July 13 2024
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New research reveals ‘trauma’ and ‘missed opportunity’ of inquests

New research reveals ‘trauma’ and ‘missed opportunity’ of inquests

Inquests are ‘alienating and disempowering’ for families, with the trauma of an inquest comparable to the trauma of the death of their loved one.

New research has revealed the psychological toll of the inquest system on people whose loved ones die in contested circumstances, including struggling with a complicated legal process and suffering due to cuts to the system.

Researchers for the Voicing Loss project undertook 89 interviews with family members who had been involved with inquests and the coronial process, as well as professionals including coroners and lawyers. It forms the largest study of its kind into how inquests and coroners courts operate.

Inquests examine all deaths which have happened in an unnatural or unexplained way, including all deaths in prisons and at the hands of the state. 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 completed.

Many interviewees were critical of the inquest process, particularly when there was a ‘Prevention of Future Deaths’ report which is issued to public bodies to learn lessons from these deaths. Many families of those who die in contentious circumstances want lessons to be learned from the death and these reports are intended to achieve that. However, interviewees spoke of ‘profound frustration and disappointment’ that these reports didn’t work, or didn’t go far enough.

The father of a young man who took his own life while at university said he wanted ‘most of all’ for lessons to be learned to prevent the unnecessary deaths of other students: ‘But it didn’t deliver that – we’ve seen this from so many other grieving families, with similar stories. It is systemic failing.’

He added that the prevention of future deaths notice ‘might as well be thrown in the bin’, describing them as ‘a false promise and a missed opportunity’. He told researchers that the inquest made his family’s situation even worse.

The project lead, Professor Jessica Jacobson, said the research has revealed an ‘under-resourced, over-stretched service’. She said many of the interviewees recounted experiences 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.’

Deborah Coles, the director of the charity, INQUEST said: ‘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.’

She described how inquests are often ‘retraumatising’ processes, and the experience of hearing about another similar death after a promise that lessons will be learned ‘cannot be overstated.’

Coles also criticised what she has previously described as the ‘inequality of arms’ between families and public bodies during inquests, in which families are out-resourced by large organisations with access to expensive legal representation. She said ‘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.’

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