PRISONS: five self-inflicted deaths at Lowdham Grange prison to be criminally investigated
Anthony Binfield, David Richards, Rolandas Karabauskas, Ricky Crosher and Matthew Osborne all took their own lives within nine months at Lowdham Grange prison. Following a damning inquest into Matthew’s death, the coroner has now referred their deaths to Nottinghamshire police for a criminal investigation.
Jasmine Osborne spoke to Channel 4 News about how prison officers played football and joked around instead of carrying out welfare checks on her brother Matthew.
Self-inflicted deaths in prison are on the rise across the country.
Gareth Chumber-Kelly, 33, died a self-inflicted death only four days after being remanded to HMP Pentonville. Now an inquest has found that multiple failures including a failure to refer him for appropriate mental health care contributed to his death.
Saroj Chumber, Gareth’s mother, said:
“My son Gareth came round for dinner on Wednesday, was arrested on Thursday, taken to Pentonville prison on Friday and died on Monday. Gareth was handed a death sentence without even having been found guilty.”
An inquest jury found that a trans prisoner's indefinite sentence “was likely the most significant factor contributing to the feelings of despair and mental exhaustion” that led to his suicide in July 2022. Taylor Atkinson died in HMP Eastwood Park, in South Gloucestershire; and is thought to have been the last remaining IPP prisoner in the women’s prison estate that had never been released.
Our recent report, Built to Harm, shows that people like Taylor would still be alive today if the government had listened to calls from campaigners and years of evidence to close women’s prisons.
INQUEST's Jessica Pandian wrote to the Guardianabout how violence is part and parcel of how prisons operate. She argues that 'there are no “good prisons” and there never will be. To end the cycle of violence, the government must cease prison building, reduce the prison population and invest in community-based services to prevent contact with the criminal justice system in the first place.
POLICE: families disappointed by police misconduct decisions for firearms officers
The Independent Office for Police Conduct (IOPC) has reversed a previous decision that the West Midlands firearms officer who killed Sean Fitzgerald in 2019 has a case to answer for gross misconduct. Sean was unarmed, holding a black mobile phone as he exited the property.
Liam Fitzgerald, Sean’s brother, said:
“This decision by the IOPC is very disappointing. We strongly disagree and believe that Officer K should face a gross misconduct hearing.
It has been 7 years since Sean was killed and our faith in the IOPC has continuously been eroded. We now want to close the door on this chapter and remember Sean for the fun-loving person that he was and not the manner in which he died.”
The IOPC have also announced that they have decided to put on hold gross misconduct proceedings against the Metropolitan Police firearms officer who killed Chris Kaba.
Chris Kaba, a 24 year old Black man, was fatally shot by Martyn Blake, a firearms officer from the Metropolitan Police on 5 September 2022 in Streatham, London. Like Sean, Chris was unarmed. The decision followed a private letter sent by the Metropolitan Police to the watchdog in November, without the family’s knowledge.
Chris family said:
“We are devastated that the IOPC has decided under this kind of police pressure to put on hold the preparations for Martyn Blake’s gross misconduct proceedings.
To not involve us until after a decision to pause has been made is deeply disappointing and has damaged our confidence in the independence of the IOPC. The lack of consideration shown to us in this process adds to our trauma and our sense of injustice.”
New research by the University of Manchester and the Institute of Race Relations highlights the tragedy of premature deaths of young racially minoritised and working-class teenagers, often following police pursuits for minor traffic violations and/or alleged non-violent offences.
MENTAL HEALTH: bereaved families write poem to Sussex NHS Trust CEO
Ellame Ford-Dunn was 16 years old when she died after absconding and ligaturing whilst a mental health inpatient at Worthing Hospital. Now an inquest jury has found that a series of failings including the inadequate provision of beds for children with mental ill health in Sussex contributed to Ellame’s death.
Ellame’s parents Nancy and Ken are part of a group of families bereaved by deaths in Sussex mental health services. SPFT Bereaved Families Unite published a poem in response to a LinkedIn post by the CEO of the Trust.
“How many times are you going to ask the same question? Til the cows come home, we silently vow Til the cows come home The morning after the night before The first day a mother wakes to a world Where her child does not.”
HILLSBOROUGH LAW: families disappointed by further delay
The government has delayed the progress of Hillsborough Law following concerns from families involved in the campaign. The Public Office (Accountability) Bill, which bereaved families, victims, INQUEST and many campaigners have been pushing for, will force a duty of candour on public officials to reveal vital information following disasters and state related deaths.
Bereaved families met with Keir Starmer for urgent talks in London, reminding him of his promise to not water down the Bill and that it must apply to all public servants and public officials. INQUEST fully supports the families in their fight to make all officials be held accountable when things go wrong.
“The duty of candour must apply in full to security and intelligence services and every public service so that no institution can hide behind secrecy.”
Scotland: review into Fatal Accident Inquiry system takes on recommendations from families
We were encouraged to see that all eight recommendations made by families in our A Brutal System Family Listening Day Report were echoed in Sheriff Principal Ian Abercrombie KC’s independent review of the Fatal Accident Inquiry (FAI) system.
Key recommendations adopted from families include:
Legal Aid: immediate access to legal aid for bereaved families after a death in custody.
Advice & advocacy: clear information for families about their rights and processes.
FAI reform: timely investigations and inquiries, and improved training for Sheriffs on FAIs and Article 2.
Pen portraits: engaging with families about whether they wish to provide a pen portrait, and ensuring it is handled sensitively.
Oversight: establishing an independent mechanism with the power to ensure recommendations lead to meaningful change.
OTHER NEWS: the Roger Sylvester Centre
We attended the launch of the Roger Sylvester centre, a multipurpose centre offering a crisis prevention house, safe haven crisis hub and recovery college in Wood Green.
A very emotional inspiring event, this marks the culmination of a 26 year justice campaign. The centre ensures that Roger's memory lives on and offers a community based alternative to policing.
We held the final session of our Memorial Working Group, reflecting on a year of collaborative work on the UNJUST DEATHS project. Over six online meetings and two in‑person workshops, the group helped shape every stage of the project, creating the Memorial Survey and analysing 185 responses, producing the Memorial Zine launched at the Preventable exhibition, supporting the appointment of Bezna as Artist in Residence, and developing the Shine a Light memorial events guidance.
Last year, eight Shine a Light events took place across Glasgow, Edinburgh, London, Birmingham, Manchester and Newport. These small gatherings brought together existing communities, providing space to connect personal experiences of state violence and collective resilience.
We are deeply grateful to the group for their creativity, warmth and critical insight, and we hope to find future opportunities to work together.
Family Updates
Upcoming events and activities for families who have worked with INQUEST, past and present.
Please note: These events are not public, so please only sign up if the above applies to you.
Workshops
We're changing how we work and are bringing you a range of workshops to help you prepare for your inquest. Find out more below!
Attending an inquest can be daunting and overwhelming. This workshop will teach you about what happens during inquest hearings and how you can best prepare.
Online
Thurs 26 Feb 5-6.30pm
Inquests and the press
An introduction to how the media works, with guidance on getting coverage if you want it, and keeping your distance if you don’t.
Online
Thurs 19 Mar 6.30-8pm
Focusing on the change you want to see
We'll be thinking about what change means to you, and where to focus your energy.
Online
Thurs 2 April 6.30-8pm
INQUEST Campaigns
An introduction to our ongoing campaigns: No More Deaths Hillsborough Law.
Online
Thurs 16 April 6.30-8pm
Parliament & You Learn how parliament works and how to make change happen.
Online
Thurs 30 April 6.30-8pm
Getting your message across
All about how to communicate your demands and calls for change.
Online
Connection Cafes - online events
The regular connection cafes are an online space for families supported by INQUEST, past or present, to come together, share, reflect, connect and build community, in a facilitated space.
Morning - Second Wednesday of every month (10:30am-12pm). To attend the event on 11 March email momansfield@inquest.org.uk
Evening - Fourth Wednesday of every month (6:30pm-8pm). To attend the event on 25 February, email momansfield@inquest.org.uk
Every year, INQUEST supports hundreds of families bereaved by deaths involving the state. We are independent of government and entirely reliant on grants and donations to continue our vital work.
Support us and bereaved families in the fight for truth, justice and accountability by becoming a regular donor today.
Newsletter: February 2026
The INQUEST Newsletter provides regular updates about our far-reaching policy, parliamentary, campaigning and media work.
Contents
Prisons: five self-inflicted deaths at Lowdham Grange prison to be criminally investigated
Police: families disappointed by police misconduct decisions for firearms officers
Hillsborough Law: families disappointed by further delay
Scotland: review into Fatal Accident Inquiry system takes on recommendations from families
Other news: The Roger Sylvester Centre
Family updates: upcoming workshops and events
PRISONS: five self-inflicted deaths at Lowdham Grange prison to be criminally investigated
Anthony Binfield, David Richards, Rolandas Karabauskas, Ricky Crosher and Matthew Osborne all took their own lives within nine months at Lowdham Grange prison. Following a damning inquest into Matthew’s death, the coroner has now referred their deaths to Nottinghamshire police for a criminal investigation.
Jasmine Osborne spoke to Channel 4 News about how prison officers played football and joked around instead of carrying out welfare checks on her brother Matthew.
Self-inflicted deaths in prison are on the rise across the country.
Gareth Chumber-Kelly, 33, died a self-inflicted death only four days after being remanded to HMP Pentonville. Now an inquest has found that multiple failures including a failure to refer him for appropriate mental health care contributed to his death.
Saroj Chumber, Gareth’s mother, said:
She spoke to ITV news about how Pentonville must be shut down to prevent further deaths.
An inquest jury found that a trans prisoner's indefinite sentence “was likely the most significant factor contributing to the feelings of despair and mental exhaustion” that led to his suicide in July 2022. Taylor Atkinson died in HMP Eastwood Park, in South Gloucestershire; and is thought to have been the last remaining IPP prisoner in the women’s prison estate that had never been released.
Our recent report, Built to Harm, shows that people like Taylor would still be alive today if the government had listened to calls from campaigners and years of evidence to close women’s prisons.
INQUEST's Jessica Pandian wrote to the Guardian about how violence is part and parcel of how prisons operate. She argues that 'there are no “good prisons” and there never will be. To end the cycle of violence, the government must cease prison building, reduce the prison population and invest in community-based services to prevent contact with the criminal justice system in the first place.
POLICE: families disappointed by police misconduct decisions for firearms officers
The Independent Office for Police Conduct (IOPC) has reversed a previous decision that the West Midlands firearms officer who killed Sean Fitzgerald in 2019 has a case to answer for gross misconduct. Sean was unarmed, holding a black mobile phone as he exited the property.
Liam Fitzgerald, Sean’s brother, said:
The IOPC have also announced that they have decided to put on hold gross misconduct proceedings against the Metropolitan Police firearms officer who killed Chris Kaba.
Chris Kaba, a 24 year old Black man, was fatally shot by Martyn Blake, a firearms officer from the Metropolitan Police on 5 September 2022 in Streatham, London. Like Sean, Chris was unarmed. The decision followed a private letter sent by the Metropolitan Police to the watchdog in November, without the family’s knowledge.
Chris family said:
New research by the University of Manchester and the Institute of Race Relations highlights the tragedy of premature deaths of young racially minoritised and working-class teenagers, often following police pursuits for minor traffic violations and/or alleged non-violent offences.
MENTAL HEALTH: bereaved families write poem to Sussex NHS Trust CEO
Ellame Ford-Dunn was 16 years old when she died after absconding and ligaturing whilst a mental health inpatient at Worthing Hospital. Now an inquest jury has found that a series of failings including the inadequate provision of beds for children with mental ill health in Sussex contributed to Ellame’s death.
Ellame’s parents Nancy and Ken are part of a group of families bereaved by deaths in Sussex mental health services. SPFT Bereaved Families Unite published a poem in response to a LinkedIn post by the CEO of the Trust.
“How many times are you going to ask the same question?
Til the cows come home, we silently vow
Til the cows come home
The morning after the night before
The first day a mother wakes to a world
Where her child does not.”
Read the full poem
HILLSBOROUGH LAW: families disappointed by further delay
The government has delayed the progress of Hillsborough Law following concerns from families involved in the campaign. The Public Office (Accountability) Bill, which bereaved families, victims, INQUEST and many campaigners have been pushing for, will force a duty of candour on public officials to reveal vital information following disasters and state related deaths.
Bereaved families met with Keir Starmer for urgent talks in London, reminding him of his promise to not water down the Bill and that it must apply to all public servants and public officials. INQUEST fully supports the families in their fight to make all officials be held accountable when things go wrong.
Speaking to ITV News, our director Deborah Coles said:
Read our latest briefing
Scotland: review into Fatal Accident Inquiry system takes on recommendations from families
We were encouraged to see that all eight recommendations made by families in our A Brutal System Family Listening Day Report were echoed in Sheriff Principal Ian Abercrombie KC’s independent review of the Fatal Accident Inquiry (FAI) system.
Key recommendations adopted from families include:
OTHER NEWS: the Roger Sylvester Centre
We attended the launch of the Roger Sylvester centre, a multipurpose centre offering a crisis prevention house, safe haven crisis hub and recovery college in Wood Green.
A very emotional inspiring event, this marks the culmination of a 26 year justice campaign. The centre ensures that Roger's memory lives on and offers a community based alternative to policing.
We held the final session of our Memorial Working Group, reflecting on a year of collaborative work on the UNJUST DEATHS project. Over six online meetings and two in‑person workshops, the group helped shape every stage of the project, creating the Memorial Survey and analysing 185 responses, producing the Memorial Zine launched at the Preventable exhibition, supporting the appointment of Bezna as Artist in Residence, and developing the Shine a Light memorial events guidance.
Last year, eight Shine a Light events took place across Glasgow, Edinburgh, London, Birmingham, Manchester and Newport. These small gatherings brought together existing communities, providing space to connect personal experiences of state violence and collective resilience.
We are deeply grateful to the group for their creativity, warmth and critical insight, and we hope to find future opportunities to work together.
Family Updates
Upcoming events and activities for families who have worked with INQUEST, past and present.
Please note: These events are not public, so please only sign up if the above applies to you.
Workshops
We're changing how we work and are bringing you a range of workshops to help you prepare for your inquest. Find out more below!
To register, please email Mo Mansfield, or contact your caseworker.
5-6.30pm
Attending an inquest can be daunting and overwhelming. This workshop will teach you about what happens during inquest hearings and how you can best prepare.
Online
5-6.30pm
An introduction to how the media works, with guidance on getting coverage if you want it, and keeping your distance if you don’t.
6.30-8pm
We'll be thinking about what change means to you, and where to focus your energy.
Online
6.30-8pm
An introduction to our ongoing campaigns: No More Deaths Hillsborough Law.
Online
6.30-8pm
Learn how parliament works and how to make change happen.
6.30-8pm
All about how to communicate your demands and calls for change.
Connection Cafes - online events
The regular connection cafes are an online space for families supported by INQUEST, past or present, to come together, share, reflect, connect and build community, in a facilitated space.
Morning - Second Wednesday of every month (10:30am-12pm). To attend the event on 11 March email momansfield@inquest.org.uk
Subscribe to the INQUEST newsletter
Make a Donation
Every year, INQUEST supports hundreds of families bereaved by deaths involving the state. We are independent of government and entirely reliant on grants and donations to continue our vital work.
Support us and bereaved families in the fight for truth, justice and accountability by becoming a regular donor today.
Donate now
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