7 The bereaved
178. Although we have heard evidence of good practice
in the coronial system, we have received written submissions detailing
cases in which the bereaved have received poor treatment and service.
- Victims' Voice cited the experience of a man
whose wife was killed in a road accident. The account details
a series of episodes in which he was treated insensitively by
police, hospital and mortuary staff, although no coroner's staff
are mentioned.[176]
- The Coroners Services Public Accountability Action
Group has made a long submission which reveals a high degree of
suspicion about the workings of the coronial system, alleging
secrecy, arbitrary decision making, lies and illegality.[177]
- Mr Gerald Wright has submitted evidence of inconsistent
treatment by the coroner in relation to post-mortem examination
of his wife who died suddenly whilst on holiday.[178]
- The parents of Nik Morgan have made written submissions
detailing their struggles to get an inquest into the sudden death
of their son.[179]
179. INQUEST, an organisation which works with those
bereaved as a result of deaths in custody, has identified a long
list of problems with the current coronial system, including:
- lack of information for the bereaved about their
rights in relation to inquests and post-mortem examinations;
- lack of understanding and sensitivity in relation
to religious and cultural issues;
- insensitivity of coroners and others in relation
to post-mortem evidence;
- regional variation in relation to time delays
and approach to inquests;
- variable quality of court accommodation;
- variable coronial practice generally;
- variable standards of conduct of coroners' officers;
and
- lack of follow-up communication on lessons learned
and prevention strategies.[180]
180. INQUEST finds that bereaved families have found
themselves marginalised by the coronial process and, far from
being comforted in their distress, they are left with more questions
than answers,[181]
adding that:
… far from being the isolated or highly controversial
cases or incidents that the system proves incapable of dealing
with, it is ill equipped to deal with most deaths and most
families suffer additional distress and grief as a result.
…[The coronial system's] potential role in guaranteeing
informed and effective access to appropriate bereavement intervention
options for bereaved families must therefore be a central concern
in developing a new system.[182]
181. The Foundation for the Study of Infant Death
(FSID) has also remarked that:
There are marked inconsistencies between different
parts of the country in the official response to unexpected infant
deaths. These variations arise mainly from differences in the
attitudes and actions of individual coroners, police officers
and pathologists. There are also variations in the extent to which
paediatricians are prepared (or permitted) to become involved.
… [there is a] lack of central guidance [which] permits wide
individual variation of approach, which at times appears idiosyncratic
and wayward.[183]
182. Dame Janet Smith agreed that bereaved families
are not well served by the existing system:
The evidence about the present post-death procedures
shows that the families of deceased persons are little involved
in the processes of certification and investigation of a death…the
needs and expectations of the bereaved relatives are sometimes
not given the consideration they deserve…. the present procedures
fail to tap a source of information about the deceased person
and the circumstances of his/her death that would be of great
value to the process of death certification and investigation…Any
changes contemplated for the future must seek to ensure that families
are kept informed about, and are consulted and involved at all
stages of, the post-death procedures.[184]
183. The Luce Review concluded that although individual
coroners and their officers were often sympathetic and supportive
to bereaved families, the current system had fallen below the
standards aimed for in other public services in matters of informed
participation.
184. The Government has accepted the recommendation
of the Luce Review that the participation of bereaved families
in the Coroners service should be secured by a Family Charter.
A Draft Charter for Bereaved People Who Come Into Contact With
The Coroner Service has been appended to the draft Bill. This
sets out:
- the objectives and values of the coroner service;
- details of the standards of service the bereaved
should expect;
- the rights of the bereaved to participation in
the death investigation process;
- availability of support and bereavement services;
- information about deaths abroad;
- rights of appeal and review of coroners' judicial
decisions;
- procedures for other complaints and comments;
- disability issues; and
- information about monitoring of service standards.
185. We welcome
the Government's draft Charter for Bereaved People. However, we
note that the raised expectations of the bereaved may lead to
severe disappointment in circumstances where serious under-resourcing
and, therefore, variable standards in service are likely to persist
as a result of inadequate funding for reform of the coronial system.
176 Ev 102-106 Back
177
Ev 154-166 Back
178
Unprinted memorandum Back
179
Unprinted memorandum Back
180
Ev 113-114, para 10 Back
181
Ev 114, paras 12-15 Back
182
Ev 114-115, paras 15 and 16 Back
183
FSID submission to Home Office Position Paper; Luce Review and
Shipman inquiry Back
184
3rd Report of the Shipman Inquiry, Summary, paras 5-7 Back
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