Roisin, the only child of Dr Tony Bennett and Margaret Hunter, went to her bedroom in Darlington on 7 March 2022 and attempted to take her own life. She died in hospital nine days later, at the age of 19.

Roisin, known as “Roi”, excelled at sports; she was popular and had received high marks as one of the youngest students to study for ­dispensing optician exams. She had no record of self-harming, ­mental illness or attempted suicide. Her ambition was to go to university and qualify as an optician. Roisin had a warm, supportive family. So what prompted her to take her own life?

Roisin’s parents have spent the last two years fighting to establish the truth, a struggle that continues. They say they are “raging” and “distraught” at how hard they have had to battle. At an inquest 16 months ago, coroner James Thompson ­concluded that Roisin had taken her own life “due to the ending of a ­relationship and the pressure of balancing work and studying for exams”.

Roisin’s parents, supported pro bono by solicitor Helen Boniface of law firm Hogan Lovells, argued that the ­evidence said otherwise. The only way a coroner’s decision can be challenged is by a judicial review at the high court, a prohibitively costly exercise unless a family has free legal advice.

In February, following a successful pro bono judicial review, the ­coroner conceded he had made an error. In a milestone case, the narrative now reads that Roisin took her own life “due to an emotionally ­abusive relationship”.

“I’ve had to have help with my mental health,” Margaret says. “We are not living. We are surviving. I fought my hardest for Roisin when she was alive. I can’t stop now.”

The coroners’ service in England and Wales, “the forgotten service”, is in crisis. It lacks adequate resources, accountability, effective data, consistency and transparency, and ­families need legal aid to navigate the system fairly, according to Sir Robert Neill KC, Conservative chair of the House of Commons justice select committee.

He was writing in a , the minister for courts at the Ministry of Justice, sent on 23 May. Neill was summarising the findings and recommendations of the committee’s inquiry into the coroners’ service, first conducted in 2021 and updated in 2023, that will now not be published as a result of the calling of the general election.

For lawyers and families dealing with domestic abuse-related suicides, the weaknesses in the coroners’ service are well known. They mean that major challenges impede the delivery of justice for bereaved families who face long and often fruitless battles, and the women who no longer have a voice.

Last year, for the first time, the number of domestic abuse victims was, at 93, higher than as a result of intimate partner homicides (80). The ­charity Advocacy After Fatal Domestic Abuse is currently supporting 98 families in which domestic abuse-related suicide has occurred.

Statistics may not reflect the true numbers involved in what some chillingly call “”. The need to improve prevention of domestic abuse, and the response in the aftermath of related suicides, is , while the updated national suicide acknowledges that domestic abuse victims present a high risk of suicide.

However, an initial cursory police investigation into a suicide may mean vital forensic evidence is lost and some coroners lack a ­crucial understanding of coercive and controlling behaviour, a crime in England and Wales since 2015, punishable by up to five years in prison.

“If we are saying that coercion and control impacts on women’s choices, agency and freedom, then we also need to ask, who is ultimately responsible for that situation?” says , a professor at Warwick School of Law.

An inquest asks who the deceased was and where, when and how he or she died. A coroner has wide ­discretion, including on the scope of the investigation, but is not able to apportion blame. The aim is to establish the facts. In the event of a homicide offence, the coroner will adjourn the inquest and allow the criminal prosecution to proceed first. A coroner can also refer a case to the after an inquest.

“If a case doesn’t reach a ­criminal threshold then an inquest will be the only forum in which a family can participate in a public investigation of what happened,” Boniface says. “When it comes to suicide cases, a coroner should be looking at why a person killed themselves and the lessons to be learned. Instead, some focus only on the question: did she kill herself?”

Roisin began going out with her ex-partner when both were 17. Margaret says she soon had concerns that Roisin was in an emotionally abusive relationship and tried to get help. Her daughter was often distressed and subdued.

Boniface and Faye Rolfe, the pro bono barrister on the case, ­analysed more than 60,000 texts and social media ­messages exchanged between Roisin and her ex-partner over two years. Many from him were abusive. He repeatedly accused Roisin of “spreading her legs for anyone” and called her “fat” and a “slag”. Shortly before she died, Roisin ended the relationship. Her parents say that, far from upset, she appeared much happier. Her ex-partner continued to bombard her with messages.

At the inquest the coroner only allowed examination of messages between Roisin and her ex-partner for the two days prior to Roisin’s decision to end her life. “That in itself shows a fundamental misunderstanding of coercive and controlling behaviour,” Boniface says.

“The coroner said he could not apportion blame and it was important to be proportionate. But if there is an overwhelming amount of ­evidence in one particular area, that’s just where the evidence is.”

The police said there would be no criminal prosecution. Her ex-partner denied all allegations of abuse.

Guidance for coroners does not permit them to comment on their cases outside a courtroom. Roisin’s parents have now requested a . If ­successful, the police must reopen the criminal investigation.

Boniface has also worked pro bono with the family of Vanessa Hamilton. She was a 60-year-old divorced mother of three when, on 19 May 2021, she drowned in the bath at her home in Worcester. She had taken a “therapeutic” dose of the tranquilliser diazepam and alcohol was in her blood. In August last year, senior coroner David Reid recorded a verdict of misadventure. He decided “on the balance of probabilities” that Vanessa had not intended to take her own life. “I find it most likely that she entered the bath, lost consciousness and was unable to extricate herself,” he reported.

Shortly before her death, Vanessa had made allegations to her mother, sister, son and brother relating to “rough sex” and abuse inflicted by her ex-­partner. She had recently ended a five-year relationship with him, seeking help from the Women’s Aid charity in the weeks leading up to her death. He has denied all allegations of abuse.

“The coroner refused to allow the family’s barrister to explore these allegations,” says Boniface . “We argued that the intention was to hear evidence of Vanessa’s state of mind in the lead-up to her death.”

Instead, the coroner set the scope of the inquest for only one month before Vanessa’s death, on the basis of proportionality, and took out ­references to abuse in written statements made by the family.

Fergus Hamilton, 36, Vanessa’s eldest son, has been diagnosed with post traumatic stress disorder as a result of the fight for justice for his mother. He says: “It would have meant a huge amount for the ­family to have had a reference on her death certificate that acknowledged that domestic abuse played a role in her death.”

Vanessa was vulnerable. She had a history of alcoholism, substance abuse and depression stemming from the death of her brother, aged 12, in a motorcycle accident when she was 10. “She believed she was somehow to blame,” Fergus says. When he went to university in 2008, Vanessa worked as an acupuncturist and stayed sober for much of the next few years, regularly attending Alcoholics Anonymous. In 2016, Vanessa met her ­ex-partner. “He was living in his van,” says Fergus. “My mother owned her own home. My mum had a strong support system in Hereford but he persuaded her to move to Wales to a remote cottage that was completely off-grid. Moving to such an isolated location without support for addiction or mental health was very risky.”

Fergus says his mother hated living in Wales and began to have regular relapses that corresponded with increasingly frequent breakdowns in her relationship. Several weeks before her death, she moved to Worcester. On the day Vanessa died, a friend who had come to countersign a new will removing her ex-partner as a beneficiary failed to get a response and alerted the police. A police investigation concluded there was no criminal case to answer.

The family made an official complaint about what they viewed as a perfunctory investigation. A West Mercia police spokesperson says: “It was found that the service level provided by the police was acceptable.”

Boniface says: “We were surprised and disappointed that the coroner did not allow the very serious allegations that Vanessa disclosed to her family to be considered at the inquest. Although Vanessa is no longer here, her voice was available to the court through her messages, emails and what she told others. Inexplicably, the coroner chose not to hear it.”

A handful of ­coroners are pushing for change. Jessie Laverack, “a vibrant young woman”, was 34 when she in February 2018. The summer before, she had fled from her home in Rotherham, South Yorkshire, to Beverley, 50 miles away. She had earlier been referred to a Marac (a multi-agency risk assessment conference, for high-risk victims of domestic abuse). Jessie had a “history of being subjected to domestic violence”, her inquest heard. Patrick Walsh, her ex-­partner, had been charged with assault but the case was discontinued when Jessie withdrew her evidence.

Sophie Naftalin, a solicitor with Bhatt Murphy, has worked on several domestic abuse-related suicides and unexplained deaths, ­including Article 2 inquests. Article 2 of the European convention on human rights extends the inquest’s scope to ask whether the state breached its duty of care to protect the deceased’s “right to life”. Article 2 families are eligible for legal aid.

Naftalin fought, unpaid, for two years to secure Article 2 legal aid for Jessie’s family, succeeding in obtaining funding only a few months before the inquest was finally held in June 2022, four years after Jessie’s death. “If Sophie hadn’t ­succeeded, I was prepared to sell my home to pay the legal fees,” says Phyllis Daly, Jessie’s mother. “I felt so strongly that professionals were not acknowledging that abuse was the cause of my daughter’s death.”

At the end of a six-day inquest in Hull in 2022, initially scheduled for only two hours, at which Walsh denied allegations of abuse, coroner Lorraine Harris made a powerful conclusion, the first of its kind in England and Wales. She found that the underlying cause of Jessie’s mental illness had been ­domestic abuse and multi-agency failings.

Crucially, the coroner to prevent future deaths to the home secretary, the minister for justice and the minister for health to ensure that the link between domestic abuse and suicide was better understood. Among her recommendations, Harris proposed a database to collect statistics on the extent of domestic abuse-related suicides and unexplained deaths, a proposal refused by the government.

This February, six years after Jessie’s death, her mother finally received a ­formal apology from Humberside police. “Jessie had agoraphobia, depression, anxiety and developed a dependency on alcohol that she was trying hard to stop,” Daly says. “I believe my daughter wanted to live but she didn’t want to live as a victim of domestic abuse. The coroner understood that. It matters that the truth is now on her death certificate.”

Assistant chief constable Thom Mcloughlin says Humberside police have since brought in a number of reforms to better tackle domestic abuse. Now a formidable campaigner, Daly had to give up her job as a health visitor, issue a three-year restraining order on Walsh and move house. She continues to work with police and coroner Harris.

“My cases are not unique,” Naftalin says. “They reflect an entirely broken system in which victims are routinely failed. That is not justice.”

The select committee’s a national coroners’ service to end a postcode lottery, and a – a new independent body to collate, analyse and follow up on recommendations arising from inquests and inquiries.

Boniface would like even more immediate action. “Although there are currently 47 guidance documents issued by the chief coroner, none of these relate to domestic abuse,” she points out. “We would ask the chief coroner to reconsider that position.”

• This article was amended on 11 July 2024 to remove some personal information.

In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis ­counsellor. Other international help­lines can be found at befrienders.org.