I have been sitting in courtrooms for almost 40 years. I’ve reported on terrorism trials, semi-secret trials, murder trials, dramatic miscarriage of justice appeals. Mostly they are a hard place to be, but the harshness is tempered by the redemptive outcome of justice being done.
There are courtrooms, however, where the sense of wrongs being righted is missing: the coroner’s courts where, in England and Wales, inquests are held every day into deaths that the state deems require further investigation.
It was in a coroner’s court last year, at the inquest into the
death of my 27-year-old daughter Maeve, that the most dispiriting words I’ve heard in a courtroom were spoken. The coroner, Deborah Archer, said she was going to write a prevention of future deaths (PFD) report, highlighting to the NHS and other agencies areas of concern. Then she added: “I write a lot of these reports, and often nothing happens.”
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My daughter died of ME. I had to fight the NHS for answers
Maeve died after suffering for half her life with myalgic encephalomyelitis (ME), a post-viral condition that is not well understood, inadequately researched and which doctors often refuses to recognise or treat.
My first aim was to use the media to highlight
what happened to Maeve and raise awareness of the plight of the hundreds of thousands of people whose lives are limited by ME and similar conditions. My second was to convince the coroner to write a PFD report and point out areas in healthcare, medical research, education and training where action could be taken that might prevent further such deaths.
The written responses to Archer’s PFD report have been underwhelming. The public health minister, (the recently resigned) Andrew Gwynne, promised an NHS delivery plan. NHS England said it would do a “stocktake” of ME services, even though there had been evidence at the inquest that such services are scarce, and in the cases of severely ill patients, “non-existent”. The Medical Research Council said it “recognises the unmet clinical need for better diagnosis and treatments for people living with ME” but defended its record to date.
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Failure to act on coroners’ advice blamed for thousands of deaths
The responses felt empty. I take some comfort from the messages I’ve received that awareness of ME and its cruel realities has been heightened. But the inquest in Maeve’s case dragged on for three years. It left me with a bitter aftertaste of injustice and the conclusion that the system is antiquated, almost completely broken and possibly futile.
There are about 400 coroners in England and Wales sitting in 75 districts. There is a chief coroner but the role is advisory. The incumbent has “very limited” experience of sitting as a coroner. The courts are funded by cash-strapped councils that might have little idea what coroners do.
Coroners are appointed by the judiciary and can sit until they are 75; when I checked a few months ago, three were appointed in the 1970s. Barristers are a common sight in coroners’ courts, usually representing NHS trusts or police or prisons or other public bodies. Their fees are met from the public purse. But bereaved families get legal aid only for representation in “exceptional cases”. Most flounder in a system not designed to give them justice or answers.
In 2023 there were more than 1,600 inquests that had been open for more than two years; often these are the most difficult cases, yet bereaved families face being repeatedly traumatised by every preliminary hearing and legal letter.
As in Maeve’s case, the best hope for a family is that a PFD report points the way to reform. A coroner is not allowed to recommend, only suggest. Yet only rarely are these reports written. The Preventable Deaths Tracker, an initiative by Dr Georgia Richards at King’s College London, records an average of 426 reports per year compared with the roughly 36,000 inquests that take place.
Those coroners who do write reports often find their suggestions ignored. Just under 40 per cent of the 5,532 PFD reports published since 2013 have received no responses. There is no other section of the legal system in greater need of reform. There should be a national coronial service, more PFD reports should be written and lessons should be disseminated. What is the point of investigating avoidable deaths — of making bereaved families relive their trauma, of spending millions of public pounds — unless we are prepared to learn how to avoid similar fatal errors?
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