Advocating for compassion and better treatment: transforming the coroner’s inquest system for those bereaved by suicide

Ellie Hatto is the founder and voice of Beside Yourself CIC, a lived experience-led social enterprise focused on talking openly about life after suicide. This thought piece aims to amplify the voices of those who have lost a loved one to suicide, shining a light and raising awareness of their subpar experiences within the flawed coroner’s inquest system. Ellie urges individuals and organisations involved in shaping the system to reflect on how their actions or inaction adversely affect those bereaved.

Experiences of the bereaved in the inquest process

Having lost my own father to suicide a decade ago, and volunteering for a national suicide bereavement peer support charity since 2017 supporting many hundreds of people and my own healing, I have become intimately familiar with the heartbreak and lasting impact that suicide leaves behind.

When someone dies by suspected suicide, or any death which appears to be due to an unknown, violent or unnatural cause, the case is handed over to the coroner to investigate key facts of the death, relating to the who, where, when and how, through a formal inquest process. While I won’t delve into the intricacies of this system, my focus lies on the invaluable real-life experiences of those thrust into the inquest process, often unexpectedly.

Photo credit: Jurien Huggins on Unsplash

There were 208,400 deaths reported to coroners in 2022, the highest level since 2019 – up 7% compared to 2021 (Coroners Statistics Annual 2022, England and Wales). Based on feedback from the suicide bereaved community I support, the system has been plagued by delays since the Covid pandemic.

For many people bereaved by suicide, including myself, the inquest is often considered a significant milestone in the suicide bereavement experience, regularly accompanied by intense feelings of apprehension, anticipation and expectation.

Neglectful treatment, interrogations, last-minute cancellations with no explanation – these are not fictional or isolated scenarios, but a small selection of examples of the real-life experiences of people I support.

Picture a bereaved parent being questioned (or in their words, interrogated) by a coroner at their adult child’s inquest, burdened by questions about why they didn’t do more to save their child, the weight of guilt and sadness growing with every question for half an hour.

The same parent having to explain under oath a discrepancy over one word they uttered in a police statement during the chaotic, devastating minutes after discovering their child had taken their own life.

Consider the apprehension felt by another bereaved parent I know in the lead-up to their teenage child’s inquest, only for it to be cancelled, not once, but several times, at the last minute, sometimes by voicemail – often with little to no explanation. I learned only recently that they are still waiting for an inquest date, nearly three unbearable years after their child died.

Imagine investing weeks of emotional effort crafting a heartfelt statement (at the coroner’s invitation) about your loved one only for it to not be read out at the inquest after all as expected and hoped – a devastating, perhaps final, missed opportunity to honour and mark a life lived, loved, and now lost. It seems unfathomable but this is another real-life example from someone I support.

Some may argue that suicide bereavement is just like any other, but what sets it apart is its profound and unique impact. The already intense feelings of loss, sadness and loneliness after any death are magnified in the suicide bereaved. The added burden of trauma, guilt, confusion, rejection and shame can make the bereavement experience all the more difficult.

It is also crucial to recognise that those bereaved by suicide are reported as being 65% more likely to attempt suicide themselves compared to those who lose someone through other causes (University College London, 2016). This stark reality underlines the critical role of compassionate treatment, not only as a support measure but also as a vital protective factor in suicide prevention.

We aren’t talking small numbers here either. With around 6,000 people in the UK taking their own life each year, a 2022 study by the National Suicide Prevention Alliance estimated that 39,000 to 878,000 people are affected by each death, many of whom will become involved in the inquest process.

Call for change and recommendations

The emotional toll of sudden and unexpected death by suspected suicide therefore demands a level of sensitivity and consistency that the current inquest system often fails to provide.

The need for a revised and more compassionate approach by coroners is not just a plea; it is an urgent call for change. While it is true that some bereaved people navigate the process relatively smoothly, others face hurdles exacerbating their grief and stifling their ability to heal.

Photo credit: Jurien Dave Lowe on Unsplash

We must learn from coroners who handle this well, ensuring that the system actively supports the identified needs of families dealing with suicide bereavement.

Coroners should engage the bereaved, incorporating their valuable lived experiences to minimise distress and frustration.

Key changes involve providing consistent and clear information throughout the inquest process, adapting procedures ensuring privacy and offering bespoke suicide awareness training for coroner staff based on insights from those bereaved by suicide. Additionally, improved collaboration with partner organisations can prevent last-mintue cancellations of inquest hearings due to delayed evidence submissions.


I’d like to dedicate this thought piece to the people I continue to support as part of my work in suicide bereavement peer support, many of whom have told me that despite receiving subpar treatment during the inquest process, they are not strong enough emotionally to complain for fear of detrimental consequences.

I listen to their voices, advocate on their behalf, and believe that collectively, we unite to demand improved treatment from coroners for those bereaved by suicide; the club that no-one wanted to join.

About the author:

Ellie Hatto is the founder and voice of Beside Yourself CIC, a lived experience-led social enterprise talking and writing openly about human behaviour and personal experiences, with a focus on life after suicide to support those directly or indirectly impacted. She is a peer support group facilitator with national charity Survivors of Bereavement by Suicide, co-founder of Voices – People with Living Experience of Suicide (Hampshire) and non-executive director of Luna Foundation CIC. Ellie was a guest on the Mentally Yours podcast and wrote for Metro UK on the loss of her father to suicide and how she’s supporting others. Ellie is part of the Sounddelivery Media Spokesperson Network.

This blog was originally published on

Twitter/ X: &
LinkedIn: &

Don't miss out on our latest news

Sign up now