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The largest ever study of bereaved people’s experiences of the inquest process in England and Wales has been published today by ����logo���, University of London and the University of Bath.

The three-year research project 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.

Professor Jessica Jacobson, Director of the Institute for Crime and Justice Policy Research (ICPR) at ����logo���, and ‘Voicing Loss’ project lead, commented: “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.”

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.

Lee Fryatt’s son died by suicide, when he was a 19-year-old student. Lee said: “This study 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.��

“What we wanted most of all from the inquest was 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.”

��‘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, by making 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.