Page 12 - When Things Go Wrong

They may be deeply distressed and traumatised by the circumstances of the
death of a victim, or by their own experience as a survivor. A graphic example
was given to us of bereaved people being faced at an inquest into the death of
a loved one by a rear view of a phalanx of lawyers debating the applicability
of Article 2 of the European Convention on Human Rights (ECHR).

1.4 Yet the engagement of the justice system may provide hope: a means of getting
to the bottom of what happened and ultimately, achieving justice:

Whenever a major tragedy occurs it engulfs and overwhelms those caught
in the trauma of its aftermath. Ordinary people going about their
everyday routines are suddenly ‘survivors’ or ‘the bereaved’. The shock
of sudden death and the pain of survival are mind-numbing, debilitating…
The law, the investigations, the inquiries, seem to operate in another
world. As people struggle with bereavement and survival they assume that
the investigative and legal process work for them, rather than against;
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they put their trust in the law.

1.5 Too often this trust has been broken. Disaster survivors and those bereaved
have been let down by the justice system. Major inquests and inquiries have
taken far too long and have cost vast amounts of public money with little gain.

The erosion of public trust

Issue one: duplication and delay

1.6 Delays in achieving resolution can be attributed, in part, to separation between
proceedings able to determine liability and those, such as inquests and
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inquiries, prohibited from so doing.

1.7 The conventional approach has been that the adversarial process should
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precede an inquiry, so that criminal liability in particular can be established

5 Scraton, supra note 2, p. 176.
6 Coroners and Justice Act 2009, s. 10(2); Inquiries Act 2005, s. 2.
7 Cabinet Office Proprietary and Ethics Team, Inquiries Guidance: Guidance for Inquiry Chairs and
Sponsoring Departments (undated), p. 6. See Scraton, supra note 2, p. 195: “The naïve assumption is
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