that the Police and Criminal Evidence Act 1984 codes of practice were breached and he should have been placed on a regime of half hourly visits;
• there were no systems in place to ensure that the indicated levels of checking as set out in the custody record were in fact being carried out;
• there was not an adequate system within the custody suite to ensure that vulnerable detainees were sufficiently monitored;
• that in fact Mr Mclean was not visited at all between 5.41pm and 8pm;
• that there was not sufficient and adequate training including refresher training for those involved in his detention;
• that the FMEFormerly known as police surgeons, Forensic Medical Examiners or police doctors examine and assess the medical needs of people detained in police custody. did not request all the necessary information or give adequate advice to the custody staff during the initial telephone conversation with the custody sergeant;
• that the FMEFormerly known as police surgeons, Forensic Medical Examiners or police doctors examine and assess the medical needs of people detained in police custody. was slow to respond and following finding Mr McLean unconscious and unable to be roused in a foetal position on the floor of the cell he did not carry out an adequate medical examination or place him in the recovery position;
• that it was inappropriate for the FMEFormerly known as police surgeons, Forensic Medical Examiners or police doctors examine and assess the medical needs of people detained in police custody. not to stay with him for the 21 minutes pending the arrival of the ambulance;
• that the level of care offered by the FMEFormerly known as police surgeons, Forensic Medical Examiners or police doctors examine and assess the medical needs of people detained in police custody. was inadequate and unacceptable and that if he had to leave the cell he should have asked a police officer to remain with Mr McLean and should have spoken directly to the ambulance crew about the seriousness of his condition;
• that the ambulance crew should have asked to speak directly to the doctor on arrival at the police station and that they were given insufficient information by the police about the condition of Mr McLean and that whilst the examination they carried out was adequate they failed to call ahead to alert the hospital of their arrival, to travel with blue lights and sirens, to bypass the queue and take him straight to triage or to monitor him on arrival.

At the conclusion of the inquest, Chief Inspector John Brennan of GMP Professional Standards Branch, apologised to the family in open court saying that “w e have failed the family and we are sorry about that.” He added that having spoken to the family he knew that they wanted to know that this will not happen again and said: “we will alter our systems to ensure that it does not happen again”. CI Brennan had given evidence to the inquest which indicated that during the time Mr McLean was in custody there were an additional 18 detainees in custody, nine of whose care caused him to want to ask questions.

Callum McLean’s family were represented by INQUEST Lawyers Group members barrister Sean Horstead of Garden Court Chambers, instructed by Fiona Borrill of Lester Morrill Solicitors, Leeds.

INQUEST JURY HIGHLY CRITICAL OF CARE OF NEWLY-SENTENCED PRISONER AT HMP WAKEFIELD

Brendan Flynn was found hanging in the segregation unit of HMP Wakefield just after midnight on 11 August 2004, a few days after receiving a 20 year sentence. He was 28 at the time of his death.

An inquest jury sitting before HM Assistant Deputy CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for West Yorkshire , Melanie Jane Williamson, today found that:

1. Brendan hanged himself while the balance of his mind was disturbed.
2. An absence of a radio and reading materials in Brendan’s cell had contributed to his state of mind.
3. Two officers (the number on duty that night) would have been sufficient to open Brendan’s door in an emergency. The rule requiring three officers plus a manager plus a dog to open a cell was too cautious.
4. Brendan should have been placed automatically on suicide watch (F2052SH) as a newly-sentenced prisoner on a long determinate sentence.
5. Brendan should have been placed on a suicide watch in any event after reporting his head was a mess on 9 August 2004.
6. The medical assessments completed on Brendan were inadequate.
7. Staff had received inadequate, insufficient and inconsistent suicide awareness training.

The jury’s verdict confirms the findings of HM Chief Inspector of Prisons, Ann Owers, whose report of an unannounced inspection in December 2008 of HMP Wakefield is published today. She found that ” it was not clear that suicide and self-harm, or violence reduction, procedures were properly targeted at the specific risks presented or faced by Wakefield’s particular population”.

Evidence received by jury

At the inquest, the jury heard that HMP Wakefield has a policy of automatically placing prisoners newly sentenced to life imprisonment on suicide watch. However, this policy was not applied to Brendan, despite the fact that he had just received a 20 year sentence, and had told staff that his �head was a mess�.

Instead, the jury heard that Brendan was placed in solitary confinement on the segregation unit, without a radio, reading material, or any other means of distracting him from his sentence. The prison doctor confirmed that he was suitable for segregation after a consultation that lasted for only 34 seconds.

The jury heard evidence that it can take as little as four minutes to die from asphyxiation. However, prison officers did not enter Brendan’s cell or carry out emergency first aid procedures until over seven minutes after Brendan was first seen to be hanging. The jury heard that the delay was due to a prison policy which prevents officers from unlocking category A prisoners during the night unless there are three prison officers, a manager and dog present at the cell door, yet only two prison officers were actually on duty in that part of the prison at night time.

The jury also heard evidence of a climate of bullying and intimidation in Wakefield’s segregation unit. One prisoner described it as a �bully block�.

A number of the prison officers who gave evidence at the inquest admitted that they could not remember when they had last received any training on suicide awareness or suicide prevention.

Falsified and missing evidence

At the inquest a prison officer admitted falsifying a local form, which some witnesses agreed was a risk assessment form, known as a BARAR form, following Brendan’s death. The officer accepted that she had completed the form on the day after Brendan’s death and backdated it to make it appear that it was completed the day before his death.

Brendan’s family are also concerned that the jury was unable to view vital CCTV footage from the segregation unit on the night of his death. During the inquest the prison said that it had failed to retain the footage for the 30 minutes before Brendan was discovered hanging in his cell due to basic error in downloading the half an hour before midnight because they did not realise that entering 24.00 (as opposed to 23.59) would select the 30mins from a whole 24 hours too early.

Daniel Machover , solicitor for the family, said:

Brendan Flynn’s family thank the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. and the jury for the attention they have given this case over the past three weeks.

They believe that the prison did not give Brendan the care and attention he needed and in particular that they were wrong to segregate him, leaving him on his own and with nothing to occupy him, so soon after he had been given such a long prison sentence and when it should have been obvious that he was vulnerable.

Of most concern to the family, however, are the very serious problems with the evidence that have emerged in this case. It is unfortunately clear that: evidence was falsified; some officers did not tell the truth; and critical material � including documents but also critical CCTV footage � has gone missing.

An inquest is supposed to help a grieving family obtain answers. Tampering with evidence is not only unlawful but also prevents a family from getting satisfaction and prevents full findings in the public interest. It leaves only suspicion and more questions. The family hopes that this will be the most important lesson to be learned from Brendan’s death.

Brendan’s mother, Audrey Milward, said:

Brendan was my youngest child and very close to me. He did cause problems � he could be as wild as the wind � but he was also outgoing and popular. I will remember him as always laughing. Words cannot express how I, his children, his nieces and nephews and all his family feel about having him taken from us so suddenly and in this way.

Brendan Flynn’s family was represented by Nick Armstrong of Matrix Chambers and INQUEST Lawyers Group member Daniel Machover of Hickman & Rose solicitors.

INQUEST TO OPEN INTO DEATH OF FAISAL AL-ANI FOLLOWING RESTRAINT IN THE CUSTODY OF ESSEX POLICE

10.00am Monday 1 June 2009
Sitting before HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Southern and South East Essex , Dr Peter Dean
Southend Civic Centre, Victoria Avenue , Southend, SS2 6ER

The inquest into the death of 43 year old Faisal Al-Ani opens on 1 June 2009 and is expected to last for 15 days.

Mr Al-Ani, who had suffered from mental health problems, was seen behaving strangely in Southend town centre on 31 July 2005. Police were called and Mr Al-Ani was then subjected to a prolonged restraint. He was taken by police car to Southend Police Station and was restrained again during the journey. On arrival in the custody area it was noted that Mr Al-Ani was not breathing. An ambulance was called but attempts to resuscitate him failed. He was pronounced dead at Southend hospital later that night.

The family has waited nearly four years for the inquest and hopes it will examine, among other things:

• Why police officers forcibly restrained someone who appeared to be suffering from mental illness;
• whether the level of force used and the duration of the restraint were justified;
• whether the techniques deployed during the restraint were appropriate, used correctly and permitted within the policy and training issued to police officers;
• what happened during the short car journey to the police station and at what point Mr Al-Ani collapsed.

Faisal Al-Ani’s family is represented by INQUEST Lawyers Group members barrister Stephen Simblet of Garden Court Chambers instructed by Carolynn Gallwey of Bhatt Murphy Solicitors.

INQUEST WELCOMES GOVERNMENT CLIMBDOWN ON �SECRET INQUESTS’

INQUEST is delighted that the Justice Secretary, Jack Straw MP, has responded to our concerns and those of the families and lawyers with whom we work as well as those of Liberty, JUSTICE and Human Rights Watch. Today’s announcement means that clauses 11 & 12 of the Coroners and Justice Bill will be removed, which sees the end of provisions that would have given the Secretary of State power to certify inquests where sensitive information is involved so that they would take place without juries, partly in private -excluding bereaved families, their legal representatives and the public at large from crucial parts of the investigation process.

We now hope that the needs of bereaved people are at the forefront of parliamentarians’ minds as the Lords debate the Second Reading of the Bill. The Bill needs to be strengthened so that it will:

• tackle delays in the inquest system;
• provide non-means-tested public fundingPublic means-tested financial assistance for representation during legal proceedings. It is not available for representation at most inquests. The Lord ChancellorThe cabinet minister in the government responsible for the effective running of the legal system in England and Wales. can grant it in exceptional cases. for bereaved families’ legal representation where a public authority is involved;
• ensure consistency of approach across England and Wales by introducing a national centrally-funded service;
• provide better information about the process to bereaved people;
• record and monitor inquest findings;
• make recommendations to relevant statutory bodies following inquest findings,
  and ensure action is taken to prevent future deaths;
• amend RIPA to allow inquests to receive intercept evidence when absolutely necessary.

We remain committed to ensuring that the inquest into the death of Azelle Rodney, that gave rise to the secret inquest proposals, takes place expeditiously. We therefore urge the Justice Secretary to introduce a simple amendment to RIPA to allow intercept evidence to be used at inquests in exceptional cases, so that Susan Alexander can ask the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. to resume that inquest. A secret inquiry is no solution to that case.

Notes to editors:

•  INQUEST’s Briefing on the Second Reading in the House of Lords of the Coroners and Justice Bill ; for more briefing papers on the Bill and other issues see http://www.inquest.org.uk/publications.html and http://www.inquest.uk/policy.html

•  Statement by Justice Secretary

•  The proposals for secret inquests arose from legal challenges bought on behalf of the family of Azelle Rodney over admissibility of intelligence evidence. Azelle Rodney in died in April 2005 after a police operation in north London in which he was shot seven times. After his death, the Independent Police Complaints Commission (IPCC) conducted an investigation and a file was passed to the Crown Prosecution ServiceThe CPS is responsible for deciding whether or not there is enough police evidence to undertake a criminal prosecution for a general criminal offence (e.g. manslaughter) both before and in some cases after the inquest, and whether or not a prosecution is in the public interest. (CPS) and in July 2006 the CPS announced that there was “insufficient evidence to disclose a realistic prospect of conviction against any officer for any offence in relation to the fatal shooting”. After the CPS decision the family was told by the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. that the full inquest could not be held because large portions of the police officers’ statements had been redacted under the Regulation of Investigatory Powers Act (Ripa) 2000, which covers information obtained from covert surveillance devices such as telephone taps or bugs. Azelle was shot seven times after the car he was in was ordered to halt in a ‘hard stop’ after being under police surveillance for over three hours in Edgware, north London. Two men were later convicted for firearms offences but there was no evidence that Azelle was armed at the time of the shooting.

INQUEST INTO DEATH OF CALLUM MCLEAN FOLLOWING DETENTION AT ASHTON UNDER LYNE POLICE STATION

10am Monday 18 May 2009
Before HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for South Manchester, John Pollard
Sitting at Stockport Magistrates Court , Edward Street , Stockport , SK1 3NF The inquest into the death of 41 year old Callum McLean opens on Monday 18 May and is expected to last for two weeks.

Callum was detained by Greater Manchester Police on the afternoon of 10 April 2008 and taken to Ashton under Lyne police station where it was noted he had a head injury. Later that evening he was transferred by ambulance to Tameside General Hospital . Callum died when a decision was made to turn off his life support machine on 11 April 2008.

Callum’s family are hoping that the inquest will examine their serious concerns about the level of care Callum received whilst at the police station and whether any actions or failings by the police and the Forensic Medical ExaminerFormerly known as police surgeons, FMEs or police doctors examine and assess the medical needs of people detained in police custody. could have contributed to his death. The family is also seeking answers to their questions about whether there were discrepancies in the monitoring and observation of Callum whilst in custody given his presentation.

Callum McLean’s family is represented by INQUEST Lawyers Group members barrister Sean Horstead of Garden Court Chambers, instructed by Fiona Borrill of Lester Morrill Solicitors, Leeds. Callum’s sister will give a statement at the conclusion of the inquest.

30 YEARS ON INQUEST REMEMBERS BLAIR PEACH

Thirty years ago today, on 23 April 1979, Blair Peach died as a result of being hit over the head by police. He, along with thousands of others, was demonstrating against the National Front in Southall, West London . No police officer was ever charged or prosecuted in relation to his death which raised serious concerns about the use of excessive force and the lawless behaviour of police officers from the Metropolitan Police Special Patrol Group while policing the demonstration.

There are evocative and disturbing parallels between his death and that of Ian Tomlinson. The public concerns about police tactics at the G20 demonstration and in particular the focus on the supervision and tactics of the Territorial Support Group are eerily familiar. As was the case 30 years ago, a principled democratic debate about police powers and methods is vital. So too is fundamental reform of the investigation and inquest system.

It was the negative experience of Blair Peach’s family and friends with the investigation and inquest system that led them to join with others and set up INQUEST in 1981. Sadly, the need for the organisation remains as urgent today as then. Since it was set up it has worked on a daily basis with bereaved families of people who die in all forms of custody � in prison, following police contact, in immigration and psychiatric detention and in secure training centres .

Many of the deaths raise issues of: negligence; systemic failures to care for the vulnerable; institutional violence, racism, sexism and inhumane treatment; and the abuse of human rights and state and corporate accountability. Cases often reveal a catalogue of failings in the treatment and care of vulnerable people in custody or otherwise dependent on others for their care. Families seeking the truth about their relatives’ death face an array of problems � lack of independent information and support, no non means tested funding for legal representation, delays of years in the investigation and inquest system, failure to prosecute or discipline and to ensure similar deaths are prevented.

Notes to editors:

The Coroners and Justice Bill 2009 is currently making its way through parliament and w e are lobbying to ensure that there is root and branch reform of the inquest system.

INQUEST’s first book, Death and Disorder , published in 1986, examined deaths involving the police during – or which sparked – public disorder – Kevin Gately (who died during a protest in Red Lion Square in 1974), Blair Peach and Cynthia Jarrett, whose death during a police raid prompted the notorious Broadwater Farm disturbances in 1985 during which PC Keith Blakelock was killed. Death and Disorder looks at these three deaths in the context of others involving public disorder, from the infamous Peterloo Massacre of 1819 to the sometimes fatal use of troops and police against strikers in the first half of the twentieth century.

Nearly 30 years to the day after Blair Peach died, the controversial circumstances surrounding the death of Ian Tomlinson who was caught up in the police response to the G20 protests while he walked home in the City of London on 1 April 2009 demonstrate there is still much to be concerned about the policing of demonstrations. 23 years later, Death and Disorder offers clear evidence of what went wrong three decades and more ago, and why the need for INQUEST to work to help bereaved families through the coroners court – and to press for their reform – remains as important as in 1981.

INQUEST TO OPEN INTO DEATH OF LISA DOE IN SEND PRISON

9.30am Monday 20 April 2009
Sitting before HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Surrey Michael Burgess
Quadrant Court, 35 Guildford Road , Woking , GU22 7QQ

The inquest into the death of 25 year old Lisa Doe opens on 20 April 2009 and is expected to last for two weeks. Lisa was found hanging in her cell at HMP Send on 11 September 2007. Lisa was a vulnerable prisoner who had a long history of drug abuse and self-harm. She suffered from mental health problems linked to her early life experiences.

Throughout her sentence Lisa was often subject to an open F2052SH/ACCT (identified as being at risk of suicide and self harm) and had spent time in a therapeutic community in prison.

On 11 September 2007 Lisa cut her wrist using a razor blade. Her wound was dressed by a prison officer and she was taken to healthcare where she was seen by a nurse. Half an hour later at 5.00pm, Lisa was found hanging in her cell’s bathroom.

The family hopes the inquest will examine:

• Whether Lisa was subjected to bullying and what effect this had on her state of mind.
• What HMP Send’s anti-bullying policies and procedures were at the time and whether they were implemented.
• Why Lisa was in a cell with an obvious ligature point.
• What impact did leaving the therapeutic community early have Lisa’s state of mind after and what support did she receive as a result.
• The management of Lisa’s suicide and self-harming risk, particularly in relation to her act of self harm on 11 September.
• Whether the support Lisa received as a life prisoner in HMP Send was appropriate.

Lisa Doe’s family is represented by INQUEST Lawyers Group members barrister Nick Brown of Doughty Street Chambers, instructed by Anna Thwaites of Hodge Jones and Allen.

INQUEST AND LIBERTY HOLD PARLIAMENTARY MEETING ON GOVERNMENT PLANS FOR SECRET INQUESTS

INQUEST and Liberty held a parliamentary meeting today on the secret inquest provisions of the Coroners and Justice Bill. Chaired by Frank Dobson MP, parliamentarians were addressed by Susan Alexander, bereaved mother of Azelle Rodney who was shot dead by the Metropolitan Police in 2005, Helen Shaw, Co- Director of INQUEST and Shami Chakrabarti , Director of Liberty.

Politicians from across the political spectrum heard that despite last minute amendments, the government’s proposals would gravely limit transparency and increase executive control over the inquest process and could exclude bereaved families, their legal representatives and the public at large from the investigation process. This could include inquests into highly contentious deaths such as deaths in custody or of individuals where issues of the state’s broader conduct are raised.

Susan Alexander said:

The secret inquest provisions in the Bill are not significantly different from the clauses that the government withdrew last year from the Counter-Terrorism Bill, at least from my point of view. They would still prevent a coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure., a jury and me from seeing key evidence and having it properly tested in court.

If sensitive material is central to explaining what happened on 30 April 2005 then it has to be part of the inquest into my son’s death and I have to see it. The public interest about keeping witnesses safe or intercept methods secret can be protected through anonymity orders, screening, jury vetting, confidentiality agreements and criminal offences relating to unauthorised disclosures, as well as holding some of the inquest behind closed doors (but in the presence of bereaved families).

The inquest into Azelle’s death will not undermine the work of the police in protecting the public from serious crime, but the public interest will be badly damaged if the truth of what happened is obscured and all the lessons of this case cannot be learned .

Helen Shaw, Co- Director of INQUEST, said:

INQUEST remains fundamentally opposed to these proposals. They amount to a fundamental attack on the independence and transparency of the coronial system in England and Wales ; are fundamentally flawed; unsupported by evidence; disconnected from legal principles and have come about without any consultation with stakeholders. The proposals will completely undermine the stated aim of government to put bereaved families at the centre of the reformed inquest system and will damage public confidence in the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. service as a whole.

Shami Chakrabarti , Director of Liberty, said:

What happened to all that rhetoric about rebalancing justice in favour of victims? This flawed policy forgets that the only point of an inquest is providing answers for bereaved families and the wider public. It is perfectly possible to protect sensitive material within an open jury system. Everything else is just politics.

Notes to editors

1. The title of INQUEST and Liberty’s parliamentary meeting was inspired by the following speech given by the Lord High Chancellor, Rt Hon Jack Straw MP on 28 October 2008 �But what about victims? The government as a whole has worked very hard to give a central voice and priority to victims, but we hear far less often from these lobbies about the needs of the victim. I think that they sometimes forget who the victim is, so lost do they become in a fog of platitudes�.�
2. The Coroners and Justice Bill will reach its Commons Report stage on Monday 23 March.
3. INQUEST is the only non-governmental organisation in England and Wales that works directly with the families of those who die in custody. It provides an independent free legal and advice service to bereaved people on inquest procedures and their rights in the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure.’s courts and conducts policy work on the issues arising.
4. INQUEST is campaigning to ensure that the Coroners and Justice Bill 2009 results in fundamental reform of an inquest system currently hampered by delay, inconsistency of approach and lack of resources and unable to fulfil its vital function of preventing unnecessary deaths.
5. The government must also make changes to ensure that bereaved families can participate effectively in inquest hearings by having equal access, alongside the police and Prison Service, to non means-tested public fundingPublic means-tested financial assistance for representation during legal proceedings. It is not available for representation at most inquests. The Lord ChancellorThe cabinet minister in the government responsible for the effective running of the legal system in England and Wales. can grant it in exceptional cases. for their legal representation. INQUEST’s briefing on the Coroners & Justice Bill

INQUEST CALLS FOR URGENT ACTION FOLLOWING INSPECTORATE REPORT INTO HMP STYAL

INQUEST calls on the government to take urgent and immediate action following the criticisms in the report of Her Majesty’s Inspectorate of Prisons into the care of vulnerable women at Styal prison.

The report identifies significant failings in the care and management of some of the most vulnerable women in the prison system, with six women dying at the prison since the last inspection, four of those deaths being self-inflicted. Yet again it is evident that there is a failure at the highest levels of the Prison Service to learn the lessons arising from the deaths of women in their care or to recognise the resources and regime necessary to ensure that women are kept safe.

The Keller Unit, previously the segregation unit, is the subject of particular concern, being described as �not an appropriate therapeutic environment� for the women it houses, many with complex mental health problems and serious patterns of self-harm. The criticisms include:

• the lack of training, support and leadership for the unit and staff;
• high levels of self-harm and use of force;
• the lack of proper action plans following previous deaths;
• weak and ineffective case planning.

Deborah Coles, co-director of INQUEST, said:

�HMP Styal continues to be a prison that gives serious cause for concern. As the report demonstrates, the response of the Prison Service does not reflect the seriousness of the failings that have been exposed both by inspection reports and inquests into the deaths of vulnerable women.

How often does it need to be demonstrated that this prison cannot provide a safe environment for some of the most damaged women in society who quite frankly should not be in prison at all? What is needed is a fundamental rethink, not only about Styal but in the whole approach to women who offend, and the provision of alternatives to custody. The government must take urgent action � unless they do so, another preventable death is inevitable. �

John Gunn, the brother of Lisa Marley who died at HMP Styal in January 2008, said:

�The people in charge of Styal have a duty of care to these women, no matter why they are there. If this was any other sort of business with this record, people would be out of their jobs and the place would be shut down � how many more women need to die before something is done?�

OVERWHELMING FAILINGS BY PRISON AND HEALTHCARE STAFF CONTRIBUTED TO DEATH OF VULNERABLE BLACK PRISONER AT HMP RYE HILL

An inquest jury sitting before HM Assistant Deputy CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Northamptonshire, Tom Osbourne, today concluded that a catalogue of serious failings at the privately-run HMP Rye Hill caused or contributed to the death of 23 year old Michael Bailey who was found hanged in the segregation unit of the prison on 24 March 2005.

The jury concluded that the prison had failed in relation to every single aspect of Michael’s care that they had been asked to consider and that there was a � failure on the part of all staff to take responsibility for ensuring Michael Bailey’s safety�.

During the five week inquest, distressing evidence was heard about the severe deterioration in Michael’s mental health in the six days prior to his death. Michael, who had previously been described by all as a confident outgoing person, began to exhibit severe symptoms of psychosis, often crying uncontrollably, stating the walls and demons were speaking to him and telling staff at the prison he was ready to die. Michael had written a detailed farewell note to his family and on one occasion walked around the exercise yard naked for two hours reciting the Lord’s Prayer.

The jury found that both prison and medical staff:

• failed to undertake an adequate mental health assessment;
• failed in their communication about his condition and care needs;
• failed to recognise the serious nature of his condition;
• failed to move Michael out of the segregation unit into healthcare when it became clear that he was at risk;
• failed to place him in a safe cell;
• failed to do all that could be reasonably be expected to prevent Michael hanging himself.

During the inquest the jury had heard that, despite a suicide and self harm monitoring form (F2052SH) being opened for Michael, key events were not recorded in it and the document was rarely read by staff. Observations required to keep Michael safe, which were supposed to be carried out six times an hour, did not take place and staff admitted to routinely falsifying these records. Indeed, when Michael was discovered motionless behind his cell door on the 24 March, an officer was instructed to falsify the watch records before going to provide assistance.

The jury also criticised the lack of trained and experienced staff, the lack of effective management and fundamental systems failure in dealing with suicide and self harm.

Deborah Coles , co-director of INQUEST, said:

�The shocking circumstances of Michael Bailey’s death, the first of three controversial deaths at the privately-run HMP Rye Hill, highlight both an appalling breakdown in procedures designed to protect life and uncaring and inhumane treatment of a vulnerable man. However, what is more concerning is that this represents not just a series of shameful individual failures, but a fundamental failure by the Prison Service to ensure that privately-run prisons are safe and meet acceptable standards for those in their care.�

Michael’s mother Caroline Bailey commented:

�Over the past few weeks, I along with Michael’s family and friends have endured hearing the details of the painful and dreadful last days of my dear son’s life.

We have listened as staff blamed each other as to why nothing was done to alleviate Michael’s suffering as he cried out for help. If just one of those involved had done their job properly, Michael could still be with us. They, each and every one owed Michael a duty of care and they failed him time and time again. I do not know how they can live with themselves.�

Michael Bailey’s family were represented by INQUEST Lawyers Group barrister Leslie Thomas of Garden Court Chambers, instructed by Nogah Ofer of Hickman and Rose Solicitors.

INQUEST OPENS INTO FIRE CELL DEATH AT HMP DURHAM

10.00am Monday 2 February 2009

Before HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for County Durham Andrew Tweddle
Sitting at Chester-le-street Magistrates Court, Newcastle Road, Chester-le-street,
Co. Durham DH3 3UAThe inquest into the death of 23 year old black prisoner Anthony Mola will open on 2 February 2009. The hearing is expected to last five weeks. Anthony died of carbon monoxide poisoning due to smoke inhalation on 15 June 2005 after starting a fire in his cell on the segregation unit in HMP Durham.

Anthony, who suffered from schizophrenia, had been remanded to Durham Prison on 13 June 2005. On arrival he exhibited signs of disturbed behaviour and was placed in Health Care under the suicide and self harm monitoring system (F2052SH). However, the next day he was taken to the segregation unit after damaging his cell and placed in a safer cell with CCTV and cardboard furniture. He remained on an open F2052SH form with hourly observations and his disturbed behaviour continued.

On the morning of 15 June smoke was seen coming from Anthony’s cell. Although the fire was detected almost immediately and the fire brigade called, there was a delay before his cell door was opened. When prison officers entered the cell they found Anthony hiding under his bed. Anthony was transferred to hospital where he later died.

Eight prison officers were also taken to hospital suffering the effects of smoke inhalation.

The family’s main areas of concern which they hope the inquest will examine are:

• Why was he placed in a cell containing cardboard furniture and allowed a lighter when Anthony had convictions for arson and had previously set fire to materials whilst in prison.
• The way fire safety is managed within the Prison Service and more particularly HMP Durham and why there was a delay before the fire service were able to enter the cell.
• Why staff did not complete a risk assessment as required before placing Anthony in a cell with cardboard furniture.
• Whether Anthony received appropriate care for his mental health problems in HMP Durham.

The family are being represented INQUEST Lawyers Group members barrister Peter Wilcock from Tooks Chambers instructed by Fiona Borrill of Lester Morrill Solicitors

MPs TO DEBATE THE CORONERS AND JUSTICE BILL 2009

The second Reading of the Coroners and Justice Bill 2009 will take place on Monday 26 January 2009. INQUEST’s work has highlighted a system in crisis and one which is currently failing bereaved families. We hope that parliament will use this opportunity to ensure that there is root and branch reform of the system as the inquest is usually the only public forum in which contentious deaths are subjected to public scrutiny . It is crucial that new legislation results in fundamental reform to ensure that, whatever the circumstances of the death, bereaved families do not feel they have been further damaged by the inquest process.

While INQUEST welcomes many of the Bill’s provisions on the inquest system we believe it could be strengthened. A nationally-funded, professional coronial system with an extended remit and powers would have a crucial role in preventing contentious deaths and act as an essential hallmark of democratic accountability. It could also play a crucial role in preventing further deaths in similar circumstances and protecting public health and safety.

We remain deeply concerned about the proposals to hold some inquests partly in secret with the bereaved family, their legal representatives and the public at large excluded . We hope that there will be an opportunity to change this part of the Bill fundamentally and find a solution that is compatible with the Human Rights ActThe Human Rights Act 1998 is an Act of Parliament that incorporated the European Convention on Human Rights into UK law. 1998.

The government states that “the purpose of the Bill is to establish more effective, transparent and responsive justice and coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. services for victims, witnesses, bereaved families and the wider public . ” While INQUEST applauds these intentions, it believes that the Bill needs to be strengthened to achieve this outcome or it is in danger of raising the expectations of bereaved people without providing a robust and well-resourced framework.

Our casework over the last 25 years indicates that the most pressing reforms needed are:

• An extension of the remit of the inquest system.
• Improvement to the support and information available to bereaved people.
• Changing the structure to create a national coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. service to improve service delivery, ensure high standards of accountability and consistency of service.
• A system of monitoring inquest verdicts and coroners’ reports; and a statutory obligation on public bodies to act on the findings of an inquest, with the Chief CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. providing a summary of coroners’ reports and the responses to them in an annual report to Parliament.
• Non-means-tested public fundingPublic means-tested financial assistance for representation during legal proceedings. It is not available for representation at most inquests. The Lord ChancellorThe cabinet minister in the government responsible for the effective running of the legal system in England and Wales. can grant it in exceptional cases. for legal representation for bereaved people following deaths in circumstances that involve public authorities.
• Specific action to be taken to counter lengthy delays in holding inquests.

The Bill is silent on the need for full, non-means-tested public fundingPublic means-tested financial assistance for representation during legal proceedings. It is not available for representation at most inquests. The Lord ChancellorThe cabinet minister in the government responsible for the effective running of the legal system in England and Wales. can grant it in exceptional cases. for legal representation for bereaved families where the death involves a public authority. This omission will fundamentally prevent the Bill from achieving its stated purpose.

INQUEST will be producing a substantial briefing on the detail of the Bill to assist and inform parliamentarians and others as the Bill makes its passage through parliament.

Notes to editors:

1. INQUEST is the only non-governmental organisation in England and Wales that works directly with the families of those who die in custody. It provides an independent free legal and advice service to bereaved people on inquest procedures and their rights in the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure.’s courts and conducts policy work on the issues arising.
2. INQUEST is campaigning to ensure that the Coroners and Justice Bill 2009 results in fundamental reform of an inquest system currently hampered by delay, inconsistency of approach and lack of resources and unable to fulfil its vital function of preventing unnecessary deaths. INQUEST is in regular dialogue with Ministers and officials in the Ministry of Justice, MPs, and members of the House of Lords, the Joint Committee on Human Rights, coroners and leading legal practitioners on the need for reform.
3. The government must also make changes to ensure that bereaved families can participate effectively in inquest hearings by having equal access, alongside the police and Prison Service, to non means-tested public fundingPublic means-tested financial assistance for representation during legal proceedings. It is not available for representation at most inquests. The Lord ChancellorThe cabinet minister in the government responsible for the effective running of the legal system in England and Wales. can grant it in exceptional cases. for their legal representation.
4. INQUEST’s groundbreaking report Unlocking the Truth – Families’ Experiences of the Investigation of Deaths in Custody presents the experiences of families bereaved by deaths in custody of the coroners inquest system in their own words and shows how current systems are failing through basic lack of provision and poor implementation of existing protocols.
5. INQUEST makes extensive recommendations and presents families’ suggestions for change, arguing that scrutiny, criticism and proposals for reform of the way the state deals with deaths in custody is a crucial contribution to the health of its democracy.

CORONERThe legal official who orders a post-mortem and who is in charge of the inquest procedure. OVERRULED IN CHILD DEATH IN CUSTODY CASE

The Administrative Court has found that a coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. acted unlawfully when conducting an inquest into the death of Adam Rickwood, a 14 year old boy who died in Hassockfield Secure Training Centre (STCSecure Training Centre). The CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for the North and South Districts of Durham and Darlington refused to rule on the legality of the force used on Adam shortly before his death and Mr Justice Blake considered that this resulted in a flawed inquiry and verdict. A new inquest will now have to be held.

Adam was 14 years old when he was found hanging in his cell at the privately-run Hassockfield STCSecure Training Centre on 8 August 2004. It was Adam’s first experience of custody. In his cell after his death were found two documents: a farewell letter to his family and a statement complaining about his treatment at Hassockfield STCSecure Training Centre earlier in the day, when he had been restrained by staff for refusing to go to his room. In his note he indicated that:

� My nose started bleeding and swelled up it didn’t stop bleeding for about one hour and afterwards it was swelled badly and really sore and hurting me a lot when I clamed down I asked them why they hit me in the nose and jumped on me they said it was because I wouldn’t go in my room so I said what gives them the right to hit a 14 year old child in the nose and draw blood and they said it was a restraint.� (emphasis added)

Mr Justice Blake has ruled that the force used against Adam amounted to an �assault on him�, was in breach of the relevant Rules, and breached article 3 of the European Convention on Human RightsThe ECHRThe European Convention on Human Rights is an international treaty to protect human rights and fundamental freedoms in Europe, incorporated into UK law as the Human Rights Act 1998. All Council of Europe member states including the UK have signed the Convention. is an international treaty to protect human rights and fundamental freedoms in Europe, incorporated into UK law as the Human Rights ActThe Human Rights Act 1998 is an Act of Parliament that incorporated the European Convention on Human Rights into UK law. 1998. All Council of Europe member states including the UK have signed the Convention.. He commented that:

� There was no right to hurt such a child in these circumstances. In my judgment it is fanciful to suppose that such an answer could have had no impact on the jury’s consideration of factors contributing to the death .� [para 71]

He went on to hold that the treatment of Adam was not unique, but was a persistent practice in Hassockfield which breached the law.

Adam Rickwood’s mother Carol Pounder commented that;

� Nothing can bring Adam back. All I have ever wanted is to find out the full truth about what happened to Adam and for those with responsibility to be held to account and to try and ensure that other families do not have to go through what my family has. �

Mark Scott , of Bhatt Murphy Solicitors who act for the family of Adam Rickwood, commented that;

� It appears that many children have been assaulted over the course of many years in privately run STCs. It is impossible to understand how this state of affairs could have taken place and been allowed to have continued by the YJB and those with responsibility for overseeing the acts of the private companies who have been entrusted to detain vulnerable children. It is my client’s hope that a fresh inquiry can lead to a proper and full investigation so that lessons can be learned .�

Deborah Coles, Co-Director of INQUEST, said,

� This judgement confirms the grossly inadequate response at all levels � the Youth Justice Board, government, and the inquest system to the death of a 14 year old child in state custody following the use of unlawful painful restraint. That serious questions remain about the safeguarding of children’s human rights in custody highlights the utter inadequacy of the current investigation and inquest system in these highly complex cases. It is imperative that the new Coroners and Justice Bill currently before Parliament addresses these problems .�

Notes to editors:

Full text of the judgment

INQUEST’s briefing on the death of Adam Rickwood

INQUEST press release on original inquest verdict

The Coroners and Justice Bill 2009

INQUEST DISMAYED BY FIRST DEATH OF A WOMAN IN PRISON THIS YEAR

INQUEST notes with sadness the self-inflicted death of 36 year old Alison Colk in HMP Styal on 8 January 2009, a prison with a disturbing history of deaths of vulnerable women.

Deborah Coles, Co-Director of INQUEST said:

� It is deeply shocking that a woman has died one day into her sentence. Vital questions need to be asked about what possible justification can there be in sentencing a woman to just 28 days. Despite high level scrutiny of Styal prison, serious concerns remain about the safety and quality of life for women held there and why lessons from previous deaths appear not to have been learned. Unless more women are diverted from prison the increase in self inflicted deaths and the associated high levels of self harm, mental distress and family disruption will continue �.

Notes to editors:

•  This is the ninetieth self-inflicted death of a woman in prison in England and Wales since 1990. See Dying On The Inside: Examining Women’s Deaths In Prison for an in-depth examination of the issues.

•  Since 2000 there have been 12 self-inflicted deaths of women in Styal prison. The inquests held into many of these deaths have raised serious concerns about the quality of treatment and care afforded women in Styal and the inappropriateness of prison for many of the women held there.

•  The Corston Review was published in March 2007. The government responded to the review in November 2007 and has failed to allocate any resources to its implementation.

•  INQUEST is the only non-governmental organisation in England and Wales that works directly with the families of those who die in custody. It provides an independent free legal and advice service to bereaved people on inquest procedures and their rights in the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure.’s courts and conducts policy work on the issues arising.

•  INQUEST is campaigning to ensure that the Coroners and Justice Bill 2009 results in fundamental reform of an inquest system currently hampered by delay, inconsistency of approach and lack of resources and unable to fulfil its vital function of preventing unnecessary deaths.

•  The government must also make changes to ensure that bereaved families can participate effectively in inquest hearings by having equal access, alongside the police and Prison Service, to non means-tested public fundingPublic means-tested financial assistance for representation during legal proceedings. It is not available for representation at most inquests. The Lord ChancellorThe cabinet minister in the government responsible for the effective running of the legal system in England and Wales. can grant it in exceptional cases. for their legal representation.

10am Tuesday 6 January 2009
Sitting before HM Assistant Deputy CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. for Northamptonshire, Tom Osbourne
Rushden and Diamond Conference Centre, Irthlingborough, Northamptonshire, NN9 5QF

The inquest into the death of 23 year old Michael Bailey opens on 6 January. The hearing is expected to last for six weeks.

Michael Bailey was found hanging in the segregation unit at HMP Rye Hill on 24 March 2005. His death was one of three controversial deaths at the privately-run prison in a fifteen month time period. In the month following the death, Rye Hill was heavily criticised by HM Chief Inspector of Prisons who found that �the prison had deteriorated to the extent that we considered that it was at that time an unsafe and unstable environment, both for prisoners and staff.�

Michael Bailey was sent to the segregation unit on 18 March 2005. He had previously been considered an outgoing person without any signs of mental illness. However, in the days prior to his death he suddenly began to exhibit severe symptoms of psychosis and talked openly of suicide. On 24 March, Michael hanged himself using a shoelace from the door of his cell.

His family hopes the inquest will examine:

• Whether staff were influenced by the fact that Michael was black and treated him as a dangerous person, rather than as a person who was seriously ill.
• Why Michael did not have a proper medical assessment and was not transferred to a health care facility.
• Why someone in Michael’s condition was kept in segregation.
• Whether the checks required under the suicide risk regime were carried out by staff and whether records had been falsified.
• Why a cell that was supposed to be �ligature-free’ had an obvious ligature point.

Michael Bailey’s family is represented by INQUEST Lawyers Group members barrister Leslie Thomas of Garden Court Chambers, instructed by Nogah Ofer of Hickman and Rose Solicitors. Michael’s family will give a statement at the conclusion of the inquest.