Written evidence from INQUEST (RHR0024)
Racial inequalities and racism: the experience of bereaved Black families
“I didn’t want the perception of the public, oh they’ve got a chip on their shoulder because he’s Black…I knew it was there just didn’t highlight it. It was also not highlighted by the IPPC” - Marcia Rigg
“With my nephew I haven’t made reference to race at all and I’ve deliberately done that as well. Everything I have put in writing I’ve just challenged the facts as they see and asked for proof for everything they’ve said that they believe is fact” - Anonymous family member
“When it comes to racism… they expected her to be as a Black woman mad and angry and loud and aggressive, where my niece was very soft, very gentle” - Anonymous family member
“We didn’t mention anything about racism either because it was more of a family discussion that we spoke about racism. When we got together to talk about what was happening with us we thought, what else could it be? They’re so hostile towards you” - Marilyn Medford-Hawkins
“The narrative from the beginning is racist, right from the get-go. They look for things to demonise your loved one. They try to get out a narrative to the press that is demonising, its racist, its dehumanising. That is their agenda” - Anonymous family member
“His character is completely destroyed and that’s what they do. Instead of looking at what the police have done all the police background, they are busy looking at what my son’s done and its them that have killed him” - Anonymous family member
“We were stone-walled; we were treated like criminals. [The IOPC] were just not forthcoming. They had no compassion” - Marilyn Medford-Hawkins, sister of Junior Medford
“The [IPCC] were investigating the family, instead of the officers” Marcia Rigg, sister of Sean Rigg
Accountability and transparency
“We know that things are not changing over the years but it’s clear to me that the reason why it’s not changing and why recommendations are never being put forward is because there’s no one challenging, we’re [families] challenging but no one from the political side the reports are actually the same, the only changes are the person that has actually died” - Anonymous bereaved family
“What’s happened to all the other reports which we all participated in?” - Anonymous bereaved family member
“When are they are going to listen to us?” - Anonymous bereaved family member
“I’d love to know what the government will do because…we’re bending over backwards, we’re doing research, we’re doing talks, we’re doing all sorts of stuff but yet there is no accountability. When are they are going to listen to us, when are they going to listen to us as a family.” - Anonymous family member
“You’ll lose the accountability if they simply know that all they have to do is put in a report to say that those recommendations have been completed” - Anonymous family member
From the individual to the systemic
“We have to raise the ugly head because it’s not a fashionable discussion by the government. The government know they just choose not to implement the recommendations and not make them accountable” - Marcia Rigg
Ensuring racism is in scope
Who else plays a role in making progress?
Conclusions and recommendations
INQUEST, September 2020
Annex 1: Racial inequalities, racism and detention
Christopher Alder MEDIA RELEASE
Christopher Alder, 37 died following arrest and restraint by police in 1998. In 2000 the jury at the inquest returned a conclusion of unlawful killing after hearing evidence that he was left unconscious, face down on the floor of the police station, partially dressed and clearly injured. In 2012 the family discovered that the person they thought they buried at Christopher’s funeral twelve years prior was in fact the body of a 77 year old woman, after his body was found in a police mortuary. The family continue to pursue legal action on this. In 2013 it was revealed that Christopher’s family and their lawyer were subject to extensive police surveillance during the inquest into his death, including attempts to listen to conversations that were likely to include matters which were private, confidential and subject to legal professional privilege.
Rocky Bennett BRIEFING
Rocky Bennett, 38 died following the use of restraint by five nurses whilst a detained mental health patient in 1998. Rocky had been a patient at the Norvic Clinic in Norwich for three years. At the inquest in 2001 the jury concluded Rocky’s death had been an accidental death aggravated by neglect, and said that the cause of death was due to prolonged restraint and long-term antipsychotic drug therapy. His death prompted a public inquiry ‘The Independent Inquiry into the death of David Bennett’ (2003) which found institutional racism within the mental health service.
Kingsley Burrell MEDIA RELEASE
Kingsley Burrell, 29 died in 2011 following a prolonged restraint by police whilst he was a detained patient under the Mental Health Act. Kingsley was forcibly restrained by means of rear cuffs, leg straps multiple times in the space of four days. When the medical staff observed that his respiration had dropped to a worrying rate, no one entered the room. When they finally did, they found that Kingsley had suffered a cardiac arrest. Further delays followed in locating a functioning defibrillator and in calling an ambulance. In 2015, the inquest concluded neglect and unreasonable police force contributed to his death, amidst a raft of other highly critical findings including that police officers lied about the circumstances in which Kingsley was left in seclusion.
Leon Briggs MEDIA RELEASE
Leon Briggs, 39 was detained under the Mental Health Act and restrained on the street by police officers in November 2013. After being transported to Luton Police Station Leon was placed in a cell where he was further restrained. Leon became unresponsive and an ambulance was called, he was later pronounced dead at the hospital. In 2020 the IOPC withdrew directions to bring gross misconduct proceedings against the five Bedfordshire Police officers involved. An inquest is awaited.
Dexter Bristol MEDIA RELEASE
Dexter Bristol, 58, died after collapsing on the street in London in 2018. In the year and a half before his death, Dexter’s family say he was placed under unbearable stress by the Home Office as he was required to prove his settled status, despite residing in the UK for 50 years. In late 2016 he was told he was unable to start the job he had been offered, because he did not have an official Right to Work document to prove his settled status in the UK. Dexter was prohibited from obtaining work, and feared losing his benefits, council housing, and access to secondary medical care and being deported. After the initial inquest was quashed, the second inquest concluded he died from heart failure and was under intense stress from a series of problems at the time of his death.
Natasha Chin MEDIA RELEASE
Natasha Chin, 39, died in 2016, 36 hours after entering Sodexo run HMP Bronzefield. Despite being on a specialist wing for people with drug and alcohol dependencies, on the day she died she had been vomiting for at least nine hours and did not collect essential medication. Healthcare staff did not follow this up or properly respond to prison officers’ requests to attend her cell. The inquest jury concluded neglect and systemic failures by prison and healthcare providers contributed to her death.
Darren Cumberbatch MEDIA RELEASE
Darren Cumberbatch, 32 died following restraint and use of force by the police whilst he was experiencing a mental health crisis in 2017. Darren was restrained by seven officers, during which he experienced baton strikes, other physical strikes, multiple punches, stamping, PAVA spray and Tasers were discharged three times, all inside a small toilet cubical. Once arrested, he was then restrained in the prone position (chest down) outside the toilet area and was further restrained as he was taken to a police van. After this restraint officers recognised Darren’s need for emergency treatment. Despite being very ill by the time of his arrival at A&E he remained in mechanical restraints at the hospital for over an hour and was restrained intermittently at the hospital after that.
Rashan Charles MEDIA RELEASE
Rashan Charles, 20, died following restraint by police officers in Hackney 2017. Despite no knowledge of or intelligence on Rashan, an officer pursued him after he exited a vehicle which had been ‘acting strangely’. Footage shows the officer following Rashan into the shop, immediately restraining then taking him to the floor. A bystander became involved in the restraint. At one point Rashan grasps toward his face, then his arm is taken back and handcuffed. The officer then turned Rashan on his side, and begins to tell him to “spit it out”, believing he had hidden something in his mouth. At some point he started choking then stopped breathing. The jury concluded Rashan’s death was ‘accidental’ but found the officer did not follow prescribed police protocol for when someone is not breathing and suspected of swallowing drugs. At the conclusion of the inquest, the family said “The police projected a criminal caricature of Rashan even after his death.”
Edson da Costa MEDIA RELEASE
Edson Da Costa, 25 died following contact with police in 2017. During a ‘stop and search’ Edson placed packages into his mouth, he was then restrained faced down by four police officers, hit with two ‘distraction blows’ and subject to two applications of the ‘mandibular angle’ pressure point pain compliance technique. CS spray was used at close proximity, despite police guidance suggesting a one metre distance. During this restraint Edson became unresponsive. He was taken to Newham Hospital where he died several days later. INQUEST reported that a hostile environment was created at the inquest through the defensive and combative tactics of police lawyers, who sought to narrow lines of inquiry and divert attention away from the circumstances that resulted in Edson’s death. The jury made a majority ruling that Edson’s death was ‘misadventure’.
Mark Duggan MEDIA COVERAGE
Mark Duggan, 29 was killed by a firearms officer in 2011 during a police surveillance operation. The inquest into Mark’s death, which followed a criminal trail, concluded he was lawfully killed despite finding that he was unarmed at the time. The IPCC and the Metropolitan Police Service each issued an apology for the way it dealt with Mark’s family in the aftermath of the shooting. Recent independent forensic investigations have cast doubt into official accounts of the shooting, particularly the IPCC finding that Mark was holding or throwing away a gun.
Prince Fosu MEDIA RELEASE
Prince Fosu, 31, died at Harmondsworth Immigration Removal Centre in October 2012. The inquest in 2020 concluded finding neglect contributed to his death, with serious failures by the Home Office and across all the agencies in immigration detention, as well as failures by police who sent him there. The medical cause was sudden death following hypothermia, dehydration and malnourishment in a man with psychotic illness. Over the six days in detention, purported checks showed no positive evidence that Prince had eaten, drunk or slept and that he was naked. His bedding had been removed on the first day, and there was nothing else in his room save for it being smeared with his own faeces, urine and food debris. Despite his condition, Prince was not referred for a mental health assessment and his capacity to control his behaviour was not even considered. In 2017 the CPS announced that criminal charges would be brought against the Harmondsworth providers at the time, GEO and Primecare, under the Health and Safety at Work Act, but this decision was reversed in 2018.
Tyrone Givans MEDIA RELEASE
Tyrone Givans, 32 died at HMP Pentonville in 2018. He was profoundly deaf and had been at the prison for under three weeks, for the most part without access to hearing aids. He had a history of alcohol dependency, depression and recent self-harm. No reasonable adjustments were made to accommodate his disability and an ACCT was not opened. Tyrone asked to move wings and reported feeling unsafe. His mattress had been slashed and he was unable to sleep as he couldn’t hear if people were approaching. The jury found multiple critical failings contributed to his self-inflicted death.
Annabella Landsberg MEDIA RELEASE
Annabella Landsberg, 45, died in 2017, following severe dehydration and organ failure relating to Type 2 diabetes. Annabella was critically unwell, lying unresponsive on the floor of her cell at HMP Peterborough for 21 hours with prison and healthcare staff failing to recognise her condition. A nurse was called to assess Annabella but instead of conducting any physical observation, threw a cup of water over Annabella believing her to be faking illness. The inquest jury highlighted a catalogue of serious failures in the management and healthcare systems at the Sodexo run prison.
Olaseni Lewis MEDIA RELEASE
Olaseni (Seni) Lewis, 23 died following prolonged restraint by Metropolitan Police officers at Bethlem Royal Hospital in 2010. In 2017 an inquest jury unanimously condemned the actions of police and healthcare staff who watched on as Seni was restrained by 11 police officers. The inquest found the force used was excessive, disproportionate, and contributed to Seni’s death.
Police officers involved in the restraint of Seni told the inquest: “The sound and tone didn't suggest he had difficulty in breathing, more something on the inside of him, an aggression and a ferociousness that couldn't be controlled." “We didn't immediately call a doctor [when he became unresponsive] because we weren't 100 per cent sure if he was definitely unconscious or not breathing. We left the room in case he was feigning, passing out as a ploy to escape.”
Gross misconduct charges against six officers were dismissed, and no officer was charged. The family and supporters campaigned for ‘Seni’s Law’, the Mental Health Units (Use of Force) Act, which received Royal Assent in 2018, and intends to protect patients in mental health settings from harmful use of force in future (though commencement and guidance is awaited).
Jimmy Mubenga MEDIA RELEASE
Jimmy Mubenga, 46 died following face-forward restraint in 2010 by three G4S security guards on a British Airways flight from Heathrow airport to Angola. In 2013 a jury concluded that Jimmy was unlawfully killed and that the security guards had used “unreasonable force” against him. Further, during the inquest it was revealed that despite repeatedly asking for help whilst being restrained Jimmy was given none, he died in his seat at approximately 20.24pm before the paramedics boarded the aircraft at 20.38pm. Extreme racist texts were found on two of the guards’ phones forwarded to friends and colleagues. The coroner concluded in a Prevention of Future Deaths report that there was an ‘unhealthy culture’ in the G4S workforce and ‘endemic racism’. In 2014, following a six week trail in which three G4S guards were charged with manslaughter, all were cleared.
Mikey Powell MEDIA RELEASE
Mikey Powell, 38 died during a violent restraint by West Midlands police officers in 2003. Mikey was experiencing a severe psychotic episode when police officers were called. On arrival officers drove a police car at Mikey knocking him down, then beat him with batons and used CS spray. Despite being injured Mikey was driven to a police station instead of a hospital, during this journey he was restrained face down on the floor of the police van. He died of positional asphyxia.
Sarah Reed MEDIA RELEASE
Sarah Reed, 32, died in 2016 at HMP Holloway. She had been held on remand for over three months, solely for the purpose of obtaining two psychiatric reports to confirm whether she was fit to plead, for an alleged offence which took place whilst she was a sectioned inpatient at a mental health unit. The inquest concluded that her death was self-inflicted, and that unacceptable delays in psychiatric assessment and failures in care contributed. Sarah had been previously assaulted by a police officer in 2012, an experience which aggravated her mental ill health.
Sean Rigg MEDIA RELEASE
Sean Rigg, 40 died of a cardiac arrest following restraint by Metropolitan police officers in 2008 when he was experiencing a mental health crisis. In 2012 the inquest uncovered a litany of failures by mental health services and the Metropolitan police. The jury found that the restraint lasted approximately eight minutes, and that Sean was in the prone position ‘throughout the entire restraint’. They also found that the police ‘failed to identify that Sean was a vulnerable person at point of arrest’ and he was therefore taken to the police station instead of an A&E department or Section 136 suite, ‘despite information about him being readily available and accessible’. Whilst Sean was in custody ‘the police failed to uphold his basic rights and omitted to deliver the appropriate care’. In the ten years which followed Sean’s death, multiple investigations and legal proceedings took place, including an independent external review of the IPCC investigation into Sean’s death (the Casale review) which was highly critical of the original investigation, a criminal trail into perjury by officers involved, and gross misconduct charges directed by the IOPC which were ultimately dismissed. To date no officer has been held to account and the family continue to campaign for justice.
Azelle Rodney MEDIA RELEASE
Azelle Rodney was shot dead while seated in the back seat of a car during a police stop in 2005. Azelle was shot eight times by an officer from no more than two metres away. The officer said he believed Azelle was reaching for, and preparing to fire, a machine gun. The public inquiry, held seven years after his death, concluded that he was unlawfully killed.
 INQUEST provides expertise to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes deaths in prison and police custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question. INQUEST’s Executive Director, Deborah Coles, sits on the cross-government Ministerial Board on Deaths in Custody and is a member of the Independent Advisory Panel on Deaths in Custody.
 We focus particularly on Article 2 (the right to life), Article 3 (the prohibition of torture and inhuman and degrading treatment) and subsequently Article 14 (the protection of all rights without discrimination)
 This is elaborated further in Deborah Coles’ chapter in Justice Matters https://www.lag.org.uk/?id=208817
 These include the Stephen Lawrence Inquiry (1997), the Independent Inquiry into the death of David Bennett (2003), Zahid Mubarek Inquiry (2006), Casale Review (2013), The Angiolini Review (2017) and the Independent Review of the Mental Health Act (2018); The Harris Review (2015).
 See, among others, INQUEST’s submission to the UN Regional Meeting on the International Decade for People of African Descent, 2017: https://www.ohchr.org/Documents/Issues/Racism/WGEAPD/RegionalMeetingEurope/Deborah%20Coles%20Paper%20-%20JUSTICE.pdf
 Dame Elish Angiolini QC (30 October 2017), Deaths and serious incidents in police custody, paragraph 1.8, available: https://www.gov.uk/government/publications/deaths-and-serious-incidents-in-police-custody INQUEST’s Deborah Coles was expert advisor to the review.
 INQUEST held an online Family Consultation Café on the 2 September 2020 with eight family members whose relatives had died between 2008 and 2019 across different state settings including police custody, prison, and in mental health detention.
 An unannounced inspection of HMYOI Feltham A in January 2019 recommended that “Consultation arrangements for children with protected characteristics should be formalised and consistent so that children can express their distinctive views and their specific concerns can be addressed.” (https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2019/06/Feltham-A-CYP-Web-2019.pdf para 2.50). The Action Plan said it had been completed https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2019/06/Action-Plan-Feltham-A-FINAL-DRAFT-Agreed.pdf (para 5.28) but at the following announced inspection six months later, HMIP said no progress had been made and the recommendation was repeated https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2019/10/Feltham-A-Web-2019.pdf (para 2.48).
 https://www.judiciary.uk/wp-content/uploads/2020/08/guidance-no-5-reports-to-prevent-future-deaths.pdf para 47.
 Home Office (2017) Deaths and serious incidents in police custody: government response https://www.gov.uk/government/publications/deaths-and-serious-incidents-in-police-custody-government-response. In the government’s response to the review in 2017 ethnicity is only referenced in relation to data being collected and published in relation to police use of force. See also Department of Health and Social Care, Home Office and Ministry of Justice (2018) Deaths in police custody: progress update https://www.gov.uk/government/publications/deaths-in-police-custody-progress-update
 Including that IPCC investigators should consider if discriminatory attitudes have played a part in restraint related death, that national policing bodies and police forces should implement mandatory and refresher training on the nature of race issues to confront discriminatory assumptions and stereotypes and that police training should include an understanding of institutional racism.
 The government responded to a parliamentary question in January 2020 (https://questions-statements.parliament.uk/written-questions/detail/2020-01-15/3763) saying they will be publishing a White Paper which will set out the Government’s response to Sir Simon Wessely’s Independent Review of the Mental Health Act. This is awaited.
 Specifically, “to establish the extent (if any) to which the events leading up to and following Mr Bayoh’s death, in particular the actions of the officers involved, were affected by his actual or perceived race and to make recommendations to address any findings in that regard” https://www.parliament.scot/S5_HealthandSportCommittee/General%20Documents/20200521CSJtoMMSheku_Bayoh.pdf
 Data on the deaths of Black people in mental health setting is not publically available as the CQC does not disaggregate the ethnicities within ‘Black and Minority Ethnic’ https://www.cqc.org.uk/sites/default/files/20200206_mhareport1819_report.pdf
 As recommended in our 2015 report Deaths in Mental Health Detention: An investigation framework fit for purpose? https://www.inquest.org.uk/deaths-in-mental-health-detention
 See HMIP annual report 2018-19 p29 https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2019/07/6.5563_HMI-Prisons-AR_2018-19_WEB_FINAL_040719.pdf
 Care and Quality Commission (2019) Monitoring the mental health act in 2018/2019 https://www.cqc.org.uk/sites/default/files/20200206_mhareport1819_report.pdf
 This recommendation has been previously endorsed by the Joint Committee on Human Rights in the interim report on Mental Health and Deaths in Prison (2017) https://publications.parliament.uk/pa/jt201617/jtselect/jtrights/893/893.pdf
 Ministry of Justice (2020) Stop and Search https://www.ethnicity-facts-figures.service.gov.uk/crime-justice-and-the-law/policing/stop-and-search/latest#by-ethnicity
 Care and Quality Commission (CQC) (2019) Monitoring the mental health act https://www.cqc.org.uk/sites/default/files/20200206_mhareport1819_report.pdf
 Ministry of Justice (2020) Prison Population: 20 June https://www.gov.uk/government/statistics/offender-management-statistics-quarterly-january-to-march-2020--2
 According to the 2011 National Census https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/national-and-regional-populations/population-of-england-and-wales/latest#by-ethnicity
 Home Office (2019) Police use of force statistics, England and Wales: April 2018 to March 2019 https://www.gov.uk/government/statistics/police-use-of-force-statistics-england-and-wales-april-2018-to-march-2019
 HM Chief Inspector of Prisons for England and Wales Annual Report 2018-2019 https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2019/07/6.5563_HMI-Prisons-AR_2018-19_WEB_FINAL_040719.pdf
 HMPPS (2019) Equality Analysis, Use of Force http://www.prisonreformtrust.org.uk/Portals/0/Documents/PAVA/Use%20of%20Force%20Equality%20Analysis.pdf; further demonstrated in a report by Runnymede and the University of Greenwich (2017) which analysed the use of force data at one adult prison and found it was much higher amongst those of Black ethnicity (5.4 per 100 amongst Black prisoners compared to 1.7 per 100 White) (p23)
 INQUEST casework and monitoring 2020
 Deborah Coles (2019) Failing healthcare in jails is killing female prisoners https://www.theguardian.com/commentisfree/2019/apr/05/healthcare-jails-killing-female-prisoners-black-women-annabella-landsberg