Page 108 - When Things Go Wrong

VII. CONCLUSION AND RECOMMENDATIONS

What often goes unmentioned is the high price paid by bereaved families in remaining
involved in the lengthy, complicated investigation and inquest process. The emotional
and physical impact of state related deaths on generations of families should not be
forgotten, nor the way it is exacerbated by state denial and defensiveness, secrecy,
insensitivity, delays, funding problems and lack of accountability… When they
function at their best inquests are a vital way of exposing unsafe practise and shining
a spotlight on the state and its agents and holding them to account for abuses of
power, ill treatment and misconduct. In other words, inquests can save lives. Deborah
Coles, Executive Director, INQUEST. 305

7.1. JUSTICE asked us to convene this Working Party to address the erosion of
public trust in the response of the justice system to deaths giving rise to public
concern. These may occur either in incidents causing multiple fatalities, or
arising from a pattern of systemic failure. If it is to enjoy the confidence of the
public, the justice system must provide a response that is consistent, open,
timely, coherent and readily understandable.

7.2. As we have sought to demonstrate, it is clear that in many respects such
characteristics are manifestly lacking in the current arrangements. Our detailed
recommendations are directed at remedying such shortcomings by building on
the strengths of the present system of inquests and public inquiries. We think
that this set of proposals, if implemented, will provide a cohesive and cost-
effective system, with the prospect of a reduction in duplication and delay, and
which in turn should serve to increase public trust.

7.3. While we consider that our recommendations will improve processes for all
users of the system, our terms of reference committed us to prioritise the needs
and experiences of bereaved people and survivors. As Dame Elish Angiolini
has trenchantly observed, the State’s responsibility to these groups under
Article 2 ECHR is to ensure that they are involved in the investigation in a
meaningful way. Lip service is often paid to the importance of placing

305 Deborah Coles, Introduction to ‘INQUEST submission to Review of the Hillsborough Families’
Experiences by the Rt Rev Bishop James Jones’, April 2017, p. 3.

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