Page 58 - When Things Go Wrong

Immediate provision of information

3.33 It is crucial that at the earliest possible point following the initial report of a
death to the coroner, bereaved people are informed of the procedural steps
ahead and their rights (including the right to be properly represented). In order
to make informed decisions, families need information about access to their
loved one’s body; the post-mortem process (including the possibility of a non-
invasive post-mortem); and the possibility of the removal of body parts. It is
also essential that family members are informed from the outset about what to
expect at an inquest hearing: the roles of the legal professionals; the order of
proceedings; the process of giving evidence; and the courtroom layout.

3.34 Equally importantly, families need to know how to find relevant organisations
offering specialist advice and support about contentious deaths involving
investigations, inquests and inquiries and how these processes impact on
traumatic bereavement.

3.35 We recognise that the Ministry of Justice already publishes a ‘Guide to
Coroner Services for Bereaved People’. 155 We note that this Guide is clearly
written, provides information on rights at each procedural stage and lists
sources of support. We also recognise that despite the absence of a formal
response to Patronising Disposition, the most recent edition of the Guide has
incorporated suggestions made in that report, including information on the
possibility of a second post-mortem. 156

3.36 However, it is unclear how widely and consistently the Guide is disseminated.
We recommend that in cases where a coroner has taken the decision to begin
an investigation, provision of the Guide should if possible coincide with the
notification of next of kin or personal representative.

3.37 Further, the Guide understates the importance of legal representation in
complex cases:

155 Ministry of Justice, ‘Guide to Coroner Services for Bereaved People’, supra note 149.
156 Ibid, para 3.10. The Jones and Angiolini Reviews are mentioned specifically at Annex A. See Jones,
supra note 16, p. 70, Point of Learning 19.

51