Families of domestic abuse victims who have died by suicide are criticising the coroner's court system in England for what they describe as a 'postcode lottery' in how inquests are conducted. The core issue lies in the discretion granted to individual coroners, who decide whether to consider evidence from only the days and weeks immediately before a death or to examine a much broader timeframe, including the months and years of an abusive relationship.
Inconsistencies in Coroner Decisions
Helen Boniface, counsel at Hogan Lovells, highlighted the frustration: '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.
Most domestic abuse-related suicides do not lead to criminal trials, making the inquest often the first or only formal setting where allegations of abuse are heard. However, the lack of an appeals process leaves families without recourse if a coroner refuses to include key evidence.
Landmark Verdict and Ongoing Struggles
In a landmark verdict in September last year, a coroner found that Georgia Barter had been unlawfully killed by her former partner, Thomas Bignell, after she took a fatal overdose following years of abuse. Bignell was not charged criminally, but the inquest heard detailed evidence from family, police, and medical professionals. In contrast, other families have faced coroners who restrict the scope to the immediate period before death.
Pragna Patel from Project Resist, a campaign group, said: 'Half of the problems... is to do with the fact that they have such inconsistent responses from coroners. There seems to be no coordinated attempt to ensure a much more consistent response.'
Call for Reform
Project Resist is campaigning for police to treat all domestic abuse-related suicides as potential homicides and for greater consistency in the inquest system. Frank Mullane from Advocacy After Fatal Domestic Abuse (AAFDA) stated: 'Some coroners do get it right, but we regularly witness coroners limiting the examination of domestic abuse... Restricting the scope to the day of death reveals an ignorance of the cumulative, sustained nature of domestic abuse.'
One family commissioned an independent safeguarding review that identified a 'problematic' and 'potentially controlling and coercive' relationship, but the inquest focused only on the immediate circumstances, leaving wider questions unanswered. The brother of the deceased said: 'Key questions about the full picture remain unanswered, with no clear mechanism for families to have those wider concerns independently reviewed.'
Boniface added: 'It remains surprising that there is no guidance from the chief coroner focused on investigating cases involving domestic abuse. This is not about removing discretion, but recognising that domestic abuse is challenging, and guidance would assist everyone involved.'
The government's violence against women and girls strategy requires a whole-systems approach, including coroners. Coroners have a critical role in public protection, but without proper understanding of domestic abuse, many inquests fail to deliver justice.
