Bereaved families expose Parliament’s failure to make inquests produce reform
Responding to Bereaved families tell MPs inquests are adversarial and lessons go unlearned, Prison News (10 Nov 2026)
Britain’s problem is not a shortage of findings but the absence of a reliable system that turns institutional failure into change.
Richard Caseby, Jonny Santer and Dr Kate Szymankiewicz told the House of Commons Justice Committee that inquests into their children’s deaths felt adversarial rather than like searches for the truth.1 They said lawyers for state bodies focused on avoiding blame instead of finding solutions.1
That is the central failure. A state can hold a hearing, produce a finding and issue a warning while leaving the conditions that caused the death intact. The public language of accountability then becomes a substitute for accountability itself.
The families described late papers, hearing dates and times changed at short notice, and wide differences between coroners.1 Some coroners pursued issues after a hearing; others simply recorded findings and sent them out.1 Families also told MPs that Prevention of Future Deaths notices had made no difference.1
This is not an argument that every coroner should conduct an identical hearing. It is an argument for a dependable route from evidence to action. Parliament has already had the warning: the Justice Committee’s 2021 report called the lack of a system for following up Prevention of Future Deaths reports a “missed opportunity”.1 A follow-up inquiry began in 2023, and the committee later wrote to the Ministry of Justice about those reports and the poor use of coronial data.1
The scale of the implementation gap is visible even within this narrow process. Dr Georgia Richards said the Chief Coroner’s office now publishes lists of unanswered notices, but that changes intended to ease pressure on the office have delayed publication.1 That makes it harder to see who has responded and harder to learn from inquests.1
Complex reforms can take years. But delay must come with an owner, a timetable and a public account of what changed. Otherwise, Britain’s inquiries will continue to document institutional failure in detail while institutions learn that documentation is the end of the process—not the beginning of reform.
References (1)
- Prison News. Bereaved families tell MPs inquests are adversarial and lessons go unlearned. 10 Nov 2026. https://prisonnews.co.uk/families/bereaved-families-tell-mps-inquests-are-adversarial-and-lessons-go-unlearned/Context ↩
How to citeCenter for Policy & Stability, “Bereaved families expose Parliament’s failure to make inquests produce reform,” 11 November 2026, https://policystability.com/post/2026-11/bereaved-families-expose-parliaments-failure-to-make-inquests-produce-reform/
