Families of domestic abuse victims who have died by suicide are criticizing coroners' courts in England for an unwillingness to consider how abuse can drive people to take their own lives. Grieving loved ones say it is not a "joined-up process" whether inquests into suicide deaths examine the treatment victims endured while alive.
Inconsistent Inquest Scopes
Individual coroners have the discretion to decide what evidence will be considered in an inquest. They may limit the scope to the days and weeks before a person's death or hear evidence from a much wider timeframe, including months or years of an abusive relationship. This inconsistency has been described as a "postcode lottery" by campaigners.
Helen Boniface, counsel at Hogan Lovells, said: "It's incredibly frustrating and feels like a postcode lottery based on where someone died – which cannot be correct." She noted that families have no easy route to challenge a coroner's decision, as judicial review is expensive, risky, and emotionally taxing.
Landmark Verdict and Ongoing Struggles
In September last year, a landmark verdict found that Georgia Barter had been unlawfully killed by her former partner after she took a fatal overdose following years of abuse. However, in other cases, families have battled coroners who refuse to consider evidence beyond the immediate period before death.
Pragna Patel from Project Resist said: "Half of the problems in terms of lack of access to justice for these bereaved families is to do with the fact that they have such inconsistent responses from coroners." She called for a more coordinated approach to ensure consistent treatment of domestic abuse cases.
Call for Systemic Change
Frank Mullane from Advocacy After Fatal Domestic Abuse (AAFDA) said that while some coroners handle cases well, "we regularly witness coroners limiting the examination of domestic abuse in the scope of inquests." He added that restricting the scope to the day of death reveals ignorance of the cumulative nature of domestic abuse and denies the inquest the chance to identify prevention opportunities.
A family of a woman who died after suffering abuse criticized the coronial system for failing to consider how domestic abuse contributed to her death. An independent safeguarding review identified a "problematic" and "potentially controlling and coercive" relationship, but the inquest focused only on the immediate circumstances of her death.
Need for Guidance
Boniface expressed surprise that there is no guidance from the chief coroner focused on investigating domestic abuse cases. She said: "This is not about removing the discretion of a coroner. Instead, it is recognizing that domestic abuse is a challenging area, and guidance would assist bereaved families, those facing allegations of abuse, and the coroners tasked by law with investigating these deaths."
