Personal and academic reflections on the effectiveness of inquests

I shall be reading this project’s ‘outputs’ with great interest.  In particular, will the ‘powers that be’ learn from them?

I have an academic interest in the role of the coroner, having asked questions about the ‘effectiveness’ of inquests, particularly in relation to how criminal justice institutions are meant to learn from their ‘mistakes’(Padfield, 2023). I also have a personal interest. 

My experience tells me that the umbrella word ‘inquest’ sits uncomfortably over such a wide variety of investigations.  In 2020 I attended several inquests: partly as part of my own education as I launched into my examination of the ‘effectiveness’ of inquests, but also sadly due to the death of a close family member who killed himself.  Then I attended part of the inquest into the deaths of Saskia Jones and Jack Merritt in the Guildhall (the Fishmongers Hall inquests).  What a contrast: my family one was small, intimate, and held online. Given the huge emotional trauma and grief which flow from an unexpected self-inflicted death, this was no easy event in which to ‘participate’.  Even I (a seasoned lawyer!) felt somewhat daunted by the occasion.  How different was my experience of the ‘drama’ of the Guildhall, with its banks and banks of lawyers (and computer screens), the jurors, the bereaved families, the witnesses …..  It is very difficult to compare the two or to make generalised conclusions which embrace both.  The first was ‘inquisitorial’ in the sense that the coroner took the lead.  (My main interest was in understanding, and improving, some of the police practice earlier in the investigation – the ‘process’ starts long before the inquest.)  The second felt heavily ‘adversarial’ – but ‘adversarial’ in an odd way.  Counsel to the Inquest (backed up by his solicitors) examined witnesses, and all the many ‘institutions’ involved were legally represented.  Every witness was likely to be examined (was it cross-examined?) by a significant number of skilled advocates, defending their client’s corner.  Witnesses were often battered by the force of questioning.  Of course the presence of legal teams makes a huge difference – they dominate.  It must be difficult for bereaved family members at such an inquest not to feel like small fish in a massive legal ‘show’ (or what one of the Voicing Loss interviewees calls a ‘circus’).  The Voicing Loss research outputs speak of a feeling of ‘exclusion’ – yes indeed.

Of course bereaved people should be at the ‘heart’ of the coronial ‘process’.  But it is an unhelpful phrase.  As with victims of serious crime in the criminal justice ‘process’, bereaved families should be respected, included, kept informed and offered every possible support.  Victims of crime and families at inquests are often deeply distressed – judges and coroners, and their staff and everyone involved, should reach out to them with genuine compassion and humanity.  Victims/families should never be peripheral – but those who run the ‘circus’ must never forget – what most families also want is that ‘we’ should learn from their tragedy. The central question:  How best to get real learning from a tragedy?  An inquest is a clunky learning tool.

Padfield, N. (2023). The “effectiveness” of coroners. Criminal Law Review, (2), 104–117. https://search.informit.org/doi/10.3316/agispt.20230413086304