Bereavement due to suicide
The inquest after a suicide
If suicide is suspected in England and Wales there is always a public investigation called an inquest into the death. Anyone can attend an inquest hearing.
At the end of an inquest hearing the coroner (or the jury in some cases) can give one of many verdicts, including death by natural causes, accident, suicide, unlawful or lawful killing, industrial disease, or an 'open' or 'narrative' verdict.
To give a verdict of suicide, the coroner must be satisfied that the deceased did the act which ended their life and intended by that act that their life would end. This verdict must be proved ‘beyond all reasonable doubt’.
The coroner may return an ‘open verdict’ to reflect that there is insufficient evidence to support any other verdict available (also see ‘Reactions to the verdict’).
A narrative verdict can also be determined, which is a longer, more descriptive statement describing the circumstances of death.
The system for investigating a death by suicide is different in Scotland. In Scotland, a procurator fiscal (a lawyer working for Scotland’s persecution service) has a duty to investigate all unexplained deaths. The Procurator Fiscal (PF) is broadly equivalent to the coroner in other legal systems.
Once the PF has all the necessary information, they send a report to the headquarters of The Crown Office and Procurator Fiscal Service (COPFS). In most cases, it stops there. However, in some cases, a Fatal Accident Inquiry (FAI) is held to investigate the circumstances of the death.
An FAI is only held when issues of public concern or safety arise from the circumstances of death. For more information, see Scottish Action for Mental Health (SAMH), ‘After a suicide’ (‘Resources and Information’).
Some of the people we talked to in England were aware of the Scottish system and suggested that it was better because it was 'less intrusive and less traumatic' for the family involved.
The purpose of the inquest, or the FAI in Scotland, is to assess the circumstances surrounding the death and to identify any issues of public concern or safety. The court will identify whether anything might be done to help avoid similar deaths in future. The court does not assign (apportion) blame for the death or make any findings of fault at the inquest or FAI.
People may have to wait many months for the inquest hearing or FAI. Some people we talked to found the long wait time difficult and felt that their lives were 'on hold' while the inquest process was 'hanging over' them. However, the delay can also be quite helpful for people to take time to manage other things and come to terms with what has happened.
Lucy found it hard to make decisions while she was waiting for the inquest hearing. The hearing made her re-live the events and felt like a “second bereavement”.
Lucy found it hard to make decisions while she was waiting for the inquest hearing. The hearing made her re-live the events and felt like a “second bereavement”.
Because this is going to change the whole way you look at life in the future. And you’ll be trundling along and everything’ll be fine and then suddenly something will happen, whether you’re having a bad day or whatever it is, and you’ll be sobs of tears or …
Hmm.
… the loneliness will just hit from, from nowhere. And just as you think that you’ve got back on your feet again, wham, they’re going, you get a letter to say the inquest is going to be on such and such a date and then you’ve got to relive it all over again. I think it takes some doing. Once you think you’re over it, you, you’ve got like two, in a way, two bereavements, because you’ve got the first one which is normal to everyone who has a bereavement where you’ve got the funeral and and the burial or whatever. But then you’ve got to relive it all again for the inquest.
Hmm.
Where it’s, you, you just think you’re doing OK and then it’s all put you back to square one again. And then you start again. But I did find that it, decisions, I was putting decisions off. We were in a rented flat and I had to make the decision was I going to stay in the flat, was I going to buy somewhere to live or; I needed a holiday and friends were saying, “Oh come and stay with us.” So, …
Hmm.
... but I was putting everything off until the inquest. “Oh I can’t do anything because the inquest hasn’t happened.” “Oh I’m waiting until after the inquest.” And so every decision, I was using that as an excuse to put off making any decisions.
Waiting nine months for the inquest gave Helen time to be calmer and to prepare for what she wanted to say about her daughter’s death.
Waiting nine months for the inquest gave Helen time to be calmer and to prepare for what she wanted to say about her daughter’s death.
Do you want to say anything about the inquest, and what happened after that? So you had the funeral and then you had to wait, how long did you have to wait after that?
We had to wait until the following May, so she died at the end of August.
That’s a long time.
Yes. And I had to wait until the following May, but again it gave me time to know what I wanted to say, it gave me time that I wasn’t in such a state really that I could be calmer, to go, and it was very important to me that I went and said my piece. So I stood up and I, I said exactly what I felt about everything, and how Charlotte had been found, and it was an open verdict because there were several reasons why they couldn’t say that it was suicide' because she hadn’t left a note; and there wasn’t enough heroin left in the syringe to know if it had been pure, too pure heroin, and the level in her body was enough as an over dose that she would have died fairly quickly. But they didn’t know whether she’d done that on purpose, or whether it was because it was a bad batch of heroin.
What do you think?
I personally am 95% sure that it was suicide. I, I do understand that there’s a possibility that it wasn’t, that maybe it was, there was pure heroin, and there had been a few people the week before Charlotte in her area, that had become unconscious and taken to hospital because there was a bad batch around, so it is possible, but given that she’d tried the week before, and the week before, and that she’d wrapped her phone up, she’d taken the plug out the wall and wrapped her phone up. And I, I, I personally, and there was alcohol on her bed that had been unopened, which she always did when she took an overdose. I, I personally think that she knew exactly what she was doing.
Not all those we talked to had attended an inquest or FAI. One woman was still waiting for her husband’s inquest: he had died 3 months previously, and she had been told that she would probably have to wait another 6 months for the hearing.
Others had decided not to attend the inquest or FAI. Since the coroner decides who must attend the hearing, family members can only decide not to attend if the coroner has first said that they need not do so.
Two people in Scotland who we had spoken with had been told that a FAI was not needed, and one woman was waiting to see if an inquiry would take place. However, most people we talked to had been to an inquest hearing, and they recalled what had happened and discussed the roles of the coroner’s officer and the coroner.
The coroner’s officer or coroner’s investigation officer gathers information and should maintain close links with the bereaved family; they should explain the timescales involved, describe the layout of the court and explain what will happen throughout the whole process, including what that process involves and what happens at the hearing itself.
Some people said that the coroner’s officer had prepared them for what might happen at the hearing, but others felt unprepared, did not understand the officer’s role, or were uncertain about what questions to ask.
The coroner’s officer was “wonderful”. He dealt with Marion and her young child very professionally. He answered all her questions and was available when she needed help.
The coroner’s officer was “wonderful”. He dealt with Marion and her young child very professionally. He answered all her questions and was available when she needed help.
I’d really like to know about the Coroner’s Officers, what their role is and what they do.
He [the coroner’s officer] was amazing. His role was basically to tell me what was going to happen. In a normal death, you as next of kin have the Death Certificate. You register the death. Well of course you can’t register a suicide death until the Coroner has pronounced that it was suicide and then he registers it. You don’t. So that is something that’s taken from you. It’s a, it’s a dubious privilege but it’s something else that’s taken from you. It’s his duty to liaise with you and the police about anything that happens. He needs to know about police interviews and statements that they take.
The Coroner’s Officer does?
Yes. And then it’s all presented to the Coroner at the inquest. And he, he needed at various times to get things clear in his own mind. It was, it was all a bit shady. I don’t know why but the police didn’t seem to understand that I had last seen him [her husband] on the Wednesday and he’d actually been found on the Thursday but he was still alive but he died. So that was suspicious because. It was all very difficult and he [the coroner’s officer] was absolutely amazing. I have heard people who’ve said, oh their Coroner’s Officer weren’t but he really was. He should have a medal. He was fantastic.
What was special about the way he looked after you and treated you?
His care of my youngest when we went to see him [her husband’s body] to start with. He was wonderful in that. The depth of his understanding of a newly widowed woman with a fairly young child with very strong emotions going on all round and he, he dealt with it professionally but so carefully. He was lovely. Whenever he phoned me, and sometimes it was two or three times a day, sometimes not for a couple of days, he would say, good afternoon, and he always used my name, always. Sometimes my Christian name but usually Mrs…. He would then tell me his name and who he was so that I knew who I was talking to. His, his depth of experience he obviously realised that people in my state didn’t have a clue what they were doing and just functioned on autopilot. Anything that happened happened. So he would always say good afternoon, tell me who he was, tell me what his job was so I knew who, that he was him and then he’d say, “You may remember that when I phoned you on, whatever day, I had to ask you X, Y and Z. I’m sorry to disturb you now. I know how difficult this is but I do just need to ask A, B and C”. The next time he phoned he would recap on both those things and then ask me what else he wanted to know. I think the most important thing was I knew he was there. I knew who he was. The police were anonymous.
Could you phone him if you had a query?
Yes, absolutely yes. The police were much less helpful, much less sensitive. And we, trying to get things like my rent card and the electricity payment card and things I rang our local police station and asked for the constable whose name I had been given. He wasn’t there. His colleague would deal with it but he wasn’t there either and when they came back they’d ring me. They didn’t. I phoned again. I got passed all around the police station and ended up with the desk sergeant who said, ‘I’m sorry I don’t know anything about it’. You know and I really needed to talk to one person who could solve this problem for me. I needed people to solve things because I couldn’t do them myself. Normally I’m quite a managing sort of person but I couldn’t do it.
No, so the Coroner’s Officer was really good
He was very, very good, yes, yes.
The coroner’s officer made insensitive comments when he spoke to Steve on the phone about his sister. Steve did not meet him and the family did not find him helpful.
The coroner’s officer made insensitive comments when he spoke to Steve on the phone about his sister. Steve did not meet him and the family did not find him helpful.
And also on the Monday we had a phone call from the Coroner’s Officer. Obviously they want, gathering evidence as well. I have to say that my experience of this particular Coroner’s Officer wasn’t that great because his initial, the way that he opened the conversation was, “I’ve been doing this job X amount of years and this is the third worst I’ve seen.” And I said, “Well that’s very nice of you to share that with me. Please do not say that to my parents.” But he did. So quite an insensitive person really.
What did he mean?
It was the, the worst. He said he’d seen my sister’s remains and, and the state of her remains were the third worst. There were two others that had been worse that he’d seen. Which is a terrible way to, to introduce yourself to a bereaved family under such tragic circumstances. And immediately I had no respect for this man at all. And then he went on to say it to my parents as his way of introducing himself to them as well. Consequently, I mean I’d never met this man up until the date of my sister’s inquest and he; I’d already built up a mental picture of how I expected this man to appear and how I expected him to behave and I was right.
Did he ask you for a statement at all?
I actually did write a statement but I don’t know if it was him that asked me for it or the Coroner himself because I had a letter from the Coroner and I think it was the Coroner himself who asked me to write a statement of what, about my sister’s life and any health problems or, or any other. He wanted a whole picture of her really. So I did that. It took me quite a while to do it because I didn’t feel like it initially. It’s as simple as that. I was, I was deeply hurt and grieving and shocked and I just left it for a little while. But it, it took me a while to do it when I did get around to writing it.
And the Coroner’s Officer, what role did he play with your parents? Did he again ask them for statements?
No. We never met him at all. It was just a phone call to say I am, this is my name and I will be the Coroner’s Officer. And that was all, all the involvement he had really. There was, there was nothing. We never met him. I mean I spoke to him perhaps on a handful of occasions on the phone but it was usually only when I wanted answers to questions that I would contact him. He didn’t really contact us. I don’t quite understand the role of this Coroner’s Officer. There was, he was certainly no help to us as a bereaved family.
Did he tell you what was going to happen at the inquest?
No.
So no preparation for the inquest?
No not really. The inquest was quite a while after the death anyway. And fortunately I’d been in contact with the Coroner by E-mail and any questions that I had I put to the Coroner directly himself. Because I didn’t want to deal with this, this cold person really, he had, I’d got no respect for.
People also talked about the coroner and their role in the inquest. Some said the coroner had treated them with kindness and understanding and had phoned them or made contact by email before the inquest.
Others thought that the coroner had been 'cold' and had 'lacked humanity, or said that the court atmosphere was 'intimidating' or ‘Dickensian’. Although many people found the formal court environment daunting, some described the time leading up to the inquest as more stressful than the event itself.
Amanda and her husband felt that the coroner had dealt with them kindly. They found out afterwards that they could have a transcript of the inquest hearing.
Amanda and her husband felt that the coroner had dealt with them kindly. They found out afterwards that they could have a transcript of the inquest hearing.
The coroner may decide that a public hearing is not necessary. They may look at written statements from people involved, such as doctors, pathologists, and family and friends, and then come to a verdict. This finding may be called a ‘chamber’s finding’, a ‘documentary’ inquest or a ‘paper’ inquest. Melanie experienced what she called a ‘documentary’ inquest after her husband died (see Melanie's interview, Interview 21, above).
Most people said that witnesses had been asked to give evidence in court. Some people had been asked to take to the witness stand themselves.
Brenda said that, had she known ahead of time that she was going to give evidence, she would have been terrified. However, when she was asked to talk about her son and explain what had happened, she was 'surprisingly calm'. She said that talking openly about her son helped her in her grief.
Taking the witness stand can be traumatic. Susan said she was quite shocked when she had to take the witness stand because, having seen the interim death certificate, she thought that the cause of death had already been established.
Typically, when there is an inquest, the coroner will issue an interim death certificate when the inquest is opened. An interim death certificate is necessary to enable the body to be released for a funeral to be held and for the administrative procedures that follow a death (see ‘Practical matters’).
The coroner registers the death after the inquest hearing is complete and issues the final death certificate, which then becomes available from the Registrar.
Susan had to give evidence at her daughter’s inquest hearing. It was an extremely unpleasant ordeal. Other witnesses were called too.
Susan had to give evidence at her daughter’s inquest hearing. It was an extremely unpleasant ordeal. Other witnesses were called too.
The inquest was extremely unpleasant. But I and I had thought it was going to be quite a sympathetic affair because it was so obvious what had happened. But of course I realised that it wasn’t.
When was the inquest?
February, the following February.
Hmm.
Which I had thought was a long time but apparently a short time. But again, I mean a cause of death had to be established. Did I shoot her or did she shoot herself? But it was pretty tough. But of course I suppose naively I thought well they know she committed suicide so why are they being so hard on me.
So did you have to take the stand?
Oh yeah totally .. totally … for the whole of the inquest. I mean even when I’d given evidence, which went on for a very long time. Other witnesses were then brought up.
I thought … you see well know I say this as I have said again maybe I misinterpreted the whole thing. Maybe they were genuinely trying to find the cause of death which I thought … since her death certificate and everything said that she had taken her own life. I didn’t see the need to put me through the mill to the extent that they did, if the cause of death I thought had already been established. I think it certainly needs to be; the whole system needs to be more victim sensitive. I mean it’s, it’s very cold. It’s very austere. You sit in serried ranks. And then you know I was shaking so much I couldn’t walk and yet I was told to stand.
So what would you recommend in future, would you recommend people were prepared properly for what was going to happen?
Much, much better yes … yes I think, I think especially in a very sensitive situation like this when you’re … the family is so traumatised, that actually you ought have a pre-session. This is where you will sit. This is, this is how it’s going to be. You’ll have a chance to speak if you want to. Is there anything you particularly want … is there you know… what would help? As opposed to the feeling, and I have checked with my husband several times, was I making a meal out ... a mountain out of it. And he said, “Absolutely not, it was appalling.”
So none of that information was given to you, you didn’t meet the coroner’s officer first or anything?
No, no, no … no. No. And I think also there shouldn’t be a strange little man in the corner who keeps looking at you like this and scribbling your evidence down. It should be done in a much more modern and subtle way. It can be recorded. But no it needs to be brought into the 21st century; it was like something out of Dickens.
Lucreta had to answer questions at the inquest hearing for her 18 year old daughter. Although the verdict was suicide she felt accused and said it had been an awful experience.
Lucreta had to answer questions at the inquest hearing for her 18 year old daughter. Although the verdict was suicide she felt accused and said it had been an awful experience.
…and then the coroner’s court, Oh, the coroner’s court that was awful. The police got all these witnesses, Dionne told all these untrue stories, she probably was not well or, you know and the police had to investigate these things, and these issues so they were trying, the child protection act was trying to get away from the main suicide thing, and sort of blaming the family. And you’re blaming, you’re going through all of this and then you have this court thing, I mean a real case, so anyway, my friends were at the court and my family and they comforted me and I answered the questions and that was finished.
Why did you think somebody was trying to blame you at the inquest?
Because, because Dionne, Dionne would’ve said, well Dionne probably said that I don’t know, she probably would’ve said unkind things.
About the family?
You know, about the family, you know children if, when they can’t have their own way they pick on, pick, pick, you know, and so, you know, and as I said our marriage was in, wasn’t a good one.
So the inquest was not good?
It wasn’t a good thing, but they didn’t find any, when they investigated whatever they were looking for, and I think if she was an adult they wouldn’t have, but because you know they just, because she’s a child they just have to investigate everything.
Did they have a jury?
No, it was one of the high court, he’s not there anymore. I can’t say his name.
It was a coroner’s court?
Yes a coroners’ court to find out the deaths and you know and because she jumped didn’t she? She jumped.
Was the verdict suicide? Or was it an open verdict?
No, suicide. Or she took her own life. Yeah, that’s what they…
So were you prepared for the inquest in any way?
No. Er no, I wasn’t prepared for what her friends would say, ‘cos whatever she told her friends you know, I wasn’t prepared for that aspect ‘cos you’re grieving.
Yes.
‘Cos you’ve lost your daughter, and I had to grieve for my son, it’s like everybody blames me for everything and some friends, who I thought were my friends, they blamed me and everybody blames mother. Isn’t it hard, and all you’ve done, you’re a young woman and you give birth and too, and you, it’s a learning, it’s a learning thing for everyone. And I set out to be different with my son, but he said to me, “What’s wrong with you, you’re fine the way you are.”
Mm. Did, was there a coroner’s officer who helped you at all, to tell you what was going to happen on that day?
I can’t remember. I can’t remember but he was, I can’t say his name the coroner, he was one of the high profile one’s, he’s retired now, but he didn’t find anything. He just dismissed it, all just so you know, you know what it really is, so that ended there.
An inquest hearing may be traumatic and distressing, and it may be a good idea to take a friend or relative along for support. Amanda took her sister with her and arranged to have a psychotherapy session immediately after the hearing.
Sometimes barristers and a jury are involved in the inquest process. The hearing may go on for days or even weeks.
At the inquest Lucy learnt that her partner had been spotted around the railway line several times before he died there. He appeared to have planned his death.
At the inquest Lucy learnt that her partner had been spotted around the railway line several times before he died there. He appeared to have planned his death.
Would you like to say a little bit more about the inquest?
Well it was, the inquest itself wasn’t, wasn’t that difficult because it was just, followed an event. You went into this room and the jury were sworn in and the coroner explained what was going to happen. The witnesses were lined up, or sat down in, in order. The statements were read out and we had to just nod and acknowledge the statements, that they were true when they were being read out. There was then a summing up of all the information that had been given, and the jury then went off to make their recommendations and, and come up with a verdict. It was, when, when you say inquest it, it sounds like it’s quite a daunting thing. But it was really just a big room with one side had the jury on it, one side had the witnesses on it and at the end were supporting friends and family ,someone from the railway, and someone from the press. But we, at no time were we forced to speak.
It was amazing the information that came out. We think we just get on with our lives and nobody notices us.
Hm.
But through the inquest, they were able to trace Darrell’s movements for the, the week before he died. And there was sightings and of him down by the railway line and watching trains. And it was amazing how much information that people do find out about you, if they, if they need or if they’re asked. So in a way, it helped me to know that it wasn’t just an instant thing. He, he didn’t just go off and do this by accident. He had it planned.
Hmm. Would you, would you have preferred it to have had a conclusion that was, that it was an open verdict to an accident or …?
No, I wanted the suicide.
Can you explain why? Was it that important?
Because an open verdict meant that nobody’d decided, it was just a bit airy-fairy what had happened. Finding the note from Darrell saying that he’d come to the end and he couldn’t see another way out to me just meant that he’d planned this and that it had to be suicide. And for it to come out on the verdict from the inquest to be anything less that that would have meant that the letter that he’d left and, and the planning that he’d done, although it’s not how we, we want to see him end his life but it would like, everything would have been a lie. For me I wanted that end, to know, yeah, this is, this confirmed what we’ve all thought from what we’ve found out since, after he died with where he’d been down on the railway line and how he’d, how he’d lived his life right up to the end and the note that he’d left. It all added up to suicide and for it to be an accidental or open verdict, it’s not like it’s a badge of honour but it was like a, a proper fitting answer to the inquest. Well for me personally anyway.
That verdict, everything added up to that verdict …
Yes.
… from you point of view.
Yeah, I couldn’t see how it could be anything else.
No.
And it, because it came out of, as a suicide in, in the inquest it sort of like finished everything off of, rather than having another thought to, “Why’s it this? Why is it that?”
Hmm.
It sort of all matched up to that and I couldn’t really see there would be another option for it to be other than suicide.
Any death which occurs in custody or in prison will always be referred to a coroner and there will always be an inquest hearing with a jury sitting in these cases.
Useful information about the inquest process is available from INQUEST. INQUEST provides independent, free legal and practical advice about the inquest process for people who have been bereaved. For more information, see INQUEST’s resources in ‘Resources and Information’.
If you or someone else is in immediate danger, call 999 or attend A&E right away. If you or someone else needs urgent help for mental health, call 111 or access NHS 111 online at 111.nhs.uk for help.
If you or someone you know is struggling, help and support are available. See NHS mental health and 'Resources and Information' for more, including help and resources for people bereaved by suicide.
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