Our younger daughter Colette died an avoidable death, whilst in care at a mental health clinic/care home in Bedfordshire, at the age of thirty-five. She was killed when hit by a lorry on the nearby A1 trunk road at 3 am in the morning. She was being treated for high functioning autistic spectrum disorder and related conditions. The lorry driver was not at fault; the A1 at that point has no pedestrian access. He could not have expected to encounter someone walking on the road there. There is no lighting on the road at that point.
Clearly there were questions to be answered as to how Colette came to be walking on that road, in the early hours of the morning, when she should have been safe in her room at Milton Park clinic? How did it come about that our mentally disturbed daughter had been allowed to roam late into the night? My wife and I assumed these questions would be addressed by a coroner, at a free and open inquest. We were shocked to find how wrong we were.
A little over four months after she died a pre inquest review was held. It was going to be the inquest itself but the collision report had not been prepared by the police so it couldn’t take place. In the event, still emotionally bruised from Colette’s death, we sat in Ampthill Coroner’s Court waiting for the acting senior coroner to arrive for the review. We had been told this would be family friendly process of explanation about the inquest to come. There was apparently no need for us to have legal representation. There were just six of us in the spacious modern court room; Amanda and I, with a family friend (a retired lawyer). There were two staff members from the clinic and a lawyer for the lorry driver. The Coroner arrived late and brusquely stated that he wanted no shouting in the court. He looked at Amanda and I and aggressively and said only one of us would be allowed to speak and only for two minutes. No mention of sorrow for our bereavement or concern for how we might be feeling. He went on to say he wasn’t concerned with why Colette had died only whether the lorry driver had been at fault. As far as he was concerned it was a simple road traffic accident. The fact that it the victim was a mental health inpatient and that the death happened at 3 a.m. in the morning was of no concern to him. He envisaged the inquest would take place in a month or two and would last a few hours.
We were devastated. We were aware that there had been multiple failures in Colette’s care and treatment by various agencies and individuals. We felt that it was essential that these alleged failings were examined and exposed. Essential in order to prevent them happening again and essential for in the name of justice for our daughter. The only legal way of achieving this is though an inquest carried out by a coroner. This man was denying us that fundamental right. There seemed to be nothing we could do. We were unable to sleep that night. Amanda was physically sick with the emotional upset of it all.
We were fortunate in one aspect here. Our retired lawyer friend who was with us in court was also appalled by the coroner’s antics. He told us we needed expert legal representation. He set up a meeting for us with Leigh Day, human rights solicitors. They accepted our case and instructed Doughty Street Chambers to be our counsel in court.
Our solicitor at Leigh Day explained that she was of the opinion that not only should we have a full inquest into Colette’s death but that it had to be an Article 2 inquest; in other words a human rights inquest. The manner of Colette’s death meant that her human rights had been transgressed. So the scope of the inquest should be much wider than just the accident, with witnesses from her NHS trust, the AMHP service and the clinic being called. In order to achieve this she felt we would have to fight this coroner. She had contacted him and he was not interested in widening scope.
Another Pre-Inquest Review was called. This time there were lawyers representing Sussex mental health (Colette’s home area), Bedford AMHP service, the clinic, the consultant psychiatrist at the clinic, the lorry driver and us, the bereaved family. Still Coroner Pears refused to consider making it and Article 2 hearing or widening the scope. It was a very bad tempered hearing. The coroner actually accused our QC, in open court, of trying to blackmail him. He took the accusation back later. At the end he suggested that all the legal teams should send their depositions to each other and not to him. He had far too much mail as it was. He was not a post box, he declared. The clerk of the court had to point out to him that depositions had to be sent to the coroner by law. Again he gave way.
The legal wrangling with Coroner Pears then went on for another eighteen months. He delayed answering emails and letters. He seemed to obstruct our lawyers at every turn. We complained to the JCIO and Ombudsman about his behaviour but no action was taken. Eventually our legal team said there was no choice but to take him to Judicial Review. This is a very scary and potentially expensive road to take. There is no legal aid for this process. It is manifestly unfair that this is the only route for bereaved families to make complaints about coroners. The system is heavily loaded against the families and in favour of the coroner who has his costs covered by the state. We sent a letter before action. The coroner delayed by giving a little ground to us but nowhere near enough to ensure a proper investigation into Colette’s death. This tactic delayed proceedings but eventually, two years after her death, Coroner Pears recused himself and avoided the Judicial Review.
A new Coroner, Martin Oldham, was appointed. He was completely different. He was inclusive from the beginning. He made it clear he wanted to put Colette at the centre of the investigation. He was respectful of our loss as bereaved parents. He wanted to know who Colette was. He asked to see some of her poetry and paintings. Not only did he agree to call all the witnesses we had asked for but he also said he would appoint two expert witnesses, a psychiatrist and a psychologist specialising in autism, to give evidence. He asked us for suggestions as to who they would be. He was humane, accessible and efficient. He answered emails quickly and he was genuinely concerned at finding out the truth of what had happened. As he said in the opening words of his narrative conclusions ‘’this was never a simple road traffic accident…’’ He was the total opposite of what we had had for the previous two years. It seems extraordinary that the first coroner was supposedly doing the same job ad Coroner Oldham. Something must be badly wrong with the training of coroners that someone like Coroner Pears was allowed to conduct our daughter’s inquest, in the first place.
Coroner Oldham carried out a through investigation of Colette’s death. He found multiple failings on the part of Sussex NHS Trust, Bedford AMHP Service and Milton Park Therapeutic Campus (the clinic). The tragedy was in his view totally avoidable. However there seems to be little monitoring of these agencies to ensure that steps have been taken to prevent other avoidable deaths taking place. There are a number of issues in the coronial service that urgently need to be addressed: