Deborah Coles, executive director at INQUEST, gave evidence on Monday 12 May 2025. INQUEST is the only charity of its kind nationally, providing expertise on state-related deaths and support to bereaved people as they navigate post-death investigatory processes.
Addressing the families of people who died in Essex mental health care, Deborah Coles spoke about the Inquiry as “testament to your perseverance” and made clear that “it’s vital that your questions are asked and answered and that, through this Inquiry, we see the transformative systemic change that is so needed”.
In her evidence, she repeated the call for a National Oversight Mechanism to oversee and monitor learning and recommendations following state related deaths. Most recently, the pressing need for such oversight has been recognised by the Housing, Communities and Local Government Committee and by the Health Services Investigations Body.
The inquiry is the first into mental health deaths in England and is examining the deaths of inpatients in Essex between 2000 and 2023.
INQUEST is represented by Charlotte Haworth Hird and Amy Ooi at Bhatt Murphy, together with Lily Lewis and Anna Morris KC of Garden Court North.
See INQUEST’s press release here and further information on the National Oversight Mechanism here.
