Jessica Jacobson and Alexandra Murray (image credit Tyla Scott Owen, tylascott1998@gmail.com)

In England and Wales, coroners are independent judicial officers with responsibility for investigating deaths suspected to have been violent or unnatural, where the cause of death is unknown, or where the person died while in prison or another form of state detention. The purpose of the investigation is to determine who died and how, when and where they died. Where necessary, the investigation culminates in an inquest: an inquisitorial, fact-finding hearing, generally held in public, and sometimes with a jury.

Voicing Loss is an ESRC-funded project (grant reference ES/V002732/1) on the coronial process, conducted by the Institute for Crime and Justice Policy Research at Birkbeck and the Centre for Death and Society at the University of Bath. The project examined the role of bereaved people in coroners’ investigations and inquests, as defined in law and policy and as experienced in practice. It also explored ways in which the inclusion and participation of bereaved people in the coronial process can be better supported. Findings of the research and other project outputs (including an Expert Insights blog and information about the coroner service for the general public) are available at the project website.

The research conducted for Voicing Loss involved interviews with 89 bereaved people with experience of the coronial process; 82 coronial professionals (including coroners, coroners’ officers, lawyers and others); and 19 individuals who had given evidence to an inquest in a professional capacity and/or supported colleagues who were witnesses. This constitutes the largest ever empirical investigation of lay and professional experiences of the coronial process in England and Wales.

One of the major findings to emerge from the Voicing Loss research was that there was a considerable gap between what many of the bereaved respondents expected of the coronial process and what they experienced.

The large majority of the bereaved respondents had had little or no knowledge of the coroner system prior to their bereavement and being told that the death was to be investigated by the coroner. As the investigation proceeded, they formulated various hopes and expectations of what the coronial process would or could achieve. These can be broadly categorised as:

• hopes that the process would provide answers, and potentially the wider ‘truth’, about the death;
• hopes that lessons would be learnt about failings which had caused or contributed to the death, leading to action to prevent future deaths;
• hopes that the identification of failings would, more broadly, be part of a process of achieving justice for the deceased and accountability for the death.

With regard to each of the above, some bereaved respondents gave positive accounts of what the coronial process had delivered, and spoke of how this had helped them as they continued to grieve for the person who had died. Many more of the respondents, however, described a process which had not provided what they had sought from it, and which they consequently perceived to have failed them and the deceased person.

For example, respondents said that the questions they wanted answering were not properly addressed by the coroner; or described coming to the realisation that the coroner’s investigation was never going to extend beyond what they already knew. Many respondents emphasised that their overriding hope for the process was that it would give rise to learning and preventive action, but only rarely did they feel that progress had been made towards prevention. More often, they voiced their profound distress that ‘nothing has changed’ as a result of the death and inquest. Much of this disappointment and disillusionment focused on ‘Prevention of Future Deaths’ reports issued by coroners,[1] which were deemed to be weak in terms of their content and – most critically – to have no effect in the absence of a system of oversight and enforcement. Hopes that the coroner might deliver ‘justice’ and ‘accountability’ went unfulfilled for respondents who felt marginalised or powerless within a process that appeared to them to be weighted in favour of public bodies or uninterested in looking beyond the immediate facts of the death.

The professionals interviewed for Voicing Loss acknowledged that there is a problem of mismatch between some bereaved people’s expectations of the coronial process and what, in practice, they experience. The problem was partly attributed to practical obstacles – particularly, relating to resourcing and staffing – that impede effective delivery of the service. Many of the professional respondents (particularly coroners, coroners’ officers and inquest lawyers who represent state bodies) also argued that the problem of mismatch is rooted in ‘unrealistic expectations’ on the part of some of the bereaved, and that its resolution therefore depends on better expectation management. In contrast, other professional respondents (including family lawyers and representatives of some support services) spoke of systemic imbalances within the coroner service as the primary impediments to the realisation of bereaved people’s hopes and expectations.

The Voicing Loss research findings suggest that the task of narrowing the gap between expectations and realities of the coronial process is complex and challenging. Meeting the challenge is likely to depend, in part, on structural reforms to the process to enhance its effectiveness, robustness and consistency. The provision of more extensive and accessible public information about the coroner service, to help ensure that bereaved people’s expectations are better informed, is also of critical importance. Beyond this, there is a need to address a number of tensions and ambiguities inherent in the coronial process and its essential functions. These tensions and ambiguities relate to the coroner’s statutory obligation to determine ‘how’ but not ‘why’ the death occurred; the status of the coroner’s preventive function; and understandings of the concepts of ‘justice’ and ‘accountability’ in the context of the coroner service.

For detailed discussion of the issues raised in this blog, see the Voicing Loss Research Findings Paper No. 1, ‘I needed more than answers’.

[1] The coroner must write a Prevention of Future Deaths report if an investigation makes them concerned that there is a risk of future deaths, and they consider that action could be taken to prevent or reduce that risk. The report should be addressed to those who the coroner believes have power to take such action.