A mother unable to ask any questions during a two-hour inquest into her son’s death. Reality hitting another mother that she was ‘in a world that we couldn’t compete with’ upon learning that health staff she was due to question would be legally represented. Disclosure failings resulting in a mother handed a ‘great big bunch of papers’ mid-hearing revealing her daughter’s distress and given only 20 minutes to read them. Parents who were represented still feeling disadvantaged by the sheer number of lawyers representing the state.

These are some of the experiences of bereaved people at inquests revealed in a landmark study, Voicing Loss, published today by Birbeck, University of London, and the University of Bath.

Academics interviewed 89 bereaved people and 82 coronial professionals.

Inquests are supposed to be inquisitorial, but one father said: ‘It’s quite intimidating actually. Because you get told initially that inquests aren’t adversarial. And then you turn up to a PIRH [pre-inquest review hearing] and all the public bodies – the police, the NHS trust, the schools, the pharmacies – they’ve all got barristers and solicitors. It’s not just them and one other person. They’ve got teams of people.’

Another father questioned for two hours as a witness said: ‘You just have to take the battering, and maybe get it over with.’ Bereaved people were ‘blanked’ by witnesses during hearings and saw them laughing and joking outside the courtroom ‘as if it’s just another day in the office’. 

Recommended ‘relatively straightforward’ changes to help bereaved people feel engaged with the coronial process include: clearer and concise guidance; timely communication on case progression, outcomes and next steps; no legal jargon in hearings and communications; and careful attention to how distressing evidence is presented.

INQUEST, a charity which provides expertise on state-related deaths and their investigation, worked with the Voicing Loss team. Director Deborah Coles said: 'We must urgently see families’ legal rights upheld in the inquest process and oversight of inquest recommendations to ensure that their preventative potential can be realised and lives can be saved. The voices of bereaved families are too strong and their stories too compelling to be ignored.'