Written evidence from a family



To sketch a brief outline of what happened prior to M’s death, he had gone on Monday 13th October 2014, to hospital and asked for help, as he was contemplating suicide. He clearly stated that he had attempted suicide in the last two weeks, this is in two different people’s clinical notes. M was given two risk assessments, and an appointment was made for what would have been a third. He did not see a consultant psychiatrist. No attempt was made to diagnose his situation, even though he clearly was having very strange paranoid thoughts. He desperately needed help, but apart from being given three Diazepam tablets, no constructive help was provided.

He died on a railway line five days later. M had no previous history whatsoever of mental health problems or depression.  He seems to have developed a serious mental health problem over a relatively short period of time.


The key issue is that the two mental health clinicians who dealt with M claim that he was ‘not suicidal’. This is simply not true.  Their dishonesty hides their inhuman treatment of M.


The triage nurse stated that M was suicidal and that he had attempted to take his own life by strangulation.  It is important to understand that the triage nurse worked for a different NHS trust. The police knew that M was suicidal. The family knew he was suicidal. Moreover, as family members were present for part of both meetings with the mental health clinicians, we knew that they were lying when giving their evidence in the Coroner’s Court.


We think this is difficult to understand for people who have not experienced it. Imagine a much loved family member has died. Imagine then attending an inquest purportedly to establish the facts surrounding their death, and then having to listen to clinicians who should have provided care spouting what you know to be a series of lies.


We have, of course, written to the Trust, also to the CQC, the Parliamentary Health Service Ombudsman, the CCG and to the Health Minister. No one within the ‘NHS’ is really interested in trying to establish the truth.  That is why the family see the inquest as important. It is the one opportunity, independent of the NHS, to try to establish the facts. 

The family have filed a complaint with the police which was eventually investigated. to see whether a criminal prosecution was relevant,  [the police have] determined it is not, but stated in writing “ I conclude that JM lied to protect her own interests but that her actions amount neither to offences of perjury or perverting the course of justice.” The bar for a criminal prosecution is high, and, we are advised that, lying in court does not necessarily equate to perjury.

The family has, at personal expense, applied for a fresh inquest. The Trust, using public money, employed two different firms of solicitors to write to the Attorney General’s Office giving reasons why they felt there should not be a fresh inquest. The request has been turned down.


Our family has been trying over a long period of time, to correspond with the Coroner,  to raise a number of issues regarding the Inquest, and what has happened since. We have been unable to gain answers to the questions we have raised.


The Coroner has refused to respond, other than to state that “Ms M, Senior Coroner for Manchester South Area as she (as was her predecessor) was dealing with this matter as Senior Coroner for the jurisdiction”.  The Attorney General’s Office has written to the Coroner’s Office regarding the possibility of a second inquest in this case. It is our understanding that it was the Coroner himself who replied to this letter. Furthermore The Coroner stated in his reply to the Attorney General that “he was not aware of any reason for there to be a second inquest”. Was it right and proper for the Coroner to have written to The Attorney General’s Office himself, if the case was in fact in the hands of the Senior Coroner?


The former Senior Coroner stated that he would request a fresh inquest if there was evidence of dishonesty. Unfortunately he retired before all the evidence came to light. The new Senior Coroner has simply said it is not possible to do anything now the inquest has been finalised.


There are a number of issues which the family believe should be considered when looking to see if there should be a second inquest, and the Coroner had been made aware of these.




Failures during the Inquest


M asked the NHS for help. He went to A and E, which is what the NHS advises people in his situation to do. Yet he was denied help. Imagine the mental anguish the torment and trauma that then drives someone in this position to go on to the railway line and stand in front of an oncoming train. It surely has to be inhuman to refuse help to someone in this situation.


Law Sheet 5 issued by the Chief Coroner and titled 'Discretion of the Coroner' states :-

"In the well-known passage in Jamieson, Sir Thomas Bingham MR explained the duty and responsibility of the coroner: ‘It is the duty of the coroner as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without, to ensure that the relevant facts are fully, fairly and fearlessly investigated … He must ensure that the relevant facts are exposed to public scrutiny, particularly if there is evidence of foul play, abuse or inhumanity. He fails in his duty if his investigation is superficial, slipshod or perfunctory. "

M died two days after his meeting with Nurse JM. There is clear evidence to show that Nurse JM knew that Michael was having suicidal thoughts and more than this; she knew that M had been researching suicide. She lied about this during the inquest.


It would have been inhuman to refuse to help someone who had gone to A and E with the symptoms of a heart attack. Why should it be different in a mental health case?

In his statement at the conclusion of the inquest, The Coroner said :-

“There appears to be some dispute between Nurse JM and M as to the exact conversations that were held in the…second part of that conversation on that Thursday evening. One of those disputes relates to whether or not M had carried out some research into suicide, which  M’s brother, reports as finding some 20 million attempts globally per year, with 1 million success rate, and serious and significant injuries suffered by many of the survivors.

Nurse JM says that conversation did not happen, although when I repeated the question to her, she didn’t recall, um, but stressed that if it had happened, that would have been a consideration for further exploration of suicidal ideation and suicidal thoughts. I’m not going to make a finding of fact as to whether that conversation did or did not happen, er, because it assists me not in determining the answer to the question how.”


The Coroner doesn’t seem to see the necessity to try to establish the facts. He states he is required only to determine “the answer to the question how”. He surely has failed to ensure the relevant facts are fully, fairly and fearlessly investigated.


He had a fundamental duty to ensure the facts were exposed to public scrutiny, particularly as there was evidence of inhumanity.  The family do not believe the Coroner can claim to have done this.




The family advised the Coroner during the Inquest, after Nurse JM had given her evidence, that she had lied in Court.  The Coroner’s response was to say  I regard those remarks as wholly inappropriate in this Court and I will not accept it”. 


Is this a reasonable way for a Coroner to behave? If the Coroner is advised that a witness has lied in Court, doesn’t a reasonable Coroner seek to investigate this further?


Would a reasonable Coroner ask what, specifically, the lies were? And what evidence exists?


Would a reasonable Coroner adjourn the inquest, to allow some time to try to establish the facts?


Is it reasonable to have dismissed such information out of hand?


Is dishonesty in a Coroner's Court totally inconsequential?  or should the Coroner make some effort to resolve conflict in the evidence presented to him or her?  Bearing in mind particularly that in this case dishonesty could be hiding inhuman behaviour?




At the start of the inquest, it was announced that there was a connection between the Coroner and counsel to the family, as they shared chambers. The family had not been aware of this before that point in time.

The Coroner is held out as being the leader of a team of barristers specialising in inquests and counsel to the family is held out as a key member of his team.  Clearly the two are closely connected. They were connected on the day of the inquest and have continued to be connected ever since. Counsel to the family does not want there to be a fresh inquest. A second inquest is unlikely to cast a good light upon his performance, and it might even have financial implications for him.

The family wrote to The Coroner raising concerns about his connection with counsel to the family. As the Coroner was aware of the family’s concerns, we believe it was wholly inappropriate for him to have responded to the Attorney General’s enquiries himself, having a conflicting interest.





There was a failure to establish the key facts in the case. These include:-





It seems to M’s family that the Coroner’s conduct has been extremely unprofessional.


We are concerned that the Coroner has, in a former career, worked for the NHS. We are concerned that the Coroner does not seem to be impartial. He seems unwilling to countenance or face up to any possibility of dishonesty on the part of NHS workers.


We are concerned that the Coroner has written to the Attorney General’s Office whilst having a conflicting interest, which the family had previously raised with him as a concern.


We are concerned that M’s inquest was inadequate in very many respects.


More than anything else, we are concerned that there was no real attempt to establish the truth, and that NHS staff were protected whilst being blatantly dishonest. M was treated in an inhuman way, and this was hidden by dishonest statements made during the inquest.

There is no accountability in the system. Coroners seem to be free to do whatever they please, there seems to be no system to review what they do or how they behave. 


I am copying this submission to The Coroner, Ms M (Senior Coroner) and the Attorney General’s Office.  My family would still very much welcome a response to or an investigation into the issues.


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