Coroner's Covid findings stoke calls for inquiry into pandemic policy

By David Conn

The failures and concerns highlighted by a senior coroner, Alison Mutch, following the deaths of two men, Anthony Slack and Leslie Harris, from Covid-19, have reinforced bereaved families’ calls for a government inquiry into the handling of the pandemic, and for more inquests.

Very few inquests have been held into deaths of people from coronavirus, following the then chief coroner’s guidance in March that Covid-19 is “a naturally occurring disease” and inquests are not normally necessary unless a person died due to additional factors, for example neglect.

Boris Johnson’s refusal to hold a rapid public inquiry after the first wave, combined with the lack of inquests, has prompted many bereaved families to complain that lessons were not learned in time to prevent thousands more people dying in a second wave.

A Guardian analysis of all coroners’ “prevention of future deaths” reports, which call on authorities to take action on concerns identified during inquests, found just two that followed deaths of people from Covid-19.

Four more reports mentioned the pandemic as a contributing circumstance, including the strain put on mental health services and other health provision. Another report produced by Mutch followed an inquest into the death of a baby caused by her sleeping position. The coroner raised the concern that nationwide, many health visitors who support parents and young children had been redeployed into other services.

Jo Goodman, co-founder of the Covid-19 Bereaved Families for Justice group, whose father Stuart, 72, died from the virus on 2 April, said these isolated coroner’s reports vindicated the group’s argument that a rapid public inquiry and more regular inquests should have been held.

“All the families in our group, which now has 2,252 members, believe something went terribly wrong in the overall response to the pandemic or the particular circumstances of their own loved ones dying. We believe the broader lessons – about the delayed lockdown, PPE shortages, infections in care homes and hospitals, for example – should be learned in a rapid review public inquiry. Individual circumstances should be investigated at inquests.

“It is hugely traumatic for our families that lessons weren’t learned, and now we are seeing so many more families suffer the same grief and heartbreak.”

Johnson refused the group’s request in the summer to hold an inquiry. The government has told the families that if they challenge that decision legally, the government may hold them liable for its legal costs.

A Downing Street spokesperson said: “The prime minister is acutely aware of the grief, heartbreak and loss suffered by families across the country as a result of the virus and has fully committed to looking back and reflecting on all aspects of the pandemic.

“And as he has said, there will be an opportunity to reflect on all aspects of the pandemic in the fullness of time but for now we need to remain focused on reducing the spread of the virus, and to protect those most vulnerable in society.”

The families’ group argues that the government has a duty to hold an inquiry under article 2 of the European Convention on Human Rights, which protects the right to life. Since the summer they have raised money, and Goodman said they are still considering mounting a judicial review challenge.

Additional reporting: Sam Cutler