When the Coronial Process Provides Answers Families Could Not Get in Life

The family of a young person who committed suicide shortly after being discharged by Mental Health Services felt supported and listened to by the coronial process. An inquest is not a forum for blame or compensation, and families should not expect it to provide formal findings of negligence. What it can do (if properly prepared for) is answer how and why a death occurred and give families a voice that was often missing during care.

An inquest into the death ventured into the details and failings of their child’s care and treatment over a prolonged period under the care of various Mental Health Services.

During the preparation and throughout the inquest, the family were supported by our Medical Negligence department. Families are often tempted to engage directly with large volumes of medical records or correspondence without guidance. In our experience, this can be overwhelming and risks obscuring the key issues. Careful preparation and structured support are essential. The team supported the family throughout, allowing them to focus on the inquest process while ensuring their concerns were clearly and accurately presented. This helped to ensure that their story, about the failings suffered by their child, was heard.

At the inquest, the Coroner asked clear and relevant questions about the care provided and the circumstances leading to the death. Witnesses were not permitted to evade difficult issues. In my view, this case demonstrates the coronial process at its best: careful, informed, and willing to confront uncomfortable systemic issues without losing sight of the individual. Every document was read and tested against the oral evidence. This allowed the Coroner to construct a clear timeline of events. Crucially, it also allowed the family to understand what happened, and when. This is something that is often lost in extensive medical records.

The family could absorb and comment on witness evidence, as it happened. Importantly, this was done in a measured and respectful way. Inquests are not adversarial, and families should avoid approaching evidence as though they are cross-examining witnesses. The coroner controls the process and will explore issues where they are properly raised. Following discussions with counsel and our team, they were able to provide further evidence during the inquest in response to the witnesses, if the evidence did not concur with their understanding. The Coroner happily listened to and accepted this evidence, as they knew their child best. The coroner’s willingness to hear this evidence reflected an understanding that clinical records do not always capture the lived experience of a patient, particularly in mental health care.

Whilst not necessary, the family decided to attend all 13 days of the inquest. This will not be right for every family. Long inquests can be emotionally exhausting, and professional advice should be taken about how and when families engage. They felt vindicated by the expert and coroner voicing all the concerns they had raised with professionals time and time again, to no avail. The family gave evidence of their child’s character and were able to share beautiful memories and pictures with the Court, ensuring their child remained at the centre of the legal jargon and medical language.

At the conclusion, the Coroner personally addressed the family and gave them the closure they needed after so many years. They assured the family they heard their child’s voice, which was overlooked by health care professionals throughout their lifetime. This case highlights what the coronial process can achieve when families are properly supported and expectations are clear. It also underlines a difficult truth: many of the answers families seek after death could, and should, have been answered during life.

Our Medical Negligence team supports families through the coronial process following deaths involving medical treatment or mental health services. We provide sensitive, structured guidance, help families understand complex medical records, prepare evidence, and ensure their concerns are clearly presented to the Coroner. While an inquest does not determine liability, it can be a vital step in uncovering what happened and identifying lessons for the future.

If you are facing an inquest and would like clear, compassionate legal support, contact our Medical Negligence team on 0330 822 3451 for a confidential discussion today. Alternatively, request a callback.