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Blind justice

“Justice delayed is justice denied”: Inquests and the impact of systemic delays

Sophie Wells and Jess Smith, who work in the inquest team in our human rights department, discuss the impact of systemic delays to inquests.

Posted on 25 October 2022

The agony so eloquently described last week by the parents of 20-year-old Jessica Powell will have struck a chord with families up and down the country, including many of those that Leigh Day represents. Jessica died in August 2020 meaning hers is one of more than 1,300 inquests that have been open for more than two years. In news reports her parents say they have been told it will be at least another year before her Inquest can be held and describe the wait as “purgatory”.

Their words echo the feelings we hear expressed time and again by the families we support, many of whom have waited two or more years for the Inquest into their loved one’s death and some of whom have had to wait four or five years.

Inquest delays in context

While delays have no doubt been exacerbated by the pandemic, it is not the root cause of the current issues facing the coronial system and it cannot persistently be used as an excuse. Prior to the pandemic in 2020, there was already a substantial backlog of inquests. As long ago as August 2010, the Director of the charity INQUEST called for delays in the inquest system to be addressed noting, “One of the biggest problems with the delay in the system is lessons aren’t being learnt and… families can wait for years for an inquest.” 12 years later, the situation is worse than ever.
According to Ministry of Justice figures:
  • the number of inquests open for more than two years has more than tripled in England and Wales since 2017;
  • in 2017, 378 inquests had been open for more than two years, representing about 4% of the total number open. By 2021, that figure has risen to 1,366 inquests - or about 8% of the inquests opened.
It is worth noting that the delays are not the fault of individual coroners or their staff who, in our experience, work incredibly hard with very limited resources. Nor, we would suggest, are they the fault of the local authorities responsible for funding the coronial system; they have faced a 37% cut in real-terms funding from central government since 2009/10. 

It is vital that the Government urgently make additional funding available to bring the backlog of inquests under control, given that delays to inquests have a huge impact on families, create a serious risk of injustice and may result in opportunities being missed to learn lessons and take timely action to prevent avoidable deaths.

Impact on bereaved families

Inquests provide a unique opportunity for bereaved families to have their concerns heard and questions answered in a public forum. However, participating in the proceedings can be emotionally draining and take a significant toll on family members’ physical and mental health.

Long waits can compound the distress of bereaved families; it can be agonising to face persistent delays and setbacks, especially when already struggling with the unimaginable horror of losing a loved one. Many families are unable to find closure whilst the Inquest hangs over them.

Anxiety for witnesses

In many of the inquests in which Leigh Day acts for bereaved families the deceased was in the care of the State, whether in hospital, prison or immigration detention. As a result, front line workers including nurses, doctors, care home staff and prison officers are often called upon to give evidence in those inquests.

Many of these witnesses will have had strong relationships with the deceased and the death may well have been a traumatic event for them too. They will also experience anxiety from protracted inquests.

Loss of Evidence

There are significant risks to the reliability of witness evidence when inquests are delayed. This is not a criticism of the witnesses, but it is inevitable that as time goes on memories fade.

There is also the real possibility that witnesses may move on from the role they previously had at the time of the death. We have experience of public bodies losing track of key witnesses due to their retiring or moving abroad in the period between a death and the final hearing meaning they cannot be called to give crucial evidence.

Delay in Prevention of Future Deaths reports

Coroners have a duty to make “Prevention of Future Deaths” reports where they believe action should be taken to prevent future deaths. The purpose of these reports is not to shame the organisations to whom they are directed but to ensure that changes are made to avoid unnecessary further tragedies. One of the great frustrations for families desperate to see some good come out of their loved one’s death is when they learn of a similar death (or in some cases deaths) occurring at the institution charged with their loved one’s care. These frustrations are all the greater when families feel, with justification, that a prompt inquest would have enabled lessons to be learned in time to prevent these further deaths.

Concluding thoughts

The grave issues in the justice system due to chronic underfunding have rightly received significant attention of late and it is vital that a spotlight continues to shine on them, particularly on the coronial system given that a delay in inquests is not just a denial of justice to bereaved families, but also risks opportunities being missed to save lives.
Sophie Wells
Court of Protection Human rights Inquests Judicial review

Sophie Wells

Sophie Wells is a senior associate solicitor in the human rights department.

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Court of Protection Inquests

Jessica Smith

Jess is a paralegal in the human rights department

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