Written evidence from Mr Iain Thacker, Director at Rosedale Products Europe



In May 2018 my eldest daughter Ceara Thacker took her own life in her first year at Liverpool University She was 19 years old.

2 days later we arrived at her university accommodation to clear her room. During the course of this visit, a member of the senior University team let it slip that Ceara had attempted suicide 3 months earlier. During the course of the next 6 weeks it became very apparent that Ceara had been struggling and reaching out for help since the very beginning. We received a phone call from Mersey Care who advised thy were conducting a full Root Cause Analysis. Details were given to us during that phone call that horrified us. The picture was beginning to emerge of a 19 year old vulnerable young girl with a declared history of Mental Health problems, living away from home for the first time crying out for help at every turn unbeknown to her family. We asked the university over and over again why they had not told us that she was struggling and the standard answer was because of Data Protection laws.


Improvements in services for the bereaved


We realised quickly that we needed some help answering our questions. We had a meeting with the university and with the lead professional conducting the RCA. Following that we were advised that there would be an inquest and this would last 2 hours. We were horrified and submitted a number of questions about the perceived failings back to the Coroner to be answered by both the University and the NHS. This is when the situation changed as suddenly barristers and legal teams were engaged by both organisations. We researched and found the charity Inquest. It then became apparent that we were out of our depth and that we were unable to receive any financial help ie Legal Aid.

This is the first point we want to make. How can a bereaved family, looking for answers amidst their grief be expected to match that level of opposition just to get answers. We are not wealthy, I am a retired Fireman, we live a ‘normal’ life and the funds that we would have to find would have meant us selling our house. Not something we were willing to do with Ceara’s sisters living at home suffering through their grief. Through pure chance my wife checked and we had an extension to our Home Insurance policy with Legal cover included. This proved to be our life line as they accepted our claim and we were able to fund a brilliant Legal team. The irony of the unfairness is not lost on us and this why I feel so strongly that the navigation of the system and the funding of it needs to change. Especially when it is obvious and transparent that there have been mistakes.

We now know more about inquests that we would have ever thought possible. But this has mainly been through our own research and then latterly with the help of our Legal team. Again, expecting a bereaved family to do this is cruel and unfair. Not to mention that the whole system is very complicated and we are sure that there are elements of society who would not have a clue. We are convinced that this WILL be leading to missed opportunities for prevention of future deaths.

Ceara’s inquest was eventually given 2 weeks and repeated failings were exposed. One prevention of death statement was given along with further questions regarding First Aid. Changes have been made immediately within Mersey Care as a result of Ceara’s death and improvements made within the University system. This would NOT have happened had we not been able to have a full inquest.


The extent of unevenness of Coroners services, including local failures, and the case for a National Coroners Service/ Fairness in the Coroners system


Through Ceara’s loss we have been heavily involved in a number of initiatives , mainly through Student Minds which has led us to many other parents who have suffered the loss of their children through suicide. The difference in their experiences in the Inquest process has been quite frankly shocking. We were lucky in that our Coroner was sympathetic and empathetic throughout. The scope of the Inquest quite rightly extended back to Ceara’s first day at Univeristy which built up the picture of her increasing desperation and exposed all the failings that had happened. We know that other families, dependent purely on where they live or where their child dies did not have that approach. Scope of Inquests were narrowed to ridiculously short time frames never allowing the full picture to be exposed. I feel it is almost a postcode lottery and this is quite simply unfair, unjust and again, cruel. Families have had to fight, really fight, to try and get someone to listen to them. We know of families having to crowd fund to get the resources to do this. All whilst grieving. There needs to be a standard approach regardless of where you live and there should be an independent body who can oversee decisions made and a clear pathway for families to go to if they are not happy. (Something similar to the FOS/FCA). The arrogance is deep rooted but these people are not above the law and families from all sections of society should be able to have the help and support to be able to navigate the system.


How the Coroners Service has dealt with COVID 19


Unable to comment as N/A to us


The Coroners Service’s capacity to deal properly with multiple deaths in public disasters


Unable to comment as N/A to us


Progress with training and guidance for Coroners/ Ways to strengthen the Coroners’ role in the prevention of avoidable future deaths


As with any organisation ongoing training should be a given. Case studies with learnings could be included and I feel that an annual training programme should be initiated that all Coroners should have to complete. An independent body should be built to have a robust audit process in place to satisfy the Government that fairness and consistency is being applied across the country. This would hep look at decisions being made locally and understand if an aligned approach to decisions about Future preventable deaths is being made. I am not aware that any such system exists.



September 2020