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The grieving family who say the Coroner’s Courts are not working

Sarah thought she knew what she was getting into when she attended a coroner’s court in May 2024 to discuss the death of her second cousin.

Her day job as a homicide detective meant she was used to courtrooms, to judges, to legal arguments. What she was not prepared for was a coroner’s court. “I felt like I was on trial,” she recalls of her first hearing, in Woking, Surrey. “I just remember feeling very railroaded…it [was] much more hostile than I ever expected.”

Her cousin, Daniel Lindsay, will die in 2023, aged 41. He lived in a home in Surrey which specializes in caring for people with learning disabilities. Daniel also had Down syndrome and type 1 diabetes.

As his death was unexpected, his case was referred to the coroner for an inquest.

What followed was one of the most stressful experiences of Sarah’s life. She discovers new details about how her cousin lived, and his cause of death. The family initially thought Daniel had died of a heart attack – but during the course of the investigation they learned that was wrong. She had expected the process to be emotional; what she didn’t anticipate was just how complex and frustrating it would be, sometimes leaving her resentful and angry.

Coroners investigate deaths that are not simple, such as unexpected or violent deaths, or those that take place in state custody. Every year, thousands of British families rely on these courts for crucial answers. For many, an investigation provides the key interaction with the arms of the state at a time of trauma.

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