I is for Inquest (part one)

At work I’ve been writing for an A-Z for families.  When I got to “I is for Inquest” I found it difficult to create a few simple sentences, mainly because I believe the inquest and the coronial system is outdated and unfit for purpose.  The Coroners Society says that although the office has been in place for eight hundred years, it’s survived for that long because it is constantly evolving.  I think it’s time for another evolution.

Currently an inquest is presided over by the coroner for the county the person died in.  The coroner is presiding over an inquest which has only one purpose – to decide where, when, why and how the person died. The role of the inquest is to find out the where, when and how.  The process isn’t about establishing blame, so the process has nothing in place to deal with the notion that there might be two very different and competing viewpoints in the coroner’s court about why the person died.

Very occasionally there may be a jury but this is usually only when the death was in police custody, or the police where involved in the death, or it was a death in the workplace.  Sometimes there’s a jury because it’s a high-profile death and the coroner feels the inquest would benefit from having a jury.  One of the main concerns I have with the current system is that very often, the coroner has no in-depth understanding of the circumstances around the death and neither will the jury.  Usually a coroner has a legal background and sometimes he may have some type of medical background, but that doesn’t mean he’ll understand the subtleties of everything that he’s being told about. 

Families often feel the coroner has an in-built bias towards the healthcare provider, rather than to the family and I will always remember the opening remark of our coroner on the first day of our inquest:

“Let us begin by thanking Southern Health, who do the work that not many of us would want to do”.  The work in question was organising the care for my son. Something they did not appear to do very well.

And then of course there’s that perennial coronial get-out clause “the inquest is inquisitorial, not adversarial”.  This simply means the coroner won’t acknowledge that on one side you have the family, their evidence and their testimony and on the other, the ranks of the healthcare provider’s legal team and that they rarely share the same version of the facts or even desire the same outcome for the inquest.  The refusal to acknowledge the adversarial element, the refusal to acknowledge that in fact you have two opposing sides telling opposing versions of the truth, means that all too often the inquest is a deeply toxic event for the family.

If I’m honest I probably think about my own inquest experience very, very often.  For my family it was one of those events which has changed us all and scarred us deeply.  We talk a lot about healthcare providers harming families twice, once through the serious incident and once more through the denial of wrongdoing.  I believe that the current inquest procedure inflicts a further harm on families because all too often the emphasis is very much on the family to try to get the coroner to believe them, as inquests seem to proceed from the view that the grieving family don’t know what they’re talking about.

A very recent inquest has confirmed that in my mind.  A few days ago the inquest into the death of Joanna Bailey shone a light on all that is wrong with the coronial and inquest system.  In all too many ways, this inquest was another example of truth denied and family traumatised.  But with one remarkable exception.  Although this inquest had a jury, the coroner refused to allow the jury to consider Joanna’s death was contributed to by neglect and insisted that the verdict be “natural causes”.  However, the jury refused to follow that guidance and instead listed 11 serious concerns around Joanna’s death, all of which painted a picture of inconsistent and chaotic healthcare and they plainly felt her death was avoidable.  But the coroner’s verdict of natural causes stands.  Another family traumatised and more truth denied.

During this inquest the barrister for the private healthcare providers asked that the family not be allowed to give evidence.  He claimed Joanna’s father’s evidence would contain no facts, but only “opinions”.  When Joanna’s father did give evidence the same barrister was allowed to cross examine him for 35 minutes in an attempt to discredit his testimony.  The same barrister also requested that the final verdict could not be left to the jury to decide and the coroner accepted this.  The barrister clearly feared the jury doing exactly what the jury did.

So once again, and very, very recently, we have an example of an inquest where the family’s evidence is not given anything like the same weight as the healthcare providers.  Once again, it seems as if everybody in the room has already decided, that the healthcare provider is right and what they want will be the best outcome for everyone.  When you are a family in the inquest it feels as if the other side (with their huge legal teams) have a much, much bigger stick than you, and they’re going to use it in every way they can to ensure everyone falls in line with what they want.  Truth and the opportunity for learning becomes just another casualty.  I’ll never forget the look of smug triumph on the faces of the Trust’s legal team when the verdict for my son’s inquest was “narrative” not “neglect”.  They actually slapped each other on the back, loudly congratulating each other. 

My idea for inquest evolution is simple. I believe that inquests should be of two distinct types.  Type One inquests are when the how, where, when and why of the death is not disputed by either side and both sides are in agreement prior to the inquest.  This type of inquest should go ahead with just the coroner and would be known as an “inquisitorial inquest”.  These inquests would end in a simple statement giving the details of the person’s death.

Type Two inquests would be known as an “adversarial inquest” and would be automatically trigged if the family do not agree with the version of events given by the other side and/or if both sides let the coroner’s court know they will have legal representation.  Type two inquests would be heard by a panel of highly experienced coroners, some of whom must have the necessary background understanding of the points of the case.  These inquests would end in a series of recommendations, one of which could include a compulsory independent investigation. 

My son’s inquest, which I usually refer to as “our inquest” because it really did feel as if the whole family was on trial, was held at the end of 2014 and I have had many months and years to think about what’s wrong with inquests since then.  You may not agree with what I’m proposing and of course, you may not even understand why I’m making such a fuss about this. 

I do realise that the majority of people in this country don’t know much about inquests.  We don’t know about inquests because we don’t need to.  We don’t think about them because we don’t need to.  We don’t know what’s wrong with the inquest system because we don’t need to.   But then, the day may come when we do need to know.  If that day ever comes for you I hope very much that my inquest evolution has already taken place.