Written evidence from Dr Rebecca Montacute


              My mum died in 2018 after several failures in the mental health care she received. Because she died in community mental health care, I had no right to a lawyer at the inquest, and had to get one myself with no state funding. Since my mum’s death, I have campaigned for improvements in mental health services and the coronial system. My experience of the inquest process is outlined in this BBC news article, and more information on what happened to my mum is available at Julie’s Mental Health Foundation.

  1. The extent of unevenness of Coroners services, including local failures, and the case for a National Coroners Service

I have heard from others that coroner’s can give very good, detailed and comprehensive support to bereaved families, but that was very far from my own experience. 

The communication we had from the coroner’s office was either messy, confusing or completely non-existent. This was extremely distressing when, as a bereaved relative, it is very difficult to get yourself to engage with the process in the first place.

I received almost no information about the inquest process from the coroner. The only information I was provided was 3 days after my mum’s death, when we went to identify her body. While we were waiting to go in, on the table there was an A4 leaflet from a charity (not actually the coroner themselves), very briefly explaining the process. However, it did not include any information on what to do if you had concerns about the circumstances around your loved ones death (my mum had died following failures in her mental health care), and I was not told I was allowed or may want a lawyer from the coroner’s office.

I had never really heard of a coroner before (my mum was my first close relative to die), and I had no idea what the process was, what my rights were, and that with a case like my mum’s, I should have a lawyer. It was only because a close friend of mine is a lawyer working on inquests that I received any of this information, and that will not be the case for many other families (especially those from lower socio-economic backgrounds, who will be less likely to have this sort of contact). I did not receive the Ministry of Justice’s Guide to Coroner Services, which I only learnt about much later through the charity INQUEST.

My lawyer (a recommendation from my friend) had a large amount of experience representing families at inquests, and as a coroner himself (in a different part of the country - he hadn’t been to a case in this area before). He was surprised that no prevention of future death order was made in relation to my mum’s death, despite 9 failings (including one gross failing) in her care from mental health services. It felt very unfair to think how reliant the outcome of the inquest was on the individual coroner you happen to get, and what appears to be a lack of a joined-up approach across the country. It feels very much like a postcode lottery, depending on where your loved one happens to be when they die.

I also think there is a risk that coroner’s in local areas can become de-sensitised to failures which frequently occur in their area, because they become so used to hearing about them that they feel inevitable. Without external oversight, I think they can miss patterns and issues which may arise. During my mum’s case, the coroner commented that he saw one of the mental health teams involved often, and I personally found many similar stories to my mum’s in the same area. However, there doesn’t appear to be any national mechanism to properly pick up failing mental health trusts with multiple deaths, especially if some of those deaths don’t lead to a prevention of future death’s order, but where failures are present which may be being repeated – these patterns are not picked up. Having a national oversight mechanism could help to ensure local areas cannot become de-sensitised to failures, while also ensuring any learnings can also be considered in other areas of the country, rather than the same failings needing to happen again and again in different areas.

At the moment, your experience of the coronial system appears to differ substantially depending where in the country you are, and which coroner is assigned to your loved one’s case. Similar deaths in different parts of the country could lead to completely different outcomes. That is extremely unfair, and risks some areas becoming trapped in failures, with lessons not being learnt and implemented.

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


  1. Ways to strengthen the Coroners’ role in the prevention of avoidable future deaths

My mum’s inquest had a narrative verdict, with 9 failings found in her care (including one gross failing, which are all outlined here). However, there was no prevention of future deaths report in relation to my mum’s death. The coroner accepted the changes one of the two mental health teams had put forward before the inquest, despite the fact most of those failings only came to light in the inquest (following questioning from my lawyer), and the Trust had failed to identify them in their own root cause analysis. The other mental health trust involved had not carried out a detailed investigation, had not made changes, but again there was no PFD.

There is no mechanisms for failures found in a narrative verdict to be acted upon. However, I had several concerns with both mental health trust’s after what I had heard at the inquest, and felt that a death in similar circumstances to my mum’s would still be possible. Because there was no mechanism for change, I had to take action myself, writing to both mental health trusts to ask them to make changes.

I had very little progress with one of the two trusts, but the other did agree to change their policies. This Trust was not my mum’s main care provider, but had discharged her from hospital after a likely suicide attempt (a car accident, where she had driven into their area), only a few days before she died. I was concerned about their risk assessment process, as it had allowed her to be discharged with no support in place. When I first wrote to them, they did not agree to make any changes, but after I sent them a transcript from the inquest (which I had to pay for) covering my concerns, they agreed to take action, including improving their risk assessment process and improving how information from emergency service staff is communicated to their mental health team. I am certain these changes will make these services safer for future patients. While failure in these processes were identified by the inquest, without my actions there was no mechanism for the right people at the mental health trust to see this information and make changes.

While I was unhappy with the decision not to issue a prevention of future deaths order, I decided not to challenge it. I was exhausted by the inquest process and knew challenging a coroner’s decision was extremely difficult and would be costly. I also knew that prevention of future death orders are themselves often not acted upon, and that the oversight mechanism for ensuring changes are made is poor, so it did not feel worth it for the likely benefit. I therefore decided to use the energy I did have to communicate the failings in my mum’s care to the mental health trusts directly (as outlined above), as I thought this was more likely to lead to change than attempting to get a PFD order.

Whether or not a PFD issue is ordered, the system currently relies far too heavily on families going above and beyond to ensure failings are learnt from, and that is not fair. I was exhausted from months of grief, supporting my family (including my mum’s elderly parents), preparing for the inquest and clearing out my mum’s home, all alongside a demanding full-time job. But I felt that no one else was pushing for these changes and without me doing it, they wouldn’t happen, and someone else could die in the same way my mum did. The current system puts far too high a burden on families.

  1. How the Coroners Service has dealt with COVID 19

My experience of the coronial service was in 2018 and was therefore not impacted by COVID-19, but I hope that COVID-19 may have one positive impact on the coronial system.

Ideally, I would have had legal representation at the pre-inquest reviews as well as the main inquest. However, the only lawyer I could find and afford lived several hours away, and I could not afford to cover his fees for pre-inquest reviews themselves (about 2 hours in total) and the travel time (several hours each way). I asked the coroner’s office if he could call or video call in for the pre-inquest reviews (so I could just cover the cost of the time during the hearings themselves), but I was told they did not have the technology needed so it was not possible. This meant I had to represent myself at the pre-inquest review, which was one of the most terrifying things I had ever done. I had to make the case (on my lawyer’s advice) for a much wider time frame to be included in scope, looking at the weeks before her death, when my mum first started to deteriorate. The mental health trust wanted to narrow the scope, and only include the 2 days before she died. Luckily, I was successful, and it was really important for the inquest itself, with several of the failings identified happening in the weeks before her death. However, I think it was deeply unfair that I was put under this level of stress, and with a relatively small investment in technology, this would not have been necessary. I hope that changes made and technology purchased to allow video hearings during the pandemic can be utilised afterwards to allow lawyers to call in.

  1. Progress with training and guidance for Coroners

As covered in my response to Q1, I had very little help and support from the coroner’s office in the run up to the inquest, and nothing to make me think staff there had any sort of training in how to deal with a traumatic bereavement like the one I had experienced.

One of the worst parts of the experience for me came in the run up to the inquest. In the aftermath of my mum’s death, I was given very little information about how she had died. Ahead of the inquest, the coroner sent through a very large number of documents about the case, including the coroner’s report on cause of death. Without any warning, when going through this pile of documents, I was reading that the cause of my mum’s death was by drowning, just hidden in the middle of a pile of other documents. I should not have been given that information in that manner, and I could not believe the coroner had not called me when the full report was available to speak through it and check that I knew this before sending it out (and for them to have checked someone was with me who could look after me when I found out).

  1. Improvements in services for the bereaved

My experience of the inquest process was that services for the bereaved were extremely poor, and while the coroner payed lip service to the family, we were seen as a secondary concern to other parties. Below are just a few of the issues that came up in my mum’s inquest.

I was not allowed to go and see my mum’s body until 3 days after she had died. At the office, I was given no help or support, and no information on what I would see (and I had never seen a dead body before).

I also had various communication issues with the coroner’s office, which made the experience much more difficult than it needed to be. For example, there was a major issue with the date of the main inquest. I had been told the inquest date would be decided at the second pre inquest review, but after being told that, at the bottom of an email about other issues (including lots of additional and very upsetting information from the mental health trust I had not previous seen) the email said the date had been set, which I had missed and had therefore given no confirmation of receiving. When you are grieving, reading correspondents from the coroner’s office is really difficult and upsetting, and I think it was entirely inappropriate to include something so important as an afterthought in an already upsetting email. At the pre inquest review, when I was expecting a conversation about a date (and had brought along a list of dates my lawyer was free), I was told it was too late and the date was already set, and that I had been informed of it, so it was now impossible to move. The coroner’s office seemed entirely unconcerned whether or not I could attend, and much more concerned about the mental health trust’s availability. I was left terrified I wouldn’t have any legal representation (it had already been incredibly difficult to find this lawyer, who was giving me an extremely reduced rate because he was a friend of a friend), and I ended up crying in my car in the carpark of the office. Luckily, another inquest my lawyer was attending ended up being moved, so he was able to make it, but a lack of clear communication caused a huge amount of unnecessary additional stress for me

The inquest itself is an extremely difficult week for families, but no one checked on our mental welling at any point during the process. The coroner’s office had one volunteer who showed us where to sit, and kindly helped my elderly grandad in and out of the room, but this was the total of the support we were given during the week. We were not warned that staff from the mental health trust would try to speak to us or given any support on how to speak to them.

I wanted to make sure press reported on my mum’s death due to the failures in her care, but I had no idea how much I was allowed to say to the press before the inquest, and I was terrified I would accidently ruin the inquest without realising I had. Clear guidance on this from coroner’s offices would have been really helpful. I also did not realise before the inquest how expensive a transcript would be, and had I know, I would have asked a friend to make notes throughout. Instead, I was only able to pay for transcripts of short sections of the inquest.

  1. Fairness in the Coroners system

I was honestly shocked when I learnt about the coroner’s system after my mum’s death. I could not believe my mum could be failed by state agencies, but that I would have no right to legal support (or even legal advice to determine if legal support was appropriate for her case), and at just 26 years old and having just lost my mum, I was left to navigate the process entirely alone. At the same time, the agencies who were meant to look after my mum had access to tax-payer funding to pay for their own lawyers. After my mum’s inquest, I found through FOI requests that mental health trusts are receiving at least 34 times more in funding for legal representation at inquests than families are following the death of a relative in contact with mental health services – this is deeply unfair and does not encourage failings to be discovered and examined.

The state clearly acknowledges that there are instances where families will require a lawyer, for example in cases where someone died while detained in mental health settings. However, in cases like my mum’s – where she should have been sectioned but was not – families are left with nothing. It makes no sense to me that by the state failing so entirely that your loved one is given no care at all, they can end up with fewer responsibilities to them then they would have had, had they provided some care. By failing to section my mum, the mental health trust was making it easier for themselves to abdicate responsibility for their failures.

I had to find a lawyer myself, with no funding from the state. Having done so was absolutely worth it, as having that lawyer made a real difference, and I am certain not all the failings in her care would have been identified without his questioning, which went into much greater detail than the questions from the coroner. This both meant the mental health trust’s involved could learn more from her death to help keep future patient’s safe, but also did a great deal to help me process my own grief. Before the inquest, I had felt guilty for my mum’s death – perhaps the mental health team had done all they could, maybe they just couldn’t have known what she would do from the information they had. As her daughter – shouldn’t I have known and done all I could to keep her safe? (These feelings of guilt are very common in families who have lost a loved one to suicide) Knowing the extent of the failures in my mum’s care, and knowing that the people who were meant to look after her had failed to do so, is what allowed me to let go of much of my own guilt, in a way I never would have been able to do without the inquest.

Lawyers are highly skilled, they know exactly the types of questions they can ask a witness and the way in which to ask them, something I could not possibly have done myself. It’s so important families have representation when they have concern about failures, as without it, the coroner is only hearing one side of the story in that level of depth. While families can question witnesses themselves, they are not trained. They will often ask the wrong sort of questions, or miss important issues. The process can also be very upsetting for family members, making it difficult to concentrate properly and ask the questions required. Although a coroner tries to be neutral – how can anyone be neutral after hearing several well thought out questions from one side (designed with the interests of the mental health trust in mind), and nothing or poorly formed questions from the other? Could you maintain a neutral stance after listening to just one side of a story for hours on end? I could not believe the system had been set up in this way, and it is clearly not set up to identify and correct failings in care.

September 2020