Coroners' service reform review delaying inquests
Promised reforms to speed up coroners' courts have been put on hold leaving many bereaved families waiting months or years for verdicts.
The Coroners and Justice Bill 2009 contains a long-awaited shake-up of the coroners' service to speed up inquests.
But the government has ordered a review of the legislation as part of the coalition government's cuts.
Inquests typically take six months but the review may be increasing the backlog of cases.
And campaigners have told BBC Radio 4's Face the Facts programme they fear the new law will not be implemented.
The appointment of a Chief Coroner to oversee a national service has already been postponed.
And Justice Secretary Ken Clarke has ordered the review into the "scope and timing" of the implementation of the new law, as part of government spending reviews.
Coroners courts investigate the medical cause of death, if it is not known, or if it appears to be unnatural or as a result of violence.
Elaine Hanson has been waiting four years for an inquest into her son's suicide.
"It's like a whirlpool of emotions, " she said.
"You don't know when you are going to get out. You don't know when you are going to have the opportunity to think, well, we've done what we can."
Her son Luke Bitmead, a writer from Wiltshire, was suffering from depression.
He took an overdose and was being treated for liver damage, but discharged himself against medical advice.
Security guards escorted Luke from the hospital while he was still in his hospital pyjamas.
Just hours after leaving hospital Luke took his own life.
The wait has left Luke's family with many uncertainties and unable to grieve properly until the inquest is concluded.
"Luke was such a fantastic dynamic guy. I hope I can be a jolly dynamic mother and make something good come out of our tragedy.
"If we can open this up and not tuck it away under the carpet, which I felt they were trying to do, and allow people to see where mistakes were made.
"I'm not in gunning for anybody's career. I just want improvements made, more understanding, reduce the stigma attached to mental health.
"For me, Luke won't have died for nothing," she said.
Helen Shaw, co-director of charity Inquest, said that delays in the system meant that for many people, the grieving process simply stopped.
"One of the biggest problems with the delay in the system is lessons aren't being learnt and what happens is families can wait for years for an inquest.
"It can be a very complex, long hearing, and at the end of the day the authorities will say we have learned all the lessons already, and it makes it feel like a meaningless experience for families," she said.
Two weeks ago, Luke's inquest finally resumed.
But after a week of evidence, the coroner, David Ridley, adjourned before giving a verdict to consider further submissions.
Mr Ridley said that it was inappropriate to talk about a specific case, but acknowledged there was a backlog of inquests.
"I take the issue of delay very seriously and since taking office in April 2009, have introduced a number of measures to actively monitor the progress of cases within the jurisdiction, with the aim of reducing the backlog I took over," he said.
"I am pleased to say that those measures and the concentrated effort of those working for the coronial service in this jurisdiction, appear to be working."
BBC Radio 4's Face the Facts programme also found huge differences in inquest waiting and processing times.
The average time for an inquest to be completed in England and Wales is six months.
But in some areas, such as Bridgend, Exeter and Portsmouth, it can take up to a year.
In Liverpool, the average time is just 10 weeks.
Pauline Davidson's husband John, died of asbestos-related lung cancer in April 2009.
She is still waiting for an inquest to be heard at a court in Essex, where in the Thurrock district the inquest process can take an average of 44 weeks.
"We should be able to say our farewells and start to heal, but you can't heal until you have said your proper farewells. Until you know why they died, you can't," said Pauline.
In 2008, the coroners' service in Essex was transferred from the police to the county council.
It told the BBC that staff shortages had been rectified, and the service had been reviewed, including improved communications with the bereaved:
"Changes made since March 2010 have already had a visible impact, with the average number of inquest heard each month up from 31 in 2009, to 49 for 2010 to date, and the delay in hearing inquests down from 44 weeks, to 39 weeks."
A Ministry of Justice spokesman said, "Consideration of the scope and timing of the coroner reform programme is continuing and ministers will decide how they intend to proceed, as soon as possible."
Each year 31,000 inquests are held in England and Wales and it is individual coroners who are responsible for holding hearings "as soon as practicable".
Inquests can also be delayed by a number of legitimate factors relevant to the inquest, such as waiting for criminal proceedings to be completed, or complex medical inquiries or hospital trust investigations.
Listen to Face the Facts on BBC Radio 4 at 1230 BST, on Thursday, 12 August, repeated at 2100 BST on Sunday, 15 August, or on BBC iPlayer.