Your Details Name Prefix SelectMrsMsMrDrRt HonSirDameRt Hon SirLadyRt Hon DameRt Hon LadyLordBaronessLord BishopBishop 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 Details of the Deceased First Name Last Name Your relationship to the deceased Age 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 Please include any relevant locations prior to death such as a prison, police station or hospital Date of death 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 Was the deceased detained or in custody at their time of death? Yes No In which setting was the deceased detained? Under Section Informal/Voluntary Patient Police Station Police Contact Youth Detention Immigration Detention Prison Other Please provide the setting for detention Brief summary of circumstances Is COVID-19 considered to be a ’direct’ cause of their death?? e.g. if the medical cause of death is COVID-19 or associated to the physical symptoms of COVID-19 Yes No Maybe Is COVID-19 considered to be an ’indirect’ cause of their death? e.g. where the deceased did not die directly of COVID-19 but received insufficient mental or physical health care due to additional pressures on systems in response to COVID-19 Yes No Maybe Do you have legal representation? Yes No If so, please state their name and firm/chambers How did you hear about INQUEST? Please SelectCoroner’s officeIOPCPPOCQCNHS TrustOther organisation (please specify)LawyerMedia reportsJournalistInternet SearchWord of mouthOther (please state)UnknownCan’t remember Please specify Would you like a free INQUEST Handbook? The handbook is a family guide to the inquest process freely available to anyone bereaved and facing an inquest. Yes No Handbook update in relation to COVID19: Please note that whilst the INQUEST office is closed, handbooks will only be available online. You can download a copy for free here: https://www.inquest.org.uk/useful-resources 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 Other (Please specify) Would you like to sign-up to our INQUEST Newsletter? To help us improve our service, can we send you a feedback survey? 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