Why can’t you hear me?

When I first met Andy and Amanda, they were not only coping with the loss of their daughter in horrendous circumstances after believing she was finally to receive specialist care, but had had their hurt compounded by the Coroner they believed could help them make some sense of their daughter’s death.

As a lawyer specialising in acting for bereaved families in inquests Andy and Amanda were not the first bereaved family I’d met who sought help because of a negative first experience with the coronial system. What was however to follow was quite extraordinary: the shocking behaviour by an Acting Senior Coroner & the stark contrast between the two Coroners - two judicial officers - who Andy and Amanda had presiding over their daughter’s inquest lays bare the appalling lottery bereaved families face in the inquest system and the mountain range to get over to get to a good one (and sadly, what Coroners can get away with).

Put shortly Andy and Amanda’s brutal journey through the inquest process took them from a Coroner who dismissed their evidence as conjecture and made them feel he had no interest in properly establishing how their daughter died, to one who placed them and Col at the centre and publicly recorded her death as avoidable, finding many failings by those who should have done better.

Seeing Andy and Amanda recently and having the privilege to participate in their book launch, has meant returning to the detail of those dark days Andy and Amanda had battling with Acting Senior Coroner Pears.

I remember well the sinking feeling I often had in the almost 18 months that followed our first meeting knowing I had yet more bad news for these lovely clients.

Here is a snapshot of their journey:

• Legal aid for the inquest was not straightforward but we got there after appeals.
• An allegation of blackmail in a PIR in March 2017.
• No answer to a complaint and a request to stand down.
• A Coroner’s Note in early May 2017 ‘increasingly terse’ and ‘sarcastic’ in tone.
• Delay.
• Still no answer to the request for another Coroner.
• One year anniversary of Col’s death comes and goes.
• October 2017 brought a negative decision on Article 2 despite no opposition from the other interested persons and an NHS Trust as well as the family arguing it was engaged.
• The first letter before action followed, the additional worry of judicial review costs on top of everything else but finally by the end of the month a concession, the Coroner accepts Article 2 is engaged.
• But...within the reasoning a description of Andy and Amanda’s evidence as “conjecture”- we were inching forward but at a hideous cost. The stress for Andy and Amanda was evident whenever I spoke to them.
• 2017 drew to a close with still no answer to Andy and Amanda’s expressions of lack of trust and confidence or their request for a new Coroner. No PIR nor the inquest was listed.
• Early 2018 brought further difficult correspondence from Acting Senior Coroner Pears. A request for their position on scope to be put “in one sentence” was complied with (anyone ever had such a request?) and a PIR listed for May 2018 – 14 months since the last one, almost two years since Col’s death.

We never made it to that PIR with Acting Senior Coroner Pears. I have sometimes wondered what another face to face to encounter would have been like...

What actually transpired led to us advising Andy and Amanda they had grounds (again) to bring a judicial review against the Coroner, this time alleging bias.

The long awaited third PIR due in May was delayed by the Coroner to 15 June. The change in date communicated to all Interested Persons resulted in first others, then us, raising concerns about availability. Despite others getting in there first, the request by Andy and Amanda to move the date for medical reasons was described by the Coroner as ‘an outcry of protest’.

The 20 page letter before action which finally resulted in the stepping down of Acting Senior Coroner Pears - from whom Andy and Amanda never heard from again, is here.

By March 2019, approaching three years since Col’s death, finally, with the benefit of two independent experts, and with a broad scope, the new Coroner, Assistant Coroner Oldham began Col’s inquest.

There are never winners in inquests but to hear Coroner Oldham describe Col’s final placement as a disaster, that it was ‘staggering’ she had been out missing the day after a serious incident, that her needs were ‘simply swept away and not addressed” and that “for most part it is difficult to understand how Colette was being helped if at all’ certainly felt some kind of victory: public recognition of the wrongs Col suffered; recognition her death should not have happened - nothing could bring Col back, but recognition of failings & accountability can and does protect others and Coroner Oldham left no room for doubt as to his findings.

I don’t know what would have happened had Acting Senior Coroner Pears not stepped down. Public law lawyers among you may read the letter before action and take a view. I hope other Coroners read the letter - there are many good ones, a few excellent, that sit in various parts of the country but it is only if we all recognise the postcode lottery & the appalling impact on bereaved families, that the coronial system might be improved and bereaved families receive a consistent, high standard and compassionate service.