27 May 2021

A cross-party group of MPs has today issued significant and wide-ranging recommendations to put bereaved people – whom it says have been “failed” by successive Governments  at the heart of the inquest process. The Justice Committee give the government an urgent deadline to provide public funding to bereaved families for legal representation at inquests where the state is represented. Informed by extensive first-hand evidence from INQUEST and bereaved family members, the Justice Committeehighlights the many limitations of the system as it currently operates and places the responsibility to address these firmly in the lap of the Ministry of Justice.

With the publication of this report, the Justice Committee concludes its inquiry, launched in July 2020, to examine The Coroner Service – not least in the light of reforms introduced under The Coroners and Justice Act 2009.

The inquest system is a crucial but often overlooked part of the justice system. For those whose loved ones died in state detention or at the hands of state actors and agencies, it is often the only way they get answers about failures in care, neglect or contentious circumstances.

While some families do have positive experiences of the inquest process, far too many experience it as an additional trauma. Bereaved families are all too often treated with a lack of dignity,respect and empathy, and are met by frequent attempts by lawyers representing the state and private organisations to deny, delay and defend actions rather than address failings. The inquest process has a key role in preventing future deaths, yet families time and time again tell us they have no confidence in this leading to change.

While acknowledging some areas of improvement introduced since the 2009 Act, this significant report tackles head on the major challenges that bereaved families face when navigating the inquest system. Most significantly, it calls for an urgent end to the system that ensures public authorities are legally represented at public expense while bereaved families are forced through hurdles to obtain legal aid. This inequality of arms faced by bereaved families, long highlighted by INQUEST, is the single greatest obstacle to families securing truth and justice through the inquest system. Every independent review and public inquiry that has considered issues faced by bereaved families over the past 20 years has recommended that this inequality of arms be addressed. This report calls on the Ministry of Justice to ensure non-means tested legal aid or other public funding for legal representation to all these families by October 2021.

The Justice Committee also highlight other major challenges faced by bereaved families: the lack of information about their rights and support; the lack of respect many experience in the way they are treated by coroners; the need to introduce an appeal system. It provides a clear critique of a fragmented service that has for too long been ill resourced and overstretched. Finally, it provides long overdue recognition of the failure to follow up on reports that aim to prevent future deaths and ensure the lessons and promised actions from the inquest process lead to concrete change.

Only days after the Queen’s speech announced a plan for new measures to introduce efficiencies into the inquest system, this report must stop ministers and policy-makers in their tracks: what is in fact needed is a significant change in government policy that is centred on the experiences of bereaved families – genuinely puts them at the heart of the inquest process – and institutionalises the culture and mechanisms to prevent deaths in future.

INQUEST gave written evidence to the inquiry, and coordinated written evidence from 51 bereaved family members.Andy McCulloch, whose daughter Colette McCulloch died whilst in the care of mental health services, also gave oral evidence to the committee alongside Deborah Coles, INQUEST’s Director.

Deborah Coles, Director of INQUEST, said: "With this report, the Justice Committee make clear that to serve the needs of bereaved families and wider society, the Coroners system needs fundamental change. The light touch reforms and piecemeal gestures around training, guidance, administration since 2009 made some improvements, but they have run their course and, ultimately, come up short. It is now for government to put the experiences of bereaved people at the front and centre, and ensure equality of arms, accountability and oversight, and candour. There can be no more false starts, broken commitments or shelved recommendations. This must be a watershed moment in ensuring a fairer and accountable coronial system and the prevention of avoidable deaths. Too often we hear that “lessons will be learned”: this must become an institutionalised practice, not an empty slogan."

Andy McCulloch, witness to the inquiry, said: "This is an excellent, accurate report. Our experience with our original coroner was appalling. From the start he was rude, dismissive and obstructed investigation of our daughter’s death. It took two years to make him stand aside. Then we faced banks of lawyers representing health professionals paid for by the state. We welcome the Justice Committee’s recognition that legal aid must be available for all bereaved families: otherwise there can be no justice. To prevent further avoidable deaths, and protect the bereaved, this report must be acted on."


For further information, interview requests and to note your interest, please contact Louise Finer on [email protected]

The report of The Coroner Service inquiry by the Justice Select Committee is available here.

For more information on INQUEST's campaign for Legal aid for inquests, visit our campaign page.

INQUEST evidence to the inquiry:

INQUEST Written Submission (September 2020)

INQUEST Family Submission (September 2020)

INQUEST Supplementary Evidence (February 2021) 

Deborah Coles, INQUEST, and Andy McCulloch oral evidence (September 2020)

For more information and to access all the evidence to the inquiry, visit The Coroner Service inquiry page from UK Parliament.