28 August 2020

these systems are too often beset with costly delay and duplication, with insufficient concern for the needs of those affected by disasters. Instead of finding answers through the legal process, bereaved people and survivors are often left feeling confused, betrayed and re-traumatised

Working Party of JUSTICE

Earlier this month the Working Party of JUSTICE, the legal reform and human rights organisation released a new report ‘When Things Go Wrong: the response of the justice system’.

This is a major, timely review by group of experts in the post death investigation, inquest and inquiry processes.

The working party was chaired by Robert Owen QC. It included INQUEST’s Director Deborah Coles, Dr Sara Ryan, members of the INQUEST Lawyers Group, the former Chief Coroner Peter Thornton, and John Goldring, the Judge who presided over the Hillsborough inquests.


The Working Party sought to address the erosion of public trust in the response of the justice system to major incidents causing multiple fatalities or deaths arising from a pattern of failure. Too often disaster survivors and bereaved people have been let down by the justice system and instead of finding answers, endure a complex, confusing and retraumatising process. The lack of formal implementation and oversight following the end of an inquest or inquiry makes the likelihood of future prevention limited.

Deborah Coles was able to bring INQUEST’s extensive experience of supporting bereaved people after state related deaths and unique overview of the investigation, inquest and inquiry processes to the working party. She also chaired a sub group on public engagement.


After a year of consideration and debate, the Working Party put forward 54 recommendations. The report notes that despite the aspiration for inquest and inquiries to be inquisitorial proceedings, evidence from bereaved families and their representatives suggest that procedures are often a ‘highly adversarial battle’.

What often goes unmentioned is the high price paid by bereaved families in remaining involved in the lengthy, complicated investigation and inquest process. The emotional and physical impact of state related deaths on generations of families should not be forgotten, nor the way it is exacerbated by state denial and defensiveness, secrecy, insensitivity, delays, funding problems and lack of accountability… When they function at their best inquests are a vital way of exposing unsafe practise and shining a spotlight on the state and its agents and holding them to account for abuses of power, ill treatment and misconduct. In other words, inquests can save lives.

Deborah Coles, Executive Director, INQUEST page 108 JUSTICE report.

It proposes that to end the culture of defensiveness and to improve inquest and inquiries a statutory duty of candour should be introduced further building on ‘The Bishops Charter’ put forward by Bishop James Jones’ review into the experiences of the Hillsborough families.

It also called attention to ‘Pen Portraits’ that were used during the Hillsborough inquests as a way to place bereaved families at the heart of inquests and inquiries, which INQUEST pushed for as part of the Grenfell Inquiry, and have recommended for their widespread use.

The report also proposed that the Chief Coroner position becomes a full-time role and for a coroners’ service inspectorate in order to provide greater oversight. These recommendations are welcomed by INQUEST and points we recently made to the Justice Committee Inquiry on the Coroners Service

The Working Party highlighted the significance of INQUEST’s Family Listening Days in providing a forum for those who have been bereaved to share their experiences and provide recommendations for best practice outside of formal processes.

The Working Party emphasised that improving the involvement of families includes expanding the support available to them during and after such inquests and inquiries.

This important report endorses many of INQUEST’s long standing calls for change. These include addressing the inequality of arms though non means tested legal aid for bereaved families at inquests and a national oversight mechanism, an independent body to oversee and monitor the implementation of inquest and inquiry recommendations.

The test of this report will be its influence and implementation. INQUEST will work to ensure that these recommendations are kept on the political and policy agenda.

Further resources

  • Justice processes 'exacerbating' grief and trauma, The Law Society Gazette
  • Give victims of tragedies like Grenfell and Hillsborough automatic legal aid, urges think tan, Evening Standard
  • Major public inquiries and inquests 'need radical reform' after Grenfell Tower Fire an Manchester bombings, campaigners say, iNews

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