What have we done so far?

To date, we have conducted 51 interviews with a total of 58 bereaved people who have attended inquests since 2013. These research participants range in age from 20 to 83, and over half are parents of the person who had died. Others include spouses/partners, siblings, cousins and adult children of the deceased person. The deaths occurred in many different settings and circumstances, and about one third of the deaths were suicide. We intend to speak to around 40 more individuals who have attended inquests in a personal capacity.  

We have also held 57 interviews and small group discussions with a total of 69 coronial professionals and practitioners:

• 14 senior, area and assistant coroners
• 21 coroners’ officers, staff and service managers
• 23 lawyers (with experience of representing families and/or state bodies at inquests)
• 16 representatives of support organisations and related networks and services

(Some individuals belong to more than one of the above groups.)

In addition, we have interviewed 7 individuals who have given evidence at inquests in a professional capacity. We are currently expanding this element of the research to include interviews with health practitioners and prison staff who have given evidence.

In their interviews, research participants are recounting diverse experiences from many differing perspectives. We believe that this wide scope of the study ensures that we are gaining unique insights into the operation and impacts of the inquest process.

What are we learning?

We have not yet systematically reviewed and analysed the data we have gathered so far, but we give an indication of some of our findings in the boxes below. (Please note that these are provisional, initial findings, which should not be cited without permission from the research team.)  

Some interviewees with personal experience have told us that they found the inquest process inclusive and supportive: “The coroner was really kind and encouraging, recognising our grief, our distress and that this was a hard process, but actually, we had a voice in this and we were an active part … I think the actual process was really healing for us as a family.” [bereaved mother] “I found peace in that inquest … For me, I found peace, because I could see everything, or pretty much everything, was uncovered.” [bereaved mother] “I was so dreading the inquest and it was such a relief. The coroner was ever so mindful. It was a really good experience, I must say, for what it was … I felt like in the centre of the process … because he included our opinions and our concerns.” [bereaved partner]

Other interviewees, in contrast, have described feeling excluded and disempowered:

“[I felt like] we didn’t have a voice. I didn’t get to speak about [my mother] … I was present, but I wasn’t really part of it.” [bereaved daughter]

“I felt really small. [The coroner] was just sitting up there on his pedestal, while we were sitting down there, tears in our eyes, crying.” [bereaved son]

“I felt as if I was begging to be involved in the process. I’m just a pleb, so leave it to the high head ones, the lawyers and the barristers to address each other as learned friends and everything else. … Nobody got up and said, ‘This poor girl, we’re sorry.’” [bereaved mother]

“I felt like K-‘s life had to be rubber-stamped: move on, next case” [bereaved mother]
 

Many of our professional interviewees have emphasised that the inquest process plays a vital role for bereaved people in providing them with answers to most (if not all) of their questions about the death.

“We do inquests to scrutinise, in public, how people die unnaturally and help the bereaved understand what on earth went on to make them be a bereaved person.” [lawyer/assistant coroner]

“The inquest isn't necessarily going to provide them with every answer that they want. …  But yes, certainly it's most important that they come away from an inquest at least having felt that the correct investigations were undertaken and that sufficient investigation was undertaken.” [lawyer]
 

Professional interviewees have also tended to stress the importance of kindness and compassion within the inquest process, which includes acknowledging the loss suffered by those who are bereaved:

“Let's not forget that every single family we deal with are going through, probably, the worst time of their life … [having] lost a loved one. That alone, really, is why it's so important for us to deal with the family how we do, and do our best for them.” [coroner’s officer]

“For me, I’ve never been privileged to meet the deceased. So, therefore I’m reliant on the bereaved bringing that person into my courtroom. So, we understand not just about why a person has died, but we understand something about the person that we’re all there for. It’s only the families that can do that.” [coroner]

What happens next?

We are continuing to conduct interviews until the end of 2022. We will be working with a number of coroners’ courts which have agreed to help us raise awareness of the study among potential interviewees.

We are keen to hear from anyone who:

• attended an inquest in England or Wales, since 2013, into the death of a family member, partner or friend; or
• gave evidence to an inquest in a professional capacity, since 2013; and
• is interested in taking part in a research interview, or submitting a written account, about their experiences.

If you can help with further promotion of the study or know anyone who might be interested in talking to us, please get in touch with a member of the project team or pass on our details to them.

Next year, we will complete detailed, systematic analysis of our research findings, and present them to our research participants and others with an interest in the inquest process. We will organise meetings and events for discussion of the findings and, in particular, implications for policy and practice. We aim to collaboratively develop proposals for reform, and to disseminate them as widely as possible to the range of relevant audiences.

We will publish the project findings and proposals in various formats and will ensure they are accessible to everyone with an interest in them.

Thank you

• We are immensely grateful for the help we have received from all the organisations and individuals who have engaged with the study so far; especially those who have shared highly personal experiences of the inquest process.
• The study also benefits from ongoing support from the Chief Coroner, the Ministry of Justice, Coroners’ Courts Support Service (CCSS) and the charity INQUEST.
• We would also like to acknowledge and thank the following who have supported us with promotion of, and recruitment for, the study.
  • Action Against Medical Accidents
  • Adfam
  • Bristol Drugs Project
  • Centre for Military Justice
  • Collective Voice
  • Covid Families for Justice
  • Cruse Bereavement Care
  • DrugFAM
  • Drugwise Daily
  • Gambling with Lives
  • George Julian
  • Last Rights
  • National Bereavement Alliance
  • Roadpeace
  • SAMM (Support After Murder and Manslaughter)
  • Sands
  • Support after Suicide Partnership
  • The Compassionate Friends
  • The Forward Trust
  • Turning Point
  • Veterans and Families Research Hub
  • War Widows