The Importance of Language – Not Proportioning Blame

Working in the Drug and Alcohol sector, we are witnessing an increasing number of deaths whether due to drug use, alcohol use, physical health issues, or mental health challenges. These sad outcomes often lead to coronial inquests, where the coroner seeks to establish:

1. Who was the person?

2. When did they die?

3. Where did they die?

4. How did they die?

Coronial inquests are deeply emotive experiences for everyone involved, staff who worked with the individual, organisations, and most importantly, the person's friends and loved ones who are seeking closure and understanding of the events that led to their death.

Inquests can take several years to be held, so it’s understandable that those involved may feel anxious, worried, and desperate for closure. Statements provided during these proceedings, must be factual and honest, offering both the coroner and the family a clear account of what happened and what support the person received. They should also acknowledge any missed opportunities and reflect on how we can learn from them to reduce the risk of future deaths.

However, one crucial aspect is our use of language.

How we describe the person and their engagement with services matters.

Whilst our aim is not to police language as this is personal, we should look to understand the impact of certain language, and by doing this we reduce the risk of blame being propositioned to the person.

“Failed to attend”

“Did not engage.”

“Non-compliant”

“Using Illicit substances”

“Dropped out of treatment”

“Not made any progress”

“Not accepting support”

“Hard to engage”

“Due to the person being intoxicated”

While it’s important to present the facts, we must strive to do so in a way that is balanced and respectful. Loved ones may be hearing this information for the first time, and this is their story too. We should tell it truthfully, but with compassion, remembering the person in a positive light. After waiting years for answers, how would we feel if we heard blame being placed on our loved one?

This raises an important question: What does engagement really mean? What we perceive as positive engagement may not align with the person’s own experience. If someone wasn’t attending or engaging, instead of saying “failed to attend,” have we truly considered whether the service was accessible, attractive, and designed to meet their needs?

Building a service that people trust takes time, what did we do to earn that person’s trust?

Did we genuinely listen to what the person wanted/needed?

These are the challenging questions we must ask ourselves, rather than defaulting to phrases like “failed to attend” or “did not engage.”

Call to Action:

Loved ones should never be left with a feeling of blame or shame about their friend or family member.

Let us commit to using compassionate, respectful, and non-blaming language when describing individuals in coronial inquests and service records. Every word matters especially to the loved ones seeking closure. Instead of defaulting to terms like “failed to attend” or “non-compliant,” we must ask ourselves: Did our service truly meet their needs? Did we earn their trust?

We must reflect honestly on missed opportunities, challenge our assumptions about engagement, and ensure our services are accessible, person-centred, and trauma informed. By doing so, we honour those we've lost and actively work to prevent future deaths.

Paul Woodward

Reducing Harm Manager

Phoenix Futures.