Inquests and the voice of victims

I am motivated to contribute to this work by my experiences of three inquests. The first into my sister’s self-inflicted death; the second into the deaths of Saskia Jones, Jack Merritt and Usman Khan at Fishmonger’s Hall tragedy. In both inquests I was both a victim of the tragedies and also a witness in the process. The third was an unexplained death of a friend’s brother, involving failings from NHS and social services, and I informally supported my friend through the process.

My experiences have led me to think inquests are a waste of public money that pay lip service to the ‘victim voice’. In my experiences, inquests are not run as neutral inquiries into an incident to gain learning and understanding and to avoid repeating mistakes. Rather, they are very expensive legal processes whereby institutions use certain victim voices to bolster specific institutional agendas and at worst prevent, or at best avoid, a broader and more neutral examination of key facts. Findings are thereby skewed, and as they are also unenforceable, they are largely pointless. The public purse is robbed, victims are retraumatised, lessons are not learned, and few people (other than legal professionals, and not all of them) go home better off. In each of the inquests I have had the misfortune to endure, I felt those who died would have been damaged by the process and underwhelmed by the outcomes, and by reporting in the press, which is often simply a repetition of what happens in the inquest. As Bishop James Jones so eloquently put it in his report to parliament to ensure the pain and suffering of the Hillsborough families is not repeated, inquests in my experience are indeed an experience of ‘The patronising disposition of unaccountable power’. 

In the inquest into my sister’s death, as her family we were, first and foremost, disinterested in the inquest process, but felt forced to produce statements and reasons and angles of enquiry. If the victim voice is clearly stating ‘please leave me alone’, there is surely a question about who the process, and its cost, is serving? My family’s experience of the inquest was that it was retraumatising, irrelevant and used our opinions to avoid a thorough exploration of relevant surrounding matters.  

In my sister’s inquest and in the Fishmonger’s Hall inquest the adversarial nature of questioning, and the fact that bereaved families were sat at the front of the hall close enough to make hurtful remarks aimed at witnesses, or, in my sister’s inquest, able to directly question witnesses, all added to a sense of vigilante violence more than level-headed, thorough, genuine and deliberative inquiry. At the Fishmonger’s Hall inquest, some lawyers appeared more concerned with soundbites that would get into the press than a thorough exploration of the issues at hand and holding powerful institutions to account. I engaged in that inquest as a witness and broken-hearted victim with a responsibility to contribute my truth in order to learn lessons. My treatment felt like a witch hunt, which was determined to find the woman guilty. There was no interest in my experiences of victimisation, in any thoughts I may have had about lines of inquiry, or in any relevant expertise I held, unless it was in an attempt to rubbish it. It made me empathise with the witness I questioned at my sister’s inquest.

My experience of my friend’s inquest into her brother’s death was also that it was an unhelpful process for her family – providing opportunity for institutional excuse-making rather than for genuine curiosity about what had happened and what could be done better in the future. 

There is much written about collaborative engagement and co-produced outcomes with system-impacted people in many fields. I listened with interest to Bishop James Jones and Duwayne Brooks discussing the infected blood inquiry on Radio 4 last week. I learned it was at the Bishop’s insistence that this inquiry was not led by the Department of Health; agreed with his logic around using panels of experts rather than inquests or public inquiries in response to tragedies. Such an approach would have been much more appropriate at the Fishmonger’s Hall inquest, within which SO15, the counter-terrorism unit of the Metropolitan Police, played a leading role in gathering the evidence. As I listened to the radio I cheered as Duwayne Brooks explained why it could be important for the police to work collaboratively with system-impacted people in their exploration of the issues and evidence. If my experiences of three inquests are anything to go by, the inquest process is a waste of public money, achieving the opposite of what is intended, and urgently needs to be reviewed and replaced, out of respect for all involved, whether or not the system deems a particular voice that of a ‘worthy’ victim. We need to be sure our inquest processes aren’t creating more victims, because currently my experience tells me they are.