There is currently an inquiry into the Coroner Service being conducted by the Justice Committee of Parliament. A call for written evidence closed at the start of this month. I submitted a response sharing some of my thoughts as a result of my #OpenJustice work, my WCMT Fellowship and the impact I’ve seen the coronial service have on bereaved families.

I just wanted to share a post to alert people to the evidence submitted by bereaved families and encourage people to learn more about their experience. I’m not going to repeat all of what people said, just give a taster from four families, a link to their submissions for more and the suggestion that you go and read all the written evidence submitted. You can find it here.

Maggie and Janet Brooks shared their horrendous experience in relation to their mother, Elsie, who died an avoidable death in an NHS hospital in 2010. An inquest took place in November 2014, which was subsequently overturned in 2018, a new inquest ordered which has opened but has yet to take place.

Maggie and Janet’s experience reads like the plot of a poor sitcom, poor because you’d claim it was over the top and unrealistic if so many things went wrong in real life: trust obfuscation and cover up; suggestion an inquest wasn’t required; a useless PHSO investigation; delays and denials including trust claiming no records or policy documents from 2010; a missing interested person who’d apparently gone to Ireland but Maggie tracked down with two phone calls and she was living around the coroner. .. that’s just the start.

Honestly, go read their submission, and ask how we can accept this. We are approaching 11 years since Elsie died, can you even begin to imagine what that does to a family? I’m not sure I can but you can read what Maggie and Janet had to say. They are now approaching a second inquest, with no legal counsel because they can’t afford it. How is this acceptable?

But the second inquest is unlikely to be plain sailing.

It is now 10 years since our mother’s death, and this time lag is wholly due to the Trust’s successful tactics of delay, deny and defend.

We find, at the new inquest, that the Trust is still at its old tricks of delaying, denying and failing to deliver – in the hope that they can stretch this out for another ten years.

The Coroner has a team of high powered lawyers managing the case for him and the Trust’s new high powered lawyer introduced herself to us at the hearing.

The only party at the inquest with no power is us.

Because of the paucity of the funding available, we see little prospect of being represented and, that being so, we contemplate the second inquest with dread.

Next up, let’s look at what Thong Nyugen has to say in his submission, following the death of his son Hayden, at just 6 days old. It starts:

I wish to share my harrowing experience with the Coroners Service. The experience shook my life-long belief in the Westminster system and has contributed to a protracted period of injustice, trauma and suffering for my family. My son, Hayden Nguyen, died at Chelsea and Westminster Hospital on August 25th 2016, only 6 days old. My wife and I were left for long periods alone as we watched our son gasp for breath and slowly die of untreated shock and respiratory failure over a period of 12 hours, ultimately witnessing his death.

Thong details the disparity of resource available to bereaved families up against state funded legal teams, their horrendous experience with the coronial system, including a coroner who suggested the Trust change their serious incident report findings to trivialise the failures uncovered and hide what they had learned, and how they’re now left without answers and the double trauma of the loss of Hayden’s life, and the way they’ve been treated since:

Having been failed in life, the inquest failed Hayden in death. It is difficult to understate the impact that the inquest has had on my wellbeing. I have thought about Hayden’s inquest every day, multiple times a day for the last 3 years; agonising over the injustice and repeatedly playing out in my mind wrongful and hurtful comments made by the Coroner and witnesses.

Please read Thong’s submission in full.

Then I move on to the evidence submitted by Rosie Tozer. Her son, Danny, died five years ago last week. You can read more about Danny here and read the poem Rosie wrote for him here. Rosie’s submission details how Danny died in Mencap care, and staff failed to follow the care plans in place:

He died in September 2015 following an unsupported & unwitnessed epileptic seizure while living in a supported living house run by Mencap, commissioned by City of York Council and partial NHS funding. Danny had autism and a learning disability and epilepsy and could not use speech to communicate. He had been left alone awake in his bedroom for 35 minutes. However his support plans stated that he should be checked every 5- 10 minutes and an ambulance called if a seizure lasted more than 5 minutes.

Rosie outlines the apathy of the coronial system, and how little interest there was into investigating the death of a fit and health young man. She reflects that:

The Coroner seemed unable or unwilling to prevent a contest between barristers and to lack professional curiosity about the evidence presented. He was intent on finding ‘natural causes’, and even asked a neurologist whether one could recover from a sudden death in epilepsy. Although no doubt a perfectly pleasant person, he seemed to prefer not to not challenge questionable practices such as staff shortages and hours of support not provided or to rock the boat with establishment bodies. His final statement was an hour’s summary of what he had heard without any analysis which shocked all parties who were expecting identification of failures, with a one sentence verdict.

This lack of analysis, and the failure to make any recommendations for meaningful improvement was a missed opportunity ‘to improve support for others as a meaningful legacy for our son’. Rosie concludes by touching on the impact of the experience of the coronial system:

Overall, apart from the poor practice and disregard exposed at the inquest which only confirmed our suspicions of how Danny had been supported during his placement, it was the most traumatising experience we have ever had, after Danny’s death and that of our younger son 15 years previously.

You can read Rosie’s submission in full here.

The final person who I’d invite you to hear from is Andy McCulloch, whose daughter Colette died in 2016. You can watch Andy on Parliament TV here. He details what happened after their daughter was killed on the A1 at 3am in the morning when she should have been in a clinic treating her for mental illness.

‘I have to say we didn’t even consider having legal representation, I had believed what I’d read, that this was an inquisitorial process and I wouldn’t require legal representation…. it was like being slammed in the stomach, I can’t tell you the pain, the agony, I’m sorry ‘.

Andy details the appalling way in which him and his wife Amanda were treated at the first PIR into Colette’s death, how their friend accompanying them advised them to seek legal advice and the steps they had to take to eventually crowdfund money to take judicial review proceedings against the coroner, until he eventually agreed to recuse himself.

These are just four examples, they are the tip of the iceberg. Elsie, Hayden, Danny and Colette, all deserved so much more. Their families should not need to fight for answers, they should not need to be crowdfunding for legal fees or studying legal textbooks to make their own submissions. Please take the time to read their submissions, to follow their families on social media and support them in their ongoing quests for answers and justice. I hope that the committee take notice, and take action.