Bereaved families are facing persistent challenges following the death of their loved one in mental health services.

INQUEST’s Family Consultation Day heard from 14 family members who were bereaved by deaths in care of mental services or setting for people with learning disabilities and/or autism.

The report shows that families face numerous hurdles during investigations and inquests into their loved ones’ deaths. Importantly, the processes are not delivering the change required.

Families felt that there needed to be a significant culture shift if the investigation and inquest system was to provide tangible change. Some of the key concerns raised by families include:

A lack of candour, transparency and accountability

  • As one person said about the trusts, “they’re marking their own homework”. This leads to a lack of faith in how independent the system is and subsequently impacts on the families’ trust in the credibility of subsequent findings. Without accountability, families argued that change is impossible because the repercussions for professional and systemic failings go unpunished.

  • At the moment, families feel let down by an adversarial process that created mistrust, and an over-reliance on the strength of legal teams rather than acceptance of responsibility when things went wrong. Families are denied apologies and truth on the basis that acknowledging such implies guilt.

  • One key desire expressed by families was a requirement for the process to be more honest. Families agreed there should be duty of candour, compelling witnesses and those giving evidence to tell the truth.

Inadequate levels of communication between families and the bodies responsible for care

  • Families were firm in their belief that the information provided before an inquest was inadequate, leaving them utterly unprepared for what was to come… The absence of information places families at a disadvantage, particularly in the context of engaging with a legal process with its own rules, etiquette and jargon.

  • There were barriers to reporting concerns regarding the quality of care, and many of the systems in place failed to acknowledge or act after repeated warnings from family members. What became clear as families spoke was how little advice, support, or information they received from hospitals, police, and NHS trusts prior to death of their loved one.

Many felt they were immediately placed on the backfoot during investigations into their loved ones’ death

  • In keeping with initial contact, families felt ill-equipped to make informed decisions or plan their engagement with the investigations, which in turn made managing expectations difficult. For many, this lack of involvement at the outset meant the process was already flawed.

  • majority of those who spoke doubted the independence and impartiality of those tasked with conducting the investigations. In extreme cases, families were not made aware that an investigation was happening, and trusts failed to communicate what would happen following a death.


Families are calling for major changes to the investigatory and inquest system, including:

  • More compassionate, empathetic, and humane treatment of families grieving the death of a loved one with support for families before and during the inquest;

  • Independent investigations into mental health related deaths;

  • A national coronial service to address inconsistences in the inquest system;

  • Non-means tested legal funding for all families involved in inquests where state bodies are involved;

  • Apologies delivered at the outset;

  • An open and honest approach from the trusts and an end to the culture of defensiveness.

Here at Farleys, our specialist inquest solicitors have represented clients in a number of inquest cases, be they deaths in mental health services, deaths in prison or police custody or other private inquest cases.

It is important that your concerns surrounding the death of your family member are appropriately addressed. An inquest can be very daunting for the family following the loss of a loved one. Our inquests team is experienced in assisting with inquests of this kind and can guide you through the process. We can provide advice, assistance, and representation to ensure that you are fully supported throughout such a difficult time.

If you require representation at an inquest, please contact our team on 0845 287 0939 or complete our online contact form.