The coroner’s inquest

A legal inquiry into a death is held when its cause is unknown, violent or ‘unnatural’. This is called a coroner’s inquest and is held in public, and the coroner determines the cause of death.

He or she does not have to establish why the death occurred, but only who the deceased was, how, when and where death occurred. The verdict depends on many factors, including the post mortem examination. The coroner may have a meeting with the relatives before the inquest, but usually next-kin or other ‘interested persons’ meet the coroner’s officer.

The coroner’s officer, also known as the coroner’s investigator, works with the coroner, the bereaved relatives, the police, doctors and funeral directors and others. Some people told us that the coroner’s officer had been very helpful, and that she had prepared them very well for the inquest. Rachel, for example, recalled that the coroner’s officer had invited her to attend someone else’s inquest, so that she knew what to expect when it was time for her son’s inquest.

However, others had been disappointed by the lack of information, and difficulties in obtaining documents. Most people met the coroner’s officer, but some only spoke to the officer by phone.

Pat and her daughter Tamsin explain what happened after Mathew died:

The coroners officer explained why a post-mortem was necessary. She answered Pat’s questions,…

Age at interview 62

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There had to be a post mortem.

How did you feel about that?

Well like everything else I accepted it like a lamb. There had to be because there might have been, there might have been actions brought by the police.

So there had to be a post mortem and I think the coroner’s officer explained that too, that was one of the things she talked about that evening that Matthew died. So we did have to wait for a post mortem and the coroner’s officer kept in touch; rang several times and she had given me her telephone numbers and had stressed to me that if I had any questions or was worried about anything then I could contact her at any time. And she was as good as her word. She was very, very good. And I spoke to her several times about various things.

You haven’t said anything about the inquest?

No, I haven’t. The inquest was a long, long time. It felt like an awfully long time although in fact it was probably, it was six months. It was six months, which was probably not as long as I thought it might be. And that was a dreaded day. And before that there was an occasion when the coroner’s officer came here. My ex-husband and my daughter and daughter’s partner and myself were all here and we had to make a statement about my son and about, particularly about his driving habits and our view of his driving.

And were you prepared for the inquest? Did the coroner’s officer prepare you for what was going to happen at the inquest?

Yes she did, very, yes, very carefully, even down to how the room would look and where, where we might sit and who would be there. And I did have a list of who would be there.

And I was told who there were like, you know, in cars following. There was, there was a, a driver who turned right, that’s what happened. She didn’t see my son, and my son didn’t know she was turning right. And there were a line of cars behind her. And [sighs] so, yes, we went, there was huge trepidation about the, the inquest. Because again it was a, another milestone and one like the funeral which I really didn’t want to come because to me it was something that the rest of the world saw as a stage in life after my son died, after the death of my son. And I didn’t want to get on with those stages.

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Before the inquest the coroners officer showed them photos of the crash site, gave them the…

Age at interview 37

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What did the coroner’s officer do to prepare you for the inquest?

Well she talked through the results of the path, the examination, and also actually allowed us to see the photos of the crash site, which was very important. We found it very important to understand what had happened. My brother was a very experienced rider.

He was not a boy racer. You know he was thirty-four and had been riding since he was sixteen. He was quite a mature rider. So we needed to understand. And I think particularly my mum who doesn’t ride bikes and hasn’t really ridden bikes, so probably had less of an understanding of what you do on a bike and how things happen.

And the coroner’s assistant visited us and talked us through all of that. And talked us through the results of the medical so we understood exactly what had killed him, and some of the circumstances around that. She ran through with us the format of the inquest and the people who would be there. And also gave us a little bit background on the coroner himself, because she was concerned that he might be one of those people who was a little bit dismissive of bike deaths.

And in fact we didn’t find that with, we found that he was, he was quite fair. He didn’t belabour any point unfairly we didn’t think. So that was helpful, so at least we knew what to expect.

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In the past relatives were not allowed to see witness statements or other evidence before the inquest, but it is now considered good practice for the coroner to supply relatives with these documents before the inquest. Since July 2013 new rules from the Coroners and Justice Act (2009) came into force along with new coroner rules and regulations. The new provisions apply to all coroner investigations, including those which are already being investigated by a coroner or ones which may have already reached the inquest stage.

The new changes should mean that families are:

  • more routinely informed of post mortems in advance;
  • given an opportunity to give their views about non-invasive post mortems;
  • able to be present at post mortems and;
  • to receive (as soon as practicable) a copy of the report.

(From INQUEST – The Inquest Handbook: November 2013 update)

Relatives or other interested persons used to have no right to look at documents – it was at the discretion of the coroner – and some were charged a fee for copies of the post-mortem report and for copies of the coroner’s notes of evidence. David had to pay for a copy of a post-mortem report.

Alison was allowed to go to the police station to see the statements and other documents that had…

Age at interview 37

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Has a coroner’s officer come to talk to you at all? They usually talk to you about what’s going on?

I was told after chasing one particular coroner’s officer that as next of kin it was not my job to chase up the files. And I said, I’m not next of kin. I’m their mother

But I did, she did grant me early, early disclosure, which she[laughs] he let me do two days before Christmas.

Does that mean she’s let you see something?

She’s let me see the complete file [prepared for the inquest].

Oh.

Yes. So I know. I said I have to see exactly what is in there because I still wasn’t clear on a few things. I had to see exactly what’s in there so when we go into that courtroom I’m ready. I don’t want to break down in front of everyone. I want to know now.

And I’m ready.

Is this a fairly new ruling?

No it’s, it’s not a ruling. it’s as I said it’s at their discretion. They don’t have to grant early disclosure. I’m considered a properly interested part, not their mum, but a properly interested part.

I also requested that they did my husband’s inquest at a different time to the children. But they won’t.

Oh. Did you have to go and look at all the files there, did you have to do it in their presence or could you take it away or did they send you copies?

No they wouldn’t send me copies. I had to go to the police station to view them there. A coroner’s officer was loitering in the background. And was busy telling me I didn’t need to see this, didn’t need to that.

Which I think had absolutely nothing to do with him.

No.

You know he’s not me. I’m sure there are some people who don’t need to but I do.

But what I did is I contacted the, the police officer who was running the case, I asked him could I have one of my FLos [family liaison officer’s] to accompany me, just in case I went off the rails a bit.

Which they did so.

That was good.

Yes. So she just came and she sat there whilst I read through. I had a bit of a sob. And I say, I didn’t know about that And she said, Sorry Alison And that’s you know, that’s it. And that’s all I needed. And I yep, bit of cry and came outside and I’m all right.

So now you know roughly what to expect when the inquest happens?

I do.

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Dorothy and her family wanted to prepare for the inquest. The coroner charged them £ƒ566 for…

Age at interview 65

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You said you’ve got the inquest coming up?

I have.

Has a Coroner’s officer not been in touch with you at all?

Never, ever. Yes I have never spoken to, I mean the Coroner that we had, the original Coroner that we had, the one who wouldn’t release the body, our solicitor asked him for disclosure of the evidence so that we could prepare for the inquest, and after initially refusing he eventually agreed but he said he would only release it if we paid him £566. The solicitor phoned and said, You know what do you think? And I said, I’ll pay anything, anything, I don’t care, it’s only money. And I just don’t care. So we paid him, my daughter in law obviously couldn’t pay, so we paid the £566 for the disclosure of evidence.

What’s the money for? For copying?

Photocopying. He also charged us, there were two other solicitors involved, there was two companies involved, my son’s employer and another company, who were all breaking the law, he also charged them £566 to supply the same photocopies. I was speaking down in London at a conference, a CCA [Centre for Corporate Accountability] conference, and I happened to say this in part of my speech. I said this, and a Coroner that was in the audience came forward and said, You should never have been charged for that.

Right.

So I contacted my MP at that point, who wrote to the Minister of Justice, and the Ministry of Justice wrote to the Coroner saying that there was no basis in law for charging for disclosure of evidence and that he should refund us the money.

And he refused.

The Coroner?

The Coroner refused. So we then, our solicitor then said that we would raise an action in the small claims court, in my name, to get this money back, which we did. We wrote to the Coroner saying that I was going to take him to the small claims court in his area, to get this money back and at that point he repaid the money and withdrew from our case.

Oh he has repaid the money?

He’s he repaid the money, but only, only after threatening him with

Was he going to keep it for himself?

It was paid to him, directly, no the money was paid to him directly, it was his money. And it was, when it was repaid it was repaid from his private bank, from his own bank account.

That’s incredible.

And he withdrew from the case. I then wrote to the Office of Judicial Complaints who deal with complaints against Coroners and that was where all the information, the information from my solicitor and all the investigation I had done on the internet, printed off what Coroners should do, how they should behave etc, etc. I sent everything off to them, and they were going to take the complaint up, they had agreed that they would take this complaint forward, and then we discovered that the Coroner was terminally ill.

That was all this year.

Well over a period of yes, yes. I withdrew the complaint on the basis that you know I would show his family you know all the compassion that he never showed to mine.

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Some people do not want to see all the documents. After Rosemary’s son died in the London bombing in 2005 the coroner sent her and her husband the post-mortem report by post. She thinks a post-mortem report might upset some people and that it should not be sent without a request.

If anyone has been charged with a criminal offence the inquest will be opened and adjourned until after the criminal proceedings. At the opening of the inquest the coroner hears the facts that have been established about the death, and interim death certificates can be issued. When any trial is over the coroner will resume the inquest if he or she considers it necessary, but often the relevant facts will have come to light during the criminal trial and the inquest is not reopened.

After Steph was hit by a bus the inquest was adjourned. The driver was charged with causing death…

Age at interview 43

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After she died, was there an inquest, did they open and adjourn an inquest?

Well the inquest was put on hold whilst the police decided whether there was going to be charges. There was going to be an inquest and when we initially thought there were going to be no charges against the bus driver, the inquest was scheduled actually for Steph’s birthday, in May, which was like eight months after the accident. Then the police changed their mind and decided it was going to go to court, so the inquest then is put off until after the court case. The court case collapsed and I, I automatically assumed there would be an inquest, in fact the local papers whod covered it, you know, had been saying have to wait for the inquest now to find out what happened and why my wife died. Then I got a letter from the Coroner saying, there was no point in having an inquest because they thought all the relevant points had been covered. It was only then that I discovered what an inquest was for, which is for who, when, where and how, but the how means literally how, you know she, she was struck by a bus, not how did the bus go out of control, they don’t cover that. And I didn’t realise that. So I got quite , a bit of a sympathetic letter from the coroner saying they were sorry but I am satisfied all points have been covered, we’re not going to have an inquest. And I wrote quite an angry letter back, in retrospect looking at it, and I do understand why legally there’ll be no inquest but I’ve still got no answers to my wife’s death, this is something I’ve got to, I know I ranted on a bit emotionally, I shouldn’t have done, but it was a polite and formal enough letter to the coroner, I never got one back though, huh. No.

But was there a Coroner’s Officer who communicated with you?

Yes, never spoke to the Coroner herself, it’s very formal, it’s very cold and clinical.

Did you meet the Coroner’s officer?

No I only spoke on the phone.

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People often had to wait months or even years for the inquest, while the police were collecting evidence, or while suspected criminals were being tried in court. Some people told us they were still waiting for the full inquest years after the death.

The inquest for those killed by the Bali bomb was held about nine months later. During the…

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Was there an inquest?

There was an inquest. That was held in the June I think. It was certainly about nine months after my brother was killed. It wasn’t until the inquest that we discovered what exactly had killed him. And in hindsight it would’ve been fantastic if they’d been able to tell us earlier, because it means that for nine months you just don’t know, I mean what really happened.

Was the inquest in this country?

Yes it was in this country and it was, for most of the British relatives, all simultaneously, and they were all declared to have died of multiple injuries associated with the bombing, but luckily we could actually talk to the pathologist, who had inspected each of the bodies, and we were able to ask questions like’ Well what does a bomb explosion do to a person? And how do you know he died instantly? And he was able to explain that, you know, essentially they didn’t need to open any of them up because they knew that; because you could tell from the physical condition of the bodies how close they had been to the source of the blast, and that essentially that your internal organs explode and that’s it, bang, and you’re very likely you would be unconscious in, you know your brain will have, you will be dead within seconds, if not instantly.

And did you attend the inquest?

Yes, we did.

Were you prepared for the inquest, did the Coroner’s Officer talk to you before hand?

No. But actually the Coroner was fantastic, and she came along afterwards to the where we had a a memorial service at St. Martin in the Fields on the first anniversarynbsp;

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During the inquest the barristers tried to blame his daughter for the accident and William felt…

Age at interview 48

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Yes, one, one of the horrible parts of the journey is that because Lauren’s death was caused by the actions of other people there is a civil case to be answered. And in civil law if the actions of others have caused something really nasty, whether it’s a nasty injury or a death, then one, you know, a party such as Lauren’s family can pursue a civil case against the parties who caused the death.

Where more than one party contributed to the fatality, you’ll find that there’s all these legal arguments and ducking and diving and it’s no longer about the fact that you’ve lost your loved one, it’s about money. And it’s about some, you know barrister saving his client two or three thousand pound. And so the reason why there were these legal representatives kicking about the inquest was that they, the school had a legal representative there, a QC no less, the bus company had a legal representative there, a barrister, and the lorry driver’s employer had a legal representative there. And during the inquest, which is not to attribute blame but rather to find out the facts, there’s all this ducking and diving going on, and basically the humiliation and extra hurt of each of these legal representatives basically saying, Ah it was Lauren’s fault. It was Lauren’s fault. She was looking the wrong way

Did you have any legal representative there?

We had a solicitor there just, but when the legal, when our legal representatives, when our solicitor saw who was representing their side, they actually became quite intimidated because they said, Oh if we’d known a QC was going to be here I would have brought a barrister for our side And so they actually felt very intimidated, but it was very, the way the inquest worked was you’re in very, very tight constraints, as to what, well as you know, as the bereaved person, what I as the father of the deceased was able to ask, was able to get information on, and so all the questions about, why did the lorry driver not see her before he hit her? Why did the bus driver let her off there? Why did the teacher take no interest? All those questions, they couldn’t really be fully addressed at the inquest.

Were you prepared for the inquest in any way? Did anybody tell you what was going to happen?

Well, informally I had some conversation with the lady from the Coroner’s office, on the phone. And they give you, you know, a handout a, a pamphlet about what happens at the Coroner’s court, but I don’t think I was prepared for it being so similar to you know, a High Court where someone would be tried for murder or something. And it was remarkably similar because I had cause to bear witness for the prosecution in a murder case previously, and it was remarkably similar, except.

So how did you, how did you feel about that?

I felt that when it comes to the law, those who implement the law and those who examine the law and test the law are fairly insensitive about people’s feelings and emotions, but I guess that’s just the nature of life. And certainly when it comes to application of the law, and the civil case, it’s not about truth or justice anymore; it’s about the letter of the law.

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Most people we talked to had attended the inquest, but a few had decided not to go because they did not want to hear more about how the death had occurred. Sometimes the inquest had been opened and adjourned very quickly and they had not realised it was taking place.

Jocelyn’s son’s inquest took place in Hong Kong because he had been living there just before he died; Jocelyn did not attend.
Many found the inquest unexpectedly formal, rather like a High Court, and some thought it frightening, austere and intimidating. William said that even his solicitor felt intimidated at the inquest when he discovered the school, in whose care William’s daughter Lauren was when she was killed, was being represented by a QC. The school, the coach company and the lorry driver’s company were all represented by barristers because they knew that the family might pursue a civil case against the parties who caused Lauren’s death. The coroner’s verdict was ‘accidental death’.

Karen felt that the inquest was a waste of time and a waste of taxpayers money. It did not…

Age at interview 40

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And can you say a little bit about the inquest?

Yeah, I mean it was um, they’d said the different people that had obviously been called because they’d called certain people. And they had gone through the process but I was glad that they didn’t ask me to take the stand, the coroner himself was quite happy to read my statement because it was quite a lengthy statement. As he said, it had just about everything in there, but, which he did say that he felt was beneficial. And it didn’t sound like lip service so, so I took that on board.

This was the statement that you made to the Coroner’s Officer?

Yes. So he’d gone through all of that. Um, obviously it’s open, so they’d got two press people there anyway. I mean you can ask questions, and he, he’d just stop and say you know, Are you happy with that And then moves onto the next bit. I didn’t feel, with the press there I didn’t feel that I wanted to ask questions.

Because to me they do their own interpretation of things. So I wasn’t prepared to ask questions even if I had, which I did have questions, there was no way I would have asked them in that environment with the press there because to me they, they’re like a dog with a bone aren’t they? They just don’t let go. You know and then what they print, people actually read and believe. And to me that’s what all
What sort of questions would you like to have asked?

There was things that I wanted to ask of, of my Mum’s ex brother-law whod since died. I mean he died before the inquest. Because his version didn’t tally up with what everyone else was saying. And I couldn’t understand how the police officer who actually with his version of events after interviewing my Mum’s ex brother-law, it didn’t, just didn’t all tally up to me. In my mind it didn’t. And it still doesn’t. You know and I did say to the coroner’s officer prior to the inquest, to me it was just a waste of taxpayers’ money because it wasn’t going to answer any questions and it wasn’t going to put any closure because there was too many questions unanswered and the length of time it took to have the inquest the person who could’ve maybe answered those questions, or actually been made to answer those questions, was no longer alive.

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During the inquest, relatives of those who died listened to evidence from people such as the police and the pathologist. Some relatives had to give evidence themselves. Others listened while the coroner read out their statement. Alison was upset and felt it was disrespectful when the coroner referred to her daughter by the wrong name. People were usually given an opportunity to ask questions, but some found that hard because journalists were there (also see Media involvement).

At the end of an inquest the coroner can give one of many verdicts, including death due to accident, suicide, or unlawful killing. A coroner may return an ‘open verdict’ when he considers the evidence insufficient for any other verdict. A verdict can also be ‘narrative’, which is a more descriptive comment. In some circumstances, the coroner summons a jury to consider the facts and return the verdict. This happens if a death occurs in prison or other custody, or could have implications for health or safety in the future.

Once the verdict has been reached the coroner informs the Registrar of Deaths, who can then issue a death certificate.

Most people said that the coroner’s verdict was what they had expected, though some were disappointed that the inquest had not answered all their questions. A few were angry about the outcome. Dorothy had hoped that the Crown Prosecution Service would charge her son Mark’s employer when he died in an industrial explosion in 2005. After many months investigating, the CPS decided against this, so in 2009 the coroner held a full inquest with a jury. Dorothy had hoped that the jury would return a verdict of unlawful killing but instead it gave a narrative verdict.

Having waited years for her son’s inquest Dorothy felt ‘totally devastated’ by the jury’s…

Age at interview 65

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My family had to look at still photographs and CCTV footage of my son’s last moments including the explosion, we had to listen to witnesses, ex-colleagues who we knew were lying and experts who said the man who killed my son so heartlessly must have known of the dangers involved. The Coroner was excellent, thorough, sensitive and extremely intelligent. We had to listen to the man who killed my son shout, rant and bully, even shouting after my family as we had to leave court too upset to listen further.

The coroner took the extremely unusual step of offering the jury the option of an unlawful killing, manslaughter verdict and explained his reasons. The jury took only 3 hours to come back with a very weak narrative verdict only for the most paltry of reasons.

How do I feel now? I am totally devastated. I have lost my son all over again. I have lost my faith in my fellow citizens who apply double hypocritical standards. Had this man been a driver in which a relative of one of the jury was a passenger, supplied no safety belts, had no driving licence, had been drinking, ignored all road warning signs, drove at 100mph resulting in crashing his car killing their relative, I’m sure the members of that jury would have rightly expected him to be charged and face a prison sentence. But when an employer does the equivalent they say he should walk away without any charge because he put his own life at risk. If I could give up my British passport I would.

I feel ashamed of my country, extremely angry and totally bereft. The terrible thing is that this is how all the families of those killed at work are treated in this country.

I know this will not help anyone who is facing this terrible experience but I can only say how I feel, there is no point in giving hope where there is none. Shall I continue to fight for justice for others through Families Against Corporate Killers? At the moment I am absolutely exhausted but I suspect I will. It took many years of struggle to abolish slavery, this is the modern equivalent.

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The family had to wait two years for the inquest. Erykah hoped that the inquest would bring…

Age at interview 36

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The inquest, the inquest was two years later. It was just, it was a week before it would’ve been two years. I’ve no idea why this is. Thing is he’d been cremated and everything else, we’ve no idea. And it’s something that happens regularly, and I know there’s a lot of groups that are campaigning because, especially the case of the Rhys Jones case, he had a funeral much quicker than any other case we’ve known, and we believe that was put down to publicity but when, in the city murders take place, the funeral and if it takes, it’s quite a lengthy process and we don’t know why.

Two years is a long time.

It is a long time. At the inquest, which I didn’t find very helpful, they told us that they’d interviewed, I think they said something like eight people, nine people. That could’ve been the same person nine times, but there were so many interviews done. We wasn’t allowed to know who it was, or any names of anybody interviewed, and I was thinking that if I knew a name that was interviewed maybe we’d know who has done this horrendous, you know, thing. Because he wasn’t a young boy in a gang, he was 27, he owned a business, he was due to get married, so it wasn’t your gang warfare gun thing, but they tried to link it to drugs and gangs at first, which is what they have to do as part of the investigation. And then they have always said that it was mistaken identity, but I don’t believe that, because he was shot too many times.

Yes.

And the fact that he was shot in his neck at point blank range, does not indicate, you know it wasn’t, it wasn’t mistaken identity. You could understand that if it was a drive by, and all the young boys do, gang things, but this wasn’t mistaken identity at all.

So you’ve never found out?

No, but the inquest, which we was waiting for forever, hoping that this would be closure, they ruled that he died Death by Association.

Death by Association?

Yes, and we had no, we were asking what does this mean? That’s all we’ve been given after two years of waiting and waiting, waiting, and trying to push for this inquest.

So what’s on the death certificate?

Death by Association. That’s what, that’s, that’s what the coroner’s report is.

How extraordinary.

Who had to give evidence?

Nobody gave evidence. My Mum stood up, that was it. It was just the police and my Mum, that was it. We’ve never had a court case, and we don’t know anything more than we did on May 23rd 2002. We don’t know anything more.

So what’s the police liaison officer been telling you all this time?

We’ve never seen one since. We haven’t seen a police liaison officer in years. His case is what’s known as box, so it’s sat, his case is what’s known as box, they call it box which means that all the evidence is in a box, sat on a shelf. It’s not closed, but if any other evidence comes to light, which will only, could only be somebody coming forward and saying they’ve done it or someone saying they know whos done it, then

So it’s an open case, they didn’t put down as murder?

Yeah, oh no. No. It’s like.

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The coroner returned a verdict of ‘accidental death. Dean would have preferred a verdict of…

Age at interview 66

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How long did you have to wait for the inquest after your son’s death?

It would have been at least six months, I would say six months.

Six months?

Yes, easily. Before the inquest and it was an inquest in a coroner’s court and the outcome of it was accidental death. And it was then referred to the magistrate’s court.

Can you describe what happened at the inquest?

Yes at the inquest we had, I had a barrister present, to represent me on behalf of my son, and the barrister was recommended to us from RoadPeace, again, that was a tremendous support. I didn’t get any chance, I didn’t have a chance to say anything at all, it was basically the coroner, the police, and my barrister just asked a few questions, but he was not permitted to interrogate or the driver of the vehicle. He’s pleaded silence and to remain silent, No comment, no comment, no comment that was all he said, all the way through.

The driver?

The driver. All he had to say was, No comment, no comment, no comment My son chose law as a profession. A profession which he very much believed, and strongly believed, but he was never given a day in court, I was not given the opportunity, nor my barrister to question this young man, which I find very, very hard.

What verdict would you have liked?

Death by dangerous driving because the devastation, with no license, no insurance, nothing at all, and these guys were literally speeding down the road. But sadly on the particular day there were no witnesses, no-one come forward. The only person that said that she saw something did, at the end of the day decided that Well, I can’t remember And that’s it, so there was no statement.

Did the police keep you up to date with what was going on?

Yes, a part of it, they came home on several occasions and kept us informed of what’s going to happen, with the inquest, the forthcoming inquest that was planned.

Did they tell you what was going to happen at the inquest?

Well at home yes, they told me that the maximum this guy could get up to 14 years. We got to the Courts, the coroners court and the magistrate. Things have changed because of technicality. The step-father owner of the car told the police under caution that he did not give him permission, and changed his tune on legal advice and would not sign a witness statement. That way the police could not bring about a charge for aggravated vehicle taking, causing death, so he was charged with careless driving.

But to start with he had told the police that he had not given permission, and then he changed his mind?

Absolutely, on advice from his solicitors. Yes.

Did you have to make an impact statement at that stage, or later in the court?

We made an impact statement later, for the, for the magistrate.

Not for the inquest.

Not for the inquest because we were not given the opportunity to say anything at the inquest.

How long did the inquest take?

The inquest took the most of about an hour, two hours if that.

How did you feel about the inqu

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The inquest was a terrible experience. Godfrey and his wife expected to hear the report that had…

Age at interview 77

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The real problem for us, in relation to his death was that it was a railway accident, and we were told that we would find out exactly what had happened when an inquiry had taken place, into the accident. And an inquiry did take place about a week after his death, but then the whole system seemed to clam up, and we were just told we would, we would have to wait for the report into the accident, and there would be a resumed inquest which would be in about six months time. And we might have to wait until then to find out exactly what had happened.

When we, the inquest was, it was a terrible experience for us because we turned up at the coroner’s inquest, and we were amazed to see there were a great horde of people at the inquest, which we knew nothing about. And it transpired that the rail company had had a whole lot of lawyers at the inquest, because they felt there might be some trouble. We expected that we might at least hear something about this report that had been conducted into the accident, but it wasn’t produced at the inquest. And we then conducted a campaign to try to get access to it, and we did this at all sorts of levels, and at the end of the day we were told that this couldn’t be given to us because it was the private property of the railway company and they couldn’t be forced to, it was a private railway company of course and they couldn’t be forced to deliver it to us, and well you know this was very difficult to accept that here’s our son, been killed in an accident, that there had been an inquiry into the accident, and that the contents of the inquiry should remain confidential.

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A coroner’s decision can be challenged by applying for a judicial review within 3 months. However, this is a complex process which needs a lawyer. A judicial review is a type of court proceeding in which a judge reviews the lawfulness of a decision or action made by a public body. In other words, judicial reviews challenge the way in which a decision has been made, not the rights and wrongs of the conclusion reached. If people want to challenge the coroner’s verdict a judicial review may not be the best way to proceed. People can at any time apply for a new inquest to be held, but it is better to apply as soon as possible and to get help from a solicitor.

Useful information about the whole inquest process can be found on a website run by an organisation called INQUEST. It provides independent free legal and practical advice to bereaved families and friends about the inquest process. It offers specialist advice to lawyers, bereaved people, advice agencies, policy makers, the media and the public on contentious deaths and their investigation.

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