top of page
  • Writer's pictureWrenAves

Justice Won't Be Found In The Coroner's Court

[Content Warning: Suicide theme, inquest]

This week last year I attended the inquest of a friend who died by suicide following negligence and abuse from mental health services. It was a four-day Article 2 inquest, held with only the coroner, not a jury, in a small rural court house in the North of England. Apart from myself and my friend’s family and GP, there were only one or two members of the public in the gallery, and some journalists who came and went as the week progressed. We squeezed into the old wooden chairs, which folded down like we were seated in an antique cinema, and the long days began. For the best part of a week we arrived and sat every day to listen to the details of my friend’s life being read out and taken apart. Mostly, it was only the sad and difficult things the court wanted to hear. The times she had hurt herself; the times she had almost died; the words other people had written about her; the details of her death; the harsh descriptions of her autopsy. We didn’t hear much about her sense of humour, her loyalty and bravery, her desire to help others. We didn’t hear much which made me think “I know this person”. The coroner allowed my friend’s Mum to bring some photos, which were placed at the front on the bench. Sometimes focusing on them made it easier to bear, sometimes it made it worse.

Throughout the days I found myself experiencing a wave of different emotions. Upon hearing things I knew to be wrong, I felt incensed, and had to hold myself back from shouting at the court, yelling at the coroner that he was wrong. The times when I heard something I had always known to be true, or which proved my friend correct, I felt a rush of strength in my chest… A promise of the truth. I tried to get it all in the correct order in my mind, but there was so much information, so fast, sometimes that was hard. I gripped the wooden bench in front of me, praying that the coroner had understood the significance of certain pieces of evidence, that he was intelligent and insightful enough to have caught on to what was being said beneath the corporate lies and medicolegal speak.

On the final day, the coroner read out the verdict. My friend had died by suicide. Mental health services had breached her human rights and contributed to her death. I burst into tears right there, openly sobbing in court. My friend's mum came over from her seat and we hugged tightly. I said "she got justice, you got justice for her". In a way, I believe that, but after walking out of the court, past the news cameras, away from the people and the noises, I stopped and sat on a wall outside a church, and that rush of happiness disappeared. I started to cry again, and couldn’t stop.

In that moment, sitting on that wall, it dawned on me finally that my friend was dead, and she wasn’t going to come back. It might seem strange, but right then I realised that I had spent almost two years, since first finding out about her disappearance, expecting her to reappear. Logically I knew she was dead, but emotionally, I felt that once everyone knew the truth; once the world had been informed of how badly mental health services had treated her; once mental health services admitted that everything she had ever said about her care was correct, she would come back. But she didn’t. And with that crushing realisation, the “victory” and the “justice” I had fleetingly celebrated, crumbled around me. I couldn’t remember why it was I had felt happy at the verdict. Because what did it even matter? Those mental health professionals, that NHS Trust, dragged my friend to her death, and that couldn't be undone. No-one went to jail. No-one got fired. No-one got a fine or a caution or even a telling off. Nothing happened. Nothing changed. She had died, and all we were left with was the hollow ruling that mental health services had caused her death, but had suffered no consequences.

I know those individual staff who tormented her. I have met them. Argued with them. Some of them have been in my house, spewing their bile at me and my family. Their names and faces didn't make it into the papers. They didn't have their lives and bodies dissected. No-one associates their names with suicide. No-one outside of their own team will ever know they were involved. They do not have a stack of old missing person posters in their car that they don’t know what to do with. They are not left replaying the image of a tiny coffin being lifted out of the back of a hearse. They didn’t bury their faces into the wooden benches at her inquest, so the coroner couldn’t see their tears. They didn’t even come. I wonder if they ever gave her another thought.

I know my friend had wanted so badly for the truth to be known. She had wanted to set the record straight. She had wanted honesty. She had wanted mental health services to finally admit they were wrong. I believe that the final official record of her care reflecting that truth is a kind of justice, because that's all I really have to hold on to.. but it's not enough, and I don’t think we should accept it. Ultimately, justice will not be found in the coroner's court, because by then it's too late. I believe inquests are necessary, but I also believe that people shouldn't have to die and face the indignity of an inquest - in which their secrets and personal lives are openly shared with the public - before they are finally believed. Before the failures in their care are finally seen. Before it is finally acknowledged they are human. My friend had not been quiet about the harm she was experiencing when she was alive. Why was she only heard once she was dead? Mental health services had the power and the time to make changes when she was alive. They could have helped her to live, but in the end, they chose not to. Promising to make changes at her inquest was too late. It was like they were mocking us, mocking her.

Our friends, our family, our peers, ourselves.. we are worth more than the ruling of an inquest. We deserve more than a line of text which attributes some responsibility for our death to the services commissioned to help keep us alive. While inquests are technically open to the public, without the press there to report on the findings, or a Regulation 28 Report produced by the coroner describing actions services should take, what was said within those walls is lost. Most inquests do not even find fault with mental health services. Most people do not have a Regulation 28 Report issued. For the majority of us, all we might expect is that the coroner points out the lack of a care plan, or a missed opportunity to offer support, but ultimately lays no responsibility at anyone’s feet, demands no changes be made. That is not justice, and the fact that so many of us think it is, shows the extent of the disempowerment, humiliation, and dehumanisation we have faced from mental health services over the years.

For many of our community who have died, their inquest has been the only forum they have ever had for truth, yet so frequently, it barely scratches the surface. Staff sit in the witness box, coating the courtroom in lies as they wriggle out of taking responsibility. Clinical notes go missing or are unlawfully doctored. Narratives are twisted, with blame placed on the dead person who cannot defend themselves. Healthcare myths, unrecognised as lies by the coroner, are used to justify and defend neglect. Nobody recalls anything. Nobody was aware of this information at the time. Everybody did their best. Trusts send in their top public speakers to talk nonsense about "learning" and "changes" and "taking things forward". But nothing ever really changes. They aren't sorry. We keep dying.

I remember hearing someone say once, “apologising at inquests is cheaper”, and that’s so true isn’t it. A quick apology and some recycled words about learning lessons is easier and cheaper than making the institutional changes required to keep us alive. “You contributed to your patient’s death” is not justice. Justice would be actual changes put in place before the person died. Justice would be our lives being valued over mental health service budgets, over managers’ and clinicians’ jobs, over their longing for power, over their reputations, over their pensions, over their desire to keep doing things the way they have always done them.. Justice would be these systems truly seeing us as people. People who not only have the right to life, but the right to have that life protected, the right to have that life valued. Justice would be the respect shown in admitting fault, without trying to defend, excuse, or justify. Justice would be not having to bury our friends and loved ones. Justice would be a family sitting down for dinner, with no empty chairs at the table. Justice would be the easing of this pain I have gripping my throat as I write this.

This week, I am thinking about my friend, and the other people in my life I have lost to suicide because of mental health service failures. Some of their inquests revealed truths; some hid them; some have yet to pass. The one thing I believe their inquests have in common is that they were and will all be unnecessary.. because the deaths they have and will rule upon were avoidable. We sit in a repeating cycle, where one person after the next after the next dies because of the same failings, the same stubborn refusal to change, the same personal inability to admit fault, the same lack of care for our lives. And so all I can think is, if inquests really are forums for justice, if change truly arises from them, why do the same failures keep occurring? Why aren’t services listening? Why do we keep dying?

It’s not good enough. We need something more. We deserve something more.


721 views1 comment

Recent Posts

See All

1 Comment

Apr 24, 2023

Brilliant post, I agree with everything that is said here. I don't understand why there is not more public outrage about the mistreatment of vulnerable mental health patients who are time after time neglected by mental health services. My sister died of cancer and actually there was negligence on the part of the Gp practise who failed to spot the symptoms or refer her. There was a court case and it was found that the notes had been altered, but it was found out. I know this is not mental health but it does go on widely in the NHS. I think there needs to be far more accountability and mistakes should be owned up to. It is the lies…

bottom of page