Reactions to the verdict of the inquest

At the end of the inquest hearing the coroner, or the jury if there is one, reaches a verdict (also see The inquest).
Most of the people we talked to seemed satisfied with the verdict (see for example, comments made by Dave below), but others would have liked a different outcome. For example, one man felt a stigma attached to a verdict of ‘suicide whilst the balance of the mind was disturbed’ and would have preferred an ‘open’ verdict. He accepted the verdict of suicide but not the implication that his son’s mind was disturbed at the time. He said that suicide might even be seen as a brave act, and that we have no idea what was going on in his head.

Dave believes that the coroner’s verdict of ‘suicide’ was correct. He is convinced that Ben’s…

Age at interview 56

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And, how do you feel about the verdict? Would you have preferred it to have been said it was an accident? Or would you have preferred it to be suicide?

Oh, we were content, I was going to say happy, but we’re never happy [laughs], we were content that it was suicide, because we.

That’s what you thought.

We knew it was suicide.

So, yes, we, we wouldn’t have been, it would have been worse if the coroner had not given a verdict of suicide.That is a little bit of a, that’s a step for us that it’s accepted that Ben killed himself, because then we have to deal with why he killed himself. And that’s what we attempted to do with the complaint, with the, the finding out about his notes, finding out about schizophrenia, finding out about treatment of people with schizophrenia.

And so are you, are you saying that if the coroner had said it was an accident, then you wouldn’t have felt that you could pursue what had happened with the Mental Health Trust?

The Mental Health Trust, when we met them on one occasion, after it had been a verdict of suicide, the chief executive of the Mental Health Trust said, Another coroner may have given a different verdict So their stance all along was, it wasn’t suicide.

Yes, yes. So it was quite important for you.

It was very important for, for that step in the, in the complaint of saying to the Trust, You know, you had some, you were involved in this.

Even when we met the chief executive, this is after the, after three years after the ombudsman’s report had been highly critical.After the ombudsman had forced them to, in theory, make changes within the trust, the chief executive was still not accepting that anything they had done, or not done, had caused Ben’s death.

So he was still suggesting it might have been an accident, in other words?

He was saying that, he was suggesting that they, they weren’t influential in Ben killing himself.

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Patricia is convinced that the coroner did not listen to the evidence at the inquest hearing and…

Age at interview 58

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The, the coroner’s officer took a lengthy statement, which obviously goes to the coroner for consideration.I don’t think the coroner paid the blindest bit of notice to what I actually said.

It was just actually a waste of time having any evidence.He’d made his mind up and in complete defiance of evidence presented as to the weather conditions at the time, which were, it was the coldest week of the year, Andrew had not eaten anything from the Monday till the Friday
Hmm.

We don’t know if he died at five to midnight or five past.He could have died on the 25th, but they gave the date of his death as the day he was found.Because that was when he was certified dead.

Hmm.

But they did say that it could be that he’d died on the, the Friday night but nobody would ever know that.There’s no way of establishing a precise time of death.You know, in those circumstances. So from, at the very least from Monday to Friday he’d had nothing to eat.

Oh.

So you’ve got extremely cold and no food.And living rough in a car.

Hmm.

He was, at the time died by carbon monoxide poisoning, undoubtedly suffering from hypothermia.

e was so weakened with hypothermia that I think his body succumbed
Hmm.

He, he just didn’t have the physical reserves. He’d had no food, and he was suffering from hypothermia. And I just think that, bluntly if you do that thing, sort of thing often enough, there’s a chance that one of these days it’s going to work.

Hmm.

One of these times your, I don’t know, your luck or, or maybe, maybe God says, You’ve had enough. Come to safet.

So you weren’t really happy about the, the inquest at all?

Because, no, because I didn’t at the time, or I’d probably have bounced to my feet and shouted at the coroner, I didn’t for the time, as it was only three months after his death, I, I barely knew which way was forward at that stage, I didn’t understand the significance of, I know you will never have me back after this episodeWhy if he had a clear intention to die, would he be worrying [in his note] about whether I’d have him back or not?

So, did the coroner come to a decision that it was a suicide but you
Oh yes.

you would have preferred an open verdict.

Yes, because I don’t think it was clear that Andrews intention was to kill himself.

Hmm.
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Ninas family found it hard to accept the coroners verdict of suicide. When the family objected…

Age at interview 27

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So then was there an inquest?

Yeah.

How long afterwards?

The inquest, so Joe died end of October and I think that the first inquest was May, June? I might be wrong about that but it was a considerable time afterwards.

But the funeral was quite soon afterwards?

Oh yeah, oh yeah. But yeah the inquest, which is not, which is not abnormal, I mean inquests do, can take up to a year after death can’t they, which is horrible because I think you just, cos you’re just waiting, and you’re expecting it, and its, closure is a horrible word, but that’s kind of, the last thing that you have to do and you are just kept waiting. I think it’s because also it was, we had to travel because where Joe actually died was not where we live so we had to travel outside, and go past the place where he died as well, to go to [the inquest]. We, our family, had great difficulty initially even accepting that Joe had committed suicide, we hate, you know the word suicide, just for our family it didn’t describe what Joe had done. I think because we had just had held the view, I mean prior to Joe doing this, that you know that people who killed themselves are depressed, down, possibly a history of mental illness, just all the things that that Joe wasn’t really, and because of this, and because he was, I think, because we were just stuck on the fact that he was actually happy, although he wasn’t happy; in the way that I kind of came to terms with it, is he wasn’t happy for that five minutes, when he actually, when he actually did it, or even half an hour, but prior you know prior to that, that its all it takes isn’t it, is just half an hour just to, just to flip. But I think because we were, because we were so adamant that he was happy, therefore how could he have killed himself, so when we went to the inquest, my Dad was adamant to the coroner that we don’t want to have suicide on his death certificate, it doesn’t, it doesn’t describe what we believe that Joe did, it was accident, it wasn’t a suicide, and the inquest got adjourned. My Dad, not so much Mum, but my Dad was upset that they you know that they didn’t take character references, you know they didn’t want to know the person that Joe was, all they were focused on was the manner in which he died. And because he had hung himself, therefore you know the coroner said that he couldn’t come up with an alternative cause of death, than suicide. But which at the time, we were angry about and we were really stuck on, but since I’ve managed to, to reconcile that with myself really, and I know that Joe did kill himself, I know that now it was just, you know, you don’t, you don’t have to be down, depressed, mentally unwell to, to kill yourself, it can happen to anybody, and so yeah I, whereas at the time when it first happened we were, we found that difficult but now that’s, I’ve resolved that for myself really, I know that he did.

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Jasvinder fought to have her sisters inquest re-opened. She was glad when the coroner…

Age at interview 42

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My family could’ve prevented it; the community leader could’ve prevented it. She was driven to commit suicide as far as I’m concerned. And I still hold people accountable for her death, in fact I fought it and it went to an inquest and it’s an open verdict now. I felt very strongly and still do, about my sister not having to die in the way that she did and the point with my sister is, suicide they tell me is a very personal matter, and you’d never know, I would never have suspected my sister was going to commit suicide, but what I do know is that she made several attempts to cry for help and nobody helped her. And that I was not in a position to be heard because she couldn’t accept my support as a disowned human being.

Was the original coroner’s verdict suicide?

Yes. It was, it was. And I fought that.

Yes it never sat with me at all that Robina would take her life in that way, and the bigger thing that never sat with me, it still doesn’t even today is that I hold people accountable for her death. I believe her death could’ve been prevented, she clearly was crying out for help and these individuals, regardless of them being some of them my family members, put honour before her life. For me that is as, worse, as I’ve grown as a person today and I’ve worked in this field, it’s equivalent to an honour killing, this you know where women are being driven to commit suicide.

You were talking about the fact that your mother went with you to the lawyers.

Yes, and there was an agreement that the file would be re-opened and looked at, and in the end the hearing was in court and the person that had to take the stand was my sister’s husband. At the end of the day he was in the house when she committed suicide, and he actually stated that she told him, because of an argument, she told him, I’m going upstairs and I’m going to set myself on fire He actually said that. And I was making the case he should have prevented that. He should’ve stopped her from doing that which he always argued, he didn’t believe she would’ve done that, he didn’t take it seriously. And when she did do that, one of the things that never sat with me again was the time it took for him to ring for an ambulance, the fact that his burns were minor in comparison to her, if somebody was standing there on fire which she was, he should’ve done more to save her. So there were so many unanswered questions for me, and there’s still unanswered questions and I suppose they always will be
Mm.

And there are unanswered questions about that incident but also the fact that other people could’ve prevented her death. And the verdict in the end was an open verdict which for me gave us a sense of justice; it will never give us full justice, because at the end of the day that man and other people cannot walk out innocently. There was a question mark put over it and we’ve been told, I was told which meant a lot to me, if there was any further evidence it could go back. And in some shape or form for me and maybe even for my Mum I think that felt reassuring.

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It was an ‘open’ verdict. Bob thinks a verdict of suicide would have been better because he…

Age at interview 59

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You felt it was important to go [to the inquest]?

It was important to go and we had some friends go along with us as well, and the coroner read out the various bits and came to the open verdict because he could not prove intent, he could not prove that Darren intended to die by suicide, because he hadn’t tried before, because he hadn’t left a note, and because he might’ve had alcohol in his system he could not faithfully reach a verdict of intent.

Mm.

Now, he, he was good, he was very compassionate and we have met him since, and we just sometimes feel that perhaps an open verdict was not the right verdict, because is it, is it, is Darren now not a statistic, because if he’s not a figure on a suicide list, does it, is it an inaccurate balance of the figures shown? Cos these figures need to be accurate to show what’s actually happening to our youngsters. But he, as I say, the coroner he did what he had to do and he was very compassionate with it, and, I’ve got no qualms about it.

Is that the main reason why you would’ve preferred a verdict of suicide for the accuracy of the figures?

Yes.

Were there any other reasons why you didn’t

No other reason at all. It, it’s accuracy of figures, I mean in the actual death certificate issued in France, does say, suicide, so he is somewhere on records somewhere, but in this county it doesn’t, it doesn’t. Does he show up as a suicide or not? Because sometimes it, to get funding for various things you need to have lots happening.

I feel it is important for figures to be accurate, because of funding for people trying to fund research into, into these reasons why so many people die by suicide. But I can see the other side as well where people have doubts about whether their loved one did actually die by suicide or whether it was a cry for help that went wrong, and it’s also still a certain amount of stigma involved with suicide.

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Ted said that his mother was very unhappy about the inquest held after his father’s death in 1964. She blamed the doctor for her husband’s suicide, and she had “hated” the coroner because she thought that he blamed the family for what had happened. Ted said that at the time he also adopted his mother’s approach but later he did some research and obtained a record of what happened at the inquest hearing and decided that he could not agree with his mother. Ted does not think that the coroner blamed his mother or the family for the events that took place when he was 12.

Ted thought that the inquest hearing was handled very professionally. Having looked at the…

Age at interview 56

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You said you were going to come back to the inquest. When you were doing all your research did you get in touch with the

Yes, Yes I got the inquest papers, and the inquest papers were very interesting. The inquest papers, and the newspaper reports, they just had statements, so they had a statement from the policeman that found my father, they had a statement from the people he worked with, and they had a statement from my mother. And he had penciled on it, and it was quite clear from the inquest, to me that the whole thing had been handled in a very professional way, so my mother’s view of things, I couldn’t, I couldn’t agree with. I don’t know about the doctor and the pills, the poor doctor was probably just doing his job,but certainly, the inquest, and this is what’s curious, because the verdict, my mother was hung up, on this he’d, verdict as she put it, the verdict was, He took his own life And she said that he, it should have been, He took his own life while of unsound mind Which I think it tends to be these days. And putting the fact on his illness, rather than, and she said that, you know, it was the finance, they’d cross questioned her on the finances of the family and all that, but he, but when you read the inquest paper and the statements and the newspaper report, it doesn’t add up to that to me, to me it’s perfectly clear that the inquest decided that the war time experiences were very significant.

The way my mother looked upon it, was that my father was ill, and I think she was probably right about this, he was depressed, and he took his life because he was depressed.

Mm.

It was his illness, his illness was caused by the war, it wasn’t the fact that there was anything wrong with their relationship, and it wasn’t the fact that they had financial difficulties.

Was that hinted at by the coroner?

That was, well the coroner asked about the financial difficulties.

Ah.

And my mother said, No more than anybody els. I think the thing is that when my father was depressed, when you’re depressed things become magnified, and that was probably one of the issues between my mother and father, my father was saying Oh, you know, we’ve got financial problems but I went into the finances, and actually you know when I, well I found the contents of the wallet and things like that, I went through it all, and there were no financial difficulties, she, she was right about that, we weren’t, we didn’t have financial difficulties.

No.

It was just the family making ends meet.

So she felt the coroner was somehow blaming her and the family etc by
Yeah. But I don’t think he was.

Right, interesting, that was her perception.

That was her perception, but we all have to have, we all have to have a story, and really it doesn’t much matter.

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Some people were surprised at the length of the verdict on the death certificate or surprised that the word ‘suicide’ had not been mentioned. Others were upset by the coroner’s words or language in the verdict.
A few people were dissatisfied because they felt that the inquest process had not helped to improve the standard of care available to those with mental health problems. Others were glad that the inquest process had at least exposed certain problems that might have contributed to their loved one’s death by suicide.

Stephen believes that his wifes medical care was supremely deficient. He had hoped that the…

Age at interview 45

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Do you want to say a little bit about the inquest?

Yes, well, being a suicide of course there has to be an inquest, and it usually takes, you know it can take anything, six months is a perfectly common sort of period of time. The police come round and have to take statements and they were again very, very good and the guy came round, I mean I thought I was going to write it [the statement] out, but I just told him and he then wrote it out, and I just had to confirm what that was. That is was right and, yeah, I mean it was pretty uneventful really, it was just another one of those things to sort to tick off, and just to say yes, that it was done. I mean, they [inquests] are pretty ineffectual really. I wanted to ask the questions about the medical care that I felt had been supremely deficient.

Were you prepared for what was going to happen at all? Were you in touch with the Coroner’s officer beforehand?

Oh they were very good, I mean the Coroner’s Officer was very good, I mean they, you know they said what would happen, the Coroner was very good as well, I mean it was quite upsetting.

Mm.

You know actually going through the whole thing and having to go through the detail of what happened on the day, you know it is, always probably going to be distressing telling that story, in my mind just thinking back on it, I mean, nothing really, it didn’t, it didn’t change anything, nothing really came out of it, and as I say the one thing that I would’ve wanted it to address is the care that she got, or didn’t get as far as I’m concerned.

Mm.

And it didn’t. And it doesn’t have the authority to do so either. So really it was just, it was an exercise, it was just a legal exercise that needed to be done and needed to be gone through, and

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Useful information about the inquest process can be found on a website run by an organisation called INQUEST. It gives 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 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....