‘The Inquest’ and the fight for answers after a care leaver dies

Most of us still needed someone to turn to when we’re 18. A place to stay. Help with a bill. Someone who’ll pick up the phone when things go wrong. Yet for young people leaving care, support can fall away just as they’re being asked to manage more on their own.In The Inquest, a new play at The Big House, David has spent three years trying to find out what happened to Jordan, the young man he thought of as his son. The story follows a foster father through his grief and into a coroner’s court. It asks a question that goes well beyond one family. When several services are involved in a young person’s life, who takes responsibility for making sure they get the help they need?Counter Culture spoke to writer James Meteyard about the gap between finding out how someone died and getting anything done about the failures their death exposed. We also asked how young people with experience of care helped shape the play, and what they could tell him about the way services work that he’d never have found in a policy document.

Counter Culture: The figures behind this play are genuinely shocking. A government-commissioned review published in August found that 112 care leavers aged between 18 and 24 died in England during 2025, with around 40 deaths thought to be suicides. These are young people who were, at some point, under the protection of the state. When you started researching The Inquest, what disturbed you most? Was it the individual tragedies, or the discovery that similar institutional failures seemed to be happening repeatedly?

James: I found both the individual tragedies and the repeated failures really disturbing. Young people in care have the potential to do extraordinary things, as we constantly see here at The Big House, so when their lives are cut short, it’s genuinely heartbreaking. In many of the cases I researched ahead of writing the play, I saw the same pattern of failures from the same organisations, in regional branches across England. What was most horrific was that they seemed to be preventable failures: not following procedure, staffing shortages, improper handovers… And the other recurrent theme was that these failures took place around this care ‘cliff edge’ at 18, where support drastically reduces during a key transitional phase. The fact that institutions could have prevented so many deaths is both shocking and sad.

Counter Culture: Most young people don’t suddenly become independent when they turn 18. They still rely on their parents for somewhere to live, financial support, advice and sometimes just a shoulder to cry on. Yet we expect young people leaving care, often with traumatic childhoods behind them, to manage on their own with much less of that support. Legally, assistance can continue until 25, but the reality appears very different. Why do you think we’ve created a system that places such enormous expectations on some of our most vulnerable young people?

James Meteyard

James: I don’t think many people believe that 18 is truly the age that you magically become an adult – it’s when you begin the journey of aging out of adolescence. However, care-leavers are prematurely ‘adultified’ by society. There’s some great research published by the Better Care Network on accelerated adulthood for care-leavers, which shows how care-leavers are expected to adapt, build an income, live alone, and support themselves, versus their peers who enjoy an ‘extended adolescence’. In some ways, we hold care-leavers to more traditional standards of what turning 18 meant, versus young people who haven’t been in care. Ultimately, I think this accelerated, compressed adultification comes down to money and resources at the root of it. Society chooses to view our vulnerable young people as adults to avoid spending more money on them, which is both infuriating and incredibly sad.

Counter Culture: Your central character, David, is a foster father who’s lost the young man he regarded as his son. He’s spent three years fighting for answers, only to find himself up against the legal machinery of the coroner’s court. There’s something particularly cruel about having to battle institutions while you’re grieving. What interested you about telling the story through the eyes of a foster father, and how much of the drama comes from the gap between what David believes is morally right and what the system is legally required to do?

James: A lot of the play’s drama comes down to that gap, to be honest! I spoke with a very inspiring foster dad during the writing process who kindly shared lots of his experience of the system – although we’ve been careful to not put any of his story directly in the play. I was very inspired by him and his belief in what he was doing, and the love and care he clearly showed to the various children that he’d fostered. But what struck me was his absolute frustration with the rigidity of the system, the complexity, the layers of red tape, the monitoring, the assessments.

I think that balance of frustration and belief drew me to the character of a foster dad. David’s idealistic nature gives a voice to the idea that change is and should be possible, but the drama comes from the reality being very different. It aims to champion someone who is not taking an easy route but who also isn’t perfect themselves. Parenting in general is tough, and foster parents take on that alongside everything that a young person in care has been and will go through, along with safeguarding, red tape and assessments. Add in the pain of losing a child and that’s where this idea of the wrestling between grief and institutional fight came into the work.

I also spoke at length with our partner, the charity INQUEST. They mentioned how much closure an inquest can bring to somebody who is desperately searching for facts on how their loved one died. Ultimately, somebody searching to find answers in order to process their own grief is a really important and emotional process that felt like it could dramatically drive a powerful play.

Counter Culture: One of the things that strikes me about these cases is the way responsibility can be divided between so many organisations. You’ve got social services, mental health teams, housing providers, the NHS and sometimes the police. Each may have followed its own procedures, yet the young person they were supposed to help is still dead. Is that the central problem you’re exploring: a system in which everybody can claim to have done their job, but nobody takes responsibility for the overall outcome?

James: It’s exactly that. The Inquest explores a fragmented system of multiple services all acting in isolation, resulting in a lack of coordinated information sharing. Don’t get me wrong, I am very grateful that we even have a system in place, and the system can work very well when it receives someone who ‘cooperates’ in a conventional manner. But the system really struggles when someone with higher needs enters, like some care-leavers, who have complications with their mental health, trauma, housing, and/or isolation, on top of being a teenager out in the world. A huge amount of capacity is needed in order to be able to flex and accommodate somebody who isn’t ‘behaving’ within the parameters that the system has been designed on. A ‘one size fits all’ approach doesn’t work for the many, many young people who need bespoke support. But it’s a big task, it’s not one where we can flick a switch, change a law or one policy, and it’ll solve everything. It takes close analysis of where those gaps are, why these patterns keep repeating, and why people keep falling through those cracks. It’s true that with our current system, everyone can claim to have done their job, but if somebody needs more support than what’s available, this is where services can struggle and the professionals can honestly feel they’ve done all they can within the parameters set. I have empathy for this, but I also feel there are certainly efficiencies that we can improve on to ensure that people don’t get dropped.

Counter Culture: You’ve previously described public services as being rather like faulty railway lines, carrying people from one place to another, sometimes breaking down along the way. I thought that was a striking comparison. But services aren’t simply machines that malfunction. They’re run by people, working within budgets, staffing levels and policies that they may have little control over. How did you approach the distinction between individual failings and wider institutional problems? And do you think there’s a danger that frontline workers end up carrying the blame for decisions made much further up the chain?

James: This was a conversation that Maggie and I had a lot early into the development of the work. When we were designing the story, it was exceptionally important to us that we also pay credit to the many, many, many brilliant people that work within the system who fight day and night, go above and beyond, and care deeply about the individuals who are engaged with their services. Because ultimately, those hard-working people are not in control, and they can be equally as frustrated as we are with the inefficiencies. For many, watching these patterns repeat will be incredibly painful because of their investment and closeness in which they sit to the issues and individuals affected. Maggie and I spent a lot of time researching and speaking to those represented in the play to ensure we’re painting a well-rounded picture of those who exist within these systems – and to champion many of them. We heard many stories of people who went above and beyond to completely transform terrible situations into brilliant ones.

However, it’s important to balance championing the champions without shying away from where things can go wrong. Sometimes that happens because both individuals and services are overstretched, and so therefore simple procedures haven’t been followed. Other times, it’s due to a bigger systemic problem. Unfortunately, sometimes there are cases where individuals themselves are at fault – some people within the system operate with incompetence, carelessness, and a lack of interest. It’s important that the play doesn’t sugarcoat that, but rather looks at every aspect to give an honest picture.

Counter Culture: Inquests are supposed to establish how someone died, and coroners can issue reports intended to prevent future deaths. But establishing what went wrong doesn’t necessarily mean anybody will be held accountable or that things will change. Bereaved families may also find themselves facing organisations with substantial legal resources. Having researched the process, do you think the inquest system gives families a fair opportunity to challenge powerful institutions, or does it need more fundamental reform?

James: An inquest is designed to establish the answers to four questions: who the deceased was, where they died, when they died, and how they came by their death. That fundamental framework is interesting in the sense that it is purely about establishing fact, and not about apportioning blame. So in that sense, it forces legal councils and institutions to really have to prove the facts to loved ones using hard evidence.

Of course, discrepancies can arise, particularly around timelines – for example, had a public body made a decision a few hours earlier, would that have changed the outcome? That allows people to begin to point to faults, and paint a picture of whether this death could have been prevented. Therefore, the process of an inquest itself removes some of the adversarial nature of a criminal proceeding.

When loved ones go up against powerful institutions, they may not have the resources or knowledge to establish the facts and, in the case of care leavers, they may not have family to seek justice for them. This points to why we need incredible organisations like our partner INQUEST, which fights day and night to make sure that families and individuals are well represented. They provide people with resources and free legal counsel through the ILG, preparing them to challenge these systems. Of course, the starting point is disproportionate, as these systems have huge amounts of resources – they’re well-versed in the law and can paint a picture that absolves them of responsibility.

An area that I believe desperately needs reform is how public bodies are mandated to respond to Prevention of Future Deaths Reports. These are documents that coroners often create following an inquest and are intended to highlight systemic problems that pose a risk to public safety. Coroners often make recommendations to public bodies of changes that ought to be made so that the same mistakes don’t reoccur. Worryingly, there is no legal responsibility for an institution to actually act on the PFD report. So a body like a mental health trust or the police, has no requirement to actually change anything – or even to respond. It’s wild that we can go through this whole legal proceeding, failures are identified, the coroner makes a recommendation of change which is possible to be implemented… then nothing happens and there are no repercussions. As it stands, an inquest gives a family an opportunity to get answers, but not justice. A PFD report has to be legally enforceable – it’s a key step towards stopping these patterns from reoccuring.

Families can, of course, open up criminal proceedings to seek justice following faults identified at an inquest. But there is a huge cost both financially and emotionally. Those close to the deceased have already been through an entire proceeding once, reliving testimonies and painful experiences that surrounded their loved one’s death. To then have to go through it all over again in an often adversarial way, where whole cases are built on narratives designed to apportion blame… it’s a lot for anyone to even consider, let alone go through.

Editorial note. Recipients of a Prevention of Future Deaths report must respond within 56 days unless the coroner grants an extension. They can explain why they propose no action. See regulation 29 of the Coroners (Investigations) Regulations 2013.

Counter Culture: The Government published its review of early deaths among care leavers in August and announced £25 million to expand housing and support through its Staying Close programme. We’ve had inquiries, reports and policy announcements before, of course. Sometimes the problem isn’t recognising what needs to be done but actually making it happen. From what you’ve learned, what practical changes would make the greatest difference? Is it principally about funding, better coordination between services, or changing the way we think about our responsibilities towards children who’ve been in care?

James: It’s a combination of all three. More resources are always helpful, but it would be foolish for us to overlook the fact that there is already a huge amount of money spent on our care system. This spending needs to come with a societal change in the attitude towards care leavers, a proper understanding of the challenges and trauma that goes along with a care background, when the early years of your life have been so disrupted. Early trauma has a huge knock on effect on teenage, adolescent and adult years, without the family network that so many other young people in the UK rely on.

On top of all the disruption during the developmental years, it’s really tough to have to transition out of services which have become familiar to you post-18. For example, a young person may have to move out of their children’s home or a care placement into supported accommodation. Sometimes in a completely different area and for a limited period of time. Then, they need to get a bidding number in order to be able to bid for a council flat, whilst having to get to grips with living independently, looking for work, navigating Universal Credit, paying bills, learning to cook and take care of themselves, etc. They’re also trying to be an 18 year old, enjoying life and pursuing their goals in education or training. It’s a huge transitional phase.

Additionally, when a young person is engaged with CAMHS (Child Adolescent Mental Health Services), they are discharged at 18. Sometimes a referral is made to AMHS, but the high thresholds mean that many aren’t accepted, meaning they have to start the process again via their GP. Shockingly, there isn’t a clear up-to-date public dataset on how many successfully transitioned, but we know that many inquests have cited the CAMHS to AMHS transition as a recurring failure. Automatic, guaranteed referral to AMHS, or increasing the number of care-affected young people that get to stay in CAMHS for longer could be a great step for care-leavers during a period of so much other change at 18.

We also need to evaluate police risk registers. Care-leavers aged 18-24 are estimated to be 5 times more likely to take their own lives than the general population. If a care-leaver goes missing, it should automatically go to high risk, particularly if you’ve been engaging with mental health services.

We need coordinated information-sharing, wrap-around systems, and we need to make the system more efficient. 18 is so young to have so much support drop away and to be expected to be independent. Services shouldn’t be allowed to take the easy route out by saying “This person doesn’t meet our threshold.” There has to be enforced crossover in communication between services, allowing them to overlap for an extended period of time. Ultimately, there has to be greater effort from the services to really get to know the young person.

Counter Culture: You’ve worked with The Big House before on productions including Redemption, No Man’s Island and Between the Lines. This production is also being developed through the Open House Project, involving young people with experience of care. I imagine their perspective can be rather different from that of politicians, social workers or theatre critics discussing the subject. How much have the young people themselves shaped The Inquest? Have they challenged your assumptions or taken the story in directions you hadn’t originally anticipated?

James: As with all the work at the Big House, the young people are always at the forefront of the conversation, without ever taking somebody’s personal story and putting it on stage. Instead, we have lots of discussions which inform our work thematically. Sometimes it’s anecdotal conversations through our drop-in sessions where we play drama games and topics arise, sometimes it’s when young people flag recurring issues with the system, and sometimes it’s targeted research where we ask young people to collectively share their thoughts on something. We take themes and patterns that emerge, do our own independent research, and start to build a picture of a story that we think will both resonate with and reflect our members. It has to be a story that our young people are proud to tell. The greatest piece of feedback we can get is that someone feels that our play represents them and feels it’s an important story that needs to be heard. That’s more important than what any critic or audience member can say.

Practically, our young people add a lot during the dramaturgical process. Once we’ve landed on an idea, I speak to as many people in the orbit of The Big House as possible: older members, partners, our network of social care professionals, etc.. The subject matter, the young people and the systems we represent need to be authentic. So all of that real lived experience is fed into the fictional characters we create. And these chats are always brilliant – powerful, joyful, and fun, as well as touching on the challenging aspects as well. Through those conversations, the richness of detail starts to emerge, where we uncover the gap between policy and reality. Online, it says a bidding number is issued within three to nine weeks, our young people tell us that it can take up to two years, or it never comes. These anecdotes all add fundamental layers of detail which make the stories feel real to a young person, even though we’re never telling someone’s story specifically. When one of our actors read a play I wrote for The Big House a few years ago, they said, “I am this character, this is my life.” I’d never met them before they joined the project, but that collective experience around The Big House is so strong that it all gets absorbed into the work osmotically.

When it comes to the acting, members of The Big House can get inside the skin of these characters in a way that a drama school trained actor never could. They’d be pretending, whereas our young people use their lived experience to charge these performances in an exceptionally powerful and compelling way – that can often be highly cathartic.

They also weigh in on the script. During rehearsals, the young people are exceptionally good at flagging when things don’t ring true. Sometimes it’s big things like, “This wouldn’t happen in supported accommodation”, or “that’s not how this process works.” Sometimes it’s seemingly small things like when a word or phrase feels inauthentic. We work together to find something that feels right – it’s those naturalistic ways of speaking that make the play feel real.

It’s the same with characters. The script gets rewritten during rehearsals, around new members, different energies, and their individual qualities, to make sure that the experience and personality matches the actor. It’s quite a unique process, but this collaborative approach to co-creation results in powerful performances by people who know how to bring these characters to life in a way that no one else does.

Counter Culture: The publicity describes The Inquest as a promenade production, with audiences moving from room to room as the story unfolds. What attracted you to that particular form of theatre? Was the intention to make the audience experience something of David’s struggle with different institutions, or were there other dramatic reasons for choosing that approach? And how do you balance creating that emotional involvement with the responsibility not to turn a young person’s death into theatrical spectacle?

James: The Big House is known for big, immersive, prominent productions. Maggie, who co-developed the story and also is directing the play, has a long history of directing extraordinary productions in unusual spaces, from underground car parks to the basements of cinemas. Our home venue in Islington is actually two adjoining Victorian framing factory warehouses, and so that creates a really interesting space itself for an audience to move around.

We’re careful to not use site-specific productions as a gimmick though; it’s reflective of what the show demands. Our spring show, A DoL House, explored Deprivation of Liberty orders and was set in a DoL placement. So, it felt right to set it in one small room, creating an intense atmosphere that authentically reflected the story.

The Inquest, on the other hand, covers a huge journey and is a sprawling story, set around Hackney, Highbury and Arsenal, and across a number of different services. So, it felt natural to lean into our signature style and pull the audience through that journey – David searches for answers, the audience searches for the next scene of the story. It really heightens the immersion, and allows the audience to join David on his journey for answers.

As for not turning a young person’s death into a spectacle, it’s something we’ve constantly wrestled with during the development of the piece. It’s important to avoid unnecessary detail, especially about ‘method’, but you also need to confront the reality that care-leavers are dying young every year, and that we have to talk about it. Art like this has to come back to the advocacy of the piece. If you include the death of a care leaver in the story as a twist, or for shock value, and it wasn’t connected to the work’s purpose, that would be an exploitative way of affecting an audience. But this piece is very much rooted in a mission, and that mission is to change society for the better. This does mean that the death of a young person has to be at the heart of the work. We balance that by bringing the young person to life. We see their wonderful qualities, we become invested in them, and hopefully as a result, invested in all of the young people that have tragically been lost, and in preventing this pattern from continuing. Systems can turn young people into statistics, processes, reports, words on a page. And this play lifts them out of that into someone that the audience will fall in love with. That is how you put the problem in our society at the forefront of people’s mind to hopefully affect meaningful change.

Counter Culture: The Big House has partnered with INQUEST, which has spent decades campaigning for bereaved families and challenging deaths involving state institutions. It seems to me that this makes the production more than a piece of theatre; it’s also an intervention in an important public debate. But there’s always a question about how far art can change things. Would you like The Inquest to make people angry, to encourage them to campaign, or simply to make them see care-experienced young people differently? And if someone with the power to change the system came to see the play, what would you most want them to take away from it?

James: I want all of those things to happen. Of course, I’m not expecting every single audience member that sees the production to go on to the Houses of Parliament and start passing a bill tomorrow to magically solve everything. But I want to raise awareness, and I want an audience to see young people in a completely different light, as real, extraordinary, multi-dimensional, incredible people with so much to offer. So much of the time they are overlooked, just reduced down to a collection of stats or a flag in a system of somebody to worry about, and they’re so much more than that. The Inquest serves a purpose, and that is to create a living, breathing pen portrait of an individual who was failed. It stops being a bunch of numbers about abstract people, and becomes a visceral experience whereby you are suddenly put in the shoes of a young person who needed help, and a foster dad fighting for answers. The Inquest reminds people that we are talking about human lives. That reminder can be what pushes somebody to make change.

We hope that the dramatisation of a social issue in its most authentic form will encourage people to come and see it, to have an experience which opens their eyes to a perspective that they weren’t aware of. The professionals in the audience may then come away from the work thinking, ‘What can I do?’. This can be small changes within the service they work at, big changes at a decision-making level, or huge changes at a government policy level. Maybe it’s just to support INQUEST, who have been fighting this fight for decades, unwavering in their campaign to make it a legal requirement to act on a PFD report. They’ve spent years pushing back against the rigidity of the system, and helped many, many, many families along the way.

But we need more than a few passionate people and a few passionate organisations. We need society to come together and say that this is a problem, and it’s a problem we won’t stand for.

Editorial note:

INQUEST supports families bereaved by deaths involving the state, including deaths in prison, police custody, immigration detention and mental health detention. The charity is independent of government and relies on grants and donations to fund its work.

You can donate directly to INQUEST through their official donation page:

🔗 Donate to INQUEST

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