I enclose transcript of two letters as evidence (points 2. and 3. below), and a brief summary of the case (point 1.)
2. Transcript of letter from Clifford Chance LLP to Chief Coroner dated 3rd March 2020
3rd March 2020
Dear Chief Coroner,
Case no. 3682/16: Inquest touching on the death of Christopher Laurence Laskaris (Deceased)
We write on behalf of our client, Fiona Laskaris (“Mrs Laskaris”) in relation to the inquest into the death of her son, Christopher Laskaris, who was murdered in November 2016.
The inquest was held at Wakefield Coroners’ court, before West Yorkshire Area Coroner, Mr Leach (“the Coroner”). The inquest was held on 3rd December 2019 for one day, with the verdict being given the next day on the afternoon of 4th December 2019, with Pre Inquest Reviews (“PIRs”) in September 2018 and February 2019.
We would be grateful if this letter could be direction to the appropriate party if we have addressed the letter incorrectly.
Christopher was a vulnerable man with high-dependency autism. He was completely isolated from the help he desperately needed, and had been forced to live in a terrible state of neglect owing to the failure by the Leeds Autism Diagnostic Service (“LADS”) to carry out a proper autism assessment for Christopher. The LADS assessment failed to meet NICE guidelines for a diagnostic assessment of adults with autism and perhaps most critically, failed to conduct a formal risk assessment of Christopher’s needs for treatment and care.
In October 2016, two police officers forced entry into Christopher’s home due to welfare concerns. The police arranged for the door to be fully boarded-up; however, the boarding was subsequently removed to allow Christopher access and this resulted in his home having been left unsecure for a period of five days before a temporary lockable door could be fitted. During this period, a violent criminal, on probation, entered Christopher’s home, groomed him in order to use his home to take illegal drugs, and, within a few weeks, murdered Christopher.
At the trial in May 2017, the Honourable Mr Justice Goss said of Christopher that “his difficulties in life were not of his making … he needed help and support, not exploitation and abuse”. Christopher’s murderer was subsequently convicted and sentenced to life imprisonment, with a minimum of 25 years.
Thereafter, Mrs Laskaris’ experience of seeking answers following the death of her son has been deeply distressing and concerning. At every corner she has encountered a system that seems designed to thwart her search for the truth behind the circumstances that led to her son’s death.
A major cause of her distress has been the decisions, behaviour and attitude of the Coroner overseeing this case. His decisions regarding the scope of the inquest are subject to a judicial review process in respect of which we are also instructed. However, at times during this long process, the Coroner appears to have shown, at best, an alarming disrespect, and, at worst, contempt, for the Laskaris family and her legal team. Mrs Laskaris is eager to raise these issues in the hope that improvements can be made so that other grieving families do not have to go through the same experience. Indeed, it appears from correspondence we have received that she is not alone in finding Mr Leach’s conduct wholly inappropriate.
By way of example, Mrs Laskaris wishes to raise the following concerns that emerged during her experiences of the inquest.
Treatment of Vulnerable individuals
*** was Christopher’s only friend at the time of his murder. [personal details removed]. He was understandably traumatised by his police interview following the discovery of Christopher’s body and consequently was terrified of giving evidence at the inquest (as he had been at the criminal trial). *** was not separately represented as an Interested Person and so had no one there to represent his interests at the inquest.
Notwithstanding this, the Coroner failed to consider special measures. Rule 17 of the Coroners and Justice Act 2009 provides for witnesses to give evidence by video link (as Daniel did at the criminal trial). However, the Coroner did not adopt this approach.
Regretfully, the evening before the inquest, a[n] [personal details removed] incident involving *** took place, and *** was accordingly unable to give evidence at the inquest.
Despite the disturbing nature of this turn of events, and their significance to the inquest, the Laskaris family was only made aware of the incident on the morning of the inquest during the course of proceedings. The Coroner, dealing with housekeeping matters before the first witness (Mrs Laskaris) was called, simply stated:
‘Secondly, I have received, well the office has received, a telephone call from the Mother of ***, who was due to give oral evidence. As a result of issues involving himself, [personal details removed]. On that basis I have informed his family that his attendance at court was not required and his evidence was such that I was happy to admit his evidence pursuant to Rule 23.’
It is not clear what the Coroner meant by “issues involving himself”.
The family remain close to *** – who was a source of great support to Christopher during a difficult period in his life. On hearing this news, Ms Laskaris was incredibly upset, as was her daughter, Cara, who was also present. They were both forced to leave the room in tears. The Coroner could have easily arranged for this news to be sent to them before the inquest had started, including via her legal team, who were in regular correspondence with the Coroner’s office.
Despite the family leaving the room distressed, the Coroner quickly moved on to further matters without suggesting a short adjournment.
This lack of sensitivity unfortunately set the tone of the Coroner’s attitude to the Laskaris family throughout the inquest. Mrs Laskaris’ barrister (acting pro bono) asked at the outset of the inquest for Mrs Laskaris to give evidence later in the day and not first, as had been set out in the schedule of witnesses.
Mrs Laskaris was very nervous. She had never given evidence at an inquest (or in any courtroom setting) before. With the media present, she was understandably wary of talking about the murder of her son and the events leading to his tragic death. Additionally, she was shaken and upset, having only just heard the shocking news about ***.
Neither barrister for the other interested parties opposed the application. Despite this, and without any consideration, the Coroner rejected this application in the following terms:
Barrister: “Thank you, sir, and thirdly there is a witness list, and Mrs Laskaris is currently down to give evidence first and she has requested…”
Coroner: ‘I will be taking her first. If she doesn’t want to give oral evidence then I will admit her documents…’
Barrister: ‘She would like to give oral evidence. She was hoping that she could give oral evidence a bit later in the proceedings mainly because she is rather nervous and I have asked the two other advocates, and I don’t believe there is any opposition – no view or opposition to that. Of course we are in the coroner’s hands, sir.’
Coroner: ‘Yes, we will take her first, I think it’s appropriate to take her first’.
This caused, in her view, unnecessary additional pressure and distress during an already traumatic process. The Coroner had, of course, just witnessed Mrs Laskaris being so distressed by the news about *** that she had to leave the room (although she had not had the benefit of any adjournment).
There were also other incidents which revealed the Coroner’s dismissive attitude to the family.
a) In May 2018 (four months before the first PIR), Mrs Laskaris made a request on health grounds for the inquest to be transferred to Woking, her local coroner’s court. She was told that the Coroner would deal with this request at the first PIR. However, he proceeded to hear submissions on various other issues before then ruling that the PIR could not proceed until the result of a transfer request to Woking Coroner’s court was available, which he had not yet made. This abortive hearing was very costly for Mrs Laskaris – who at this point was paying for a barrister and solicitor, as she felt unable to represent herself in a complex case with health concerns (see below). She did not have the benefit of legal aid funding. It also involved the significant cost of travel to Wakefield from Surrey.
b) Woking Coroner’s Court rejected the transfer as the Woking Coroner said that, based on information supplied to him by the Coroner, that the inquest was likely to be a lengthy Article 2 inquest, with many witnesses called from the local area (Leeds).
c) However, the Coroner later decided the scope was incredibly narrow, with only three professional witnesses giving short live evidence.
d) At the first PIR, and contrary to Mrs Laskaris’ wishes, the Coroner disclosed Mrs Laskaris’ confidential and personal medical information in open court. The press subsequently reported that she [personal details removed], and this information is now publicly available (and debated) on the internet Mrs Laskaris is devastated, as she had hoped and expected that this information would remain private.
e) In his written ruling that Article 2 was not engaged, the Coroner repeatedly confused the names of Christopher and his murderer. The family, understandably, found this extremely distressing and were shocked that such a mistake would be made in an important legal ruling. They felt it showed that the Coroner had not read the documents with sufficient care and had taken a cavalier attitude to the most distressing event ever to have taken place in their lives.
f) Following a complaint made by Mrs Laskaris’ solicitor after the first PIR, the Coroner apologised for “transposing some surnames” in his ruling and for disclosing her personal medical information. This apology (which was only provided as a result of a written complaint) came across as perfunctory and dismissive. Indeed, the Coroner then proceeded immediately to apologise for the temperature in the room, giving the impression to the family and their representatives that the temperature in the room and incorrectly referring to the deceased person by the name of their murderer in a written ruling were of the same magnitude. The family felt that this was a deeply inappropriate comment to make.
g) During Mrs Laskaris’ evidence, the Coroner’s body language was also far from appropriate. He was repeatedly leaning back and giving the impression of not really listening to what Mrs Laskaris was saying. In the previous PIR he was also leaning back and rolling his eyes upwards when the family’s barrister gave submissions as to the relevance of Christopher, with his recognised disability and extreme social phobia, having no front door for five days in a high crime area of Leeds.
h) The Coroner seemed unconcerned about the impact of the proceedings in Wakefield on Mrs Laskaris’ [personal details removed]. He commented that she had managed to get to Wakefield and therefore she could travel, implying this was not a genuine issue for her and contradicting her [personal details removed] written advice. He did not think to ask Mrs Laskaris about the impact of her previous travel to Wakefield nor did he give any cogent reasoning for his taking a view contrary to that of a medical expert. In any event, he was wrong: she had travelled at considerable cost to her health, [personal details removed] prior to the final inquest. Even more concernedly, the Coroner was aware at the first PIR that Mrs Laskaris [personal details removed]. He was again dismissive of Mrs Laskaris’ health condition in his final ruling on the day of the inquest refusing the renewed application for an adjournment and transfer to a coroner’s court more local to Mrs Laskaris.
Mrs Laskaris felt dehumanised and deeply traumatised by the inquest, which was held 200 miles away from her home. Mrs Laskaris felt as though the proceedings were run for the benefit of the state agencies.
Before the inquest, the family’s legal team – acting pro bono – had written detailed submissions as to the scope of the inquest and whether Article 2 was engaged, following the commission and receipt of further expert evidence regarding the assessment on Christopher of the autism services in Leeds and the effect of his lifelong impairment. The Coroner initially refused to provide any reasons at all for refusing the application, despite requests from the family’s solicitor that reasons be given. Eventually, the Coroner indicated that he would provide his reasons on the first morning of the inquest. The Coroner then dismissed the application with a short oral decision at the beginning of the inquest.
The family’s barrister sought written reasons so that they could consider whether to challenge the Coroner’s decision via judicial review. The Coroner simply stated that “You can ask for a copy of the recording and you can do your own transcript”. The Coroner clearly had no regard for the costs and time constraints for a family acting without legal aid.
At the end of the inquest, the family’s barrister sought to renew the application for written reasons. He pointed out that getting a full transcript would take money and time. Despite clearly having written reasons he was reading from, the Coroner refused to share these written reasons with the parties. The family have since obtained their own transcript from the audio recording of the inquest and has written a pre-action letter and intends to issue an application for judicial review of the coroner’s decision.
The Coroner did not invite any legal submissions before giving his verdict. He simply began by reading out his verdict, without allowing the lawyers the opportunity to address him on the law. The family’s legal team, present at court, seemed surprised by the unreasonable attitude shown by the Coroner to due process. The Chief Coroner may consider that this is also at odds with paragraph 23 of this own guidance (No. 5 on Conclusions) which indicates that submissions should be invited from interested persons in ‘more complex’ inquests where the parties are represented. No reasons were given for his ruling on conclusions either – again, contrary to good practice and the guidance provided by the Chief Coroner.
Mrs Laskaris is deeply concerned that bereaved families are treated in this manner at inquests. In Christopher’s case, this has taken a huge toll on the family, both financially and emotionally, and they still have none of the answers they need. Without these answers, they cannot process the loss, nor can changes be made to prevent future deaths of vulnerable people in the same preventable circumstances.
It is important that families in similar situations are not treated in the manner set out above. The treatment of Mrs Laskaris and her legal team by the Coroner has been insulting and, in our view, highly irregular. In this instance, Mrs Laskaris was able to secure some legal representation by virtue of the generosity of counsel acting pro bono. You will, of course, be aware of the wider concerns about the availability of legally aided representation for families and the risk that other families will find themselves without any legal representation at all. It is therefore of even more important that coroners act fairly, with sensitivity and compassion for the bereaved and that they put the family at the heart of the inquest while fully, fairly and fearlessly investigating the death. We therefore consider it necessary to take the unusual step of alerting you as to the circumstances of this case, and to request that you ensure that appropriate standards are upheld for all coroners over which you exercise oversight.
Clifford Chance LLP
3. Transcript of letter from Fiona Laskaris to Chief Coroner dated 22nd August 2020
22nd August 2020
Dear Chief Coroner,
Case no 3682/2016; Inquest touching the death of Christopher Laskaris deceased
I am the mother of Christopher Laskaris. I am writing to you further to the letter dated 3rd March sent on my behalf by Clifford Chance raising serious concerns about the inquest into my vulnerable autistic son’s death, held in December 2019 at Wakefield Coroner’s Court before former West Yorkshire Area Coroner Mr Jonathan Leach. I am attaching a copy of this letter as I am not sure if the original reached your personal attention.
My purpose in writing is to request that you take steps to relist my son’s inquest due to serious concerns regarding Mr Leach’s unfair and inappropriate conduct of inquests, as evidenced by a number of serious similar complaints made against him by other bereaved families. I understand that following all these complaints Mr Leach now no longer sits as a coroner.
Following state agency failures over many years to diagnose and support my son’s autism, he was left living alone in a terrible state of neglect in a dangerous area of Leeds some 200 miles away from his concerned family. This was despite a well-documented history of abuse and neglect, including being beaten up by a violent neighbour the previous year causing him to abandon his flat, and multiple documented safeguarding concerns raised by family and professionals alike, all flagging his inability to live safely independently without appropriate support.
My son lost his life after a violent criminal, who had just been released from prison on licence and housed nearby, wandered into his flat as a passer-by during a period of 5 days when there was no functioning front door. Special constables on a passing patrol had recently broken it down due to welfare concerns for the occupant after hearing shouting from inside and a coffee jar coming through the window. The officers found Christopher alone and distressed inside, in a mental health crisis. They forcibly removed him from his home, then arranged for his front door to be fully boarded up, with no arrangements for him to regain access and stay secure inside. Somehow the boarding was ripped off – we do not know how or by whom as this has not been investigated - and it then took 5 days for a temporary lockable door to be fitted.
Mr Leach refused our request for disclosure of the police logs and records relating to their interaction with Christopher at this critical time, and therefore we have been unable to ascertain whether or not officers returned to the flat and were involved in the removal of the boarding and then left the property unsecured with its vulnerable occupant inside. We feel this was very unfair to us as a family as it has left us with many unanswered questions and an incomplete picture of events which led to Christopher’s murder.
International autism expert, Professor Patricia Howlin, in a detailed report which was sent to the coroner, stated
“ I consider it inconceivable, and totally unacceptable, that Christopher was left to cope in accommodation in a high crime city area with no front door for five days and was then provided only with a temporary door…..Christopher’s difficulties in making social relationships with his peers were persistent and pervasive and had been documented since his initial contacts with child mental health services. Indeed his social anxiety in early adolescence was so severe that Dr Connor described him as having “social phobia”. Thus it is most unlikely that Christopher would ever have met Philip Craig had his property not been left unsecured. In addition the social vulnerability of someone with autism means that Christopher was probably neither able to recognise the potential danger of allowing strangers into his flat, nor able to protect himself from being exploited by such people. It is my opinion that for Christopher to have been placed in such an obvious position of danger represents a total failure of care by local services”
All the evidence, including that heard at the murder trial, showed that Christopher was a virtual recluse. He had lived for four years in Leeds but, as Judge Goss recorded in his sentencing remarks (which Mr Leach had been sent) had made only one friend in the city, ***, who he had met when they were living together in sheltered accommodation in 2013. Christopher’s severe social phobia meant that he rarely went out because he was so afraid, and if he did it was normally to visit *** by pre-ordered taxi so as to avoid meeting people.
Mr Leach dismissed Professor Howlin’s report, having previously dismissed a witness statement from the National Autistic Society explaining the particular vulnerability of people with autism. He dismissed without explanation the recorded recent findings of the Maudsley Hospital, a National Centre of Excellence with an international reputation in autism, that Christopher had a diagnosis of autism and his capacity to make decisions about his own care seemed to be impaired, which was likely to be due to his autism. He stated that, in his opinion (which contradicted all of the expert evidence) the prolonged lack of a front door was not relevant to Christopher losing his life because he could have met the murderer anywhere as he lived nearby. Therefore this serious safeguarding failure, which clearly for a very reclusive and vulnerable autistic person contributed significantly to the tragic events which followed, was excluded from investigation at the inquest, and the police and local authority were not included as Interested Parties.
It seems that Mr Leach’s consideration of all the evidence was perfunctory. As a result of his decisions on the scope of the inquest and engagement of Article 2, which were at complete odds with the stated views of the Woking coroner (based on information supplied to him by Mr Leach )after I had asked for the inquest to be moved to my local coroner’s court, there has been no investigation into the door issue, or any of the other serious concerns relating to Christopher’s lack of appropriate care and support as a disabled autistic person who was receiving Disability Living Allowance at the highest care component rate when he was murdered. It seems therefore that the scope and quality of investigations at inquests is entirely a postcode lottery, which is clearly unfair and unjust.
Mr Leach did not appear to have undertaken any meaningful preparation for the inquest, evidenced by the fact that in court, when reviewing the probation issues, he merely read out verbatim the lengthy report supplied by the Community Rehabilitation Company and then agreed with it, without even allowing my barrister to make submissions on it. He was openly oppositional and hostile to us as a family. This was noted and commented upon by other independent observers present. By contrast his manner towards the police and probation service witnesses and barristers was warm, friendly and supportive.
All this has left us with many unanswered questions, which could - and we believe should - have been answered through the inquest process. This has greatly added to our distress and trauma, leaving us with an open and agonising wound. The title of Bishop James Jones’s insightful report into Hillsborough comes to mind: “The Patronising Disposition of Unaccountable Power”.
Other police forces have a policy to make arrangements to allow an absent occupant back into their property if their door has broken down by the police and then boarded up, by fitting a lock and padlock and giving the occupant the key. The Metropolitan Police policy states:
Where it is necessary and appropriate a padlock will be fitted to allow access to the property. If the owner/occupier is not at the scene the padlock keys will be left at the nearest police station.
This would have saved Christopher’s life. But following Mr Leach’s alarming decision West Yorkshire Police have refused to change their boarding policy to make it safe and bring it into line with that of other forces. The Police and Crime Commissioner’s office told me recently:
“we have not been able to persuade West Yorkshire Police that … there is a need to review its door boarding policy. In the case of the door, West Yorkshire Police maintains that its obligations ceased when Mears boarded up Christopher’s door to make the property secure and that this has been echoed by the Coroner recently.”
Mr Leach has been the architect of bad case law with a decision which flies in the face of the statutory safeguarding duties imposed under the Care Act 2014 on the police, local authorities and NHS in relation to vulnerable people. He has legitimized boarding vulnerable people out of their homes - effectively making them homeless - leaving such people in West Yorkshire at a much higher risk than those in other parts of the country, and performing a great disservice to autistic people and their families across the UK.
Throughout all the investigatory processes we have been faced by hostility, opposition and obfuscation, with contradictory versions of events provided at every turn by the police, the Safeguarding Board (which refused my request to carry out a statutory safeguarding review claiming that Christopher did not have care and support needs) and the other authorities. Christopher’s mobile phone records produced by the police have strategic gaps in them coinciding with his contact with the force, including the period when he had no front door, and the force failed to make a referral to the IOPC for an independent investigation, even after they heard the murderer describe in court how he had first met Christopher by wandering in opportunistically after the door had been broken down by the police (corroborated by the other evidence).
The authorities have tried to smear Christopher’s character and reputation by claiming that he was just a drug addict who had met the murderer out and about on the estate whilst looking for a drug fix, which all the evidence shows was completely untrue. Christopher was a victim of “cuckooing”, as all the murder trial evidence showed. The criminals used his property to take hard drugs, but Christopher did not join in.
This is the very worst thing you can do to a bereaved family. Not only have we lost Christopher, but we have lost our family life, our privacy, our health, our hopes for the future and everything in which we had previously had faith, eg the competence and integrity of the police and other public services, the coronial system, and the justice system itself.
Our request to have the inquest reopened by judicial review was refused in the High Court and I have now been ordered to pay the coroner’s costs of several thousand pounds in addition to my previously incurred legal fees. This has left me in great financial hardship as I have only been able to return to work in a very limited capacity [personal details removed] as a result of the protracted trauma I have suffered. I had really struggled to fund my legal representation as I did not have legal aid for the inquest, but the judge severely criticised my “delay” in bringing the challenge, despite it being filed within the time limit. Unlike the coroner, who had unlimited access to taxpayers’ money to fund his legal representation, I had to wait for my own lawyers, acting pro bono, to find time to deal with this complex case in between their paid work.
The judge was reluctant to override the coroner’s decisions as she stated that he had seen and reviewed all the evidence, which she had not. In Mr Leach’s case, however, this was an ill founded presumption. He had clearly demonstrated to us that he had scarcely considered any of the evidence; he had even repeatedly called my son by the name of his murderer in one of his written rulings. Apparently forgetting the name of the deceased was not uncommon for Mr Leach – a complaint against him was made the next month by another family who said they were “disgusted” that he repeatedly called their loved one by the wrong name during the hearing. They too complained that there had been no full and fearless investigation into their loved one’s death.
Whilst Mr Leach’s departure is good news for others, what about the cases, such as Christopher’s, where there has been no appropriate level of scrutiny at the inquest, and no prevention of future death reports where they were clearly warranted? In the circumstances I believe all these cases should be relisted for hearing, as Mr Leach’s inquests have fallen so far short of acceptable standards of coronial investigation.
I cannot put into words how we, as a traumatically bereaved family, have been affected by Mr Leach’s conduct of my son’s inquest. [personal details removed]. It is very shocking that innocent individuals not only have to endure the loss of a loved one in such tragic and terrible circumstances, but then have to suffer in this way through inappropriate care and conduct at inquests. Christopher’s inquest has taken a huge toll on us, both financial and emotionally, and we still have none of the answers we need to begin to process our loss.
Christopher was just 24 years old. He was, as Judge Goss stated in his sentencing remarks, “an intelligent and gifted man”. He had won an academic scholarship to Charterhouse School and was selected to play in the National Children’s Orchestra. He could have done so much with his life had the authorities put in place suitable “reasonable adjustments” for his disability. Instead he suffered a lifetime of neglect and abuse by others, due to professional failures identified by Professor Howlin which have been not been investigated as they should have been. This is despite all the legislation brought in to protect people like him, including the Care Act 2014 and the Autism Act 2009 and subsequent Statutory Guidance. Mr Leach’s conduct of the inquest, and his decision on its scope, has given a strong message to the authorities that all this legislation, including statutory safeguarding duties for vulnerable people, can be ignored with impunity. The failures are therefore now likely to be perpetuated and other vulnerable autistic people will suffer and potentially lose their lives like Christopher did.
I am sure if Christopher had been your son, and we had been your family, you would also feel completely failed by the judicial processes involved which have resulted in there being no independent investigation whatsoever into why such a vulnerable young man was left by the authorities with no appropriate care and support for his disability, in such a dangerous situation with no functioning front door, many miles away from his concerned family.
Thank you in anticipation of your time and I do hope that, as Chief Coroner, you will be in a position to review and take steps to rectify the damage caused by Mr Leach’s conduct of my son’s inquest, relisting the inquest for hearing at an independent coroner’s court with no connection to any of the authorities in Leeds.
Fiona E Laskaris (Mrs)
*** name of friend redacted and personal details removed