A three year "Voicing Loss" study from the The Centre of Death and Society at the University of Bath and the Institute for Crime & Justice Policy Research at Birkbeck, University of London has carried out in-depth interviews with 89 bereaved people and concluded that several key practical changes are urgently needed to coroners' inquests and investigations in England and Wales. Families told researchers the inquest process offered a sense of “relief” and “catharsis”. However, more of the interviewees found that coroners’ investigations and inquests were “alienating and disempowering” and struggled to navigate the complicated legal process while grieving.

The trauma of an inquest was compared by some to the distress caused by the death itself.

Coroners’ inquests examine deaths which have occurred in a violent, unnatural or unexplained way. All deaths in prison or other forms of detention must be subject to an inquest.

In the "Voicing Loss" study, grieving relatives and friends told academics they wanted lessons to be learnt, especially where the state or another institution was involved in the death. Coroners are obliged to alert relevant bodies – such as the government, hospitals, schools and companies – by writing Prevention of Future Deaths reports, when they believe there is a risk of future deaths, and they consider that action could be taken to prevent or reduce that risk. However, the study found “profound frustration and disappointment” among bereaved interviewees who felt the inquest had seemingly done little to help prevent future deaths .

Lorna Templeton, from the Centre for Death and Society at the University of Bath said:

“One of the most powerful findings from our research is how much bereaved people’s experiences of the coronial process varied. During a period of personal grief, some told us about professionals who were kind and thoughtful, while others reported inconsiderate and disrespectful behaviour. A kind word, or an opportunity to show a photo or give a pen portrait can bring welcome humanity in what for most is an alien legal world.

“Our wide-ranging study shows the hidden, often long-lasting impact of an inquest on grieving processes. It is essential that humanity is at the heart of the coronial process. This can be achieved in ways that facilitate, rather than compromise, justice. For example, bereaved people should be supported to show a photo and give a ‘pen portrait’ of the person who died as a matter of course.”

“Voicing Loss” calls for several key practical changes which are urgently needed:

• 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.

• Improve communication: Make 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.

Professor Jessica Jacobson, Director of the Institute for Crime and Justice Policy Research (ICPR) at Birkbeck, University of London, and Voicing Loss project lead 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.

The "Voicing Loss" project was funded by the Economic and Research Council (ESRC).

A “Voicing Loss” website about coroners’ investigations and inquests and the role of bereaved people is now available.