Page 57 - When Things Go Wrong

the investigation. 152 The organisation should be independent from the
circumstances of the death.

3.30 Furthermore, we have been told that families are not uniformly given reasons
where a decision is taken not to investigate, and so are left unsure as to whether
to challenge a decision. We recommend that where a coroner decides that an
investigation should be discontinued, the coroner’s office should ensure
that the next of kin or personal representative are always informed of the
reasons for the decision within seven days.

Communication about the procedure

3.31 The importance of proper communication has been a constant throughout our
evidence gathering. Families consistently speak to the experience of being
unaware of the procedural steps ahead, their rights in the process and in
particular the possibility of seeking specialist legal representation.

3.32 The issue of insufficient communication pervades the different forms of
investigation and inquiry. In respect of death in custody cases, Dame Elish
Angiolini found that “the sense of frustration and anger at being left completely
out of the picture in the first days and weeks of the investigation was evident
from the many families I met during the review”, recommending that
consequently, “all agencies need to look urgently individually and collectively
at their internal processes for disseminating information to bereaved families
in these cases”. 153 Participants in the Grenfell Family Consultation Day
convened by INQUEST “felt there was no systematic plan for communicating
to families when the Public Inquiry would start, its terms of reference and how
families could engage with it”. 154

152 INQUEST has previously recommended that the Official Solicitor be recognised as an interested
person in this category of cases.
153 Angiolini, supra note 15, para 15.9.

154 INQUEST, ‘Family reflections on Grenfell: No voice left unheard (INQUEST report of the Grenfell
Family Consultation Day)’, May 2019, p. 6.
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