Part 7: Attending a Coroner's Inquest: What I Wish I'd Known
Please note: This article shares my family's personal experience of attending a coroner's inquest in England. Every inquest is different, and the process and outcome will depend on the individual circumstances of each case.
If you've already read Grandma's story, you'll know why our family found ourselves attending a coroner's inquest. This isn't an article about why we were there. It's about what the day was actually like and what I wish I'd known beforehand.
Writing My Statement for the Coroner
One of the hardest parts of the whole process wasn't attending the inquest. It was writing my statement.
The coroner asked our family to provide statements explaining what had happened from our perspective. We each wrote our own.
When I first sat down to write mine, I couldn't do it.
Every sentence came out filled with frustration, anger and questions I still didn't have the answers to. I wanted someone to explain why we had lost Grandma. I wanted someone to be accountable for the things I felt had gone wrong. Looking back, that was part of my grief.
Eventually, I realised that if I wanted my statement to help the coroner understand what had happened, I had to approach it differently.
So I did something that felt completely unnatural at the time - I put my emotions to one side and, in many ways, put my HR hat on. Instead of writing what I felt, I wrote what I knew. I focused on dates, conversations, events and facts. I removed assumptions. I removed emotion. I simply explained, as clearly as I could, what our family had experienced.
It wasn't easy. In fact, it was probably one of the hardest things I've ever written.
On the day of the inquest, the coroner chose to read my statement aloud.
I wasn't expecting that.
As difficult as it was to hear, it reminded me why accuracy matters. My statement wasn't there to assign blame or tell people how I felt. It was there to help establish the facts.
That doesn't mean the emotions disappeared. They were still there, and they still are. But there was a time and place for them, and the statement wasn't it.
If you're ever asked to write a statement for a coroner, my advice would be this: write your first draft exactly as you feel, then put it away. Come back later and write a second version based on the facts. Both versions are valid but only one is likely to help the investigation.
It's okay to be angry. It's okay to be heartbroken. But it's also okay to let the facts speak for themselves.
Receiving the Date
The first date we were given didn't go ahead because the care home hadn't provided the information the coroner had requested.
When the second date finally came through, I wasn't anxious in the way I expected to be. More than anything, I just wanted it over with.
By that point we'd already been waiting for months. We'd read the bundle of evidence that had been sent to us before the hearing and, if I'm honest, my gut feeling was that we probably weren't going to get the answers we desperately wanted.
I remember thinking, "Is this all going to be worth it?" and "Is it actually worth going?"
I hoped we'd finally understand what had happened.
Deep down, I wasn't convinced we would.
Arriving at Court
When we arrived, we weren't sitting in the same waiting area as the witnesses from the care home. Instead, we were taken into a separate room where one of the coroner's support officers came to speak with us.
She explained how the day would work, what the process would look like and what we could expect once we went into the courtroom.
Although it was a court, it wasn't nearly as formal or intimidating as I'd imagined. We were told that if we didn't understand something, we could ask questions and the coroner would explain anything we were unsure about.
That simple reassurance helped more than I realised at the time.
The Hearing
I have to give the coroner enormous credit.
From the moment the hearing started, he explained everything clearly and respectfully.
Before anything else, he took a moment to ask us about Grandma herself.
Like many people, she had several names throughout her life and rarely went by her official first name. Rather than simply reading the name on the paperwork, he asked us what she preferred to be called and how we referred to her as a family.
It might seem like a small thing, but it meant a great deal to us.
For those few moments, she wasn't just another name on a case file. She was our Grandma, Mum and a beloved family member - a woman who had lived a full life, was deeply loved and deserved to be remembered as the person she was.
Throughout the hearing, he continued to refer to her by the name we knew and loved her by. It was a simple act of kindness that made what could have felt like a very clinical process feel much more personal and compassionate.
He then took us through how we had come to be there, how the hearing would be structured and what would happen next. Everything was explained clearly, and we always knew what stage of the process we were at.
The coroner had received statements from three members of our family. To my surprise, he chose to read mine aloud in full. He also took the time to summarise the other two statements, explaining the key points he had taken from them.
Witnesses were then called to give evidence.
As the hearing progressed, the coroner asked whether I would be willing to take the witness stand and answer questions under oath.
I hadn't expected that.
My immediate response was yes.
At first, I wasn't nervous. If answering questions helped establish what had happened, I wanted to do it.
As the questions continued, I realised there were parts of what I was describing that only I had witnessed or experienced. I had no photographs, no recordings and no independent evidence to support what I was saying. All I could do was answer honestly and tell the truth as I remembered it.
And somewhere during those questions, the floodgates opened.
Not outwardly.
Internally.
I realised just how much guilt I'd been carrying.
I'd blamed myself for choosing the care home.
I wondered whether Grandma had been trying to tell me something and I'd dismissed it because Lewy Body Dementia had caused so much confusion.
I questioned decisions I'd replayed hundreds of times in my head.
Saying those thoughts out loud made me realise they had never really left me.
Following the post-mortem and the inquest, the coroner stated and then recorded that Grandma died from unnatural causes, with Lewy Body Dementia and other underlying medical conditions contributing. Despite the investigation, it wasn't possible to determine exactly what had happened or identify a single definitive cause.
After the Hearing
When it was over, I didn't feel relieved.
I felt numb.
Sick.
Sad.
Part of me had known we probably wouldn't get every answer we wanted, but hearing the conclusion made everything feel final.
As we were leaving, something happened that has stayed with me ever since.
The police representative who had attended the hearing came over to speak to me.
Then one of the coroner's support officers did the same.
Completely independently of one another, they both said the same thing.
They told me to stop feeling guilty.
It stopped me in my tracks.
My own family had told me countless times that none of this was my fault.
But hearing those words from two people who didn't know me, who had simply watched me speak that day, somehow reached me in a different way.
The police representative also said something I'll never forget.
She told me that, based on what she knew, she would have chosen exactly the same care home we did because it had been considered one of the better homes.
That sentence lifted a weight I hadn't realised I was still carrying.
Looking back now, I don't think they were responding to the facts of the case.
They were responding to me.
They could see the guilt I'd been carrying long before I admitted it to myself.
And that's when I finally cried for my Grandma.
Not when she died.
Not at her funeral.
Not when we scattered her ashes.
Standing in a coroner's court was the moment I truly allowed myself to grieve.
I'd spent months searching for answers about how Grandma died.
Instead, I left with an answer about myself.
I'd been carrying guilt instead of grief.
What I Wish I'd Known
If you're reading this because you're about to attend a coroner's inquest, there are a few things I'd like you to know.
It's okay to be frightened.
It's okay not to understand the process.
The people supporting us that day were kind, compassionate and patient. We were encouraged to ask questions if we didn't understand something, and we were treated with respect throughout.
You don't have to know all the answers.
The inquest may not answer every question you have.
Sometimes the outcome brings clarity.
Sometimes it doesn't.
And sometimes the most important thing you take away isn't the verdict at all.
Sometimes it's something you learn about yourself.
For me, it was realising that grief had been hiding behind guilt.
I can't tell you what your experience will be like, because every inquest is different.
But I hope that by sharing ours, the unknown feels just a little less frightening.
If reading this helps even one family walk into a coroner's court feeling less alone than we did, then sharing one of the hardest days of my life will have been worth it.
Because no family should have to walk into a coroner's court feeling completely alone.
Looking Back
Looking back now, I don't think those questions that I kept asking myself ever disappear completely.
But I've come to understand that making decisions with the information you had at the time is very different from judging those same decisions with hindsight.
We loved Grandma. Every decision we made was because we believed it was the best one for her at that moment in time.
If you're reading this before attending your own inquest, I hope it reassures you that while the day may be emotional, it doesn't have to be something you face with fear.
Links for Support
If this article has brought up difficult emotions, you may find these organisations helpful...