The inquest into the death

In England and Wales, if suicide is suspected to be the cause of death there is always a public hearing, which is called the inquest. Anyone can attend an inquest hearing. At the end of an inquest hearing the coroner, or jury in some cases, can give one of many verdicts, including: death due to accident, suicide, open, or unlawful killing.

To give a verdict of suicide the coroner has to be satisfied that the deceased carried out the act which ended their life and intended by that act that their life would end. This has to be proved ‘beyond all reasonable doubt’. The coroner may return an open verdict to reflect that there is insufficient evidence to support any other verdict available (also see Reactions to the verdict). A narrative verdict can also be returned, which is a more descriptive comment, and less of a label than other verdicts.

The system in Scotland seems more straightforward. The procurator fiscal has a duty to investigate all unexplained deaths. His or her functions are broadly equivalent to the coroner’s in other legal systems. Once the procurator fiscal has all the necessary information, they send a report to the headquarters of the Procurator Fiscal Service. In most cases it stops there. However, in some cases a ‘fatal accident inquiry’ is held. Some of the people we talked to in England were aware of the Scottish system and suggested that it is better because it is less intrusive and traumatic for the family involved.

People bereaved by suicide may see the inquest as an important opportunity to find out what happened to their friend or relative and to publicly state their version of events. This may be their one opportunity to ask questions about how a relative died. However, some of the people we talked to felt that the inquest was an intrusion into their family’s tragedy and they disliked the way it was played out in public.

Patricia thinks that the inquests held in England and Wales are ‘utterly unnecessary’ in the…

Age at interview 58

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Why do we have inquests?

Umm.

They’re utterly unnecessary in the modern age.Inquests grew from the twelfth century from the medieval Norman kings’ desire to raise taxation.In the Middle Ages, when somebody died the, the death dues were due to the Lord, which was ultimately the King.

Hmm.

Work it back up the line.And the family of the deceased had to pay the death dues.Where somebody had died

Hmm.

and nobody knew why, you didn’t know why, who had to pay the death dues.So if somebody fell, somebody, I don’t know, a load of wood fell off a wagon and crushed somebody to death, then the Waggoner would have to pay the death dues.

Hmm.

Where somebody was murdered if the community could not produce the murderer, whose own goods were then forfeit to pay the death dues, then the deceased’s family had to pay it. And where it was a suicide death, all the possessions of the suicide were forfeit, not just the tenth or whatever the percentage was, of that person’s wealth, the whole lot went.

Right.

So this idea of who, who has died, who is responsible, therefore who pays the money, is a medieval thing which has absolutely no, you know, revenue raising and taxation these days isn’t quite as bad as that, though incidentally, the law which said that the property of somebody deceased from suicide was all forfeit to the Crown I think was only repealed in 1921.

Yes, things have changed.

Hideous when you, you think of that.

Hmm.

But this idea of having a public inquiry, and I called an inquest before a public inquiry into a private tragedy

Hmm.

because it if wasn’t you’d be being charged with a crime.

Hmm.

Manslaughter or whatever.And north of the border, if you live in Scotland, there are no inquests.The police investigate the death.When they put in a report to the Procurator that they are satisfied that this person brought about their own death

Hmm.

It is signed off and that’s it.

I see.

There is no public inquiry. But then the Crown legal system of how money was raised, Scotland wasn’t governed by the Norman kings.

That’s very interesting.

So I have a sort of historically educated perspective on it that I know is totally unnecessary

Hmm.

It is an intrusion into a family’s tragedy. But why should that be played out in public?

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Melanie did not see the need for an inquest after her husband’s death. She thinks that the…

Age at interview 45

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Why was it a Documentary Inquest rather than asking people to come?

Because there wasn’t anything in dispute. Simon had left a letter so his intention was clear. The coroner said if I had wanted to cross-examine any of the doctors then we could have had an inquest with witnesses. There wasn’t any need to.

You don’t need to do that.

I didn’t need.

So you just have to have the coroner there?

Well summarising the statements. It was obvious. I mean in the sense I felt why did there need to be an inquest. I know the system, well. I understand that the system in Scotland is if the; it’s either the police or the Procurator Fiscal and I’m not sure which one, but someone in Scotland will be able to tell you. If they determine that it’s a suicide or there is nothing suspicious there doesn’t need to be an inquest. And I think that should be adopted in this country. I know there’s been a recent commission on it. We have enough agony to live through without having to go through that as well.

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The purpose of the inquest, or in Scotland the fatal accident inquiry, is to assess the circumstances surrounding the death and to identify any issues of public concern or safety. The court will identify whether anything might be done to help avoid similar deaths in future. The court does not apportion blame for the death or make any findings of fault.

People may have to wait many months for the inquest hearing or fatal accident inquiry. Some people we talked to found the long wait difficult and felt their lives were on hold while the inquest process was “hanging over them”. However, the delay can also be quite helpful.

Lucy found it hard to make decisions while she was waiting for the inquest hearing. The hearing…

Age at interview 39

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Because this is going to change the whole way you look at life in the future. And you’ll be trundling along and everything’ll be fine and then suddenly something will happen, whether you’re having a bad day or whatever it is, and you’ll be sobs of tears or
Hmm.

the loneliness will just hit from, from nowhere. And just as you think that you’ve got back on your feet again, wham, they’re going, you get a letter to say the inquest is going to be on such and such a date and then you’ve got to relive it all over again. I think it takes some doing. Once you think you’re over it, you, you’ve got like two, in a way, two bereavements, because you’ve got the first one which is normal to everyone who has a bereavement where you’ve got the funeral and and the burial or whatever. But then you’ve got to relive it all again for the inquest.

Hmm.

Where it’s, you, you just think you’re doing OK and then it’s all put you back to square one again. And then you start again. But I did find that it, decisions, I was putting decisions off. We were in a rented flat and I had to make the decision was I going to stay in the flat, was I going to buy somewhere to live or; I needed a holiday and friends were saying, Oh come and stay with us So,
Hmm.

… but I was putting everything off until the inquest. Oh I can’t do anything because the inquest hasn’t happened Oh I’m waiting until after the inquest And so every decision, I was using that as an excuse to put off making any decisions.

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Waiting nine months for the inquest gave Helen time to be calmer and to prepare for what she…

Age at interview 53

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Do you want to say anything about the inquest, and what happened after that? So you had the funeral and then you had to wait, how long did you have to wait after that?

We had to wait until the following May, so she died at the end of August.

That’s a long time.

Yes. And I had to wait until the following May, but again it gave me time to know what I wanted to say, it gave me time that I wasn’t in such a state really that I could be calmer, to go, and it was very important to me that I went and said my piece. So I stood up and I, I said exactly what I felt about everything, and how Charlotte had been found, and it was an open verdict because there were several reasons why they couldn’t say that it was suicide’ because she hadn’t left a note; and there wasn’t enough heroin left in the syringe to know if it had been pure, too pure heroin, and the level in her body was enough as an over dose that she would have died fairly quickly. But they didn’t know whether she’d done that on purpose, or whether it was because it was a bad batch of heroin.

What do you think?

I personally am 95% sure that it was suicide. I, I do understand that there’s a possibility that it wasn’t, that maybe it was, there was pure heroin, and there had been a few people the week before Charlotte in her area, that had become unconscious and taken to hospital because there was a bad batch around, so it is possible, but given that she’d tried the week before, and the week before, and that she’d wrapped her phone up, she’d taken the plug out the wall and wrapped her phone up. And I, I, I personally, and there was alcohol on her bed that had been unopened, which she always did when she took an overdose. I, I personally think that she knew exactly what she was doing.

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Not all those we talked to had attended an inquest or fatal accident inquiry. One woman was still waiting for her husband’s inquest. He had died 3 months previously, and she had been told that she would probably have to wait another 6 months for the hearing. Others had decided not to attend. Since the coroner decides who must attend the hearing, family members can only decide not to attend if the coroner has first said that they need not do so.

Two people in Scotland had been told that a fatal accident inquiry was not needed, and one woman was waiting to see if an inquiry would take place. However, most people we talked to had been to an inquest hearing, and they recalled what had happened and discussed the roles of the coroner’s officer and the coroner.

The coroner’s officer, sometimes called a coroner’s investigator, gathers information and should maintain close links with the bereaved family, explain the timescales involved, and explain the layout of the court and what will happen throughout the whole process, as well as what that process involves and what happens at the hearing itself. Some people said that the coroner’s officer had prepared them for what might happen at the hearing, but others felt unprepared, did not understand the officer’s role, or were uncertain what questions to ask.

The coroner’s officer prepared Dave and his wife for what might happen at their son’s inquest.

Age at interview 56

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The coroner’s office was very helpful. They gave us information and we went over to see them before the inquest. The inquest was about six months later, but we had been over to the coroner’s court before then to talk to the coroner’s assistant.

And did the coroner’s assistant prepare you for what was going to happen?

Well, he asked us for, he would have answered any questions we’d got, but you don’t know what questions to ask.

No.

Because you, it’s the first time through it. You could ask lots, it’s like everything, you could ask lots of questions afterwards, but he would have answered anything we’d of asked him, and he, he did tell us what the procedure would be, and how it would be organised, and how we’d be at the front of the court, everyone else behind us. And so there weren’t any real surprises when we got to the inquest.

That’s good, because sometimes people say they’ve totally unprepared and haven’t had a chance to ask any questions.

But again the inquest was very difficult, we just sat sobbing all the way through it, I think.

Did you have to say anything at the inquest?

No. No, but the, the coroner kept asking us, Were we okay?’ And we could ask questions, if we wanted.

Mm.

So, yes, even that was sensitively held.

So, so who had to talk? Who had to give statements, the police?

The police gave statements. The driver of the lorry that Ben crashed into, he gave a statement. The friend of Ben’s who he’d sent the message to, the text message to, she had written a statement. She didn’t stand up and give a statement, but she’d given a written statement. And the coroner’s verdict was suicide. They were; killed, said he’d killed himself, that was, yeah, the word, yeah.

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The coroners officer was wonderful. He dealt with Marion and her young child very…

Age at interview 58

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I’d really like to know about the Coroner’s Officers, what their role is and what they do.

He [the coroner’s officer] was amazing. His role was basically to tell me what was going to happen. In a normal death, you as next of kin have the Death Certificate. You register the death. Well of course you can’t register a suicide death until the Coroner has pronounced that it was suicide and then he registers it. You don’t. So that is something that’s taken from you. It’s a, it’s a dubious privilege but it’s something else that’s taken from you. It’s his duty to liaise with you and the police about anything that happens. He needs to know about police interviews and statements that they take.

The Coroner’s Officer does?

Yes. And then it’s all presented to the Coroner at the inquest. And he, he needed at various times to get things clear in his own mind. It was, it was all a bit shady. I don’t know why but the police didn’t seem to understand that I had last seen him [her husband] on the Wednesday and he’d actually been found on the Thursday but he was still alive but he died. So that was suspicious because. It was all very difficult and he [the coroner’s officer] was absolutely amazing. I have heard people whove said, oh their Coroner’s Officer weren’t but he really was. He should have a medal. He was fantastic.

What was special about the way he looked after you and treated you?

His care of my youngest when we went to see him [her husband’s body] to start with. He was wonderful in that. The depth of his understanding of a newly widowed woman with a fairly young child with very strong emotions going on all round and he, he dealt with it professionally but so carefully. He was lovely. Whenever he phoned me, and sometimes it was two or three times a day, sometimes not for a couple of days, he would say, good afternoon, and he always used my name, always. Sometimes my Christian name but usually Mrs. He would then tell me his name and who he was so that I knew who I was talking to. His, his depth of experience he obviously realised that people in my state didn’t have a clue what they were doing and just functioned on autopilot. Anything that happened happened. So he would always say good afternoon, tell me who he was, tell me what his job was so I knew who, that he was him and then he’d say, You may remember that when I phoned you on, whatever day, I had to ask you X, Y and Z. I’m sorry to disturb you now. I know how difficult this is but I do just need to ask A, B and C. The next time he phoned he would recap on both those things and then ask me what else he wanted to know. I think the most important thing was I knew he was there. I knew who he was. The police were anonymous.

Could you phone him if you had a query?

Yes, absolutely yes. The police were much less helpful, much less sensitive. And we, trying to get things like my rent card and the electricity payment card and things I rang our local police station and asked for the constable whose name I had been given. He wasn’t there. His colleague would deal with it but he wasn’t there either and when they came back they’d ring me. They didn’t. I phoned again. I got passed all around the police station and ended up with the desk sergeant who said, ‘I’m sorry I don’t know anything about it. You know and I really needed to talk to one person who could solve this problem for me. I needed people to solve things because I couldn’t do them myself. Normally I’m quite a managing sort of person but I couldn’t do it.

No, so the Coroner’s Officer was really goo

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The coroners officer made insensitive comments when he spoke to Steve on the phone about his…

Age at interview 37

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And also on the Monday we had a phone call from the Coroner’s Officer. Obviously they want, gathering evidence as well. I have to say that my experience of this particular Coroner’s Officer wasn’t that great because his initial, the way that he opened the conversation was, I’ve been doing this job X amount of years and this is the third worst I’ve seen And I said, Well that’s very nice of you to share that with me. Please do not say that to my parents But he did. So quite an insensitive person really.

What did he mean?

It was the, the worst. He said he’d seen my sister’s remains and, and the state of her remains were the third worst. There were two others that had been worse that he’d seen. Which is a terrible way to, to introduce yourself to a bereaved family under such tragic circumstances. And immediately I had no respect for this man at all. And then he went on to say it to my parents as his way of introducing himself to them as well. Consequently, I mean I’d never met this man up until the date of my sister’s inquest and he; I’d already built up a mental picture of how I expected this man to appear and how I expected him to behave and I was right.

Did he ask you for a statement at all?

I actually did write a statement but I don’t know if it was him that asked me for it or the Coroner himself because I had a letter from the Coroner and I think it was the Coroner himself who asked me to write a statement of what, about my sister’s life and any health problems or, or any other. He wanted a whole picture of her really. So I did that. It took me quite a while to do it because I didn’t feel like it initially. it’s as simple as that. I was, I was deeply hurt and grieving and shocked and I just left it for a little while. But it, it took me a while to do it when I did get around to writing it.

And the Coroner’s Officer, what role did he play with your parents? Did he again ask them for statements?

No. We never met him at all. It was just a phone call to say I am, this is my name and I will be the Coroner’s Officer. And that was all, all the involvement he had really. There was, there was nothing. We never met him. I mean I spoke to him perhaps on a handful of occasions on the phone but it was usually only when I wanted answers to questions that I would contact him. He didn’t really contact us. I don’t quite understand the role of this Coroner’s Officer. There was, he was certainly no help to us as a bereaved family.

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

No.

So no preparation for the inquest?

No not really. The inquest was quite a while after the death anyway. And fortunately I’d been in contact with the Coroner by E-mail and any questions that I had I put to the Coroner directly himself. Because I didn’t want to deal with this, this cold person really, he had, I’d got no respect for.

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People also talked about the coroner and his or her role in the inquest. Some said the coroner had treated them with kindness and understanding, and had phoned them or made contact by email before the inquest. Others thought that the coroner had been cold and lacked “humanity” or that the court atmosphere was intimidating or “Dickensian”. Although many people found the formal environment daunting, some described the time leading up to the inquest as more stressful than the event itself.

Amanda and her husband felt that the coroner had dealt with them kindly. They found out…

Age at interview 53

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Yes, our inquest, when we actually got there it had been delayed because the cases had overrun, which actually worked in our favour because one thing I was aware of was that the Press could be there and could therefore put it, put out stuff from that and I didn’t want sensational stuff put in because it, it was late I think all the Press had gone to lunch because they must have got very hungry, we were sent off to have some food, not that we were very hungry ourselves [laughs], but it meant there wasn’t Press there so that was, that was a great relief. I looked round, there weren’t, they weren’t there.It was a bit like being in a sort of strange courtroom but they had prepared us and told us what, what the room was going to be like.There was the lady who had done the autopsy and she was really lovely, and I remember thinking ‘what a nice lady, I’m pleased it was her’, and afterwards, I to this day I wish I’d said thank you to her for some reason.The Coroner was very, very nice. I remember at one point he stopped, and he said, So you had three boys?And he, he paused and it was as though he was putting us all in context, as though we weren’t just facts we were a real family.At the inquest I had my best friend, my friend whos a doctor, my husband,Lori’s girlfriend, who I held, who somebody sat with and held her hand, her mother was there, I think that’s about all but it’s kind of important to take along people that would support you. That’s really good and people that can remember it. Also it’s worth knowing, which I didn’t realise at the time, they record it and if you want a recording of it, which I, we have requested and we have now.We haven’t listened to it, the reason I have it is so that my other two sons if they ever want to know what, what happened at the inquest can have it.They chose not to come, but it’s a piece of history.

I don’t think it’s a healthy thing to sit there and listen to, but it does mean it’s, it’s recorded there and I think that that might be, for some people, might be useful for them.

Yeah.

The doctor gave all the details and I, I wanted to know, the statements are read out, and that’s quite hard because you’re hearing about the last moments and for us, because he was still alive, to hear the woman’s story who was with him, that was, hard, but I had met her, what is very important for me, it was very important for her she came and met us, what a couple of days after he’d died and she really wanted to hug me, she wanted to know if I wanted the coat she’d covered him up in, which I didn’t Iit was, for some reasonbut that was very important that link.The last people to see him their, their statements were read out so it’s quite a lot of statements and I remember I was sitting on the edge of my seat listening to every word at the time ‘cause I was frightened of missing it, so I suppose knowing that you’re going have a recording could be useful because then you, you wouldn’t feel like you’re trying to listen to, so intently to absolutely everything.

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Colin felt that the coroner lacked ‘humanity’ when dealing with his family during the inquest…

Age at interview 69

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Mm. To go back to the inquest, I got the impression you weren’t very happy about how it was conducted. Do you want to say a bit more about why?

Well let me just put it this way, it was conducted entirely properly in accordance with the precepts of the law as affecting coroners inquests. I did not like the personality of the coroner concerned who seemed to me to lack humanity in dealing with, in dealing with bereaved families. I did not particularly like the police force but these are simply personal responses to people who by their own standards were doing the proper job which the law required of them.

How could, people might learn from this, how could the coroner or the police have made themselves more human and comforting?

Well I have to say that I did meet, I did meet in what, in the, in my early dealings with the coroners office, the sort of retired police officer who you felt very comfortable in dealing with because they, he had the humanity to recognise that he was dealing with a human being in grief.

Mm.

And he to his credit, understood and showed compassion in his dealings. That was not replicated by the coroner himself, or by the police officers who are dealing with deaths of various sorts from time to time as a necessary consequence of their occupation.

Was that by the choice of their words or just their manner?

Manner, manner yes.

Mm, because it’s important we learn from this.

And indeed, yes yes yes. Yes, I have to say that I can remember one retired police officer who was the, one of the coroners officers and he distinguished himself in my mind by the humanity with which he dealt with me, but he was unusual in the context of the people with whom I was dealing at this stage.

So would, would you have preferred, liked the coroner just to have said how sorry he was, or something like that at the beginning?

That would’ve been a help, wouldn’t it?

Mm.

Would’ve been a help yes. It would, perhaps they’re now under strict instruction to do exactly that, but at that particular stage it didn’t seem to occur to the coroner you have to allow for the fact that coroners deal with a number of disagreeable elements in society, when I was wheeled in front of him on this particular sad errand, he was probably recovering from some dealing with something even less agreeable, I don’t know.

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The coroner may decide that a public hearing is not necessary. He or she may look at the written statements from people involved, such as the doctors, the pathologist, family and friends, and then come to a verdict. This may be called a chambers finding, a documentary inquest or a paper inquest. Melanie experienced what she called a documentary inquest after her husband died [see Interview 21 above].

However, most people said that witnesses had been asked to give evidence in court. Some people had been asked to take the witness stand themselves. Brenda said that had she known she was going to give evidence she would have been terrified. However, when she was asked to talk about her son and explain what had happened she was surprisingly calm. She said that talking openly about her son helped her in her grief.

Taking the witness stand can be traumatic. Susan said she was quite shocked when she had to take the witness stand because having seen the interim death certificate she thought that the cause of death had already been established. (When there is an inquest the coroner will issue an interim certificate when the inquest is opened. An interim death certificate is necessary to enable the body to be released for a funeral to be held and for the administrative procedures that follow a death: see Practical matters.) The coroner registers the death after the inquest hearing is complete and then the final death certificate becomes available from the Registrar.

Susan had to give evidence at her daughters inquest hearing. It was an extremely unpleasant…

Age at interview 54

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The inquest was extremely unpleasant. But I and I had thought it was going to be quite a sympathetic affair because it was so obvious what had happened. But of course I realised that it wasn’t.

When was the inquest?

February, the following February.

Hmm.

Which I had thought was a long time but apparently a short time. But again, I mean a cause of death had to be established. Did I shoot her or did she shoot herself? But it was pretty tough. But of course I suppose naively I thought well they know she committed suicide so why are they being so hard on me.

So did you have to take the stand?

Oh yeah totally .. totally for the whole of the inquest. I mean even when I’d given evidence, which went on for a very long time. Other witnesses were then brought up.

I thought you see well know I say this as I have said again maybe I misinterpreted the whole thing. Maybe they were genuinely trying to find the cause of death which I thought since her death certificate and everything said that she had taken her own life. I didn’t see the need to put me through the mill to the extent that they did, if the cause of death I thought had already been established. I think it certainly needs to be; the whole system needs to be more victim sensitive. I mean it’s, it’s very cold. it’s very austere. You sit in serried ranks. And then you know I was shaking so much I couldn’t walk and yet I was told to stand.

So what would you recommend in future, would you recommend people were prepared properly for what was going to happen?

Much, much better yes yes I think, I think especially in a very sensitive situation like this when you’re the family is so traumatised, that actually you ought have a pre-session. This is where you will sit. This is, this is how it’s going to be. You’ll have a chance to speak if you want to. Is there anything you particularly want is there you knowwhat would help? As opposed to the feeling, and I have checked with my husband several times, was I making a meal out… a mountain out of it. And he said, Absolutely not, it was appalling

So none of that information was given to you, you didn’t meet the coroner’s officer first or anything?

No, no, no no. No. And I think also there shouldn’t be a strange little man in the corner who keeps looking at you like this and scribbling your evidence down. It should be done in a much more modern and subtle way. It can be recorded. But no it needs to be brought into the 21st century; it was like something out of Dickens.

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Lucreta had to answer questions at the inquest hearing for her 18 year old daughter. Although the…

Age at interview 57

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nd then the coroner’s court, Oh, the coroner’s court that was awful. The police got all these witnesses, Dionne told all these untrue stories, she probably was not well or, you know and the police had to investigate these things, and these issues so they were trying, the child protection act was trying to get away from the main suicide thing, and sort of blaming the family. And you’re blaming, you’re going through all of this and then you have this court thing, I mean a real case, so anyway, my friends were at the court and my family and they comforted me and I answered the questions and that was finished.

Why did you think somebody was trying to blame you at the inquest?

Because, because Dionne, Dionne would’ve said, well Dionne probably said that I don’t know, she probably would’ve said unkind things.

About the family?

You know, about the family, you know children if, when they can’t have their own way they pick on, pick, pick, you know, and so, you know, and as I said our marriage was in, wasn’t a good one.

So the inquest was not good?

It wasn’t a good thing, but they didn’t find any, when they investigated whatever they were looking for, and I think if she was an adult they wouldn’t have, but because you know they just, because she’s a child they just have to investigate everything.

Did they have a jury?

No, it was one of the high court, he’s not there anymore. I can’t say his name.

It was a coroner’s court?

Yes a coroners’ court to find out the deaths and you know and because she jumped didn’t she? She jumped.

Was the verdict suicide? Or was it an open verdict?

No, suicide. Or she took her own life. Yeah, that’s what they
So were you prepared for the inquest in any way?

No. Er no, I wasn’t prepared for what her friends would say, cos whatever she told her friends you know, I wasn’t prepared for that aspect cos you’re grieving.

Yes.

Cos you’ve lost your daughter, and I had to grieve for my son, it’s like everybody blames me for everything and some friends, who I thought were my friends, they blamed me and everybody blames mother. Isn’t it hard, and all you’ve done, you’re a young woman and you give birth and too, and you, it’s a learning, it’s a learning thing for everyone. And I set out to be different with my son, but he said to me, What’s wrong with you, you’re fine the way you are

Mm. Did, was there a coroner’s officer who helped you at all, to tell you what was going to happen on that day?

I can’t remember. I can’t remember but he was, I can’t say his name the coroner, he was one of the high profile one’s, he’s retired now, but he didn’t find anything. He just dismissed it, all just so you know, you know what it really is, so that ended there.

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Since the inquest hearing may be traumatic and distressing it may be a good idea to take a friend or relative along for support. Amanda took her sister with her. She also arranged to have a psychotherapy session immediately after the hearing.

Sometimes barristers and a jury are involved in the inquest process. The hearing may go on for days or even weeks.

At the inquest Lucy learnt that her partner had been spotted around the railway line several…

Age at interview 39

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Would you like to say a little bit more about the inquest?

Well it was, the inquest itself wasn’t, wasn’t that difficult because it was just, followed an event. You went into this room and the jury were sworn in and the coroner explained what was going to happen. The witnesses were lined up, or sat down in, in order. The statements were read out and we had to just nod and acknowledge the statements, that they were true when they were being read out. There was then a summing up of all the information that had been given, and the jury then went off to make their recommendations and, and come up with a verdict. It was, when, when you say inquest it, it sounds like it’s quite a daunting thing. But it was really just a big room with one side had the jury on it, one side had the witnesses on it and at the end were supporting friends and family ,someone from the railway, and someone from the press. But we, at no time were we forced to speak.

It was amazing the information that came out. We think we just get on with our lives and nobody notices us.

Hm.

But through the inquest, they were able to trace Darrells movements for the, the week before he died. And there was sightings and of him down by the railway line and watching trains. And it was amazing how much information that people do find out about you, if they, if they need or if they’re asked. So in a way, it helped me to know that it wasn’t just an instant thing. He, he didn’t just go off and do this by accident. He had it planned.

Hmm. Would you, would you have preferred it to have had a conclusion that was, that it was an open verdict to an accident or

No, I wanted the suicide.

Can you explain why? Was it that important?

Because an open verdict meant that nobody’d decided, it was just a bit airy-fairy what had happened. Finding the note from Darrell saying that he’d come to the end and he couldn’t see another way out to me just meant that he’d planned this and that it had to be suicide. And for it to come out on the verdict from the inquest to be anything less that that would have meant that the letter that he’d left and, and the planning that he’d done, although it’s not how we, we want to see him end his life but it would like, everything would have been a lie. For me I wanted that end, to know, yeah, this is, this confirmed what we’ve all thought from what we’ve found out since, after he died with where he’d been down on the railway line and how he’d, how he’d lived his life right up to the end and the note that he’d left. It all added up to suicide and for it to be an accidental or open verdict, it’s not like it’s a badge of honour but it was like a, a proper fitting answer to the inquest. Well for me personally anyway.

That verdict, everything added up to that verdict
Yes.

from you point of view.

Yeah, I couldn’t see how it could be anything else.

No.

And it, because it came out of, as a suicide in, in the inquest it sort of like finished everything off of, rather than having another thought to, Why’s it this? Why is it that

Hmm.

It sort of all matched up to that and I couldn’t really see there would be another option for it to be other than suicide.

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Any death which occurs in custody or in prison will always be referred to a coroner. There will always be an inquest hearing with a jury sitting.

Margaret describes part of the inquest hearing that was held after her daughter died in prison,…

Age at interview 62

Gender Female

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So I read out the statement and I had said beforehand, When I go up I don’t want to swear on the Bibl, because to me that would be very insincere, because I really do think so many people base their lives on a book, and forget what it’s all about. And so to me it’s caused more trouble in people’s lives
Hmm.

I’d rather, I’m a pantheist, I’d rather just know what’s real, what’s true and so, that would be like saying I don’t really mean what I say if I held the Bible. So I said I, they said, Well you will take the pledg, vow, whatever it’s called, so that’s what I did.

But in the end of my reading this, this chap, the barrister for the Home Office, jumps up and he starts, his first question was, How old was your daughter when you adopted her So I thought, What has that to do with the price of fish Really. I mean, really and truly, What’s his tack here

Hmm.

What’s going on And I realised because his, and then he said, Did you tell her she was adopted And I can remember saying, it’s the law Well, actually it’s the law in this country, if you’re in front of a High Court judge and have gone through an adoption society. But, I mean, he was just going on this like I was almost, and I suddenly thought, Do you know what? He’s trying to make it out, I think he’s trying to make out, let’s find a reason that she might have wanted to end her life that has nothing to do with the prison service And I thought, This really, I rdquo; and one thing I don’t like is bullying, I can’t bear bullies.

Hmm.

Really and truly. So my mouth was already dry from reading the statement but I thought, I’m going to stay, if it kills me, focused to answer him, whatever he’s asking And then when he said, he said, Would you like to tell the juryrdquo; Oh and the coroner said to him, Mr, whatever his name was, there’s no need to stand up; because he did all this pacing up and down and posturing. Well, I didn’t get where I am today [laughs] as I say, without seeing people posturing and I was thinking, You naughty person

Hmm.

Really, of all the situations to do this in, this is not appropriat. So he started his walking up and down. He’d ask me a question and then turned his back on me and walked away, obviously not wanting to hear the answer. It, there were like questions, just questions for the sake of asking them. And the coroner said to him, There’s no need to stand Mr, whatever his name wa And he said he wouldn’t sit down. He wouldn’t sit down for the coroner. He said, I want the jury to see me And you always think afterwards of what you could have said at the time but anyway I’m so glad that I just stayed very focused on what he was asking me. So he went off the tack of asking when I’d said that, it’s the law you know, that you tell your child

Hmm.

Anyway, then he said, so then he went on another tack and he said, Would you like to tell the jury about your daughter’s relationship with Mrrdquo;, meaning her boyfriend., I, I believe the relationship didn’t always go well Or something like that. And so I said, No I wouldn’t, that is nothing to do with anyone but her and her boyfriend And I said, And it’s not for me to rdquo; and t

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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.

The headstone or other memorial

The people we talked to wanted to have one or more ways of remembering the person who had died (also see Coping with grief and...