Written evidence from Mrs Margaret Abrahart

Evidence is provided on three key issues:


  1. An eight-day inquest into the death our daughter, Natasha Abrahart, was held at Flax Bourton, Bristol, in May 2019. Natasha took her own life on 30th April 2018. The Senior Coroner for Avon, Maria Voisin, concluded that there had been a gross failure by the Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) to provide basic medical care, and that a clear and direct link existed between this failure and Natasha’s death. Her death was accordingly recorded as “suicide contributed to by neglect”. But that finding only addressed part of the story. Natasha had sought medical help from the NHS, for her suicidal thoughts and behaviour, so the NHS was obviously not the original source of her suicidality.
  2. The wider context is also important. Natasha was one of 3 students at the University of Bristol, who took their own lives in a period of just over 2 weeks. Earlier in that academic year, 3 other students at the University of Bristol had also taken their own lives, plus another 5 in the previous year, making a total of 11 such deaths in an 18-month period. This spate of suicides at one institution is unprecedented.
  3. Early in the inquest process, a friend suggested that we should get a solicitor. It sounded absurd, surely it was up to the coroner to gather the evidence and investigate the circumstances of our daughter’s death? However, as we later discovered, nothing could be further from the truth. Another grim reality, that we rapidly discovered, was that the entire process must be driven by the family, particularly the identification and analysis of evidence, and by ensuring that the right questions are asked.  Nobody should be placed in such a situation unaided.
  4. Each party at an inquest should primarily be interested in gathering together a set of key facts on the circumstances surrounding a death. It is not a trial. They were never intended to be adversarial environments, but have sadly become so, producing intimidating situations in which large institutions are represented by articulate lawyers who will argue against anything and everything. They seek only to defend the interests and reputations of their client, by fighting to shut down or narrow all lines of enquiry. The inquest process, consequently, is no longer in keeping with the purposeful mechanism that was originally envisaged, such that the necessary safeguards which apply in most other courts now need to be introduced. Either that, or the entire inquest process needs to be revisited. The system needs a major overhaul. Trust must be restored.
  5. We found the coronial process an unpleasant and disappointing mechanism, and in a city where more student lives continue to be lost.  It did nothing to bolster our confidence in any of the institutions concerned. We put aside a year of our lives, to ensure that all relevant facts were included/presented at our daughter’s inquest, but not all of the available evidence was heard.  So, in our view, the job remains unfinished. Events/factors that could have caused or contributed to our daughter’s death were not adequately scrutinised. The daunting task of completing an investigation has simply been passed back, from the state, to her bereaved family, who have no real power and have already invested a huge amount of time, effort, money, and energy into supporting an inquest. 
  6. Suicides among university students should be a major concern for the Coroner Service. In the 12 months leading up to July 2017, 95 suicides were recorded among higher education students in England and Wales. This equates to one death every four days. The coroner has a duty to identify concerns where action should be taken to prevent future deaths, but if matters are not properly investigated, are the family expected to pick up the baton, in whatever way they can, or does society just have to sit and wait for the next student suicide to occur?

Overbroad Discretion

  1. The scope of an inquest is a post code lottery, producing substantial inconsistencies in depth and breadth of content from one coroner to another. Losing a daughter is bad enough, but the coroner in our case refused to address what to us was an obvious “elephant in the room”. For our daughter’s inquest, Maria Voisin, the Senior Coroner for Avon had ruled in writing that “the scope of the inquest does not include the adequacy of support provided to Natasha by the University”. This in our view prevented any proper scrutiny of the facts and, as such, no so-called full and fearless investigation was conducted. Matters that we believed were important, were not addressed. Key questions were not allowed and therefore left unanswered. This left us feeling angry, resentful and cheated.
  2. Now, contrast that decision on scope, with what has happened in several other recent inquests into a ‘student suicide’. Example 1: Raees Rauf took his own life on 12th September 2018, approximately 10 weeks after he had been asked to withdraw from studying at The University of Bristol. For his inquest, Emma Serrano, Assistant Coroner for Derby and Derbyshire, adopted a completely different position on what should be examined. Nothing appears to have been purposefully excluded. The University was appropriately scrutinised, resulting in various policies and procedures being listed as matters of concern that required action to be taken in a Regulation 28 Report. Example 2: Ceara Thacker took her own life on 11th May 2018. During her inquest, support services at The University of Liverpool were fully scrutinised by Anita Bhardwaj, Coroner for Liverpool and Wirral. Nothing again appears to have been purposefully excluded.
  3. The coroner has a duty to “prevent future deaths”. Each life that can be saved is what counts, and anything that might have caused or contributed to a death should be investigated, so that any potential failings can be identified and flagged for improvement. But excluding evidence, that is believed to be important, and has not yet proved to be irrelevant, is to limit the court’s ability to prevent similar deaths from occurring. The inexplicable ruling at Natasha’s inquest in our opinion represented a dangerous missed opportunity. Each student death will have a devastating impact on their family and friends. Prior student deaths at Bristol had received short read only inquests. Such deaths should not be treated as an occupational hazard, and it would be an absolute tragedy for a preventable suicide to occur, simply because a previous inquest had been too superficial.

Inequality of Arms

  1. The government has recently declined to provide automatic non means tested legal aid to families for specialist legal representation immediately following a state related death. This has perpetuated a significant injustice in the coronial system. The other interested parties at our daughter’s inquest had expert legal representation paid for either by public money, from insurers, or out of deep pockets. There were at least six opposing barristers and/or solicitors. In stark contrast, we were disadvantaged from the start, having no initial knowledge or understanding of the coronial process, and no access to similar funding. To hire lawyers, we were forced to crowd fund. This is a fundamental injustice, tailor made for the wealthy. Essentially, if you cannot afford legal representation, you have no real ability to engage with the system, or put another way, no access to your rights and/or only limited access to justice for the deceased.
  2. Prior to engaging legal support, we had great difficulty in getting useful information out of the coroner service regarding our input. Numerous letters and emails remained unanswered. In our view, they did not treat us seriously or with proper respect. Legal representation produced an instant and dramatic improvement after we were referred to specialist lawyers by the charity INQUEST. The case was transferred from an Assistant Coroner to the Senior Coroner. The court responded to requests. Three pre-inquest reviews were arranged. The date of a 3-week hearing was set. Evidence was obtained from interested parties over a 12-month period. An expert witness was instructed. Legal arguments were considered on the need for Article 2 of the European Convention on Human Rights to be engaged.
  3. Most families would struggle to engage with the heavy financial and emotional challenges that had been foisted upon us, at a time of maximum grief. Even with our lawyers working at substantially reduced rates, our legal costs exceed £60,000. The family, however, are the ones who have the least to gain, having already lost their loved one. They simply hope that important lessons might be learnt that could spare others from such pain.
  4. We believe that our meticulous approach, personal financial commitment, and pursuit of an unfettered investigation was instrumental in the final findings at our daughter’s inquest. The evidence that was initially submitted to the court, portrayed a very different picture from that which emerged at the end of the inquest. This is something that could not have been achieved without the help of our lawyers.  Financial support for legal representation is essential, and should be provided for the benefit of society and the common good since all lessons learnt would be in the public interest. 

Limited Accountability

  1. The issues of uncontrolled discretion, bizarre rulings and urgent need for a level playing field all come together when as a ‘dissatisfied customer’ you want to set matters right. Here you hit the ‘double whammy’ of enormous potential costs and maximum uncertainty. There is no easy way forward.
  2. Coroners have wide powers of discretion. But there is no clear path to challenge matters that appear unjust, since there is no formal right of appeal from an inquest. This places too much unconstrained power in the hands of one individual. Section 40 of the Coroners and Justice Act 2009 provided for a new system of appeal against some decisions and determinations made in connection with investigations and inquests into deaths. There was obviously a need for it, but that section was never brought into effect. It has now been repealed, but with no replacement so far created.  Nobody is flawless, but with no proper safeguards, the inquest process is open to misunderstandings, poor decision making and an individual’s own subjective views on what is right and proper. More worryingly, the proposed system did not cover “scope”.  There should be a right of appeal from any lower court, it should be all embracing, and not limited on account of what is convenient or practical. True justice cannot and should not be done on the cheap. In our case, the coroner’s baffling restriction on scope could not be appealed. This quirk of the legal system is in nobody’s interest.
  3. It is sometimes possible to challenge a coroner’s decision, or the outcome of an inquest, either in the High Court by way of an application under section 13 of the Coroners Act 1988, or by application for a judicial review. Such remedies are beyond the reach of most individuals, since they could have huge cost implications for anybody wanting to take such action. This creates a second inequality based on wealth: so once again, if you can’t afford it, you can’t get justice! Moreover, having endured the inquest, which had already necessitated twelve months of detailed engagement, the additional cost and uncertainty of a post-inquest judicial review on account of scope was well beyond anything that we could realistically pursue or risk funding – despite wanting it.


September 2020