Your Details Name Prefix SelectMrsMsMrDrProfRt HonSirRt Hon SirDameRt Hon DameLadyRt Hon LadyLordBaronessBishopLord Bishop First Name Last Name Contact telephone number Please include international dialling code for non-UK telephone numbers Street Address Street Address Line 2 City Postcode County (UK only; please leave blank for other countries) Email Which of the following best describes your ethnic background? As a charity, monitoring is required by our funders. It also enables us to adequately develop services best suited to the diversity of the families we support. - Select -ArabAsian - any otherAsian - BangladeshiAsian - ChineseAsian - IndianAsian - PakistaniBritish AsianBlack - AfricanBlack - CaribbeanBlack - BritishBlack - Any otherMixed - Any other / Multiple EthnicMixed - White & AsianMixed - White & Black AfricanMixed - White & Black CaribbeanWhite - Any otherWhite - IrishPrefer not to sayUnknownAny other ethnic groupWhite - English/N.Irish/Scottish/Welsh/BritishWhite - Gypsy/ Irish Traveller Do you have any access requirements you would like us to be aware of? How did you hear about INQUEST? Please SelectCoroner’s officeIOPCPPOCQCNHS TrustOther organisation (please specify)LawyerMedia reportsJournalistInternet SearchWord of mouthOther (please state)UnknownCan’t remember Details of the Deceased First Name Last Name Your relationship to the deceased Age of the deceased Date of birth of the deceased Gender of the deceased - Select -FemaleMaleNon-BinaryGender-fluidOtherPrefer not to sayUnknownMultipleTransgender Ethnicity of the deceased As a charity, monitoring is required by our funders. It also enables us to adequately develop services best suited to the diversity of the families we support. SelectArabAsian - BangladeshiAsian - ChineseAsian - IndianAsian - PakistaniBritish AsianAsian - any otherBlack - AfricanBlack - BritishBlack - CaribbeanBlack - Any otherMixed - White & AsianMixed - White & Black AfricanMixed - White & Black CaribbeanMixed - Any other / Multiple EthnicWhite - IrishWhite - Any otherAny other ethnic groupPrefer not to sayUnknownWhite - English/N.Irish/Scottish/Welsh/BritishWhite - Gypsy/ Irish Traveller Please provide ethnicity details Case Details Place of death e.g. which prison, mental health hospital, police station or other establishment was the deceased in at the time of their death? Date of death Was the deceased detained or in custody at their time of death? Yes No Don't know In which setting was the deceased detained? Under Section Informal/Voluntary Patient Police Station Police Contact Youth Detention Immigration Detention Prison Other Was the deceased’s death self-inflicted? No Yes Don't know Did any of the following play a part in the deceased's death? Alcohol Drugs Restraint / use of force Please provide the setting for detention Brief summary of circumstances including what you have been told about how the deceased died Has the inquest concluded? Yes No Is there an urgent upcoming date? For example upcoming inquests, pre-inquest reviews or post-mortem examinations Yes No Urgent upcoming date Nature of urgent upcoming date Do you have legal representation? Yes No If so, please state their name and firm/chambers Please specify Other (Please specify) You can access a list of Frequently Asked Questions on our website here: https://www.inquest.org.uk/pages/faqs/category/inquest-faqs To help us improve our service, can we send you a feedback survey? Would you like to sign up to our INQUEST Newsletter? Data Policy INQUEST will record the information I provide you (such as name, telephone numbers, email and postal addresses, name of relative etc) for the purpose of the services it provides, including support and advice. • Please read and accept the Data Policy below. Inquest Data Protection & Privacy Policy I accept the Data Policy