Bereavement due to traumatic death
The coroner's inquest
A legal inquiry into a death is held when its cause is unknown, violent or ‘unnatural’. This 'coroner’s inquest' is held in public and the coroner determines the cause of death. He or she does not have to establish why the death occurred, but only who the deceased was, how, when and where death occurred. The verdict depends on many factors, including the post mortem examination. The coroner may have a meeting with the relatives before the inquest, but usually next-of-kin or other ‘interested persons’ meet the coroner’s officer.
The coroner’s officer, also known as the coroner’s investigator, works with the coroner, the bereaved relatives, the police, doctors and funeral directors and others. Some people told us that the coroner’s officer had been very helpful, and that she had prepared them very well for the inquest. Rachel, for example, recalled that the coroner’s officer had invited her to attend someone else’s inquest, so that she knew what to expect when it was time for her son’s inquest. However, others had been disappointed by the lack of information, and difficulties in obtaining documents. Most people met the coroner’s officer, but some only spoke to the officer by phone.
Pat, and her daughter Tamsin, explain what happened after Mathew died.
In the past relatives were not allowed to see witness statements or other evidence before the inquest, but it is now considered good practice for the coroner to supply relatives with witness statements and other evidence before the inquest. Since July 2013 new rules from the Coroners and Justice Act 2009 came into force along with new coroner Rules and Regulations. The new provisions apply to all coroner investigations, including those which are already being investigated by a coroner or ones which may have already reached the inquest stage.
"The new changes should mean that families are:
- more routinely informed of post mortems in advance;
- given an opportunity to give their views about non-invasive post mortems;
- be able to be present at post mortems and
- to receive (as soon as practicable) a copy of the report."
(INQUEST - The Inquest Handbook: November 2013 update)
Relatives or other ‘interested persons’ used to have no right to look at documents and it was at the discretion of the coroner and some were charged a fee for copies of the post-mortem report and for copies of the coroner’s notes of evidence. David had to pay for a copy of a post-mortem report.
"The new changes should mean that families are:
- more routinely informed of post mortems in advance;
- given an opportunity to give their views about non-invasive post mortems;
- be able to be present at post mortems and
- to receive (as soon as practicable) a copy of the report."
(INQUEST - The Inquest Handbook: November 2013 update)
Relatives or other ‘interested persons’ used to have no right to look at documents and it was at the discretion of the coroner and some were charged a fee for copies of the post-mortem report and for copies of the coroner’s notes of evidence. David had to pay for a copy of a post-mortem report.
Some people do not want to see all the documents. After Rosemary’s son died in the London bombing in 2005 the coroner sent her and her husband the post-mortem report by post. She thinks a post-mortem report might upset some people and that it should not be sent without a request.
If anyone has been charged with a criminal offence the inquest will be opened and adjourned until after the criminal proceedings. At the opening of the inquest the coroner hears the facts that have been established about the death, and interim death certificates can be issued. When any trial is over the coroner will resume the inquest if he or she considers it necessary, but often the relevant facts will have come to light during the criminal trial and the inquest is not re-opened.
People often had to wait months or even years for the inquest, while the police were collecting evidence, or while suspected criminals were being tried in court. Some people told us they were still waiting for the full inquest years after the death.
The inquest for those killed by the Bali bomb was held about nine months later. During the inquest Susanna found out exactly what had killed her brother Dan. She wishes she had known earlier.
The inquest for those killed by the Bali bomb was held about nine months later. During the inquest Susanna found out exactly what had killed her brother Dan. She wishes she had known earlier.
Sex: Female
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Was there an inquest?
There was an inquest. That was held in the June I think. It was certainly about nine months after my brother was killed. It wasn’t until the inquest that we discovered what exactly had killed him. And in hindsight it would’ve been fantastic if they’d been able to tell us earlier, because it means that for nine months you just don’t know, I mean what really happened.
Was the inquest in this country?
Yes it was in this country and it was, for most of the British relatives, all simultaneously, and they were all declared to have died of multiple injuries associated with the bombing, but luckily we could actually talk to the pathologist, who had inspected each of the bodies, and we were able to ask questions like' Well what does a bomb explosion do to a person? And how do you know he died instantly? And he was able to explain that, you know, essentially they didn’t need to open any of them up because they knew that; because you could tell from the physical condition of the bodies how close they had been to the source of the blast, and that essentially that your internal organs explode and that’s it, bang, and you’re very likely you would be unconscious in, you know your brain will have, you will be dead within seconds, if not instantly.
And did you attend the inquest?
Yes, we did.
Were you prepared for the inquest, did the Coroner’s Officer talk to you before hand?
No. But actually the Coroner was fantastic, and she came along afterwards to the where we had a a memorial service at St. Martin in the Fields on the first anniversary…
During the inquest the barristers tried to blame his daughter for the accident and William felt upset and hurt. The inquest did not answer all his questions.
During the inquest the barristers tried to blame his daughter for the accident and William felt upset and hurt. The inquest did not answer all his questions.
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Yes, one, one of the horrible parts of the journey is that because Lauren’s death was caused by the actions of other people there is a civil case to be answered. And in civil law if the actions of others have caused something really nasty, whether it’s a nasty injury or a death, then one, you know, a party such as Lauren’s family can pursue a civil case against the parties who caused the death.
Where more than one party contributed to the fatality, you’ll find that there’s all these legal arguments and ducking and diving and it’s no longer about the fact that you’ve lost your loved one, it’s about money. And it’s about some, you know barrister saving his client two or three thousand pound. And so the reason why there were these legal representatives kicking about the inquest was that they, the school had a legal representative there, a QC no less, the bus company had a legal representative there, a barrister, and the lorry driver’s employer had a legal representative there. And during the inquest, which is not to attribute blame but rather to find out the facts, there’s all this ducking and diving going on, and basically the humiliation and extra hurt of each of these legal representatives basically saying, “Ah it was Lauren’s fault. It was Lauren’s fault. She was looking the wrong way.”
Did you have any legal representative there?
We had a solicitor there just, but when the legal, when our legal representatives, when our solicitor saw who was representing their side, they actually became quite intimidated because they said, “Oh if we’d known a QC was going to be here I would have brought a barrister for our side.” And so they actually felt very intimidated, but it was very, the way the inquest worked was you’re in very, very tight constraints, as to what, well as you know, as the bereaved person, what I as the father of the deceased was able to ask, was able to get information on, and so all the questions about, why did the lorry driver not see her before he hit her? Why did the bus driver let her off there? Why did the teacher take no interest? All those questions, they couldn’t really be fully addressed at the inquest.
Were you prepared for the inquest in any way? Did anybody tell you what was going to happen?
Well, informally I had some conversation with the lady from the Coroner’s office, on the phone. And they give you, you know, a handout a, a pamphlet about what happens at the Coroner’s court, but I don’t think I was prepared for it being so similar to you know, a High Court where someone would be tried for murder or something. And it was remarkably similar because I had cause to bear witness for the prosecution in a murder case previously, and it was remarkably similar, except.
So how did you, how did you feel about that?
I felt that when it comes to the law, those who implement the law and those who examine the law and test the law are fairly insensitive about people’s feelings and emotions, but I guess that’s just the nature of life. And certainly when it comes to application of the law, and the civil case, it’s not about truth or justice anymore; it’s about the letter of the law.
Most people we talked to had attended the inquest, but a few had decided not to go because they did not want to hear more about how the death had occurred. Sometimes the inquest had been opened and adjourned very quickly and they had not realised it was taking place. Jocelyn’s son’s inquest took place in Hong Kong because he had been living there just before he died - Jocelyn did not attend.
Many found the inquest unexpectedly formal, rather like a High Court and some thought it frightening, austere and intimidating. William said that even his solicitor felt intimidated at the inquest when he discovered the school (in whose care William’s daughter was when she was killed) was being represented by a QC. The school, the coach company and the lorry driver’s company were all represented by barristers because they knew that the family might pursue a civil case against the parties who caused Lauren’s death. The coroner's verdict was ‘accidental death’.
Karen felt that the inquest was a waste of time and a waste of taxpayers' money. It did not answer important questions; she did not want to ask any questions because press reporters were there.
Karen felt that the inquest was a waste of time and a waste of taxpayers' money. It did not answer important questions; she did not want to ask any questions because press reporters were there.
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And can you say a little bit about the inquest?
Yeah, I mean it was um, they’d said the different people that had obviously been called because they’d called certain people. And they had gone through the process but I was glad that they didn’t ask me to take the stand, the coroner himself was quite happy to read my statement because it was quite a lengthy statement. As he said, it had just about everything in there, but, which he did say that he felt was beneficial. And it didn’t sound like lip service so, so I took that on board.
This was the statement that you made to the Coroner’s Officer?
Yes. So he’d gone through all of that. Um, obviously it’s open, so they’d got two press people there anyway. I mean you can ask questions, and he, he’d just stop and say you know, “Are you happy with that?” And then moves onto the next bit. I didn’t feel, with the press there I didn’t feel that I wanted to ask questions.
Because to me they do their own interpretation of things. So I wasn’t prepared to ask questions even if I had, which I did have questions, there was no way I would have asked them in that environment with the press there because to me they, they’re like a dog with a bone aren’t they? They just don’t let go. You know and then what they print, people actually read and believe. And to me that’s what all…
What sort of questions would you like to have asked?
There was things that I wanted to ask of, of my Mum’s ex brother-in-law who’d since died. I mean he died before the inquest. Because his version didn’t tally up with what everyone else was saying. And I couldn’t understand how the police officer who actually with his version of events after interviewing my Mum’s ex brother-in-law, it didn’t, just didn’t all tally up to me. In my mind it didn’t. And it still doesn’t. You know and I did say to the coroner’s officer prior to the inquest, to me it was just a waste of taxpayers’ money because it wasn’t going to answer any questions and it wasn’t going to put any closure because there was too many questions unanswered and the length of time it took to have the inquest the person who could’ve maybe answered those questions, or actually been made to answer those questions, was no longer alive.
During the inquest, relatives of those who died listened to evidence from people such as the police and the pathologist. Some relatives had to give evidence themselves. Others listened while the coroner read out their statement. Alison was upset and felt it was disrespectful when the coroner gave her daughter the wrong name. People were usually given an opportunity to ask questions, but some found that hard because journalists were there (also see ‘Media involvement’).
At the end of an inquest the coroner can give one of many verdicts, including death due to accident, suicide, or unlawful killing. A coroner may return an “open verdict” when he considers the evidence insufficient for any other verdict. A verdict can also be “narrative”, that is a more descriptive comment. In some circumstances, the coroner summons a jury to consider the facts and return the verdict. This happens if a death occurs in prison or other custody, or could have implications for health or safety in the future.
Once the verdict has been reached the coroner informs the Registrar of Deaths, who can then issue a death certificate.
Once the verdict has been reached the coroner informs the Registrar of Deaths, who can then issue a death certificate.
Most people said that the coroner’s verdict was what they had expected, though some were disappointed that the inquest had not answered all their questions. A few were angry about the outcome. Dorothy had hoped that the Crown Prosecution Service would charge her son’s employer when Mark died in an industrial explosion in 2005. After many months investigating, the CPS decided against this, so in 2009 the coroner held a full inquest with a jury. Dorothy had hoped that the jury would return a verdict of unlawful killing but instead it gave a narrative verdict.
The family had to wait two years for the inquest. Erykah hoped that the inquest would bring 'closure' but it didn't. Many unanswered questions remain and the case is still not closed.
The family had to wait two years for the inquest. Erykah hoped that the inquest would bring 'closure' but it didn't. Many unanswered questions remain and the case is still not closed.
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The inquest, the inquest was two years later. It was just, it was a week before it would’ve been two years. I’ve no idea why this is. Thing is he’d been cremated and everything else, we’ve no idea. And it’s something that happens regularly, and I know there’s a lot of groups that are campaigning because, especially the case of the Rhys Jones case, he had a funeral much quicker than any other case we’ve known, and we believe that was put down to publicity but when, in the city murders take place, the funeral and if it takes, it’s quite a lengthy process and we don’t know why.
Two years is a long time.
It is a long time. At the inquest, which I didn’t find very helpful, they told us that they’d interviewed, I think they said something like eight people, nine people. That could’ve been the same person nine times, but there were so many interviews done. We wasn’t allowed to know who it was, or any names of anybody interviewed, and I was thinking that if I knew a name that was interviewed maybe we’d know who has done this horrendous, you know, thing. Because he wasn’t a young boy in a gang, he was 27, he owned a business, he was due to get married, so it wasn’t your gang warfare gun thing, but they tried to link it to drugs and gangs at first, which is what they have to do as part of the investigation. And then they have always said that it was mistaken identity, but I don’t believe that, because he was shot too many times.
Yes.
And the fact that he was shot in his neck at point blank range, does not indicate, you know it wasn’t, it wasn’t mistaken identity. You could understand that if it was a drive by, and all the young boys do, gang things, but this wasn’t mistaken identity at all.
So you’ve never found out?
No, but the inquest, which we was waiting for forever, hoping that this would be closure, they ruled that he died Death by Association.
Death by Association?
Yes, and we had no, we were asking what does this mean? That’s all we’ve been given after two years of waiting and waiting, waiting, and trying to push for this inquest.
So what’s on the death certificate?
Death by Association. That’s what, that’s, that’s what the coroner’s report is.
How extraordinary.
Who had to give evidence?
Nobody gave evidence. My Mum stood up, that was it. It was just the police and my Mum, that was it. We’ve never had a court case, and we don’t know anything more than we did on May 23rd 2002. We don’t know anything more.
So what’s the police liaison officer been telling you all this time?
We’ve never seen one since. We haven’t seen a police liaison officer in years. His case is what’s known as “box”, so it’s sat, his case is what’s known as box, they call it box which means that all the evidence is in a box, sat on a shelf. It’s not closed, but if any other evidence comes to light, which will only, could only be somebody coming forward and saying they’ve done it or someone saying they know who’s done it, then…
So it’s an open case, they didn’t put down as murder?
Yeah, oh no. No. It’s like.
The inquest was a terrible experience. Godfrey and his wife expected to hear the report that had been conducted into the accident but they were told that it was private property of the railway company.
The inquest was a terrible experience. Godfrey and his wife expected to hear the report that had been conducted into the accident but they were told that it was private property of the railway company.
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The real problem for us, in relation to his death was that it was a railway accident, and we were told that we would find out exactly what had happened when an inquiry had taken place, into the accident. And an inquiry did take place about a week after his death, but then the whole system seemed to clam up, and we were just told we would, we would have to wait for the report into the accident, and there would be a resumed inquest which would be in about six months time. And we might have to wait until then to find out exactly what had happened.
When we, the inquest was, it was a terrible experience for us because we turned up at the coroner’s inquest, and we were amazed to see there were a great horde of people at the inquest, which we knew nothing about. And it transpired that the rail company had had a whole lot of lawyers at the inquest, because they felt there might be some trouble. We expected that we might at least hear something about this report that had been conducted into the accident, but it wasn’t produced at the inquest. And we then conducted a campaign to try to get access to it, and we did this at all sorts of levels, and at the end of the day we were told that this couldn’t be given to us because it was the private property of the railway company and they couldn’t be forced to, it was a private railway company of course and they couldn’t be forced to deliver it to us, and well you know this was very difficult to accept that here’s our son, been killed in an accident, that there had been an inquiry into the accident, and that the contents of the inquiry should remain confidential.
A coroner’s decision can be challenged by applying for a judicial review within three months. However, this is a complex process which needs a lawyer. A judicial review is a type of court proceeding in which a judge reviews the lawfulness of a decision or action made by a public body. In other words, judicial reviews challenge the way in which a decision has been made, not the rights and wrongs of the conclusion reached. If people want to challenge the coroner’s verdict a judicial review may not be the best way to proceed. People can at any time apply for a new inquest to be held, but it is better to apply as soon as possible and to get help from a solicitor.
Useful information about the whole inquest process can be found on a website run by an organisation called INQUEST. It provides independent free legal and practical advice to bereaved families and friends about the inquest process. It offers specialist advice to lawyers, bereaved people, advice agencies, policy makers, the media and the public on contentious deaths and their investigation.
Last reviewed October 2015.
Last updated January 2015.
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