The Mark Duggan verdict: why families often feel let down by the coroner system

We expect too much of the inquest – they are inquisitorial, not adversarial, and cannot apportion blame.

The family of Mark Duggan are not the first to feel let down by an inquest.

But that is not the fault of the inquest, the coroner, or the jury who spent three months listening to evidence and seven days deliberating over their conclusions only to face abuse and threats when they made them known.

We expect too much of the inquest, and that stems from a lack of understanding about what they actually do.

I have sat on the press bench in many a coroner's court and all too often have seen bereaved families arrive expecting that someone will be taking the blame for the death of their relative. Even though every coroner I have seen patiently explains at the beginning of proceedings that blame is not what the inquest is about.

Inquests, as their name suggests, are inquisitorial, not adversarial. No-one is on trial, no-one is in the dock, save for those being tried in the so-called court of public opinion - which is where the Metropolitan Police found themselves during the Duggan inquest.

However, in the absence of any criminal proceedings, an inquest can provide a focus for friends and family of the deceased. This, they think, is where they will get at the truth of what happened.

That is what the families of 96 people who went to watch a football match at Hillsborough and never came home thought when they attended the first inquest into their deaths. It did not give them the answers they sought, and it has taken 25 years of campaigning, the work of the Hillsborough Independent Panel, and the commitment of a government minister, Andy Burnham, to get them any closer to justice.

Another Hillsborough inquest approaches, we will see in time whether it delivers the answers the families want.

Recent reforms have been instituted to update the coroner system, including a Chief Coroner, Peter Thornton; national standards and qualifications; support staff and training.

These changes came about in the wake of the murders committed by Harold Shipman, whose victims' deaths went unexamined by any coroner because the deaths were all explained on a death certificate issued by the very GP who murdered them.

But, even after reform, can a system that was established in 1194, as the Coroners' Society puts it, “as a medieval tax-gatherer” adequately investigate the circumstances of deaths at the hands of police officers?

Deaths inflicted by armed officers and deaths in custody, it could be argued, are a special case, worthy of a different kind of investigation, because any doubts about the inquiry can undermine our faith in the police.

Inquests in these circumstances do not have a satisfactory history, as those who remember Blair Peach will confirm. He was killed during an anti racism demonstration, probably by a blow from a police radio, yet an inquest returned a verdict of misadventure.

We have policing by consent in this country and if suspicions are allowed to fester then some sections of some communities, feeling victimised, may feel that consent is not deserved. As Met Commissioner Sir Bernard Hogan-Howe has himself said, the Met has to work to rebuild the confidence of some communities it polices.

This is not to criticise the coroner in the Duggan case, or the jury. It would seem likely that no conclusion other than one of unlawful killing would have satisfied the family and friends of the dead man.

While the officer who took the fatal shot may have acted lawfully, as the jury found, we cannot be complacent. An unarmed man was killed and a wider-ranging inquiry with greater powers and increased options to issue findings and recommendations might have better answered some of the concerns of Duggan's family.

Very, very few people are shot by police in the country, but significantly more die in custody. Still the overall numbers are relatively small and the time and costs involved in investigating them are inconsequential next to the need for public trust in the police. These deaths deserve the sort of inquiry that inspires public confidence, which is ultimately what we should all want, especially the police.

Pam Duggan (right), mother of Mark Duggan, with her son Marlon Duggan outside the Royal Courts of Justice. Photo: Getty