September 2023

INQUEST was commissioned to hold a Family Listening Day as part of a wider study of bereaved peoples’ experiences of inquests, being conducted by Birkbeck’s Institute for Crime & Justice Policy Research in partnership with the Centre for Death and Society at the University of Bath.

The wider study, Voicing Loss, involves interviews with individuals who have personal or professional experience of the coronial process.

The focus of the research was to hear from families who had experienced the inquest system and Coroner’s Service following a death that occurred in state care: police custody or prison. 

Families discussed the themes arising from the deaths of their loved one in police custody or prison. There was a consensus on key issues and these are outlined in this report. Families described delays and inconsistent relationships with the Coroner’s Service, coroners and the investigatory bodies.

The research highlighted predominantly negative experiences but there were examples of good practice too including empathetic coroners, supportive Coroner’s Service staff and the vital role played by INQUEST caseworkers and specialist, experienced inquest lawyers Important contributions were made on the significance of context; whereby a death in state care has the potential to influence subsequent events and experiences.

Families also wanted to discuss the paucity of information and lack of independent advice, the need for support to engage effectively with the process, and the vital role legal representation plays in securing successful outcomes.

Families also considered the nature of the inquest itself, including the role of coroners, state lawyers and the importance of juries. Finally, the FLD considered what changes could be made to encourage greater family engagement in a process that requires more empathy, consistency and a greater emphasis on placing families at its heart, rather than as bystanders with limited faith in its potential to prevent future deaths.