Call for more humanity in inquests after study finds some bereaved feel let down

Many bereaved who have gone through an inquest after the death of a loved one have been left feeling let down by the process, the findings of a study described as the largest of its kind have suggested.

While some felt a catharsis, peace or relief from the experience, more of those who took part in the three-year research project by Birkbeck, University of London and the University of Bath told of negative impacts.

Feelings of anxiety and uncertainty during what could be lengthy investigations subject to delays were cited, with some even saying the distress caused by the process was comparable to that caused by the death itself, researchers said.

The project involved interviews with 89 bereaved people on their experience of the coroner service, 82 professionals, including coroners, coroners’ officers and lawyers, and 19 professional witnesses such as police officers and prison staff.

Inquests are held if a cause of death is unknown, the person died a violent or unnatural death or the person died in prison or police custody.

The researchers, who said their work is the “largest ever empirical investigation of lay and professional experiences of the coronial process in England and Wales”, stressed that it was qualitative and therefore does not provide an exhaustive or representative portrayal of the process, and added that the self-selected sample of bereaved people “is likely to be skewed towards those who had been bereaved in contentious circumstances”.

But they argued that this does not take away from the value of their personal accounts of direct experiences of the system.

The findings highlighted a “profound mismatch between what was expected and what, in practice, was experienced” for families during inquests, they said.

The paper stated: “In other words, most respondents felt they had been let down by a process that failed to deliver what, in their eyes, it should.

“When we interviewed coronial professionals, they largely acknowledged that the coronial process risks disappointing bereaved people involved in it.

“However, their views were mixed as to the extent to which this risk arises from uninformed and unrealistic expectations on the part of the bereaved, or from systemic imbalances within the process.”

One mother who took part in the research was quoted as saying “the inquest was probably not far off as traumatic (as the death) for me”, while a sister said “we felt (as if we were) in the moment of my brother’s death again, it felt like I was experiencing it twice”.

While some bereaved said they had “kind and encouraging” or “very warm” experiences with the coroner and officials, others described “stern” attitudes and insensitivity such as the use of the phrase “good news” regarding an autopsy having been completed.

The researchers described a “challenging wider context” for coroners today, in being “under-resourced and over-stretched”, with an increasing workload “and (growing) societal expectations of what it can achieve – particularly in terms of addressing the causes of preventable deaths”.

The paper noted that a source of “profound frustration and disappointment” to many bereaved respondents was a feeling that little was being done to help prevent future deaths.

“Failings in prevention were variously attributed to the narrowness of the investigation; to the weak content of PFD (prevention of future death) reports; and to the lack of oversight of institutional responses to reports,” it said.

In a series of recommendations, the researchers said the role and functions of a coroner should be clarified, including in relation to prevention of future deaths, as part of wider discussions about the future of the service; communication must be improved to ensure bereaved have access to clear, concise and practical information about the process and how they can engage with it; communication must always be kind and compassionate using respectful language and always giving the opportunity for pen portraits and photographs to be presented at hearings.

They also recommended that new opportunities and forums for restorative dialogue should be provided between professionals who had some involvement in the death and the bereaved.

Project lead, Professor Jessica Jacobson, director of the Institute for Crime and Justice Policy Research (ICPR) at Birkbeck, said many the bereaved interviewees “recounted experiences of the coronial process that fell far short of their expectations”.

She added: “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.”

The Voicing Loss research is published at https://voicing-loss.icpr.org.uk/

Measures have previously been taken in an effort to make inquests more sympathetic to bereaved families, including training for coroners and coroner officers and a refreshed Guide to Coroner Services for Bereaved People being issued in January 2020.