Voicing loss: meanings and implications of participation by bereaved people in inquests
Research considers the role of families during coroners’ inquests and how their inclusion and participation can be better supported.
Birkbeck’s Institute for Crime & Justice Policy Research (ICPR), in partnership with the Centre for Death and Society at the University of Bath, conducted a three-year study on the role of bereaved people in inquests in from 2021 to 2024.
Coroners are independent judicial office holders appointed by the local authority. In 2023, around 195,000 deaths (34% of all registered deaths in England and Wales) were reported to the coroner, and around 37,000 inquests were opened. The purpose of an inquest is to determine who died, and when, where and how the death occurred, in cases where the death was violent, unnatural, unexplained, or took place in custody or other form of state detention.
Close family of the deceased, as ‘interested persons’, have certain rights during the coroner’s investigation. These include the right to question witnesses and to ask to see evidence in advance of the inquest hearing. Moreover, there is an explicit policy commitment – reiterated by government and successive Chief Coroners – to locate bereaved families 'at the heart of' the coronial process.
What did the research involve?
Voicing Loss is the largest ever empirical study of lay and professional experiences of the inquest process in England and Wales. The project involved interviews with 89 people who had experience of the coroner service following the death of someone they were close to. Interviews were also conducted with 82 coronial professionals (including coroners, coroners’ officers, lawyers and others) and 19 witnesses.
Key findings
Some of the bereaved respondents who took part in the Voicing Loss research reported that their experience of the coronial process had helped them and offered some sense of ‘catharsis’, ‘peace’ or ‘relief’. More of the bereaved respondents, however, spoke of being negatively impacted by the process. They described anxiety and uncertainty over the often lengthy period of investigation, severe distress during inquest hearings, and the subsequent long-lasting emotional and psychological toll it took on them.
Factors which shaped respondents’ positive or negative evaluations of the coroner’s investigation and inquest variously related to the nature of the process itself; to their experiences of participation; and to the outcomes of the process.
The aspects that made people feel either positively or negatively about the coroner’s investigation and inquest were linked to how the process worked, how they felt about being involved, and the results of the process.
Process: Respondents described the difficulty of navigating a complicated legal process of which they had little or no prior knowledge, while in the early stages of grief. Problems were exacerbated by a lack of information from, and poor communication with, the local coroner service. Experiences of being treated with, and without, compassion, sensitivity and respect were vividly recalled; as were instances of respectful, and disrespectful, conduct in relation to the deceased person.
Participation: Many respondents made strenuous efforts to ensure their voices were heard and their concerns about the death were addressed. Yet they frequently encountered barriers to participation and found many aspects of the process alienating and disempowering. Opportunities to share details about the life and character of the deceased person were welcomed.
Outcomes: Some respondents found it helpful that the inquest gave them answers about the death. Others learned nothing new from the inquest. Many were deeply frustrated and disappointed by the limited capacity of the coroner to help prevent future deaths.
Impact
Based on the Voicing Loss findings, the research team have identified a range of policy and practice measures that would alleviate the harms caused by poor experiences of the coroner service and bolster the chances of positive experiences. They call for a number of changes:
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Clarify the role of the coroner and functions of the coroner, including in relation to prevention of future deaths – as part of wider discussions about the future of the coroner service.
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Improve communication, by 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.
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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.
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Provide new opportunities and forums for restorative dialogue between professionals who had some involvement in the death and the bereaved.
Project lead and Director of the Institute for Crime & Justice Policy Research, Professor Jessica Jacobson said, “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.
“Research reports, policy and practice briefings and other project outputs are available on our Voicing Loss website. We are continuing to analyse and present the study findings and to develop follow-up work.”
Project fact file
Full project title: Voicing loss: meaning and implications of participation by bereaved people in inquests
Funder: Economic and Social Research Council (reference ES/V002732/1)
Project Funding: £780,756
Duration: May 2021 to June 2024
Project website: https://voicing-loss.icpr.org.uk/
People: Principal Investigator, Professor Jessica Jacobson, ICPR