Written evidence from bereaved parents

We are the parents of Sarah *** who was found dead on the 4th January 2018 while living in supported housing in ***. We are submitting this evidence because we feel the Coroner we dealt with had no empathy for the bereaved, prejudged, did not gather all relevant evidence and did not listen properly to evidence that was given during the Inquest. We also feel there are other failings that will become obvious as this statement is read. We have recently seen the Record of Inquest which was factually wrong and we feel a very inaccurate record of events leading up to Sarah’s death. If our experience is a reflection of the Coroners Service nationwide we can fully understand why evidence is being sought to improve it. We feel that the best way to submit our evidence would be in the form of a narrative of events from the day Sarah was found dead until the present day, 2 years after the Inquest as we seek to have the Record of Inquest amended to an accurate Record of Inquest.

Our daughter was found dead in her flat on 4th January 2018 while in the care of *** which was supported living accommodation that was staffed around the clock. At the time of her death *** was run by ***, now known as ***. Sarah was in supported living because of her chaotic lifestyle, she was a recovering alcoholic who in the past had been known to use illicit substances. She had multiple mental health issues including schizophrenia and psychosis and had a CPN who oversaw her weekly depot and monitored Sarah’s fluctuating mental health.  Her post mortem showed her to have died from the toxicity of a mixture of Pregabalin and Haloperidol, two medicines prescribed for her.

Our first contact with the Coroner’s Office was shortly after Sarah’s death when we were informed that there would be an inquest into Sarah’s death. The process was briefly explained to us. At the same time we were already in the process of making a complaint about the actions of staff after Sarah’s death in ***. We felt there was something not right about the circumstances of Sarah’s death and that a cover up had started as many of her belongings were destroyed. At this point we found out that the level of police investigation into a sudden death was governed by the instructions of the Coroner, or so we were told by the SIO. We felt that *** had a duty of care towards Sarah and that they had neglected to fulfil their duty of care. We contacted the Coroner’s Office and the person we spoke to told us that they had it on good authority there was no duty of care and therefore nothing to look into. The ‘good authority’ was a local manager of another facility run by ***. Coincidently the ‘good authority’ was the same person who responded to our complaints about *** and within the reply it was stated that *** did indeed have a duty of care towards Sarah. We contacted the Coroner’s Office to inform them of this fact thinking they would act on this revised information. At the same time that our complaint was being dealt with we had had a meeting with some representatives of the local Mental Health authority who suggested we should ask for the CCTV recordings in *** to be reviewed by the police. It was in requesting this to be done by the investigating officer, that we found the Police “only take their instructions from the Coroner”. These two incidents were ignored by the Coroner’s office at the time. By this time we had been given a date and time for the Inquest Hearing. We could not believe that it was to be held in a building directly opposite where we lived. At the time we had moved away from Scarborough because we had Sarah’s 3 girls living with us and wanted to put a little distance between them and their mother’s life. We felt it was extremely insensitive that the Inquest was to be held in Pickering and had expected it to be held in Scarborough. We asked if it was possible to change the venue and were told “No”.

At this point I asked who I could make a complaint to about the Coroner’s office because we were not at all happy with their involvement so far. I was told there was no system of complaint but got a facetious reply that “You could try the Chief Coroner in London”. I said I would do that and asked how I made contact with the Chief Coroner, the equally facetious reply was “Look it up on the Internet.” I did this and sent an email to the Chief Coroner’s Office. Within hours I had a very caring and helpful reply, in which he outlined the role of the Chief Coroner’s Office, stated he had no jurisdiction over individual Coroners and was sorry that we had been misled by the local Coroner’s Office. He added he would be in contact with the local Coroners Court if we were happy for him to do so, which obviously we were. He also told me how to apply to change the venue for the Inquest which we did and the venue and date were changed.

By this time we had been sent copies of the statements that were to be used at the Inquest. We read through these and amongst other things constructed a timeline of Sarah’s final hours using the statements given to the Police at the time and statements written for the Coroner. We felt that there were periods of time when little duty of care was shown for Sarah, there was contradictory evidence and all in all there was a need for a more detailed investigation into the last 48hours of Sarah’s life, as to us there was evidence that the staff of *** had neglected Sarah in her hours of greatest need. We once again contacted the Coroner’s Office with our thoughts and request for further investigation, we were not met particularly favourably. After this we found our emails were being answered by a different member of staff in the Coroner’s Office and eventually the Coroner agreed to ‘review the file’.

We were then informed that the date set for the Inquest Hearing was going to be changed to a Pre Inquest Review. Not being legally trained we were not exactly sure what this was but hoped we would be able to get answers to many questions that we had in relation to Sarah’s sudden and unexpected death. The PIR did not pan out as we had hoped. The Coroner opened the proceedings by getting the name of our daughter wrong, when I pointed this out rather than get a polite apology the response from the Coroner intimated that if he had the power I would be sent to prison for life for pointing out his error. We had already pointed out to the Coroner’s Office they had used the wrong name on the temporary death certificate, days after Sarah’s death. Presumably this information was not shared with all people involved because the Post Mortem report has the same incorrect name on it.

At the PIR we were told that we should get legal representation and under no circumstances would there be another adjournment and the date and venue for the Inquest were set. At our suggestion it was agreed that a statement would be taken from an additional member of staff from ***. The CCTV was to be reviewed at last, but it was no surprise that it no longer existed 5 months after Sarah’s death. We got the impression that as hard as we had been pushing for more investigation *** had been covering up their failings, for they were praised by the Coroner for their improvements to systems of work within *** since Sarah’s death. We left the PIR and immediately got legal support.

The Inquest was held on 4th July 2018 at a Country Hotel in the middle of nowhere. On the day of the Inquest we felt quite confident there was enough evidence for our solicitor to make a case for negligence towards Sarah and we had many questions we wanted answers to and the Inquest proceedings raised more that we could not ask, for reasons stated below. We met our solicitor at the venue and she explained the procedure of the Inquest and told us that it was normal practice for us to be sat near her so we could raise any points we had through her. This turned out not to be the case and we were seated some way from her and our expected line of communication with her had been severed. This made the hiring of a solicitor a pointless and expensive action. We have been told recently by others who have been in our position that they were able to sit within whispering distance of their solicitor and get them to ask questions as proceedings went on. Very quickly we felt that the Coroner had already prejudged his decision. We were surprised that I was called to give evidence and not my wife, as when we had prepared our statement for court we deliberately signed it so that my wife was the first signatory and in our thoughts would be called as a witness if either of us were. I raised this point while giving evidence and was told by the Coroner, quite bluntly and without explanation “I wanted to hear from you and not your wife”. This seems to be a sexist attitude and perhaps a family should be given the choice as to who will give evidence if a family member is needed to do so in this situation. During my cross examination, because that it is what it felt like, I was asked a question by the Coroner and felt he had no interest in my reply and in fact stopped me before I felt I had finished my answer. There seemed to be no acknowledgement I was a grieving parent and not a well paid legal eagle with many Inquests under their belt. Through my questioning it was obvious that the Coroner seemed more interested in Sarah’s past than establishing facts about the last 48 hours of her life. At one point our solicitor was told “You have already had an answer to that question” and told to sit down by the Coroner. We knew that the question referred to a different day to the one the Coroner was referring to, but he seemed oblivious to this. A fanciful conjecture delivered by the *** representative for *** was accepted by the Coroner without question. To us, Sarah’s parents, we knew how fanciful the description of Sarah’s last hours were, as suggestions about her possible routine were out of character. The fact no one saw Sarah conscious in over 36 hours was never questioned. When the final verdict was given we felt let down, we still had unanswered questions and a feeling that the Coroner had not actually understood the timings involved in Sarah’s last hours.

We recently, August 2020, got a copy of the Record of Inquest and this in effect confirmed our suspicions that the Inquest had been prejudged and the Coroner had not really been in complete understanding of the facts and timescale leading up to Sarah’s death. The Record of Inquest states that the hearing was held in Pickering on 14th of May 2018.Wrong. This gives the impression that the Record of Inquest had been completed before the Inquest was held, a pre judgement. It states Sarah’s partner died in 2017. Wrong. It states Sarah was seen by a support worker on 3rd January 2018.Wrong. It intimates that Sarah’s children had been taken from her in 2017. Wrong. The short paragraph that describes Sarah’s last hours gives the impression events took place over 24hours not 48hours as they actually did. There is nothing written in the section ‘Conclusion of the Coroner as to the death’ and it is not even signed. This is as we understand it is a legal document that can be read and used by various agencies. We know for a fact it has been used as evidence for a Safeguarding Inquiry and feel it is unbelievable this can happen when it is full of factual inaccuracies. 

Reading this you will see that our one and only dealing with the Coronial System has not been a satisfactory one. We felt our dealings with the Coroner lacked any compassion, did not answer the questions we had about our daughter’s death. In fact it has opened up the question would things have been different if proper investigations had been made and witness statements taken at the time and not 5 months after the event. It has been a totally negative experience and now nearly 3 years after our daughter’s death we are trying to get a Record of Inquest that reflects the truth and not imagination of an Officer of the Crown. This has highlighted that there appears to be no formal system of complaint that the ordinary member of the public can use.

This list summarises our experience of dealing with the Coroner’s Office in North Yorkshire.


*** Details witheld by Committee


August 2020