“We are the forgotten grievers”: Bereaved family members’ experiences of support and mental ill-health following a road traffic collision

Abstract

Road traffic collisions (RTCs) are a global public health concern; however, research on the impact of bereavement on families remains limited. A critical realist approach was adopted to explore experiences of families suffering bereavement following RTCs, using interviews with 14 participants in the United Kingdom (UK) who have lost a family member. Three key themes were identified: (1) worsening mental health following bereavement, (2) negative impact of an RTC-related bereavement upon family members, (3) limited support following an RTC. Findings highlighted the requirement for appropriate support for bereaved families, and outlined significant flaws within the UK legal system, sentencing, and treatment of families.

Introduction

Road deaths are a global public health concern (Foreman et al., 2018), and in the United Kingdom (UK) these statistics have shown little improvement during the last decade, with 1,752 people being killed on UK roads in 2019 (Department for Transport, 2020). Huang (2016) identified the lack of research surrounding the impact road traffic collisions (RTCs) have on bereaved families, despite statistics demonstrating that road death is one of the top ten causes of death globally. Hewison et al. (2020) recognized that the best approach to support bereaved families is currently unidentified, despite research outlining the importance of individuals receiving support, and which coping mechanisms should be developed (Cacciatore et al., 2021). Tsujimura-Ito (2019) outlined that there is a high occurrence of complex grief symptoms and post-traumatic stress disorder in bereaved families. Therefore, it is paramount that bereaved families receive the appropriate support, to positively impact their health outcomes (Logan et al., 2018).

Further research into RTC bereavement is vital to inform support systems on how to best care for those who are bereaved (Tsujimura-Ito, 2019), as bereaved family members are regarded as “hidden victims” (Huang, 2016). This focus on the bereaved is critical, as Shear (2012) recognized that humans do not grieve well alone, and the complications caused by grief must be addressed to begin the healing process. Broadly speaking, bereaved individuals have reported challenges when attempting to gain support, with some victims never requesting help (Ghesquiere, 2013). A possible explanation for this limited support might be that health professionals are unsure of how to deal with bereavement (Cook et al., 2002). The review by Hewison et al. (2020) found that important themes for bereavement support include: the interaction with staff and volunteers, who should offer kindness, understanding and demonstrate compassion; timely and helpful information, which is offered alongside other sources of support; appreciation of the varying impacts when considering different causes of death; recognition that there is a limited evidence base for the effectiveness of bereavement support; and considering the different phases of the bereavement process (for instance, with long-term illnesses there might be a period prior to death, the death itself and then the bereavement period). Therefore, the suddenness of an RTC related death will impact bereaved family members in certain ways (that might be different to other causes of death), and there will not have been a “pre” period as it was not expected and there was no way for family members to prepare. Furthermore, bereavement that is sudden and traumatic (such as with an RTC) is related to major depressive disorder, post-traumatic stress disorder, and complicated grief (Breen & O’Connor, 2009).

The UK road safety charity Brake (2021) identified flaws within the UK legal system, specifically the differences in sentencing dependent upon the charge of Section 3 “causing death by careless driving” compared to Section 1 “causing death by dangerous driving,” with the term “careless” underestimating the severity of the crime. Also in the UK, RTC victim charity Aftermath Support (2020) identified the negative impact sentencing can have on families, with one of the main obstacles being the UK’s Crown Prosecution Service finding it difficult to secure a conviction for “causing death by dangerous driving.” Additionally, Road Peace (2021) called for change within the legal system and acknowledge that the perceived leniency of sentencing can come as a shock to bereaved families. Family members have reported that the impact bereavement has had on them is felt to be the least considered factor in sentencing, despite the pressures of producing a victim impact statement early in their grieving process (Reid et al., 2021).

Non-RTC related studies identified the impact bereavement can have on individuals, such as exacerbated anxiety (Eisma et al., 2020) and increased mortality rates (Prior et al., 2018). However, the generalizability of these studies may be uncertain as responses to the research may contrast dependent on the cause of death, for instance, Breen and O’Connor (2009) identified that the trauma caused by losing a loved one in an RTC often creates a grief response beyond society’s expectations. Currently, the most appropriate support to provide bereaved individuals because of an RTC in the UK is unidentified (Hewison et al., 2020). An explanation for this may be that studies involving bereaved families can be hard to conduct due to a low participant response rate (Buckley et al., 2012). Irrespective of the challenges, Huang (2016) has identified the long-term impact bereavement of this nature can have on families, and the need for timely mental health support. Therefore, in terms of RTC bereavements, more research is needed to explore the support that families receive, and how this is currently experienced by those impacted.

Materials and procedure

This study aimed to explore the experiences of individuals who have been bereaved due to an RTC involving a family member, while also providing them with a voice that is often neglected in the existing literature. Qualitative methodologies are favored for providing rich data and giving participants a voice to discuss topics that may not receive much attention (Mallozzi, 2009). This methodological approach aligns well with the philosophical assumptions of a critical realist, as outlined by Bhaskar (1998). A critical realist perspective aims to gain an understanding of experiences as opposed to a description (Vincent & O’Mahoney, 2018).

The study was conducted using semi-structured interviews, often used to avoid research becoming too invasive (Condomines & Hennequin, 2014), as it comprised of open-ended questions (Jamshed, 2014), forming a less controlled conversation. Invasive research can trigger distressing emotions for both the researcher and the participants (Schmied et al., 2011). Semi-structured interviews have been used effectively in previous bereavement research (Downar et al., 2020; Mahat-Shamir et al., 2021), so were chosen as the method of data collection. A particular benefit of using interviews is that they allow rapport to be built up between the researcher and the participants, encouraging the interviewees to feel protected and relaxed with discussing their experiences (DiCicco-Bloom & Crabtree, 2006). Feeling comfortable was particularly important in this study due to the sensitive nature of the topic and the experiences bereaved participants will have had. Due to the nature of the research, a distress protocol was used during the process, and participants were offered a follow-up debrief session to check on their wellbeing and answer any questions that they had.

Participants had to be 18 years of age or over and experienced bereavement due to a road traffic collision. The UK road safety charity Brake was able to support the study by having access to these “hard-to-reach” (or just neglected in the research) individuals, and Brake promoted the research project via their social media platforms. In addition to the recruitment via Brake, there was some snowball sampling (five participants recruited via this sampling approach), whereby participants were asked if they could recommend other potential participants (Flick, 2013).

Following ethical approval from the university ethics committee, 14 participants who took part in the interviews. The first author conducted all of the interviews, during which participants were asked open-ended questions with follow-up probes to explore and clarify, including “How would you describe the impact on your own health following the loss of [your family member] due to the RTC?,” “What support did you receive following the bereavement, either individually or as a household,?” and “What could be changed in the future to help support families following an RTC related bereavement?” In line with Braun and Clarke (2006, 2014, 2019) approach to thematic analysis, interviews were transcribed, and then reviewed, and recordings were listened to multiple times. Throughout the iterative process of familiarization, coding, and analysis, themes were identified, interpreted, and categorized, resulting in the production of superordinate and subordinate themes, which reflects moving from the descriptive level of coding through to the development of understanding represented by the generated themes. These themes were subjectively interpreted and conceptualized as patterns of shared meaning underpinned or united by a core concept to develop a broader understanding based upon the collation of the individual voices contained within the data (Braun & Clarke, 2019). The analysis of the data was informed by Lincoln and Guba (1985) criteria and techniques for trustworthiness. For instance, in terms of credibility, there was a prolonged engagement with the data over several months, audio recordings were transcribed verbatim and transcriptions were read and re-read multiple times. There was a debrief immediately following interviews, and then at a much later date the interviewer contacted the participants to see if they wanted to read or hear about the research and ask any questions they might have. Following the completion of the initial analysis by the first author, the analysis and themes identified were discussed with the second and third authors to help attest that the findings, interpretations, and recommendations are supported by the data, or what Lincoln and Guba (1985) might describe as confirmability. The generated themes provide a broader understanding of what participants have experienced, while also keeping the important individual voices of the participants evident as much as reasonably possible through the inclusion of direct quotations.

Results

Three superordinate themes were identified: worsening mental health following the bereavement, especially during the court proceedings; the negative impact of RTC bereavement on family members’ mental health; and the limited support following an RTC for families. Pseudonyms are used to ensure participants’ identities remain protected (Table 1).

Table 1. Participant demographics.

Participant pseudonym	Age	Gender	Legal relationship to the deceased	Years since RTC	Age of deceased
Lily	26	Not disclosed	Child	7	Not disclosed
Mary	Not disclosed	Female	Aunt	Not disclosed	6
Lucy	60	Not disclosed	Married partner	5	Not disclosed
Mark	41	Male	Brother-in-law	24	Not disclosed
Shannon	Not disclosed	Female	Sibling	2	22
Ali	35	Female	Fiancée	3	28
Sandra	57	Female	Mother	9	26
Mick	57	Male	Father	7	Not disclosed
Maria	42	Female	Sister-in-law	3	Not disclosed
Mandy	Not disclosed	Female	Mother	13	18
Damien	Not disclosed	Male	Father	13	18
Gemma	18	Female	Cousin	Not disclosed	6
Mia	Not disclosed	Female	Sibling	24	Not disclosed
Sydney	37	Female	Wife	3	Not disclosed

Worsening mental health following bereavement, especially during court proceedings

Participants reflected on their experiences of the criminal justice system following the RTC that led to the death of their family member. The data demonstrated participants’ frustration with, for instance, the justice process not being followed as they expected. Thus, in addition to the family bereavement, further mental health challenges were posed by the justice system, sentencing, and related processes. The following comment demonstrates this:

It just so happened on the day the magistrate was also a judge, so he decided to hear the whole case there and then, and we hadn’t prepared for that, so when they said to me do you want to read out your victim impact statement, I wasn’t ready to read it that day. If I have one regret, it’s really that. The judge said I have already read it, but you can read it out to the court if you want. And it was almost like saying don’t bother. (Mick)

These negative experiences were elaborated on by other participants, with the sense that the victim feeling less important in comparison to the perpetrator being identified throughout the data collection. Participants provided examples of receiving what they felt was inferior treatment and the negative impact that had upon them. The following statements highlight this:

The whole court case being dragged out has made all of us kind of feel like we can’t kind of move on. The fact that he’s still driving round despite what he’s done, that caused quite a bit of anxiety [for] me. I just feel like my brother’s taken a second seat to the lorry driver. (Shannon)

The court was horrible because they don’t separate the people. [The driver’s family/friends] were standing there laughing and joking and kept looking at us. When the door was open for us to go into the court, we had to stand back and let them walk in first. The driver was sentenced to six years. In the end, he served 1 year [and] 363 days; 2 days off the 2 years purely for the fact that prison doesn’t release anybody on the weekend… There was an [item of clothing]. To them that’s nothing but they circled it as evidence. I asked them what happened to it, “oh we must have left it there.” I said to him well, where’s [the family member’s] sunglasses and they said brutally, well they probably flew off in the collision. (Sandra)

In addition to the personal reflections on their own poor mental health, the data provided explicit examples that demonstrated the significant impact the RTC had upon the broader family and their relationships.

Negative impact of RTC bereavement on family members’ mental health

Although not being present at the RTC, the (extended) family of the deceased are also victims due to their experiences of the death of their relative. Participants reported how their mental health was negatively impacted because of their bereavement, and the ripple effect this had on their family dynamic. Distinct from the stress related to the criminal justice system proceedings, the loss of family member, and the nature of the loss carries its challenges to individual and family mental health. Participants expressed the strain this placed on some of their relationships, as the following excerpts highlight:

It definitely affected my relationship with my husband. Sometimes frustration… I feel he doesn’t fully understand. I think there’s an extra layer of dynamic in that we’ve had to put in place or deal with challenging situations with our son as a result of his grief. (Maria)

I think the hardest thing definitely between myself and my sister is our relationship has been quite challenging over the years because of how differently we dealt with our mum’s death. There were some challenges initially. She missed me and wanted me at home, but I didn’t want to give up on my studies. (Lily)

In addition to the impact bereavement had on relationships, all participants identified the struggles they have faced with their own mental health. The following statements provided a snapshot of how participants suffered, although they alone do not do justice to the extent of the pain and grief communicated during the interviews:

I’d been to see her in the chapel of rest like when she was made up before her funeral. Every time I went to sleep, I had these horrific images that my brain had manufactured of what could have happened. (Mary)

We were a family that enjoyed each other’s company anyway. I think that’s intensified. I never appreciated it, not one bit did I appreciate it. My eldest daughter was eight months pregnant when [family member] was killed. Obviously, that had a massive effect on her because she was grieving and having a baby at the same time so that was really, really hard for her. (Lucy)

The mental health of the participants and their family members was reported as deteriorating considerably following the RTC. A related theme that was identified was based on the perceptions of the support following the RTC.

Limited support following an RTC for families

Participants provided information on their experiences of the (lack of) support that they received following the RTC and their relative’s death. Some participants reported no support offered at all, and even when some was either offered or provided it was felt that participants were subjected to what they felt was mistreatment from staff within different organizations (including, but not limited to, hospitals, schools, and support providers). These statements reflect some of these poor experiences. Mandy said, “support [following the RTC] for [my daughter] at school was appalling, she moved in the end” and Mary shared, “After my counselling session meeting, who then quite bluntly told me that actually because of my own mental health I have messed up my own child, I did fall into a depression.” Lucy recalled:

We didn’t think some of the staff were very good in the way that they spoke to us or didn’t speak to us. Right from when I first got to the hospital and this awful consultant just said to me, “you can hope for the best, but you need to prepare for the worst.” And I just felt every bit of strength fall out of my body. He didn’t offer me a chair, a glass of water, nothing.

Participants also described their struggles of seeking the appropriate support, and their perceptions of other family members struggling to gain that support. The following statements exemplified this further. “He doesn’t think his feelings are as valid as ours because he wasn’t blood related” (Sydney), “You don’t get referred to anyone. You just get told you can speak to these, so it’s up to you to decide and when your head is an absolute mess, you don’t know what day it is” (Alison), and “We are the forgotten grievers, the siblings” (Shannon).

I would probably say as a general rule there isn’t enough support. The guy in the car in front was a really nice man. He was obviously first on the scene and saw it all happen. He was giving CPR. He will be really traumatized by that and there won’t be any support for him. The police then gave him a lift up the slip road off the motorway and dropped him at the end of the slip road. They weren’t allowed to take him any further. (Maria)

The data demonstrated that there are many instances throughout the overall process following a fatal RTC where the treatment, support, and consideration of family members was felt to be insufficient. Therefore, these findings are important to highlight these experiences to begin to enact some positive change within the UK system.

Discussion

Participants reported that their bereavement experience negatively impacted their mental health and their relationships. Scott et al. (2020) recognized the detrimental impact sudden loss can have on bereaved family’s health and wellbeing. It is good practice to be able to prepare someone for a family member’s death (Stephen et al., 2013), however, clearly with an RTC this is not possible, and therefore additional considerations need to be put in place to support family members. This is in keeping with Hewison et al. (2020) findings, especially the considerations of a sudden bereavement and the lack of the ‘pre-bereavement’ period, which would mean that extra support would be necessary in terms of timely and helpful information to aid them through the process that they would be unexpectedly facing. It is important that individuals receive appropriate support, as this can determine the trajectory of their grief experience (Sealey et al., 2015). The support received by participants was perceived not to be sufficient, and participants did not feel that they were even “signposted” appropriately to potential support. Other studies have highlighted the negative experiences related to trying to gain support, with individuals not being assessed correctly, and the support not meeting their expectations (Dyregrov et al., 2014). These challenges may be due to very few interventions targeting complicated grief indicators (Wetherell, 2012) resulting in a lack of understanding of this complex and heterogenous trauma.

In the context of the analysis, it is relevant to consider the relationship of the bereaved to the deceased when reflecting on the support made available (either legally or socially), as Doka’s (1999) concept of disenfranchized grief outlined this type of grief is experienced by those who are subjected to loss that is not openly acknowledged, publicly mourned, or socially supported. Although the majority of the participants in this study might be considered immediate family members, the provision of legal support might be influenced by a country’s or an authority’s interpretation of the relationship. Doka (2002) highlighted “each society has grieving rules that define, and in some ways limit, the role of the griever” (p. 7), and this would extend to the support provided. Therefore, given the experiences highlighted here by the family members it is important for governments, charities, and health services to consider those ‘disenfranchized grievers’ and provide adequate, context-specific support.

Participants identified how their relationships have suffered. These findings support the work of Sandberg-Thoma (2012), who identified the difficulties bereaved family members may face in maintaining relationships. Participants also expressed the inappropriate responses they received from support systems (which was often not forthcoming), which seemed to be experienced within hospitals, police settings, support providers and schools (as described by participants). Healthcare professionals have previously admitted to being unsure of how to support bereaved individuals (Hewison et al., 2020) which has also been identified within school staff populations (McManus & Paul, 2019), who do not feel confident enough to support children when they are bereaved. Supporting bereaved children can prove to be challenging for staff members, as children may feel demotivated, reducing their academic performance (Dyregrov et al., 2020). This would again highlight the need for consideration of the contextual differences of bereavement, and how children may face very different challenges to adults in the bereavement process.

Although not a specific aspect of the inclusion criteria, most participants attended court proceedings for the offender in the RTC, and many spoke at length about the negative impacts during these experiences. Despite the ‘benefits’ of the courts being able to sentence the offender, participants felt that the criminal justice system and its process can also intensify the challenges victims are facing, which can often cause secondary victimization to occur (Parsons & Bergin, 2010). Unfortunately, when victims are dissatisfied with the criminal justice system, this also has an impact on their interest in seeking help in the future (Hotaling & Buzawa, 2003). Participants supported the existing literature by expressing the negative impact the criminal justice system had on their mental health and the additional stressors they had to manage, while also reporting poor treatment they received. These issues are exacerbated as participants felt they were given less consideration than the offender. Alm (2019) similarly found that crime victims often find themselves frustrated due to feeling they have not been treated equally. The reason may be because there are so many factors taken into consideration when sentencing offenders, such as their personal circumstances, the offender’s response to the crime and past convictions (Jacobson & Hough, 2007).

These results extend previous research and offers insights in the development of more effective support for the bereaved. Thus, it should inform UK services such as Brake, Aftermath Support, and Road Peace, as well as government and organizations that have a direct impact on bereaved families. First, a greater provision is required to adequately support the emotional welfare of the bereaved, recognizing the lack of preparation for the loss noted by Hewison et al. (2020). Support is needed immediately following the RTC as well as throughout any subsequent court proceedings, which will likely reduce the long-term negative impacts experienced. Second, greater support related to the processes and proceedings of the criminal justice system will promote the mental health of the bereaved. More specifically, support might consider the grief among (the extended) family members, the expectations and procedures of court hearings, the interactions with offenders, and the perceptions of the sentencing.

Third, provisions need to be extended to a broader group of individuals experiencing the loss. This should also include specialist support for particular groups, such as children and their support networks that include teachers. Finally, provisions should support close groups as well as individuals. The relational wellbeing within a group is a fundamental element of individual’s social and mental health (Manwell et al., 2015). These findings suggest the interpersonal functioning and interdependence can be vulnerable following such a loss, thus the group-based support should be given greater priority.

The current findings highlight the strengths and weaknesses of support provided to the bereaved. This study further highlights the need (previously made by Hewison et al., 2020) to evaluate this support and develop an evidence base that is context specific. Previous evaluation of bereavement support programs is recognized to be ad hoc and sporadic (Wilson et al., 2021).

International research has shown similar trends in the experience of bereavement and grief from, for example, the United States (e.g., Hardt et al., 2020), Europe (e.g., Spooren et al., 2001), and Japan (e.g., Tsujimura-Ito, 2019). When generalizing these findings internationally, caution is required due to legal, charitable, and health structures found within the UK. However, it does demonstrate the engagement with multiple services, for groups and individuals, through various contexts is needed throughout a prolonged period of grief.

It was noted that the participants involved in the study were predominantly women, which is in line with several other studies on bereavement (Hewison et al., 2020). This is both a limitation in terms of transferability of findings and also an area for future consideration. Stelzer et al. (2019) discussed the many similarities in the grief of men and women; nevertheless, grief is different for everyone, and making specific judgements or generalizations about the grieving process can be detrimental (Zisook & Shear, 2009). However, although there are specifics of the UK context and systems referred to here, as Smith (2018) suggested many points may resonate with individuals in other countries or contexts, as they consider how the findings can be applied to their own settings.

The bereavement support provided in the UK remains varied and limited, and the evidence base for bereavement support itself is contested (Hewison et al., 2020). This study contributes to the limited evidence-base surrounding the impact road traffic collisions have on bereaved families (Huang, 2016), while also highlighting the mental health issues and lack of support that bereaved families can face. A key component of this study was providing the family members with a voice. A clear message from the participants in this study is that bereavement support is perceived to be lacking or inadequate, and that the progress in the future in this area must include a continued appreciation of the family members left behind following a fatal RTC, as they continue to feel like the forgotten grievers within the current UK system.

Acknowledgements

The authors would like to thank the participants for their involvement in the study and sharing their experiences. The authors would also like to thank the charity Brake for their support during the study.