Written evidence from Mr D Blackham.


Our case summary:-

My Son Joshua, was a Police ofcer in Surrey Police who was suspended following a malicious complaint from a member of the public. He was suspended in Sept 2016 . He was arrested at the Police station while working, his home searched and possessions taken without explanation. As part of his suspension he was provided with a Police welfare ofcer to oversee his suspension. He died by Suicide on 29th November 2016 at his home (in Thames Valley.) An IOPC independent Investigation was published in Jan 2018. This found deciencies in Joshua's welfare management and Surrey Police welfare procedures. A pre-inquest hearing was held in May 2018 and a further pre-inquest hearing in November 2018 and Article 2 Inquest in May 2019. Following the Inquest the Snr. Coroner announced several PFD ndings. Subsequent to Joshua death an Independent Police force investigated the original complaint and found that, had he lived, Joshua would not have faced any disciplinary action for the charges levelled against him.


In response to the requested feedback I offer the following observations.


1.The extent of unevenness, local failures and case for National Coroners Service.


Our case was originally handled by the sitting Snr.Coroner of Reading who was due to retire in the following few months. At that time no replacement Coroner had been interviewed for the upcoming vacant post and we suffered a further 6 month delay while a replacement was appointed. We found it distressing that after suffering such delays for an Inquest there was no Snr. Coroner even interviewed to ll the vacant post. At the initial pre-Inquest he recommended a Jury inquest but failed to discuss Article 2. I appealed his recommendation and we had a further pre-inquest with the new Snr. Coroner. Despite recognising that the evidence and witnesses would be the same the Surrey Police QC argued against Article 2 as she wanted to limit the scope of the Inquest. The family felt this was unfair. Fortunately with the help to the family of pro-bono legal assistance the new Snr Coroner agreed and an Article 2 inquest was announced.


The original Snr Coroners decision was wrong and the delay in finding a replacement was distressing.This wrong decision regarding Article 2 Inquest was only averted due to the pro bono legal assistance.I support the ability of the Coroner to ask that the state fund all interested parties fairly to ensure equality of arms during an Article 2 Inquest


2.The Coroners Service capacity to deal with multiple deaths in Public Disasters.


Sadly the workload for the Reading Snr Coroner appeared to be very high, we were seeing many delays to our case. I don't know how she and her limited team would have coped with a major disaster event requiring her time over the same period..clearly there needs to be some National support for such events.


3. Ways to strengthen the Coroners role in the prevention of future deaths.


The IOPC recommendations were not enforceable. in January 2018 Surrey Police argued against the IOPC findings of gross misconduct charges at the nominated welfare officer and argued that their polices were already adequately updated.


The family was not originally entitled to legal assistance. The Police Federation refused to support the bereaved family. Surrey Police had a respected QC and supporting legal team, The nominated Surrey Police Welfare officer had his own Legal representation. But the family were left to apply for a limited legal aid support and to beg for pro-bono legal assistance, which fortunately stepped in to help argue for an Article 2 Inquest.


Following the Inquest there was a significant PFD report for Surrey Police to act on.. But I did not see any request from the Snr Coroner to review any similar deaths over recent history. The fact that HMICFRS had also highlighted inefficiencies with Surrey Police welfare procedures following previous PEEL inspections was not highlighted during the Inquest. There is no governing body accumulating and assessing the various findings from IOPC, Coroners PFD and HMICFRS PEEL audits. The learnings from Surrey Police failures are not being shared by other Police Forces.

( who no doubt could use the recommendations.) I recently approached the new National Police Wellbeing Service and sent them the PFD report as they didn't have it. I have not received any feedback.


Ultimately the PFD recommendations are not enforceable. I respectfully suggest any IOPC findings and PFD issued by Coroners to UK Police Forces are also sent to HMICFRS so that oversight, enforcement and improvements can be publicly monitored. ( and HMICFRS role is reviewed to support this)


Also there was no accountability from Surrey Police for the highlighted errors. Those responsible for managing the welfare Policies and the direct supervision of my son have not apologised for the errors highlighted during the Inquest. My only course to get an apology would be to take out a civil case. In such a case as ours, I suggest The Coroner could offer a "post Inquest review" where this could happen and allow proper closure for the family.


I support the ability of the Coroner to ask that the state fund all interested parties fairly to ensure equality of arms during an Article 2 Inquest.


4. How the Coroners Service has dealt with Covid-19


No Comment


5. Progress with training and guidance for Coroners.


The Charity Inquest has some tremendous experience and resources which should be used by the Coroners service.


6.Improvements in services for the bereaved


The learning curve for most bereaved families is huge when facing an Inquest as well dealing with the practicalities of a distressing loss and grief for their family member. For Article 2 Inquests the involvement of the State is doubly distressing and quickly creates an adversarial atmosphere. Unless the family have access to proper legal assistance, and can manage the realistic expectation of outcomes there will be needless pain and suffering for the family.


The IOPC referred me to the charity Inquest who were supportive an informative, They provided useful resources and sourced a pro bono legal advice. Without their support we would have been unprepared for the Inquest and no doubt the outcome could have been different, and certainly more distressing for the family.


I support the ability of the Coroner to ask that the state fund all interested parties fairly to ensure equality of arms during an Article 2 Inquest.


As a witness as well as an interested party the Coroner agreed to cover my estimated expenses to attend the Inquest, but after the Inquest refused to support my submitted costs stating that their funds were limited and depleted. The Coroners service needs to be better funded to offer some expenses for pre inquest and Inquest hearings. This was unnecessarily distressing.


7. Fairness in the Coroners system


In addition to the above points and our own experience with the initial Snr Coroner I also participated in the Legal aid Family group discussion held by the Ministry of Justice on 26th October 2018 and the lack of training, empathy and erratic rulings by some Coroners was very distressing to hear... I kindly suggest the Committee review the notes from this meeting and interview those family representatives attending.I support the ability of the Coroner to ask that the state fund all interested parties fairly to ensure equality of arms during an Article 2 Inquest.


I found the Reading Snr Coroner Mrs Heidi Connor very professional and supportive to the families needs throughout our case. However the lack of enforcement and accountability of the PFD process has left us without a solid conclusion. There is nothing that can bring my son back but an apology and implementation of valuable learnings to try to avoid such similar events, is all we were looking for. For this it appears the Coroners system is still not delivering its intended outcome.


24th August 2020