Date:
Author: Jessica Jacobson, Professor of Criminal Justice, Birkbeck, University of London
Original article: https://theconversation.com/im-utterly-utterly-despondent-and-disappointed-bereaved-families-describe-being-failed-by-the-inquest-system-247949
This story contains discussion of suicide. All names and some other details of people mentioned in this article have been changed to protect their privacy.
“Up to the age of 12 … she was bright, popular, sporty. Everybody wanted her on their team; everybody wanted her at their party.” But as a young teenager, she “literally changed overnight and became somebody we didn’t recognise”.
Kasia was talking to us about her daughter, Sophia, who began suffering from spiralling mental health issues which led to homelessness and addiction. Kasia also had to deal with a mental health team that didn’t talk to one another (“incompetent people who relied on other incompetent people”). At the age of 28, Sophia took her own life by stepping in front of a train.
“I could see it coming,” Kasia said. “I absolutely knew it was coming and nobody would listen to me, and I think that was, probably, the worst time … It, literally, was coming towards us like a speeding train.”
We interviewed Kasia about what it had been like to attend the coroner’s inquest that followed Sophia’s tragic death. The interview was part of Voicing Loss, an extensive, three-year research project on bereaved people’s experiences of the coroner service in England and Wales, in which we interviewed 190 people with personal or professional experiences of inquests.
Laurel was another bereaved parent who spoke about failings in care. Her son, Finn, had a developmental disability and died at the age of 15 after an accident. Laurel told us:
We had been systematically let down by services for many, many years up to his death – we’d been campaigning for help for him … He ended up falling through the gaps in the system. Not disabled enough and not enabled enough. This is where it all started to go wrong … You’re already made to feel that you’re, kind of, a pain. It’s your fault and you’re a pain … You do shout out, but you’re silenced, and you feel nervous to rattle that cage. You live in terror.
Hope and vindication
Coroners in England and Wales are a special kind of judge, appointed by the local authority, whose role is to investigate violent, unnatural and unexplained deaths, and deaths which have occurred in prison and other forms of state detention.
The inquest is the final stage of the coroner’s investigation, unless the coroner has already established that the death was a “natural” one and requires no further examination. If it was a death in custody, even of natural causes, an inquest must be held.
The Insights section is committed to high-quality longform journalism. Our editors work with academics from many different backgrounds who are tackling a wide range of societal and scientific challenges.
The inquest most commonly takes the form of a public court hearing, at which the coroner, sometimes with a jury, addresses four questions: who died, how did they die, when and where did they die? In some cases, the inquest must not only look at the cause of death but also at the “circumstances” in which the death occurred. But, an inquest is not a trial, and does not assign blame or establish liability for the death.
Government figures show that, in 2023, 195,000 deaths – one-third of all registered deaths – were reported to the coroner for possible investigation, and coroners concluded almost 40,000 inquests.
Many bereaved relatives, like Kasia and Laurel, hope that the inquest will identify any institutional failings that caused or contributed to the death. They hope that, in so doing, the inquest will shine a light on precisely how the failings came to have such devastating consequences.
Most of all, many hope that the resultant learning will help to ensure other families do not endure similar tragedies. The same hopes emerge in widely differing contexts. For example, whether the failings at issue relate to health services, social care provision, the criminal justice system, employers’ treatment of their employees, corporate governance, government policy, or any other sphere of life.
For Kasia, the inquest into Sophia’s death went at least some way towards fulfilling her hopes. The coroner recognised the serious shortcomings in the healthcare that had been offered to Sophia over the many years she had suffered from severe mental illness. Kasia said:
I felt I was honouring her by getting some of these people accountable, having them made accountable … One of the outcomes for me was that all the issues I had raised were vindicated.
Laurel, too, was greatly relieved that the coroner who heard Finn’s inquest identified inadequate support from services as the background to the incident in which he died. “I found peace in that inquest, strangely,” she told us. “For me, I found peace, because I could see everything, or pretty much everything, was uncovered.” The inquest was meaningful to Laurel in other ways, too. After having been treated by services as if she had herself been “at fault” as Finn’s mother, the love and care she had always shown her son was now acknowledged:
The thing was, during the entire inquest, there was nothing but praise … and it came from the coroner, and it came from the people who were questioned … That helped me a lot, because of what I’d been through … to have one of the social workers say (because I’d had a terrible time with some social workers) ‘You’ve never seen a mother’s love like it’.
Unfulfilled expectations and severe underfunding
However, for many of the bereaved relatives we spoke to, the realities of the inquest fell far short of their expectation that all factors relevant to the death, including institutional failings, would be thoroughly and robustly scrutinised. Our research found that this mismatch between expectations and realities was a cause of anger and despair. It could make the grief that follows traumatic bereavement even more crushing.
Shutterstock/BlackSalmon
Various factors contributed to this problem. Like most public services, the coroner service – which is based in local authorities – is severely underfunded. In an Extraordinary Report published in early 2024, then chief coroner Thomas Teague KC noted the “chronic under-resourcing” of the service, and that local coroners’ teams are “understaffed and overworked”. The consequences include widespread backlogs and delays, and excessive caseloads for coroners’ officers whose job it is to facilitate coroners’ investigations and to liaise with bereaved relatives and others.
In the context of an overstretched service, many inquests are less detailed and probing than families want. Adding to the risk of disappointing the bereaved is the fact that coroners have wide discretion when it comes to setting the scope of inquests: that is, in deciding which specific issues will be examined, what evidence will be considered, and which witnesses, if any, will be called. What some coroners deem an adequate investigation may appear, to grieving relatives, to be cursory and far too narrow.
Elle spoke to us about a coroner who did not seem interested in exploring, in depth, the potential causes of her son Daniel’s death. She described having fought for proper care for Daniel, since the moment of his birth. A serious birth injury had left him with a number of disabilities, in relation to which compensation had been awarded. He died in hospital at the age of 17, after falling ill. She said the family had been raising concerns in the hospital that he was really ill because they had seen it before and he had been given the appropriate care. But this time their pleas seemed to fall on deaf ears. Elle said:
[This time] they would tell us that there was nothing wrong with Daniel, that he was fine. Or they would tell us that he was dying because of his cerebral palsy. It was clear to us that he had a very obvious infection … Things got worse, and worse, and worse. Daniel just got more and more ill. There were endless mistakes in his care.
Yet, the inquest into Daniel’s death produced a conclusion that was far from what Elle had expected. At the end of the inquest, she said, “the coroner just came in, didn’t even look at us, and read out this thing basically saying that the death was a natural death, and that he didn’t find any faults in Daniel’s care at all”.
Elle vehemently disagreed with the coroner’s decision, adding: “There’s no way in a million years his death was natural. It’s an unnatural death caused by clinical negligence at his birth, exacerbated by the treatment at hospital.” As far as Elle was concerned, there were “lots of issues that were just ignored” by the inquest, which “left us in despair”. She summed up her experience of the inquest with the comment: “It’s just shock, distress, trauma. We’ve been traumatised by it without any question.”
‘It made us feel like we’d failed dad’
Sylvia attended the inquest into the death by suicide of her husband, Ronan, at the age of 50. Ronan was suffering from multiple, deep-rooted mental health and addiction problems, in relation to which he was struggling to access help, when he took his own life. Sylvia had expected the coroner to look at the many “contributing factors surrounding Ronan’s death”, but found “there was a total lack of understanding of these factors – the coroner brushed over them”.
We interviewed Sylvia with her son, Tom, who had also attended the inquest. Mother and son agreed that the coroner’s investigation had been wholly inadequate. Tom said: “It made us feel like we’d failed dad. There was no justice for him whatsoever … It was sort of like: ‘Yes, suicide’.”
Sylvia agreed, adding: “I think the overwhelming thing was that Ronan wanted the help. He was speaking to all these agencies and he was telling everybody, asking for help … But [the inquest] was very short and brief, like ‘he meant to do that, and off you go.’ …And that’s the thoughts that it leaves you with: that we haven’t done Ronan justice.”
Sylvia believed the inquest had let Ronan down, as had the services which did not respond to his pleas for help before his death. “All these people that have failed him, even at the inquest – before, during and after – all these people that have failed him, they’ve walked away from it, scot-free.”
Reflecting on the inquest into her husband Louis’s death, Eva spoke similarly of her sense of injustice at how the coroner’s investigation had proceeded. Louis was a longstanding member of the armed forces when he died from suicide, aged 55. According to Eva, the coroner showed no interest in the pressures relating to Louis’s military role that, in her view, had precipitated the suicide. The result was that the armed forces were not held to account.
She said that after the coroner gave his conclusion, people from the military and Ministry of Defence “came running up to me, shook my hand: ‘Oh, we’re very sorry. Goodbye.’ In other words, ‘Oh, so there’s no more work for us here – the coroner has said his bit. Goodbye.’ Pat on the head. ‘Bugger off now.’”
Ten years after the inquest, Eva still felt great anger about it. “I’ve seen something and it’s wrong, and I just can’t swallow it. I can’t.”
Limits to the coroner’s role
It is widely assumed – by bereaved people and the public more widely – that the main purpose of the coroner’s inquest is to learn lessons from the death, in order to help prevent future such deaths.
By law, however, the prevention of future deaths is an “ancillary” or supplementary part of the coroner’s role. The coroner’s central task is to find the “facts” of the death – particularly, the cause of death. If, in so doing, the coroner becomes aware of a risk of future deaths and considers that action can be taken to reduce that risk, they must write what is commonly known as a Prevention of Future Deaths (PFD) report.
The report is sent to people and organisations in a position to take appropriate action, who are required to respond within 56 days. Most PFD reports, and recipients’ responses, are published online on the judiciary website. The independent database the Preventable Deaths Tracker also provides access to reports along with detailed analysis.
As made clear in guidance for coroners, PFD reports are recommendations that action should be taken, but do not specify what the actions should be. And, crucially, the coroner has no powers or part to play in monitoring, overseeing or enforcing any organisational changes that may – or may not – result from their reports.
The coroner’s limited powers in relation to prevention were a source of acute frustration and disappointment for some of the bereaved people we interviewed.
Vivienne’s daughter, Lara, died from suicide at the age of 18, during a mental health crisis. The inquest proved to be, in some ways, “quite cathartic”. Vivienne explained:
When Lara died, people stopped saying her name; she was no longer part of the conversation … We come to the inquest, and her name is being used almost every other sentence, which was wonderful. It’s heartbreaking, but it was wonderful.
Vivienne was initially satisfied that the coroner issued three Prevention of Future Deaths reports for health trusts and other services. However, she rapidly became disillusioned: “I had a moment where I thought that actually something might happen as a result [of the reports] … but of course it hasn’t.”
Vivienne contacted the local trust and found out that almost a year after Lara died, a young girl died under almost identical circumstances. “Then I realised that if I’m standing in the trust’s crisis centre, talking to the chief person when Lara was alive – begging for their help to save her life – if they didn’t listen to me then, they’re not going to listen to me now she’s dead … It was at that point that I thought: ‘Enough. Enough.’ And I just let it go because I ran out of fight.”
Tabitha’s son Cy died in prison at the age of 23 after a delayed response to a health emergency. She told us: “It was all about the officer not calling code blue [the emergency response code] … he could have been saved, if he’d had his medication.”
At the inquest, Tabitha and her family “just felt it was just something to write on the death certificate, to close the case of this person’s life”. They came to the view that “the coroner is powerless” and that there was little concern with systemic problems in the prison. Tabitha said another boy died in the same circumstances a year later. She added:
Even though they make recommendations for prevention of future deaths, it’s not binding … We go through the whole process for something, which absolutely means nothing … So it makes you wonder: what was the point of the whole thing?
Mistrust
Many of the bereaved in our study said their hopes of the inquest had been dashed. They regarded the inquest as yet one more instance of institutional failing, on top of other institutional failings that had – over days, weeks, months or even years – formed the backdrop to the death of their relative.
This caused or entrenched a deep sense of mistrust. They now mistrusted not only the coroner service, but also the law and state authorities more widely. Eva told us that before her husband Louis’s inquest, she used to have “total faith in the law being objective, based on fact.” But today she thinks “if I had anything to do with the law or the coroners: no. I don’t trust them.”
Sidney was 37 when he died from suicide after struggling with a gambling problem for almost 20 years. Sidney’s stepfather, Luke, was shocked and disillusioned when the coroner showed little interest in gambling as the likely cause of Sidney’s suicide, and in how gambling-related deaths could be prevented. Luke told us:
I am utterly, utterly despondent and disappointed in the whole system … My God, I’m just an ordinary guy, who’s been a normal citizen for years. But I see this sort of thing where we just don’t get anywhere, and we’re stuck in it – whether it is Grenfell, or all the way that the Manchester bombings were handled … And I am getting very, very disappointed in – not society – but the way that society is governed.
What needs to change?
Over the course of our research, we heard from bereaved people who told us that their deceased relative had been denied justice; that there was no accountability for the death; and that they saw little prospect of change that would help to prevent similar deaths in the future.
We also heard about other aspects of the coronial process that added to the pain of what was an inherently difficult and distressing experience. Many interviewees, for example, said that they had received minimal information about the process, leaving them baffled and anxious. We also heard about interactions with professionals who – over the course of the investigation and even during the inquest hearing at the coroner’s court – displayed a marked lack of compassion, sensitivity and respect. When the deceased was spoken about in a disrespectful manner, this was a cause of particular hurt.
The repercussions of these experiences were often profound and long-lasting. Maria’s brother Leon, who had a learning disability and a number of physical health conditions, died at the age of 45 while he was at a residential treatment and assessment centre. Maria described an exchange at the inquest, when a witness referred dismissively to “people like Leon” which made her feel “in the moment of his death again. It felt like I was experiencing it twice: we haven’t come out of it; gosh, we’re never going to come out of it; we never will”.
Tom said he felt “really defeated” after his father Ronan’s inquest, while his mother Sylvia commented: “I’m terribly sad really that they’re treating people this way … You know, the experience we’ve had with them – I would not wish that on my worst enemy.”
Celia – Sidney’s mother – told us that her experience of the inquest was “probably deeply damaging to my own personal journey with the grief, because disappointment is not something you want on top of trauma”.
It is evident from our findings that there is an urgent need for reform to the coroner service. Reform should include changes to practice: for example, in the form of better provision of information; more empathetic and supportive treatment of bereaved people; and greater emphasis on respect for the deceased.
But, more fundamentally, time is overdue for a public conversation about the functions and purposes of the inquest process. A question that must be central to this conversation is whether the process should be more consistently, clearly and comprehensively focused on identifying and tackling institutional failings and other underlying causes of preventable deaths. And, if so, what structures and resources are required if this is to be done effectively. As Celia told us:
It’s not about the process as it exists today. There are so many improvements that need to be made that can’t be done by simply throwing a few more ushers at it, or a couple of therapists, or a person who tells you what your rights are. It’s deeper than that. It’s got to go further than that and it’s got to be kinder than that. We’re not flaky people; we’re flawed people. We are people that have been through a terrible experience. And some of us have got important things to say.
If you or anyone you know require expert advice about the issues raised in this article, the NHS provides this list of local helplines and support organisations.
For you: more from our Insights series:
To hear about new Insights articles, join the hundreds of thousands of people who value The Conversation’s evidence-based news. Subscribe to our newsletter.