Andy Slaughter
MP for Hammersmith and Chiswick · Labour · United Kingdom
“I welcome the Bill, and thank the Government for introducing it and bringing it back to the House before the summer recess. It is the result of years of committed campaigning, led by the families of the victims and survivors of Hillsborough.”
“I know that case means a huge amount to the hon. Lady as a constituency MP, and I thank her for all the work she does on the Justice Committee. I think we have only begun to scratch the surface. This Bill will be a transforming piece of legislation. I will make one final comment.”
“This would be a new, independent public body that collated, analysed and followed up on the conclusions and recommendations made after official investigations into deaths and state failings, in order to improve oversight and implementation of them.”
“I think I have taken enough time, but I thank the Member for that intervention. This afternoon, the Justice Committee signed off a new major report on legal aid, which will be published on Friday. Those who are interested can read more there.”
“In the time that I have, I will focus my remarks on clauses 1 to 16, which create a new appeals body for immigration and asylum cases known as the independent immigration appeals authority.”
“From that visit, our diagnosis was that these are operational problems. There are two key questions for the House: will the IIAA fix the problems with the current system, and will it be truly independent from the Home Office?”
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“Inquests following state-related deaths are intended to seek the truth and to expose unsafe practices and abuses of state power. However, the preventative potential of inquests is undermined by the pitting of unrepresented families against multiple expert legal teams defending the interests and reputations of state and corporate bodies. What is more, bereaved families often struggle for legal representation, while public authorities have unlimited access to lawyers at the taxpayer’s expense. I want to mention the intervention from the hon. Member for East Worthing and Shoreham (Tim Loughton) in the Westminster Hall debate on 28 October. The Minister was there replying for the Government. The hon.”
“Ms Coles says: “It is now for the Government to put the experiences of bereaved people at the front and centre and ensure equality of arms, accountability, oversight and candour. There can be no more false starts, broken commitments or shelved recommendations.” Ms Coles knows well what she is talking about. Inquest has worked on more than 2,000 cases and investigation processes, with 483 families currently needing their support after a bereavement. This work is done to secure more effective scrutiny of the state when people die. These are people who die in police custody, in prison cells, in health or social care settings, but also in major disasters such as Hillsborough and, more recently, Grenfell. When these deaths occur, there is a fundamental inequality of arms when it comes to what follows.”
“My amendment to clause 38 would ensure that the wishes of families are respected in decisions on whether to hold a paper-only inquest instead of having a hearing, as ordinarily happens. Some families may wish to have a hearing so that evidence can be fully aired and they have the opportunity to raise any concerns with the coroner directly. The amendment would ensure that inquests are not held without a hearing if that is against the wishes of the family of the deceased. I move on to new clauses 10, 11 and 12. I start with a quote from Deborah Coles, the executive director of Inquest. She sums up the position we are in and why I am asking the Government to support the three new clauses on legal aid at inquests.”
“The inquest into Jessica’s death was originally listed as a rule 23 documentary inquest. However, given emerging evidence that there were serious problems in Jessica’s care, representations were made to the coroner that the inquest should be adjourned. That request was granted, and a pre-inquest review is scheduled for later in the year, when lawyers will be able to argue that article 2 is engaged. If clause 38 had applied in this case, Jessica’s family might have struggled to make clear their arguments that the coroner should proceed to an inquest hearing; an inquest in writing might have proceeded at the coroner’s discretion and against the family’s wishes.”
“Further, at the point where a family would be invited to make representations to the coroner on whether an inquest should or should not be held in writing, many families would not necessarily have legal representation to support them in making their views heard. That would put families at a disadvantage in comparison with other interested persons with the benefit of legal teams who were also invited to make representations and argue against a hearing. I will refer to a particular case; my purpose is to illustrate the argument rather than deal with the specifics of the individuals concerned. Jessica died on 16 October 2020 at a women’s crisis centre called Link House. Jessica had mental ill health and had suffered from an eating disorder and depression for most of her adult life.”
“It is acknowledged that clause 38 provides some safeguards in this regard. However, we believe that those safeguards are insufficient. For instance, clause 38 does not mention the need to consider the bereaved family’s wishes in terms and there is no guarantee that they will be given any weight in the coroner’s ultimate decision. Therefore, it is not clear that a family’s wishes would constitute the reasonable grounds needed to decide against conducting an inquest in writing. The current drafting of the Bill leaves a wide discretion to individual coroners to determine whether reasonable grounds for a hearing have been made out by a family.”
“They include ensuring that all interested persons have been invited to make submissions; considering whether an interested person has put forward “reasonable grounds” for a hearing to take place; and determining that there is no public interest in holding a hearing. The key concern with clause 38 is that there may be circumstances in which the bereaved family wants an inquest with a hearing but a coroner deems one unnecessary. Other interested persons invited to make representations may argue against a hearing. Holding an inquest in writing in this context could deprive the family of the opportunity to explore all available evidence and limit their ability to scrutinise the account provided by relevant authorities, including by hearing oral evidence and questioning key witnesses.”
“As we move on to clause 38, I will speak to amendment 73 and the three new clauses about legal aid for representation and other matters. Clause 38 gives coroners the power to hold inquests in writing where they decide that a hearing is unnecessary. Currently, rule 23 of the coroners’ rules allows for documentary inquests to take place, where no witnesses are required to give evidence but a hearing must still take place. Clause 38 would change that by creating a new section 9C to the Coroners and Justice Act 2009, allowing a coroner to hold an inquest entirely in writing. New section 9C does include a list of considerations that the coroner must make before deciding to hold an inquest in writing.”
“The coroner and all the interested parties treated this person as next of kin, but despite that, the Legal Aid Agency maintained that funding could not be provided because the person was not family under the definition set out in LASPO. I therefore propose new clause 12, which would bring the definition of family in LASPO in line with the definition used in the 2009 Act.”
“Crucially, that definition also covers a personal representative of the deceased and others acting in an official capacity on behalf of the deceased. That will apply where there is a personal representative who may not be directly related. This change has the common-sense advantage of making the legal aid eligibility under LASPO consistent with the 2009 Act. An example of why that is important comes in the case of an ex-prisoner who had no or very little contact with her family owing to her time in prison and other factors. The only person who could represent her interests was someone she had become close to in her community, and whom she had named in a letter to her probation officer as next of kin.”
“I therefore propose new clause 11, which would remove the means test in legal aid applications for legal help for bereaved people at inquests, as the Government have committed to doing for advocacy services. New clause 12 would bring the definition of family in the Legal Aid, Sentencing and Punishment of Offenders Act 2012 in line with the definition used in the Coroners and Justice Act 2009. Article 10(4) of LASPO refers to services offered only to members of the deceased’s family. The amendment would bring that definition of family in line with that used in the 2009 Act, ensuring that the eligibility for those services includes an “Interested Person”, which as per that definition can be a spouse, child or sibling, but can also be a child of a sibling, a partner, civil partner, grandparent, step-parent or half-sibling.”
“Legal help is important, because as soon as a death occurs, complex legal processes are triggered involving multiple interested persons and agencies. Families often need expert advice on areas such as access to and release of the body, post-mortems, communication with investigation teams, securing of evidence, inquest scope, witnesses, article 2 inquests, criminal investigations and so on. As previously highlighted, legal help can significantly impact the scope and quality of an inquest. It is imperative that families secure specialist legal advice at the earliest possible stage. Until the Government remove the means test for legal help, that will not be possible for a significant number of families.”
“It is a pleasure to serve under your chairmanship, Mr Rosindell. I am sure you have been told that, before the short adjournment, I had made my remarks on amendment 73 and new clause 10. I will deal with new clauses 11 and 12 briefly because I dealt with most of the points on new clause 11 in my opening remarks on the group. New clause 11 asks for the removal of the means test for legal help prior to an inquest hearing. It is complementary to new clause 10, which deals with representation. As I indicated, the Government have given certain assurances on legal help and on representation for bereaved families at inquests. We are keen to hear more details on that. However, what we have heard so far does not go far enough, or in this case, fast enough.”
“I am grateful for that, and I will not press the Minister further on timing beyond “the new year”, although we know that that could last up until December. However, is he saying that the measures on legal help will be dealt with at the same time and in the same way as those relating to exceptional case funding?”
“As I indicated at some length this morning, this is the overwhelming opinion of not just practitioners but practitioner organisations, family organisations and all those who have done these reports for 20 years, and the Government are conceding that in part. This is an area on which the Government have moved, and I respect the fact that they have done so, but if they really believe in equality of arms in these matters, they have to put families at inquests on the same footing as those parties who are fully represented. It still will not be equality of arms. Frankly, in many cases, there will still be a number of different parties reinforcing each other. I have appeared in many inquests of that kind against a family, often a single family, and their lawyer.”
“I hear what he says about legal help: he has made essentially the same point that he made about new clause 10, which is that this is an inquisitorial process and additional lawyers could complicate the matter, so in that sense, the new clause is not necessary. I will not push new clause 11 to a vote—let us see what the Government come up with—but we will wish to vote on new clause 10. Frankly, the arguments that the Government are repeating in a rather tired way have been completely debunked now. As the Minister has said, we did hear from Mr Rebello, who is a senior coroner, but there are many coroners who do not share Mr Rebello’s view.”
“I hear what the Minister has said in relation to the amendment and the new clauses. Notwithstanding his comments on amendment 73, it is not our intention to press that amendment to a vote, or indeed to oppose the clause as a whole when we come on to clause stand part. I accept—although it is far from perfect—that there are some caveats built into the text of the clause, which are not built into clauses 37 and 39 in the same way. As for the legal aid clauses and new clause 12, I hope the Minister will at least see that there is a logic and a consistency to adopting the same definitions as are in the Coroners and Justice Act 2009, and notwithstanding his comments, I hope that the Government might look at this issue again.”
“I beg to move amendment 74, in clause 39, page 51, line 10, at end insert— “(2B) Coroner rules that provide for the conduct of hearings wholly or partly by way of electronic transmission of sounds or images must not allow the conduct of hearings wholly or partly by sound only.” The purpose of this amendment is to prevent an inquest from being conducted by telephone or other means which are audio only.”
“The review must include a consultation with bereaved families, to ensure that all concerns are fully considered and, where necessary, addressed. That would also highlight any gaps in the technology required for remote hearings and ensure the necessary investment.”
“As a result of the pilot, Justice concluded that whether remote inquests are appropriate is highly dependent on a case’s circumstances facts, complexities and attendees, and, vitally, on the impact of a remote hearing on access to justice for the bereaved family, who already face barriers to effective participation. Justice also concluded that vital safeguards for families, greater investment in technologies, and a pilot and evaluation are essential. I share that view, because the Government must be asked to produce evidence to support these dramatic changes, or be asked to conduct further research and consultation with bereaved families on the implications of remote hearings, prior to enacting clause 39. The research must consider the positive and negative consequences of both fully and partially remote hearings and inquests.”
“The Government state that remote hearings will reduce the “additional distress” of the inquest process for bereaved families—a claim for which they provide no concrete evidence. I have not been made aware of any evidence base in academic or other research to support this move. Indeed, it seems that remote or partly remote inquest hearings can, in fact, add to the distress of bereaved families. The only research into the experience of remote juries was a limited pilot study by Justice, which did not look specifically at inquests.”
“Amendment 78 would ensure that remote inquest hearings and pre-inquest hearings are still held in a manner that is accessible to the public. Turning to amendment 79, I can support measures to conduct pre-inquest reviews remotely, as we have seen that working well in many instances. I note that many organisations that support the legal profession have said the same. The Bar Council said in its brief: “In line with our tradition regarding criminal trials, we are in favour of a presumption that proceedings for a jury are conducted in a room in which key interested persons are able to be physically present, and in which the coroner also sits.” However, there may be some sense in allowing pre-inquest review hearings to be conducted wholly remotely.”
“Public hearings are a fundamental element of the coronial system, ensuring that there is public accountability, investigation and explanation where an individual has died. There must be public access to hearings and, as I have said, although we recognise that in some circumstances a remote hearing can increase availability for members of the public and media to attend the inquest, we are concerned that the Bill does not provide any assurance that continued public access to inquests will not be limited in a remote setting. Clause 39 should therefore be amended to ensure that remote inquest hearings, including pre-inquest reviews, continue to comply with rule 11 of the Coroners (Inquests) Rules 2013, which requires hearings to be held in public.”
“That would row back on the important principle outlined by the Chief Coroner: “In public means not just open to the public but arranged in such a way that a member of the public can drop in to see how an inquest is conducted.” It would appear that clause 39 amends section 45 of the Coroners and Justice Act 2009 to allow coroners more generally to attend hearings remotely. That must be clarified. The proposed new section does not say explicitly that coroners can attend remotely from outside court, or that they can attend remotely from outside court as long as the hearing is still held in public. That may be appropriate where an inquest is set to take place otherwise remotely with the family’s consent, but we have concerns about where that is not the case.”
“The survey highlighted the difficulties that journalists had experienced in gaining access to remote inquest hearings and the technical difficulties faced. The Bill is unclear on the precise circumstances in which inquests would sit remotely and provides no stipulations on the way in which interested persons and the wider public should be able to access hearings. As a result, there is a risk that these measures will crystallise the gradual process towards reduced access, rather than being motivated by the opportunities of new technologies to increase it.”
“Coroners have been sitting in court throughout the pandemic, because pre-inquest reviews and inquest hearings must be held in public. The current variation in wider access relates directly to the availability of premises and the very different approaches taken by different coroners. This has meant that families face extremely different experiences. The same relates to access for journalists and other members of the public, who have at times been denied remote access to hearings on various grounds. Remote hearings have a negative impact on access for the wider public and media, as shown in a recent survey of journalists’ experiences of remote coroners’ courts during the covid-19 pandemic.”
“38”, on remote participation in coronial proceedings, recognises that need, specifying that where coroners order a partially remote hearing, they should set out their reasons to interested persons at the conclusion of any pre-inquest review or in writing, by letter or email. It is important that this important step is not misplaced by clause 39. Amendment 77 would ensure that interested persons are provided with the reasons for any remote inquest hearing. Turning to amendment 78, hearings in public are a central and cardinal feature of the coronial system, and there is an obviously public interest in ensuring transparency and openness. Since the beginning of the pandemic, practice with regard to the ways in which inquests are held has become extremely variable.”
“To help to mitigate those risks, clause 39 could be amended to ensure that certain safeguards are met before a remote inquest hearing is held. Turning to amendment 77, it is important that interested persons, including bereaved family members, are provided with the reasons why an inquest hearing is to be held remotely. That helps to ensure that, if necessary, they have a basis on which to contest a decision to hold an inquest remotely. It is crucial that bereaved family members are engaged throughout the inquest process and provided with regular updates on what decisions are being made by the coroner and why. Without this communication, bereaved families, who often find the inquest process complex and alienating, risk experiencing further alienation, confusion and distress. “Chief Coroner’s Guidance No.”
“Inquests play an important role in allowing bereaved families to understand the circumstances around their family member’s death; however, if family members have difficulty engaging with the inquest remotely, that may disconnect families and key witnesses from this important process. Given the highly personal and distressing nature of inquests, it may be difficult for family members to put forward arguments and explanations to a coroner of why they do not want a remote hearing, especially since many bereaved family members do not have access to legal advice and representation, and may be faced with competing arguments from other interested persons. A remote inquest hearing should occur only if family members have consented to it.”
“It is possible that some families may welcome a remote hearing, including the practical benefit that it can provide for some participants; however, it is very possible that requiring bereaved families to attend inquests remotely from their own home, which may make it more difficult to detach the inquest from their personal lives, will risk increasing unnecessarily the distress for bereaved families. In addition, bereaved families who attend from home risk not having the same level of support, including vital in-person support from charities such as the Coroners’ Courts Support Service. They will also be required to navigate the additional technological challenges that remote hearings can pose.”
“As with any remote hearing, myriad issues, including health conditions and disabilities, may make it difficult for individuals to follow or engage with a virtual hearing. Those same issues may make it difficult for them to explain to the coroner why they would prefer to attend in person. Furthermore, inquests can be highly distressing and re-traumatising for bereaved family members. The Government state that remote hearings will reduce the additional distress of the inquest process for bereaved families; however, it is unclear what evidence there is for that statement.”
“The Government’s rationale for clause 39—that it would bring inquests to “the same position as civil courts”— fails to recognise the specific nature of inquests, which often differ from mainstream courts and tribunals because of the highly sensitive and distressing nature of the issues addressed and their potential complexity, especially for state-related deaths. Whether remote inquests are appropriate depends on a case’s circumstances: its facts, complexity and attendees, and their ability to participate electronically in the proceedings. The introduction of remote inquest hearings without considering the needs and wishes of bereaved families, who already face many barriers to effective participation in the inquest process, is extremely concerning.”
“Every case and every family is different, but being in court allows families to be supported by their legal representatives not just professionally but emotionally. That could be difficult if they are in different locations. Some families may not have internet access, or an internet connection that is good enough to allow them to take part in an online hearing. Amendment 75 will ensure that those families are not excluded from an inquest by ensuring that their agreement is secured before one is conducted remotely.”
“It can be vital to see a witness who is being questioned during the inquest; otherwise it is impossible to know whether that person is being prompted on what to say by someone else, for example. Furthermore, if a hearing is audio only, neither the coroner nor anyone else will be able to get a sense of the body language of the witness, which could help to establish credibility. The amendment would prevent an inquest from being conducted by telephone or by other means that are audio only. Inquests can help to provide closure for grieving families and, according to families who have been through this experience, part of that closure can be achieved by physically being in court. It is the opposite point to the one that the Minister made on families who may find it more comfortable not to be in court for various reasons.”
“There is much to be said for support measures to make pre-inquest reviews more readily available remotely, and we have seen this working well in many instances. In some cases, it is true that remote inquest hearings will be appropriate and some families have welcomed them during the covid-19 period. There can be additional benefits of remote hearings in facilitating wider participation for public and media access, but only if arranged in a way that ensures that is established. Given the way in which the clause is drafted, I have significant concerns about accessibility, transparency, participation and open justice with remote hearings. Amendment 74 does not dispute the fact that there is a place for remote hearings, either partly or in full, but I argue that it would be inappropriate for an inquest to be conducted by audio only.”
“The Committee will see that we have a number of concerns about the way in which the amendment is presented, but not about the principle. We covered the role of technology and so forth in a previous part of the Bill, but we repeat some of those concerns and we have additional concerns in relation to the coronial process. Clause 39 would enable remote attendance at inquest hearings by amending the coroners rules to allow provision for the conduct of hearings either wholly or partly by way of electronic sounds or images. Proposed new subsection (2A) sets out a provision to allow members of the jury to take part in a hearing virtually. It clarifies the fact that all members of the jury must take part in the same way and from the same place.”
“Earlier, the Minister quoted with approval Mr Rebello’s evidence, which we took at the start of the Committee proceedings. The Minister agreed with him on the issue of representation, which one might think is more of a point to be debated. Mr Rebello is an experienced coroner and his evidence was persuasive on whether it was as acceptable to have people remotely as it was to have them in the room, in terms of not just the individual parties—there are many different parties—but the collective impact. I wonder why the Minister was not persuaded.”
“The Minister conceded, I think, that there is no evidence here and we are taking a bit of a leap in the dark. It is reasonable that more investigation is needed.”
“We respect their right to run their own courts and they have wide discretion about which evidence is heard, but it is giving all the weaponry to the coroner and perhaps a bit of a brake needs to be left with the family. I will mention amendment 76, too, because considering the ability of interested persons to deal with the hearing is crucial. I will not push that to a vote and I accept what the Minister has said about these being matters to which he has regard. I hope that they will appear in guidance, because I have concerns about the double whammy of someone not being in a position to articulate their views and being further discriminated against by a remote hearing in which they are unable to take part. I will press amendment 79 to a vote.”
“I thought for a moment that the right hon. Member for South Holland and the Deepings was rising to indicate which of the amendments he is going to support, but we will see. They are all good amendments. I will not trouble the Committee by putting them all to the vote, but with all due respect to the Minister I do not think that the case for them has been rebutted. The failsafe is in amendment 75, which states that the agreement of families must be secured before an inquest is conducted remotely. The Minister said in an earlier discussion that that could be used obstructively in some way, but I think that the chances of that are vanishingly small. I regret to say that there are cases—I may come on to this in the clause stand part debate—where the coroners have not been entirely sympathetic to the wishes of families.”
“Amendment proposed : 75, in clause 39, page 51, line 10, at end insert— “(2C) Coroner rules that provide for the conduct of hearings wholly or partly by way of electronic transmission of sounds or images must provide for all interested persons to have to give their agreement to the conduct of hearings wholly or partly by way of electronic transmission of sounds or images.”— (Andy Slaughter.) The purpose of this amendment is to ensure the agreement of families is secured before an inquest is conducted remotely.”
“On the whole, it has been reasonably sympathetic to what the Minister is trying to do, but it says of clause 39 that “it is our belief that this measure should not become law without thorough research, evaluation and consideration of the impact on the administration of justice and justice outcomes.” I think that must be right. We are not opposing the clause, but before we go ahead and support it, we are asking to have the consent of the parties, including the families, and further evidence. I will not press amendment 74 to a vote, but I will press amendments 75 and 79. Amendment, by leave, withdrawn.”
“I hear what the Minister says. This is not making the best the enemy of the good: we have got through, and Zoom and other methods have been a great help during covid, but most of the Zoom, Teams and other meetings that we have taken part in have been professional meetings and even then, I am afraid, some colleagues—probably myself on some occasions—struggle with the technology. Most of the parties to an inquest will be professional—we made this point in relation to our new clauses—but some people will struggle, and it may not be entirely apparent that they are struggling. That is my point. I pray in aid the comments of the Bar Council.”
“They are putting all matters into the hands of the coroner. Of course, there must be judicial discretion, but they need to go further. We hope that the Minister in the other place will table amendments to improve the provisions and mitigate against the possible harmful effects of remote hearings, and perhaps then we will be delighted to support the clause. For present purposes, however, we will vote against clause stand part.”
“Despite the distress, frustration and pain that can be caused by the inquest process, bereaved families go through it to understand the circumstances of their family member’s death, and to bring to light harmful practices with a view to preventing similar deaths in future. I am concerned that remote hearings may disconnect families and key witnesses from that important process, which serves a wider public interest. We are not against the further introduction of new technology; in some circumstances, such as pre-inquest hearings, it clearly seems appropriate. We have serious reservations about remote hearings for full inquests, but we accept that that can be mitigated. The problem with the way in which the Government have handled the matter in the Bill is that they have not offered those mitigations.”
“We are also concerned that families engaging in the inquest process remotely will be unable to access in-person support from charities such as the Coroners’ Courts Support Service. In the Justice Committee’s inquiry into the coroners’ service, the Chief Coroner emphasised the critical role played by Coroners’ Courts Support Service volunteers in meeting families and ensuring that they are not by themselves. Justice Committee members picked up on that point and made recommendations to make the service more widely available. The Bill’s provisions, rather than strengthening those services, would roll them back.”
“Lawyers from the Inquest Lawyers Group have spoken of inquests they have sat on where the jury has sat in a separate room to the coroner, watching the hearing via video link. In more than one instance, lawyers have reported seeing members of the jury sleeping and eating without the coroner having any knowledge. That type of situation would be very hard to prevent if the proposals in clause 39 are enacted. Inquest hearings can have a uniquely distressing impact on bereaved families. The process, which involves hearing details about an individual’s last moments before death, can have a retraumatising effect on families. Clause 39 will make it more difficult for many families to separate the distress of the inquest hearing from their personal lives.”
“However, clause 168 of the Police, Crime, Sentencing and Courts Bill, which has been referred to, would introduce remote juries in criminal trials. That clause is still under consideration in the Lords, and prompted a joint briefing from the Bar Council and the Law Society raising “wide-ranging” concerns that included “the risk of alienating juries and/or witnesses; ensuring security of proceedings (both in terms of the privacy of the process and individuals, and data privacy); additional expense to the taxpayer; the requirement of new technology and IT systems; and the associated issues arising out of these aspects”. For families, this brings the additional challenge of them being unable to witness a jury’s reaction to evidence being heard.”
“There were two main issues. First, Chris’s family saw a witness who was giving evidence remotely and representing Pennine Care “laughing and pulling faces with a colleague” on their screen. This came just after another member of staff gave evidence concerning the failure to observe Chris properly while he was sleeping. Secondly, the family accidentally saw CCTV footage of Chris’s last hour, which was to be used by another witness. Unsurprisingly, the family found those moments very distressing and wrote to the senior coroner to “ensure relatives of the deceased are not put through unnecessary additional distress”. Clause 39 also proposes introducing remote juries to inquest hearings, which is justified on the basis that it would bring coroners’ courts in line with other jurisdictions where it is presently an outlier.”
“However, while we support the principle of increased use of technology in the form of remote proceedings for certain situations in the justice system, this cannot apply without restriction across the justice system, and must be implemented with caution and with appropriate safeguards. Let me give an example in which a remote hearing failed to safeguard a family. Chris died after suffering cardiac arrest on 24 March 2019. Chris had been sectioned under the Mental Health Act 1983 and was under the care of Pennine Care NHS Foundation Trust. The inquest into his death took place in April 2021, and was deemed an article 2 inquest and was conducted with a jury. Following that inquest, Chris’s family wrote to the local senior coroner to highlight the challenges they faced due to the remote technology used at the inquest.”