A three-year study of bereaved people’s experiences of the Coronial inquest process in England and Wales has been published in June 2024, concluding that several key practical changes are urgently needed to Coroners’ inquests.

In-depth interviews were carried out with 89 bereaved people. The ‘Voicing Loss’ study was conducted by the Centre of Death and Society at the University of Bath and the Institute for Crime & Justice Policy Research at Birkbeck, University of London.

Whilst the inquest process is supposed to offer answers to families whose loved ones have died, often the process can be intimidating. Some of the interviewees said that the investigations and inquests were “alienating and disempowering” and that they struggled to understand the complicated legal process, in a time whilst they were grieving their loss.

An inquest is held when the cause of death is unknown, or the person died a violent or unnatural death. The Coroner has to answer four questions: who the deceased was and where, when and how they came by their death.

What is an Article Two Inquest?

If Article 2 is engaged for the inquest, the scope will be broadened to include the circumstances leading up to the death. This refers to the ECHR Article 2 Right to life. Article 2 will be engaged when someone has died whilst in state custody, such as in prison or police custody or whilst detained under the Mental Health Act. Article 2 may also be engaged whilst someone is under the care or protection of the state and the state fails to recognise any real and immediate risk of death. Article 2 can further be engaged where there are systemic or policy-based failures that have led to the death. Legal Aid funding is often available for families for an Article 2 inquest.

Here at Farleys, we find that a lot of families want lessons to be learned from the deaths. Where Coroners believe there is a risk of future deaths, they are obliged to write a Prevention of Future Deaths. We recently wrote about what a Prevention of Future Deaths report is in this blog.

One thing that is clear from the research is how much the experiences of bereaved families differs. Some interviewees spoke about professionals who were kind and thoughtful, whilst others found inconsiderate behaviour. The ability for the family to read out a pen portrait statement or to bring a photograph into Court can humanise the inquest, putting the family and their loved one at the heart of the process.

Calls for Changes to the Inquest Process

Voicing Loss calls for several key practical changes to the inquest process:

  • Clarify the role of the coroner and functions of the coroner – including in relation to prevention of future deaths.

  • Improve communication – 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.

Legal Representation at Inquest

Our dedicated team at Farleys will fight on your behalf and guide you through the inquest process, making it less daunting for families. There are a number of ways to fund specialist representation and we will discuss with you whether Legal Aid is available. We can also consider any potential claims for compensation arising out of the death.

If you would like to discuss inquest representation, please get in touch with us on 0845 287 0939, contact us by email, or use the online chat below.