The Brutality of Inquests

I recently tweeted "The inquest process is brutal" and went on to describe my experience. I got several replies in support from those who understood my pain. I was sitting across from Kings Cross station having lunch before catching a train back to my home in Newcastle. I had spent the previous 24 hours back in my hometown of Croydon, preparing for and attending my son Samuel's 3rd pre-inquest review.


I felt pretty flat as I reflected on the meeting, the lead-up and the hangover effect afterwards. It's over 2 years since Samuel died by suicide at South Croydon railway station. So far, we've had three inquest reviews, one change of coroner, four changes of coroner officer and it can feel like we are no further forward in this cruel process.


Few people understand inquests unless they are sadly thrust into this alien legal world. It's so hard to explain the basics, let alone convey why it is so incredibly important to a bereaved parent. The inquest process feels like your last chance to advocate for your child, to stand your ground and have your and their voice heard.



Samuel's inquest is messy, multifaceted, and complex, reflective of his final few years of life. Sadly, it's also feeling like my eyes have been opened to the darker side of the process.

The other parties involved, the Metropolitan Police, British Transport Police, Social Services and the Mental Health Trust are determined to protect their reputation and distance themselves from responsibility, it appears.


As I sat in my bland hotel room the previous night paperwork was emailed for review. At 8pm I receive BTP's submission. A lawyer refers to Samuel as "nearly 18 and not vulnerable", challenging the view that he was a highly vulnerable young person. I should shrug it off, but it riles me. Is this the norm, are these lawyers paving the way with derogatory language, sweeping statements and unjustified judgements? Sleep doesn't come easy and as I walk to the coroner's offices the next morning all the memories and familiarity of Croydon floods my senses.


My legal team have prepared well for the review, a lengthy submission of paperwork, stating our case. The previous week I Interrupted my daughter's wedding dress fitting appointment as an urgent response was needed. Sadly, within 5 minutes of the review starting, we established that the coroner had somehow missed our carefully prepared paperwork. He had caught sight of the MET papers though, which had been emailed across at 10:01, for the 10am hearing. You couldn't make it up!


My barrister did a good job of stating our case but it was frustrating that due consideration and preparation hadn't been undertaken by all parties. The 2 biggest issues, which have been on the agenda for 18 months, were still to be unanswered today. The coroner stated that he would not be ruling on Article 2 or a jury inquest and would reflect on these himself.

Again, where does that leave you? A round trip of over 600 miles, being told that key questions are off the agenda? How do you trust someone who hasn't even read your carefully prepared report?


'Causation' was the word of the day. Did Samuel's challenges and vulnerable state lead him to lose all hope and take his life? Hell yes! Of course, it's related. His mental health and accompanying addiction spiralled during early Covid lockdown.


It became apparent that protecting organisational reputation and minimising Samuel's situation was evolving. Listening to the other parties diminish his condition. The mental health trust even suggested he was on an upward turn. This felt like I was getting a taste of what was to come. The duty of candour, openness, honesty, and willingness to collaborate to learn lessons was missing in action.


I came away flat but my expectations had not been high. In my care of Samuel, advocating on his behalf, and in subsequent work after his death, I've learnt that it's vital to focus on what you can control. Raging at establishment and getting caught in negativity is not helpful. It drains your energy, leaves you powerless, and pushes you into being a victim.


I've realised that I need to protect myself. This process is not personal. These legal people didn't know my son or our family and are just holding a legal position. Coroner's courts are a different legal entity and I had been pre-waned to expect the unexpected.

I need to live my life alongside all this uncertainty, not let it dominate, erode hope or darken the positives. It is not a reflection on me, or more importantly on Samuel.