Written evidence from The United Families and Friends Campaign (UFFC) – a coalition of family campaigns

Please note our collective personal family experiences of 40 plus families who have been subjected to the Coroners Court Inquest system, that span many years, form the basis of these submissions.


  1. The extent of unevenness of Coroners services, including local failures, and the case for a National Coroners Service:


  1. Our Families are very concerned with the apparent individual discretion of the Coroner in relation to disclosure of evidence to the affected families. This disclosure is essential for families to gain a real understanding of the circumstances surrounding their loved one’s death. Without it, they have no real ability to form any questions that would be essential to the scope of the Inquest and ultimately this means that all the evidence will not be heard in front of the Jury.


Disclosure in this instance, relates to any and ALL documentation gathered during the investigation process and also the clothes and property of the deceased loved one. These items should be disclosed to families in good time before the Inquest. In some cases, families have had Coroners suggesting that the disclosure of evidence to the family be delayed until the morning of the Inquest.


This is completely unacceptable, and in some cases can be considered a direct affront and deliberate attempt to sabotage a grieving families’ inclusion at the Inquest and the subsequent conclusion of the Jury. All families have a right to know how their loved one died.


  1. Our families have very real and grave concerns about the inhumane and degrading treatment that they are subjected to during the Investigation and Coronial proceedings. These concerns relate directly to the way in which their loved one’s bodies are treated during autopsy, sample taking and storage procedures. Our families have been violently traumatised by the abject refusal to keep families included in the process immediately following their loved one’s death. Families demand that the state recognise families’ rights to view their loved ones body before autopsy proceedings commence. This means that families see the entire body and any subsequent injuries should they wish to before the body is desecrated by the autopsy procedure. Many of our families have been left with lasting trauma as they have not been able to view the body at all, or if they have, have been subjected to the degrading experience of having the police or IOPC investigators hovering over them.

This is an assault on the families right to have proper inclusion in the           rites of passage that come with any death. Research has been written detailing the increased risk of PTSD, if a family does not have access to adequately view the body in peace following a traumatic bereavement.


  1. Nearly all of our families have had adverse experiences in relation to the removal of individual Organs for testing. When their loved ones Organs are removed, none of the families are made aware of where the Organs are being stored, how long they are being held for or why. The same goes for any smaller samples that have been taken for testing. In some cases, extreme delays in sending Organs for examination have occurred after removal and years later the families still do not have the information regarding why this occurred despite significant legal pressure.


The sickening procedures that appear always to happen behind closed doors with no inclusion of the families at any point has led to, in many of our families cases, organs never being repatriated with the body. Organs being taken without consent have often been used for medical research, bodily samples have been returned to families in forensic bags to their doorsteps and in one case, the wrong body was given back for burial.


The torturous months and sometimes years of waiting to have your loved ones’ body returned for burial leading to the extensive decomposition of your loved one’s body coupled with the outrageous and inhumane treatment that families are subjected to above has had devastating and profound traumatic effects on all the families concerned. Following the Alder Hay scandal, that these processes are still being violated behind closed doors is diabolical and our families demand an end to the barbaric and degrading treatment of bodies and families listed above. Our families demand full disclosure of location of Organs and bodies and would like to see a system put in place that logs all movement/testing/removal of Organs, samples and bodies so that the state is held accountable for any issues that may arise during these procedures.


  1. Our families have significant concerns around the lack of independence surrounding the Coronial process as a whole. We are specifically interested in why families are not included at any stage in the selection of the Home office pathologist, presented with relevant skills or experience of said pathologist or, furthermore, not included in the selection of the toxicologist employed to analyse fluid and hair samples.


At no point are families told where the samples are and no families have been offered the ability to conduct independent toxicological analysis, often times the samples are tested to destruction.  This is unacceptable and our families demand full inclusion and disclosure of this process.


Our families also have grave concerns relating to the inclusion of Police representatives at the autopsy of their loved ones when clearly the police officers being represented have been involved in the killing or death of their loved one. Police officers should be treated as suspects not witnesses until any proceedings have been concluded and therefore should not be any where near the deceased body of a person that they have been involved with ending of life.


This is especially pertinent when considering the vast majority of families are not told that they can be represented at the autopsy. Our families find this insulting and take this as a direct affront to inclusion and basic respect for the due process, transparency and equal rights of families in the search for the truth about how their loved one really died.


  1. All of our families have been subjected to treatment during the coronial process that has left them feeling as if they are not important and that their thoughts and feelings do not matter. We believe that families should be at the forefront of Inquest proceedings as essentially the Inquest is there to satisfy the questions of the families. Instead the family voice is always marginalised.


We would demand that families are treated respectfully at all times and this would include being given involvement in the entire process, from investigation to the Inquest, from autopsy proceedings to Pre-Inquest reviews. This means that any issues that families raise or indeed evidence, should never be dismissed as unimportant and furthermore that all evidence gathered be presented before a jury.


The torturous process of being dragged through many, many years of traumatic processes with no involvement and having to relive and be subjected to some of the most disturbing, traumatic and violently graphic circumstances only to realise that those responsible for your loved ones death will ultimately, never be held to account by due process of the law is an abomination and a national disgrace.


It is unacceptable that families are often invasively questioned and treated as though they are the ones on trial, it is well documented that the Coroners Court Inquest proceeding tends to be adversarial. This approach leads families to suffer great and unnecessary distress and echoing the findings of Dame Elish Angiolini, our families demand an end to adversarial proceedings.


In particular our families demand an end to adversarial lines of questioning during an inquest to bereaved and traumatised families, the sole intention of which are to demonise innocent families to detract attention away from state violence and murder.


  1. Improvements in services for the bereaved:


  1. Our families consider that the Coroner should advise that the state should fund therapeutic intervention via an independent trauma specialist of the families choosing, in order that the catastrophic damage inflicted on families of dead victims be adequately treated to avoid the long term consequences of the barbaric treatment that they are routinely subjected to.


  1. Ways to strengthen the Coroners’ role in the prevention of avoidable future deaths:


  1. Our families demand that Coroners be given the power to enforce recommendations listed in prevention of future deaths reports. Without this power, the function of the Coroner becomes defunct and the state becomes complicit in the future deaths of many people whose lives could be saved. Refusal to implement these powers for Coroners is very painful for families who see report after report full of recommendations rejected and not implemented.


  1. Fairness in the Coroners system:


  1. We have serious concerns that still, in 2020, families are being denied access to justice and an equal inclusion in all proceedings by being refused automatic access to Legal aid funding while police officers are given unlimited funding and the best barristers at the tax payers expense. This only shows derision and disregard for the victims whose lives have been taken and their traumatised families.


Our families demand an end to means tested legal aid funding for families.


  1. How the Coroners Service has dealt with COVID 19:


  1. Our families have concerns relating to the disproportionate number of black people represented in Covid-19 deaths. In particular we would raise the need for all people identified as at risk of death from Covid-19 to be given information regarding preventative measures such as supplementation with Vitamin D.


We also raise concern over the apparent power of only one doctor certifying deaths of Covid-19 as this can be interpreted as being prejudicial.


September 2020