26 April 2023

Bereaved families are facing persistent challenges following the death of their loved one in mental health services.

The report shows that families face numerous hurdles during investigations and inquests into their loved ones’ deaths, and the processes are not delivering the change required. They are instead shrouded in delay, secrecy and animosity towards families, who simply wanted active participation and a truthful account of what caused their relatives’ deaths. 

INQUEST’s Family Consultation Day heard from 14 family members who were bereaved by deaths in the care of mental health services or settings for people with learning disabilities and/or autism, and had faced or were going through inquests and investigations.

Key concerns raised by families include:

  • A lack of candour, transparency and accountability
  • Inadequate levels of communication between families and the bodies responsible for care
  • Many felt they were immediately placed on the backfoot during investigations into their loved ones’ death. 

Bereaved people engage in the post death processes with the hope that they can access truth, but also that their participation can inform change to prevent future deaths in similar circumstances. However, the research found that a litany of issues left unchanged following these processes is adding to the distress families feel and risks making them disengage from investigatory processes entirely or being retraumatised by the process. 

Families are calling for major changes to the investigatory and inquest system, including: 

  • independent investigations into mental health related deaths,  
  • a national coronial service to address inconsistences in the inquest system,  
  • non-means tested legal funding for all families involved in inquests where state bodies are involved to provide proper equality of arms.  


The report was written by Chris Tully and designed by Rachel Carr. The Three Guineas Trust have funded this work.