Voicing loss: Meanings and implications of participation by bereaved people in inquests

Lead Research Organisation: Birkbeck College
Department Name: Inst for Crime & Justice Policy Research

Abstract

Context of the research

Coroners are independent judicial office holders appointed by the local authority. Over 40% of registered deaths in England and Wales are typically reported to the coroner each year, of which around 12-16% (amounting to nearly 30,000 deaths in 2018) become the subject of a coroner's inquest. The purpose of the inquest - an inquisitorial hearing almost always held in public - is to determine who died and when, where and how the death occurred, in cases where the death was violent, unnatural, unexplained, or took place in custody or other form of state detention.

Close family of the deceased can attend the inquest as 'interested persons'. This gives them the right to question witnesses (either directly or through a legal representative) and to ask to see evidence in advance of the hearing. However, the limited empirical research conducted to date on coroners' courts suggests that, in practice, bereaved people have an uncertain and ambiguous role and status in the inquest, and receive highly variable treatment. This is notwithstanding the repeated assertion by government and both the current and prior Chief Coroner that bereaved families should be 'at the heart of' the coronial process, and reforms having been instituted in support of this broad goal, most notably under the Coroners and Justice Act 2009.

Aims and objectives

In light of the apparent divergence between policy goals and empirical realities, we are proposing to investigate what it means - in theory and practice - for bereaved people to be 'at the heart of' inquest proceedings. We will examine bereaved family members' understandings, expectations and experiences of inquests, and the legal and policy framework within which coroners' courts operate. We will identify and assess contrasting justifications for bereaved people's inclusion and involvement in inquest proceedings, and consider any tensions or contradictions between different functions - such as the administrative, preventive and therapeutic - of the coronial process. On this basis, we will propose answers to the questions of whether bereaved people should indeed be 'at the heart of' the coronial process and have an active role in inquests; and, if so, for what purposes and in what ways. We will, further, explore the implications of these findings for policy and practice, and devise recommendations for reform.

The research activities will encompass a policy review, empirical investigation, conceptual and normative analysis, and extensive stakeholder engagement. The main empirical component will entail gathering personal accounts from individuals who have been bereaved in a range of circumstances. In one-to-one interviews and written accounts and at Family Listening Days (to be run by the charity INQUEST), research participants will be invited to reflect on their expectations and experiences of the inquest with respect to its outcome, the way it was conducted, the support or assistance they received, the part they played in proceedings, and whether and how attending the inquest impacted their grieving.

Potential applications and benefits

The research and analysis will provide rich insights into the empirical and policy phenomena under study, while also refining the theoretical perspectives typically brought to bear on these issues. In close collaboration with lay, practitioner and policy stakeholders, we will draw out the practical applications of the findings: identifying what kinds of policy and practice changes could support the inclusion and involvement of bereaved people in inquests in ways that are viable, appropriate and attuned to their own expectations. In so doing, we will also consider the implications for other kinds of legal proceedings (including public inquiries and criminal prosecutions) which are concerned with deaths and involve bereaved people.

Publications

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Fox AW (2021) How well do Regulation 28 reports serve future public health and safety? in Medicine, science, and the law

 
Description The project 'Voicing Loss' examined the role of bereaved people in the coronial process, as defined in law and policy and as experienced in practice; and explored ways in which the inclusion and participation of bereaved people in the process can be better supported. In addition to reviewing law, policy and existing research, the Voicing Loss team conducted interviews with 89 bereaved people with experience of the coronial process; 82 coronial professionals (including coroners, coroners' officers, lawyers and others); and 19 individuals who had given evidence to an inquest in a professional capacity. This constitutes the largest ever empirical investigation of lay and professional experiences of the coronial process in England and Wales.

The study found that the large majority of the bereaved respondents had had little or no knowledge of the coronial process prior to their bereavement and being told that the death was to be investigated by the coroner. As the investigation proceeded, they formulated various hopes and expectations of what the process would or could achieve, which can be broadly categorised as:

• hopes that the process would provide answers, and potentially the wider 'truth', about the death;
• hopes that lessons would be learnt about failings which had caused or contributed to the death, leading to action to prevent future deaths;
• hopes that the identification of failings would, more broadly, be part of a process of achieving justice for the deceased and accountability for the death.

With regard to each of the above, some respondents gave positive accounts of what the coronial process had delivered, spoke of how this had helped them as they continued to grieve for the person they had lost. Many more of the bereaved respondents, however, described a process which had not provided what they had sought from it, and which they consequently perceived to have failed them and the person who had died.

For example, respondents said that the questions they wanted answering were not satisfactorily - or at all - addressed by the coroner; or described coming to the realisation that the coroner's investigation was never going to extend beyond what they already knew. Many respondents emphasised that their overriding hope for the process was that it would give rise to learning and preventive action; but only rarely did they report on progress made towards prevention. More often, they voiced their profound distress that 'nothing has changed' as a result of the death and inquest. Much of the disappointment and disillusionment was focused on Prevention of Future Deaths reports, which were deemed to be weak in terms of their content and - most critically - to have no effect in the absence of any system of oversight and enforcement. Hopes that the coroner might deliver 'justice' and 'accountability' went unfulfilled for respondents who felt marginalised or powerless within a process that seemed heavily weighted in favour of public bodies or uninterested in looking beyond the immediate facts of the death.

The professionals interviewed for the study acknowledged that there is a problem of mismatch between some bereaved people's expectations of the coronial process and what, in practice, they experience. The problem was partly attributed to practical obstacles - particularly, relating to resourcing and staffing - that impede effective delivery of the service. Many of the professional respondents (particularly coroners, coroners' officers and inquest lawyers who represent state bodies) also argued that the problem of mismatch is rooted in 'unrealistic expectations' on the part of some of the bereaved, and that its resolution therefore depends on better expectation management. In contrast, other professional respondents (including family lawyers and representatives of some support services) spoke of systemic imbalances within the coroner service as the primary impediments to the realisation of bereaved people's hopes and expectations.

These findings suggest that the task of narrowing the gap between expectations and realities of the coronial process is complex and challenging. Meeting the challenge is likely to depend, in part, on structural reforms to the process to enhance its effectiveness, robustness and consistency. The provision of more extensive and accessible public information about the coroner service, to help ensure that bereaved people's expectations are better informed, is also of critical importance. Beyond this, there is a need to address a number of tensions and ambiguities inherent in the coronial process and its essential functions. These tensions and ambiguities relate to interpretations of the core questions which, according to statute, the coroner must address; the status of the coroner's preventive function; and understandings of the concepts of 'justice' and 'accountability' in the context of the coroner service.
Exploitation Route We envisage our research outcomes being taken forward as follows.

First, we hope the findings will support improved practice in the coroner service. To this end, three 'Principles for Practice' documents have been made available via the project website, along with a short video. Wide dissemination of the project findings, as described in the 'Engagement activities' section, will help to ensure that the range of practitioner audiences are reached.

Secondly, we hope that our findings will help to inform policy change. Our policy proposals are outlined in two policy briefs also made available via the project website. Additionally, we contributed to the Justice Select Committee follow-up inquiry on the coroner service. (This inquiry was halted due to the election, but we expect there to be other opportunities to contribute to the vital national debate on the future of the coroner service.)

Thirdly, we are developing proposals for further research to build on the Voicing Loss findings. As recorded under 'Further funding', ESRC impact funding has already been obtained for follow-up research led by the University of Bath. The Voicing Loss team are also in discussion with academics from the University of Leeds and Kings College London about new collaborative proposals.
Sectors Communities and Social Services/Policy

Education

Healthcare

Government

Democracy and Justice

URL https://voicing-loss.icpr.org.uk/research
 
Description Submission to UK Parliament Justice Committee follow-up inquiry on the Coroner Service
Geographic Reach National 
Policy Influence Type Contribution to a national consultation/review
URL https://committees.parliament.uk/work/8029/the-coroner-service-followup/publications/
 
Description ESRC/University of Bath IAA funding 'Supporting Loss: Improving information and support for bereaved people engaged with the coroner service following deaths related to substance use'
Amount £19,952 (GBP)
Organisation Economic and Social Research Council 
Sector Public
Country United Kingdom
Start 04/2025 
End 04/2026
 
Title Voicing Loss: Meanings and Implications of Participation by Bereaved People in Inquests: Qualitative Interviews and Group Discussions, 2021-2024 
Description The Voicing Loss research project examined the role of bereaved people in coroners' investigations and inquests. Research data comprise interview transcripts, interview write-ups and one written submission. The total number of interviews will differ from the number of uploaded transcripts, as participants were given the choice to opt out of having their transcript included in the repository. 
Type Of Material Database/Collection of data 
Year Produced 2024 
Provided To Others? Yes  
Impact This data-set comprises anonymised transcripts of interviews conducted for the study Voicing Loss. The dataset are available for secondary analysis by researchers interested in death investigations, the operation of the coroners courts, and bereavement. 
URL http://reshare.ukdataservice.ac.uk/id/eprint/857425
 
Description Birkbeck and University of Leeds 
Organisation University of Leeds
Country United Kingdom 
Sector Academic/University 
PI Contribution The ICPR/Birkbeck research team contributed to a successful application by an academic from the School of Law, University of Leeds for ESRC/University of Leeds IAA funding for a workshop on 'Who and what is coronial death investigation for?' The workshop was attended by legal and coronial professionals, and explored themes identified by the Voicing Loss research and related research by the University of Leeds academic. Since the workshop, the collaboration is continuing in the form of joint work on prospective research proposals on coronial death investigations.
Collaborator Contribution The University of Leeds obtained the IAA funding and co-organised and co-facilitated the resultant workshop.
Impact Co-facilitated workshop, with ESRC/University of Leeds IAA funding, on 'Who and what is coronial death investigation for', held on 24 May 2024. For more details, see 'Engagement Activities' section of Researchfish. The collaboration is multi-disciplinary, spanning law and social sciences.
Start Year 2024
 
Description ICPR (Birkbeck) and the Centre for Death and Society (University of Bath) 
Organisation University of Bath
Department Centre for Death & Society
Country United Kingdom 
Sector Academic/University 
PI Contribution ICPR at Birkbeck invited the Centre for Death and Society (CDAS) at the University of Bath to collaborate on the ESRC funding proposal which resulted in the project Voicing Loss and continued collaboration on production and development of outputs and further research proposals.
Collaborator Contribution Collaborative development of the original proposal and work on the Voicing Loss project; in the process of collaborative development of further outputs and future research on related themes.
Impact Voicing Loss project. Collaboration is multi-disciplinary, spanning law and social sciences.
Start Year 2020
 
Description ICPR and INQUEST 
Organisation INQUEST
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution ICPR invited INQUEST's contribution to the Voicing Loss study.
Collaborator Contribution In relating to the Voicing Loss project, INQUEST has provided strategic advice and support, assistance with recruitment of research participants, and conducted a Family Listening Day which has contributed data to the project.
Impact Family Listening Day conducted in November 2022; additional FLD is planned for later in 2023. INQUEST will be producing short reports on both FLDs.
Start Year 2020
 
Description Alexandra Murray - speaker at NHS Resolution webinar 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Speaker at webinar organised by NHS Resolution and a law firm on 'Inquests - differing perspectives' - providing information for medical practitioners who may be called to give evidence at inquests
Year(s) Of Engagement Activity 2023
 
Description Article in The Conversation 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Publication on 11 March 2025 of Insights article in The Conversation, based on project findings: '"I'm utterly utterly despondent and disappointed." Bereaved families describe being failed by the inquest system'.
Year(s) Of Engagement Activity 2025
URL https://theconversation.com/im-utterly-utterly-despondent-and-disappointed-bereaved-families-describ...
 
Description Bereavement Sector webinar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Presentation on project findings by Jessica Jacobson & Alex Murray to Bereavement Sector webinar, hosted by National Bereavement Alliance, on 3 July 2024. Title of presentation was: 'Voicing Loss: The role of bereavement people in the coronial process.' Webinar was attended by over 80 people, and presentation was subsequently circulated to the Bereavement Sector mailing list of1,100.
Year(s) Of Engagement Activity 2024
 
Description Blog for Patient Safety Learning Hub 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Blog for Patient Safety Learning Hub on project findings, by Jessica Jacobson: 'When bereaved people are left more distressed by the inquest process, something needs to change. Findings from the Voicing Loss study'. Published on 1 August 2024; 1776 views as of 3.3.25.
Year(s) Of Engagement Activity 2024
URL https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-comp...
 
Description Clinks webinar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Third sector organisations
Results and Impact Co-presented Clinks webinar for promotion of Clinks Evidence Library publication on 'Procedural Justice and the Courts', January 2023
Year(s) Of Engagement Activity 2023
 
Description Contribution to Lifting the Lid festival 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Third sector organisations
Results and Impact Member of panel on death investigations, at Lifting the Lid Festival of Death & Dying, November 2022
Year(s) Of Engagement Activity 2022
 
Description Interviews for local BBC news stations (radio & TV) 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact As the lead researcher on the project, Jessica Jacobson was interviewed for local BBC news (radio and TV) programmes, as follows:
- BBC Radio Dorset breakfast show (Steve Harris), 20.6.24 - interview with research participant & JJ
- BBC Radio Solent breakfast show (Alun Newman), 20.6.24 - interview with research participant & JJ
- BBC South West TV Spotlight lunchtime news, 18.6. 24 - interview with JJ https://www.bbc.co.uk/iplayer/episode/m0020djk/spotlight-lunchtime-news-18062024
Year(s) Of Engagement Activity 2024
 
Description Items about launch of Voicing Loss research on multiple news websites 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact A variety of news outlets covered the launch of the research via the Voicing Loss project website. These include:
- BBC news website https://www.bbc.co.uk/news/articles/cljjxeddrxyo
- BBC news website https://www.bbc.co.uk/news/articles/cv22yw48xpro
- The Independent https://www.independent.co.uk/news/uk/england-wales-university-of-bath-change-b2564280.html
- The Daily Mail https://www.dailymail.co.uk/wires/pa/article-13540375/Call-humanity-inquests-study-finds-bereaved-feel-let-down.html
- The Standard https://www.standard.co.uk/news/crime/england-wales-b1164983.html
Year(s) Of Engagement Activity 2024
 
Description Jessica Jacobson: Panel member at 'Lifting the Lid' festival 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Member of panel at Lifting the Lid festival of death and dying. Panel focus was on 'Death investigation: purposes and politics of inquests and inquiries'
Year(s) Of Engagement Activity 2022
 
Description Lecture for the Victorian Institute of Forensic Medicine 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact In-person lecture by Jessica Jacobson on project findings for the Victorian Institute of Forensic Medicine, Melbourne, Australia, 5.2.25. Title of lecture: 'Voicing loss: Mismatched expectations and experiences of the coroner service in England & Wales'.
Year(s) Of Engagement Activity 2025
 
Description Panel presentation at 'Whose death counts' CDAS webinar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Presentation by Jessica Jacobson and Lorna Templeton on project findings: 'Voicing Loss: The search for justice & accountability in coronial death investigation'. This formed part of a panel at the CDAS webinar 'Whose Death Counts? Social (in)justice and public health in death and dying', held on 10.10.24.
Year(s) Of Engagement Activity 2024
 
Description Panel presentation at ADEC webinar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Panel presentation by Jessica Jacobson and Lorna Templeton for a webinar on 'Difficult Deaths', for the US-based Association of Death Education & Counselling (ADEC), 21.1.25. Presentation title: 'Voicing Loss: A research and policy project on the role of bereaved people in coroners' investigations and inquests'.
Year(s) Of Engagement Activity 2025
URL https://adec.mycrowdwisdom.com/diweb/catalog/item?id=17455841
 
Description Presentation to Patient Safety Management Network 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Presentation on project findings by Jessica Jacobson and Lorna Templeton at Patient Safety Management Network webinar on 1 1.11.24. Presentation title: 'Voicing Loss: Bereaved people's & witnesses' experiences of coroners' investigations & inquests'. Webinar attendees numbered more than 100; slides were circulated.
Year(s) Of Engagement Activity Pre-2006,2024
 
Description Production of judicial training video 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Co-development for the Judicial College of training film 'The Confident Judge', focused on judicial interaction with lay court users.
Year(s) Of Engagement Activity 2022
 
Description Project website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Creation, launch and publicisation of website providing access to project outputs including research reports; policy and practice briefings; information about the coroner service for the general public and witnesses; and an expert insights blog. Website was launched on 18 June 2024. Google Analytics data show that there were 5,825 page views by 4,014 active users over the period 22 July 2024 to 2 March 2025. (Analytics data are not available for the first month that the website was live.)
Year(s) Of Engagement Activity 2024,2025
URL https://voicing-loss.icpr.org.uk/research
 
Description Response to journalist inquiry & news coverage of Voicing Loss report 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Jessica Jacobson, as lead researcher on Voicing Loss, discussed a new report based on the research - co-published with charity Gambling with Lives - with Observer journalist John Ungoed-Thomas. A prominent article citing the report, the wider Voicing Loss research and Jessica Jacobson was published in the Observer (print and online editions) on 19 January 2025.
Year(s) Of Engagement Activity 2025
URL https://www.theguardian.com/society/2025/jan/19/unwilling-coroners-failed-us-say-families-of-gamblin...
 
Description Socio-legal blog (1) 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Blog (no. 1 of 2) on project findings, for Socio-Legal Studies Association, 'Voicing Loss: "I needed more than answers"', published 24.6. 2024
Year(s) Of Engagement Activity 2024
URL https://slsablog.co.uk/blog/blog-posts/previous-series/series-1-title/icpr-guest-edited-blog-voicing...
 
Description Socio-legal blog (2) 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Blog (no. 2 of 2) on project findings for Socio-Legal Studies Association, 'Voicing Loss: "I know it's all about the death, but somehow it becomes about their life when you've got the inquest"', published February 2025
Year(s) Of Engagement Activity 2025
URL https://slsablog.co.uk/blog/blog-posts/icpr-guest-edited-blog-6-voicing-loss-i-know-its-all-about-th...
 
Description Talk to Sentencing Council event 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Invited panellist at Sentencing Council seminar on 'Current issues in sentencing policy and research'
Year(s) Of Engagement Activity 2023
 
Description Turning Point presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Third sector organisations
Results and Impact Presentation on project findings by Jessica Jacobson to the Research Governance Group of Turning Point, 25 July 2024. Presentation title: 'Voicing Loss: The role of bereaved people in the criminal process'.
Year(s) Of Engagement Activity 2024
 
Description Workshop: 'Who and what is coronial death investigation for?' 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact One-day workshop co-hosted and facilitated with the University of Leeds, on 'Who and what is coronial death investigation for', in London on 24 May 2024. Workshop was attended by coroners, pathologists, anatomical pathology technicians, inquest lawyers and representatives of third sector organisations.
Year(s) Of Engagement Activity 2024