Dorit Young Published in the Times on 2 March 2023 Coroners’ inquests are always in the news, though their purpose rarely extends beyond their findings — but the court’s conclusion may have huge meaning for the bereaved. Such findings depend on the evidence and scope of the inquest, which are within the wide discretion of the coroner; it must be exercised reasonably. The Ministry of Justice states that “the bereaved should be at the heart of the inquest process”. My experience was the opposite. My previously well daughter, Gaia, died in 2021, aged 25, of an unknown brain condition shortly after admission to hospital. I expected at least a neurologist and independent clinical evidence at court. The coroner and hospital opposed my request for a neurologist in court and there were no independent clinicians despite disputed medical issues. It is widely believed that the health service cannot reliably investigate itself. The court’s conclusion was that the cause of death was “unclear”, consistent with the hospital considering my daughter’s death a “tragic case”. Eighteen months later, Gaia’s death remains unexplained. After an exhausting battle on my part, the hospital has now agreed to commission four independent expert opinions at its expense, including a neurologist. The instructions have been agreed with me. But why not collaborate to begin with for the inquest? The hospital has shown scant regard for the court, making the inquest appear futile. In an age of open justice, I want to publish the transcript of the hearing, along with Gaia’s medical materials. Her legacy should include medical and legal scrutiny of her death and its aftermath. It is about shared learning. The coroner initially refused to consent to my publication of the hearing transcript; there was a veiled threat of “contempt of court punishable with imprisonment”. However, I asked the coroner for the legal authority for refusal and there was apparently none. Coroner’s duties and powers originate in the law; judicial officers must act in accordance with the law. It may be that ultimately Gaia’s death remains unexplained. All I want is an investigation that is informed, independent, focused and proportionate. What I have seems well short. Judicial review is unaffordable, but public scrutiny is more potent. Gaia could have been anyone’s child. Nothing can bring her back. But the aftermath has exacerbated my loss. What have I learnt? Be prepared to learn and understand law and medicine; use such knowledge to empower yourself. Do your own research, fight your own battles — and get to the truth. Dorit Young is the mother of Gaia; more on her campaign is available at truthforgaia.com