What I've learned about coroners and inquests – part 1

Most people will never have to be involved with a coroner or inquest during their lifetime. I found myself in the position of having to face the inquests of both my son and mum this year. It is a bewildering situation and an intimidating process when you are at your most vulnerable.


My 17-year-old son died by suicide in September 2020 and, in January 2021, my mum died suddenly, following a varicose vein bleed at home. I was to discover this immediately meant an inquest was required as it is such a rare event.


The inquests were due within three weeks of each other, so I undertook research to understand the process and sought advice from my fellow suicide bereavement support group members.


Here are some of the lessons I learned during the initial process which might help others:

  • Dates can be set for inquests but this doesn’t always mean they will go ahead. My mum’s inquest was postponed with 10 days’ notice. No one had followed up initial statement requests as key information was missing. I found this incredible given the legality of the process. My son’s inquest was reverted to a pre-inquest review at a week’s notice as the coroner realised it was far more complex than anticipated

  • The communication with the coroner’s office is very variable. It ranges from kind conversations (in my mum’s case) to complete radio silence (in my son’s case) – each is being handled by different coroner's offices.

  • As an interested party, you can ask for all the paperwork to be shared with you. A note of caution though, as although I wanted to know the details I underestimated the impact of reading this information.

  • Written communication can be brutal. I received my son’s post mortem results in the late Christmas post with no forewarning. The British Transport Police report was graphic and left me truly distraught. I would suggest finding a balance of how much you want to know and sharing the burden of knowing traumatic details with those closet to you. My youngest daughter is a doctor so she read the post mortem results first and interpreted them for us.

  • You can write to the coroner and express your wishes for the inquest. I wrote a heartfelt letter describing my son, our family and the impact of his death. I used sub headers to cover key areas such as press coverage and witnesses. I enclosed his funeral order of service to show his life and family in pictures. I felt it was a way of having some control and influence at a time of huge uncertainty.

  • The press can attend an inquest – even for under 18s. As it is a public legal process, they can attend and report. There are guidelines they are asked to adhere to but you don’t know if they will be there beforehand which feels pretty unsettling.

  • Inquests can be face to face, online or hybrid versions, as I found in my son’s case. This actually felt ok as we could see each person speaking remotely via video call on a large screen without the possible intimidation of sharing a room with them

  • There is a lot of legal language involved – Google can be your friend I found. Trying to interpret ‘rules’ and possibilities in paperwork beforehand is tricky but I gave it a go.

  • There are a lot of lawyers involved in some inquests. This shocked me the most and I was ill-prepared for this. They are asked by the coroner to use plain language and they mostly kept to this.

  • Lawyers do not want their organisations to be interested parties if possible, I discovered. There is some implication of guilt which they obviously try to avoid.

  • You can have juries at inquests if there is a query about their death being linked to others' action. This is still being considered for Samuel’s case.

  • The coroner may not have the full picture initially, as in my son’s case, so additional information is required, delaying the final inquest which is now likely to be 18 months after this death.

  • You can have your voice heard – the coroner asked for a spokesperson from our family. I was prepared and confident to stand my ground as I knew my son best and it was my final chance to be his advocate. My opinions were sought and I have felt a key part of the process so far.

Samuel’s inquest is yet to happen. We have another pre-inquest review in November before his inquest in 2022. I’m still chasing for a date for my mum’s. I will update on how the process evolves and share our continued learning along the way.