Help with the inquest process

My adult son aged 28 died 6 months ago of a sudden cardiac event. It was totally unexpected and he was a very fit young man. He leaves us as his parents and a slightly older brother who loved him dearly and who is devastated. I would be interested to know how parents in similar circumstances deal with thoughts of your child? Sometimes one thought can lead to another and I can get into a terrible spiral of grief.

I am a coroner. Whilst I cannot give detailed/specific advice, if anybody has any general query regarding the process ( which can be difficult to navigate) I might be able to answer those queries on this forum. That way, at least I can feel I am helping you in some small way.

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I have a question, I lost my husband in November to penile cancer, if the hospital had done a biopsy instead of sending him home every time, would he might of had chance with chemo.
We found out 22nd October and 13th November we were told there was nothing they could do and he was too weak for chemo he died 10 days later.
I only had 4 weeks in total with him.
He was only 50.

Hi. I am so sorry to hear of your loss. As I have said previously, I cannot comment on individual cases. That said, if you feel that the hospital could have done more, then you can ask the patient advice and liaison service (PALS) to assist you. They provide a point of contact for patients and their families and can help you resolve concerns or problems when you are using the NHS. You can find your nearest office on the NHS website or ask your GP surgery or hospital for details of the nearest PALS organisation.

I lost my Son last May, age 30. We are waiting for inquest date. The inquest is open but waiting for all evidence and testing on my family. Have you had a diagnosis for your son? I’m so sorry we are here and our sons aren’t. It’s too much isn’t it. I’ve had an awful time with our coroners officer, he was very judgemental and had no idea about sudden cardiac death in the young. I’ve since found Cardiac risk in the young and they have been more than supportive and helpful.

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Hi. I am so sorry for your loss. Unfortunately we belong to the ā€œclubā€ that nobody wants to belong to. The post mortem for my son was inconclusive. Unfortunately as a coroner I know that sudden cardiac death in young men can be unexplained despite the best efforts of the pathologist and specialist heart surgeons who examine the heart after death. I am glad that you have been able to contact CRY which is an excellent organisation. You are probably aware but CRY offers a free screening service for young people to determine whether or not there are any cardiac issues which could be a problem in the future. After my sonā€˜s death a friend had her adult son tested through CRY and unfortunately something was discovered which Is the subject of further examination. If we can I think it is worth passing it on to people to have their children – especially sons – tested by way of an ECG to see if there is something which can be treated to avoid a tragedy in the future. Sometimes there is a genetic link which is worth exploring, but it seems that you are pursuing this already. I hope that the inquest process is not too difficult for you. The reality is that in these types of cases the coroner is guided by the medical evidence and there is little more that the coroner can add at the inquest itself.

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We are having all the tests to see if genetic. Can I ask - what is the job of coroner? You get all the medical evidence, families can’t speak to you only officers. We asked to speak with our coroner but were told we could only speak with CO. Do you tell families about CRY when it is sudden death under age 35?

Ive put a complaint in to PALS and have a solicitor dealing with the case for delayed cancer diagnosis.
Sorry I just wanted your opinion with being a coroner

Hi. A coroner is a lawyer /judge whose role is to determine who has passed away and how when and where that person came by their death. Unlike judges in other courts, a coroner does not determine any issues relating to ā€œfaultā€œ although a coroner can make a determination if they feel that there is some shortcoming somewhere and furthermore can make a recommendation to the government or any other institutional body regarding systems which could be improved. Because a coroner is a judge, the coroner can only speak to anybody who has an interest in the inquest (including the family) in the inquest court. Proceedings are always recorded in the inquest Court so there is transparency and so one interested person does not think that another interested person is having private discussions with the coroner… This is exactly the same in any other court proceedings and is to ensure fairness. That is why in the coroner’s Court all communication between the family has to go through the officers. That said, once the matter is her as an inquest the coroner is perfectly open to discuss matters with the family or any other interested person at the inquest hearing itself. Hope that helps to explain the procedure.

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I am very sorry to hear of the loss of your son and I send my condolences. It must be strange, and perhaps difficult, for you to be experiencing what has happened from the perspective of a parent, rather than a coroner. It is very good of you to be offering advice to others. My son died in November aged 33 and the ambulance crew thought it was a heart attack. However the post mortem was inconclusive, so further tests have been carried out and we are awaiting the results any day now. There seem to be a lot of young men dying from heart problems nowadays and I wondered whether it has always been the case or whether, in your role as a coroner, you have seen more of this in the years since covid?

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Hi. Have you had the post mortem results yet? In reply to your query; in 20 years as a coroner I have seen happily very few sudden unexplained cardiac deaths in young people.

Hello, WilliamEdward, and thank you for replying. We are still awaiting the test results, but I gather it is not unusual for them to take this long. The wait is stressful though. There has been a lot of talk generally online about covid / covid jab causing more heart attacks in young people, so I am interested to hear that you have not found this to be the case.

Hello, I am somewhat shocked that you have seen so few when the facts are there 12 a week under age 35. Do you recommend Cardiac Risk in the Young to families when they first with you? Have you gone back to work? How are you coping? Must be very difficult for you, with your huge personal grief. Did you have a result for your son?

Hi William.

I’m grateful for you reaching out as a coroner - what strength.

My 17 year old son died in a car accident in February and the police finalised their investigation and sent the case files to the local coroner a couple of weeks ago. It’s clear what happened in this tragic accident, as all was on CCTV, millisecond by millisecond.

My question is whether at the inquest we are able to ask the coroner whether they may be able to make recommendations for safety measures in cars, which are not currently standard, particularly in respect to automatic cars. I know you can’t advise on specific cases, just more of a question as to whether we can ask such a question.

With thanks :pray:

Also - I wanted to say that Jake had two older brother and they also had a huge bond with him and would do anything to protect him, until the one time they couldn’t, so I totally understand your elder son’s grief. Ours is immense, but theirs is on a different plane to go through their lives at pivotal moments without their brother with them. Our lives are changed forever - our sons’ brothers will be reaching milestones that their little brother will never experience, and it will hurt them, or let them celebrate who they had through their childhood forever.

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Hello, WilliamEdward. I wonder how things are for you and your family now? Have you had more information on exactly what your son died of? Two weeks ago we received the pathology report on our lovely boy, Simon. Our son died of a rare and serious infection of the heart membranes, called Infective Endocarditis. The infection is more likely if you have a faulty heart valve - our son had a bicuspid aortic valve. We now think that Simon actually had IE for several months before his death. He had initially been sent for blood tests and an x ray, the results of which came back normal. Simon asked the doctor if he might have long covid and the doctor said it could well be that. So from then on Simon was convinced that he had long covid. Unfortunately long covid and IE have very similar symptoms. If Simon had been diagnosed with IE at the beginning of his illness, and if he had been given antibiotics, then there is a chance he would have survived. It is very upsetting, but the fact is that Simon wouldn’t go back to the doctors, as he thought they couldn’t do anything for him. And the doctors thought he had long covid too, and didn’t offer him any further tests. Nobody realised that his faulty heart valve could be involved. As a typical young male, Simon thought that he had to deal with the ā€˜long covid’ on his own and he thought that he could beat it. We had been told by a doctor during Simon’s teens that the faulty aortic valve would only cause problems in old age. Nobody had suggested that he go for regular testing during adulthood. I believe that in the US, it is recommended that people with valve defects have regular tests throughout their lives. This doesn’t seem to be offered in this country though and I feel strongly that it should be, plus more training for doctors so they are aware of the potential dangers of heart valve defects.

Hi. There was no real answer why our son died. Sudden cardiac arrest. But the coroner after a one day inquest thought that that the AdHd drugs our son was taking- ampetamine based - might have contributed to the death.

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Hi. At the inquest you can ask the coroner to make a PFD report. In other words to draw an organisation’ s attention to an issue that needs attention. ( prevention future deaths)

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Edward. So sorry for you and your families loss and like all of us on here we are all trying to understand our reality of the situation we find ourselves in. We lost our youngest son on April 6th 2025, 10 weeks ago today, he was 27. We have an older son like you have who is 33 and all 3 of us are totally devastated and struggling to cope. We have had no information as yet as to any reason and have been told the post mortem will take up to 6 months. Matthew was fit and healthy and the only thing different that weekend was he was complaining about his sinus which he had had for a few years and had used a nasal wash and Sudafed. Matt did collapse at university in Jan 2020 he was studying at UCL in London and spent a couple of nights in hospital struggling to breathe after collapsing at his rented flat. We always put this down to an early case of Covid. Matt didn’t get Covid at all but did have all the injections he was entitled too. The medical system didn’t do any follow up tests. Matt was on a lot of medication for his mental health that was never reviewed and simply reissued each month. The interim death cert just says unascertainable based on further examinations and we haven’t heard anything since April when that was issued. Any help greatly appreciated. We are all struggling every day minute by minute to understand the enormity of what has happened to Matthew and understand how we can continue with our lives without Matthew in it. We are all completely broken. Any thoughts on what we could ask at this point ? The police didn’t take his bed sheets even though there is blood on them and Matt had blood around his nose when we found him. I have kept them in case we need them but they are still just on the bed. Should I do anything with them ? Anything else you could advise as to what we can find out would also really help. Thank you. :broken_heart::people_hugging::broken_heart:

Oh Jen, my Sam had taken Sudafed and nasal wash the day it happened to him too. He also had nosebleed. I keep thinking about this Sudafed and wondering if that added to it. It’s so hard isn’t it. Did you look at the charity ā€˜Cardiac Risk in the Young’? They have been so helpful with my family and Sam. Sending you love.

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Lisa ! No really. The police were very interested in the Sudafed they kept asking a lot of questions about it and one of my friends had an allergic reaction to it a few years ago but Matt had used it before but never with a nasal wash. It’s the only thing different to when he had used it before. It haunts me that it could be something so simple and preventable but also haunts me that this may not show up if the investors do not look for it. I did write this on the notes I sent through to the coroner. Please please don’t let this be what has taken our sons. I pray it’s not this :broken_heart::people_hugging::broken_heart:

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Hi. I am so sorry for your loss. What usually happens in a situation like this is that the heart and sometimes brain are sent away for specialist testing. It’s this which causes the delay. The post mortem itself is usually done very soon after death. At post mortem the pathologist takes samples of blood for toxicological testing (testing for alcohol and drugs of whatever nature)which doesn’t really take very long. You could ask the coroner, whilst the specialist tests are awaited, for a copy of the initial post mortem report and the toxicological reports to see if anything jumps out.

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