New research reveals the psychological toll for bereaved families involved in coroners’ inquests
Today (18th June) the largest ever study of bereaved people’s experiences of the inquest process in England and Wales will be published by Birkbeck, University of London and the University of Bath.
The three- year research titled “Voicing Loss” carried out in-depth interviews with 89 bereaved people. For some of them, the inquest process offered a sense of “relief” and “catharsis”. However, more of the interviewees found that coroners’ investigations and inquests were “alienating and disempowering” and struggled to navigate the complicated legal process while grieving.
The trauma of an inquest was compared by some to the distress caused by the death itself.
Coroners’ inquests examine deaths which have occurred in a violent, unnatural or unexplained way. All deaths in prison or other forms of detention must be subject to an inquest.
In 2023 almost 200,000 deaths – 34% of all registered deaths in England and Wales – were reported to the coroner, and almost 40,000 inquests were concluded. In addition to the bereaved people, 82 professionals (including coroners, coroners’ officers, lawyers and others) and 19 professional witnesses took part in the newly published research. A new website will also go live on 18th June to provide access to the research as well as information to promote understanding of coroners’ investigations and inquests.
In the “Voicing Loss” study, grieving relatives and friends told academics they were hoping for truth and justice from an inquest. They also wanted lessons to be learnt, especially where the state or another institution was involved in the death, so that others would not lose their lives in a similar way. Coroners are obliged to alert relevant bodies – such as the government, hospitals, schools and companies – by writing Prevention of Future Deaths reports, when they believe there is a risk of future deaths, and they consider that action could be taken to prevent or reduce that risk. However, the study found “profound frustration and disappointment” among bereaved interviewees who felt the inquest had seemingly done little to help prevent future deaths. The communication style throughout the coronial process and respect for the deceased was found to be widely varied.
“Voicing Loss” calls for several key practical changes which are urgently needed:
- Clarify the role of the coroner and functions of the coroner – including in relation to prevention of future deaths – as part of wider discussions about the future of the coroner service.
- Improve communication: Make sure that all bereaved people have access to clear, concise and practical information about the investigative process and how they can engage with it, and about the progress of their own case.
- Put humanity at the heart of the coronial process, by communicating with the bereaved in a kind and compassionate way at all times, using respectful language in talking about the deceased, and providing the opportunity for the bereaved to present pen portraits and photographs at inquest hearings.
- Provide new opportunities and forums for restorative dialogue between professionals who had some involvement in the death and the bereaved.
The research recognises that these changes must take place against a challenging backdrop. Like most public services today, the coroner service is under-resourced and over-stretched. Its workload is increasing in size and complexity, and the public’s expectations of what it can achieve – particularly in terms of addressing the causes of preventable deaths – are growing. There are continuing calls for far-reaching structural reform and the creation of a unified national service to replace the current local authority-based system.
Lee Fryatt’s son died by suicide while at university, aged 19. The inquest into his death took place one year later, in 2019. Mr Fryatt:
“This study is vital; it shines a light on a hidden part of justice which few of us think we’ll need. When families like ours are sucked into a coroner’s inquest, it happens when chaos is in your brain and turmoil is in your heart.
“The wait is all-encompassing; the longer it takes, the worse it gets. You can’t go through the grieving process until afterwards.
“Most of all we wanted lessons to be learnt to prevent unnecessary deaths of other students like Daniel. But it didn’t deliver that - we’ve seen this from so many other grieving families, with similar stories. It is systemic failing. The prevention of future deaths notice sent to public bodies and health authorities to guard against repeated failings might as well be thrown in the bin. They’re a false promise and a missed opportunity. The inquest, frankly, made our situation even worse. This study shows many other families share that experience.
“It's time to put humanity at the heart of a hidden service you only ever use at your most vulnerable. Respect and consistency cost nothing, they need to be enshrined in the process from start to finish.“
Professor Jessica Jacobson, Director of the Institute for Crime and Justice Policy Research (ICPR) at Birkbeck, University of London, and Voicing Loss project lead:
“For our research, we interviewed bereaved people about their experiences of the coroner service. We also spoke to professionals who, in the context of an under-resourced, over-stretched service, strive to ensure that inquests provide bereaved people with the answers they are seeking.
“Many of our bereaved interviewees, however, recounted experiences of the coronial process that fell far short of their expectations. The answers and accountability they sought were not forthcoming. Opportunities to learn lessons were missed. Even basic decency and compassion were sometimes lacking.
“Change is urgently needed to close the gap between expectations of the coroner service and what, in practice, it can deliver. It is time to ensure that humanity is put at the heart of the service; that bereaved people receive sufficient support to navigate the process; and that they are always treated with empathy and respect. Also essential is a wider public conversation about the purposes of coroners’ inquests and what they can – and can’t – achieve.“
Lorna Templeton, Research Associate at Bath University’s Centre for Death and Society:
“One of the most powerful findings from our research is how much bereaved people’s experiences of the coronial process varied. During a period of personal grief, some told us about professionals who were kind and thoughtful, while others reported inconsiderate and disrespectful behaviour. A kind word, or an opportunity to show a photo or give a pen portrait can bring welcome humanity in what for most is an alien legal world.
“Our wide-ranging study shows the hidden, often long-lasting impact of an inquest on grieving processes. It is essential that humanity is at the heart of the coronial process. This can be achieved in ways that facilitate, rather than compromise, justice. For example, bereaved people should be supported to show a photo and give a ‘pen portrait’ of the person who died as a matter of course.“
Deborah Coles, Director at INQUEST:
“INQUEST has welcomed the opportunity to work with the Voicing Loss team on this wide-ranging and unique project centring bereaved families and their experiences of the coronial system.
“Bereaved families describe how they cannot begin to grieve until they find out the truth about how their loved one died. Families participate in the inquest process in the hope of establishing the truth, to hold those responsible to account and for learning and change so that future deaths are prevented.
“Instead, they are faced with protracted, complex, and distressing processes and a culture of denial and defensiveness. Often these are retraumatising processes and the psychological impact of hearing of another similar, avoidable death after the hollow promise of ‘lessons will be learned” cannot be overstated.
“We must urgently see families’ legal rights upheld in the inquest process and oversight of inquest recommendations to ensure that their preventative potential can be realised and lives can be saved. The voices of bereaved families are too strong and their stories too compelling to be ignored.”