18 September 2020

Families go through the inquest process in the hope that they will get answers and acknowledgment of went wrong. This is out of the hope that future deaths are prevented. This hope is in the public interest, to identify faults and harmful practices that if put right could protect life.

Yet this is frustrated by a culture of institutional defensiveness from many public agencies at inquests, who are focused on reputational management rather than a meaningful search for the truth.

Deborah Coles, Director of INQUEST, told the Justice Committee

The Director of INQUEST, Deborah Coles, appeared before the House of Commons Justice Committee as part of their ongoing inquiry on The Coroner Service, alongside Andy McCulloch on Tuesday 8 September.

Based on INQUEST’s work with bereaved families over the past 30 years, as well as recent written contributions from over 50 families, they highlighted the inequality of arms that hinders bereaved families’ abilities to secure truth and justice and the inadequacy of the systems meant for preventing future deaths.

Watch the evidence session

Read the transcript

Change is urgently needed

In the evidence session, Deborah Coles highlighted that now more than ever, as coroners struggle to respond to the high number of deaths arising from COVID-19, change is urgently needed. INQUEST is calling for:

  • A full time Chief Coroner and a National Coroner’s Service, rather than the current part time Chief Coroner and inconsistent localised services.
  • As part of the National Coroner’s Service, there should be a team of specialist Article 2 coroners responsible for state related inquests, to ensure the appropriate experience and training needed to manage and effectively deal with these often highly complex cases.
  • The introduction of a right to appeal to the Chief Coroner, to address the current absence of accessible appeal mechanisms against coroner’s decisions.
  • The Chief Coroner should establish a regular advisory group/forum to consult directly with bereaved people and those organisations that support them.
  • Written information about sources of specialist support and advice, including information about INQUEST, should be passed immediately to every family by the coroner’s court following a state-related death.
  • Automatic non-means tested funding to families for specialist legal representation immediately following a state related death, as described in the Legal Aid for Inquests campaign.

Levelling the playing field

Andy is the father of Colette McCulloch, who died whilst in the care of mental health services. Their family faced multiple challenges in navigating the inquest system, and he told the Justice Committee of the shocking treatment his family received from one coroner. They came to the process believing what they read, that it would be an inquisitorial process and that they wouldn’t need legal representation.

I seriously thought that this coroner would be there to help us through and that we would have an inquisitorial process, where we would all sit around to discuss what had gone wrong. That could not have been further from the truth. The fact is that it is a highly adversarial system.

The legal representatives that all the interested parties had were aggressively defending their corner. They were not concerned with the truth of the situation coming out. They were not concerned with learning what might or might not have happened and what could be done to stop it happening. They were concerned with defending their clients’ interests—financial interests.

- Andy McCulloch told the Justice Committee

Deborah Coles also responded firmly to the suggestion made by Andre Rebello, the Senior Coroner Liverpool and Wirral Area and Secretary to The Coroners' Society of England and Wales, who provided evidence in the preceding session, that as a response to COVID-19 jury inquests could be suspended.

We were deeply concerned by his language, referring to the “dark arts” of lawyers at inquests, and we reject his comments implying efforts to widen the scope of investigations to “trawl for additional information that is not necessarily part of the means of arriving at the cause of death” are inappropriate.

Prevention of future deaths

Andy and Deborah reminded the committee that the motivation of bereaved families in seeking justice at inquests is to prevent the same circumstances leading to the death of someone else. The inquest can play an important public duty in preventing future deaths, but currently fails to do this.

This is why INQUEST is calling for the establishment of a National Oversight Mechanism; a new independent body with the duty to collate, analyse and monitor the currently disparate, hard to access and locally held recommendations of coroners and other post-death investigations and inquiries.

Testimonies of bereaved families

We are grateful for the contributions of all 51 families who provided INQUEST with evidence. The full written submission summarising all family evidence has now been published.


The full written submission by INQUEST is also available.

Read INQUEST's written submission

INQUEST will be monitoring the next stages of this inquiry closely. INQUEST Lawyers Group and Steering Group member, Charlotte Haworth Hird is due to give evidence, alongside a representative from the charity for patient safety and justice, AVMA.

We expect that the Justice Committee will call the Chief Coroner to respond to some of the issues raised. The Justice Committee will write a report to the government in the coming months and we hope they will use this opportunity to call for changes that make the inquest process better serve bereaved families.

Further information

  • All written evidence submitted to the Justice Committee inquiry on the coroners service will be available on the inquiry webpage. This includes full submissions written by families on their experiences and by other organisations representing bereaved families such as AvMA.
  • Read INQUEST's written submission to the Justice Committee
  • For more information on INQUEST's campaign for Legal aid for inquests, visit our campaign page.