We write in response to your call for evidence about the need for improvements in services for the bereaved at inquest and about the need for fairness in the Coronial system
We refer to our experience of an inquest which took place in November 2014. This was into our mother’s avoidable death in an NHS Trust hospital,
This inquest was subsequently overturned in 2018 and a new inquest ordered in a new jurisdiction, which has opened but has yet to take place.
To summarise, in this submission we give instances of:
We told the ITU Consultant Intensivist who had overseen completion of the death certificate that it was inaccurate.
We said we would be making a complaint of neglect. We asked about a post mortem.
He said there were no grounds for a post mortem.
He told us the death had been ‘waived’ by the Coroner.
There followed an 18 month long investigation by the NHS Trust. This brought no facts to light.
But the Trust supplied a set of my mother’s medical records to the Ombudsman with over 100 crucial records taken out.
As a result, the Ombudsman’s year-long investigation produced a report that was inaccurate and gave a totally misleading account of our mother’s death.
The Ombudsman was in the process of reviewing its investigation report because of the records the Trust had withheld.
No Win No Fee to fund the inquest
However, the only way to finance the inquest was if we took out a No Win No Fee claim for clinical negligence.
This was not something we had ever thought of doing but now we had no option.
The first Pre-Inquest Review took place on 17 December 2012.
The Coroner warned the Trust and our lawyers that the inquest was not to be used to fight the clinical negligence claim.
We did not understood what he meant.
We thought the inquest process was supposed to be inquisitorial and all the parties were there to help the Coroner gather the facts.
We did not realise that the clinical negligence claim guaranteed that the inquest would be adversarial.
And that the NHS Litigation body would soon send in its own advocate to represent the Trust, whose job would be to fend off or minimise any future liability.
The NHS Trust did not provide these statements for 10 months.
No-one at the Coroner’s court chased these up and the Coroner did not express disapproval to the Trust because of this delay.
We believed that it had been a serious system failure which caused our mother’s death.
To investigate this, we needed to get the wider scope of inquest which looked at ‘the circumstances’ around the death.
It seemed that the Coroner accepted this.
We tried repeatedly to explain to the Coroner that the Ombudsman’s report was currently under review because the Trust had withheld records from the investigation but we never seemed to get this point across to her.
The Trust / NHSLA advocate claimed ignorance of the DND’s identity, putting forward 3 wrong names to confuse matters, although the DND had been referred to the NMC by name so everyone knew who she was.
The Trust claimed to have no records or policy or operational documents from the time of the events in 2009. / 2010. This made it hard to see how the recently appointed Deputy Head of Nursing could comment on these events that had happened 5 years before.
But these consultants had not been present at the events.
The three pre inquest reviews were over and we seemed to be hurtling towards an inquest for which we were completely unprepared. I spoke to the Senior Coroners Officer about this.
I told him that my mother had not had pneumonia and that the purpose of the inquest was to bring the true facts to light. But he did not reply
Trust makes Part 36 offer
In a case with a No Win No Fee agreement such as ours, this offer results in the insurers withdrawing funding for representation of the bereaved at inquest.
We parted from our lawyers in late August.
From the Trust / NHSLA lawyers’ point of view, with our ‘representing ourselves’ our inquest was now an open goal.
Coroner grants Article 2
Being amateurs, these submission took us two months to formulate with the help of an inquest book.
I was pleased and said, “We’ll need another Pre Inquest Review.”
He said, “The Coroner won’t want any more delays.”
I said we needed independent expert medical opinion.
He said, “The Coroner’s a doctor.”
This was true but she had been a GP and long out of medical practice. We needed an expert with specialist knowledge of Acute Respiratory Distress Syndrome and sepsis.
But the Senior Coroners Officer now said the Trust / NHSLA advocate advised that she had relocated back to Ireland.
He said he had made extensive inquiries but she could not be traced, not even through her NMC registration.
We did not believe this.
It only took us 2 phone calls to establish that she still lived locally and had a new post at a private medical facility on the same Trust hospital site where my mother had died.
Our request to Coroner for adjournment
We wrote asking the Coroner to grant an adjournment for a further Pre Inquest Review so we could:
Considering that the Trust had caused a 10 month delay, and had since failed to name various crucial witnesses, we thought this was extremely unfair on us.
The Coroner wrote on her email to the Senior Coroner’s Office – ‘Give them time for Judicial Review.’
We weren’t sure if this was a private joke between them or whether relatives were expected to attempt Judicial Review as part of the process.
Our attempt to take Coroner to Judicial Review
We listed the witnesses we felt were essential and why we felt the Coroner would not be able to do a proper inquiry without independent medical opinion.
We went to the High Courts of Justice to file this. Our application was turned down the night before the inquest.
We had waited 4 years for an inquest. And now we were going to have to sit through a 2 day inquest that stood little to no chance of bringing any facts to light.
The first day of the inquest hearing
The file of documents we had submitted to the Coroner to support our submission for Article 2. The Trust claimed to have no policy documents from 2009 and no memory of how systems had worked back then.
But we had Trust FOI responses from 2009 / 2010 which gave insight into the system at that time.
And transcripts of the surgeon and anaesthetist’s testimony to the NMC about the system failures which had led to my mother’s death.
We knew the Coroner had absolute discretion as to what evidence she allowed –
But it was hard to see the logic in an Article 2 inquest of ruling out the evidence which had led her to give us Article 2 in the first place.
It felt like the Coroner was laughing at us.
The Trust witnesses
It was torture to listen to them when we had actually been present at these events. But our eye witness accounts were given no weight against anyone with ‘doctor’ or ‘nurse’ in their title.
Some of the clinician witnesses seemed to had been asked by the Coroner to double up as ‘experts’ for economy’s sake but this smacked of conflict of interest when it was their own actions they were commenting favourably on.
At this point, the witness would visibly relax and snap into a different, more vivacious, persona – expounding with practised fluency how the Trust was totally reformed and how what had happened back then could never happen again.
Since the inquest was falling well short of establishing what actually HAD happened to my mother, it was infuriating to listen to witness after witness trot out these glib assurances aimed at avoiding a Preventing Future Deaths report.
The key witness
She had been called to our mother in the early hours of the morning after my mother had been vomiting bowel contents non-stop for 11 hours and had aspirated the vomit into her lungs.
Miss S explained in her testimony how aspiration occurs in this situation and how the aspiration of bowel contents causes serious and immediate irritation to the lungs.
She said that the x-ray she had ordered at the time had not suggested the presence of infection and that the diagnosis she had made was ‘pneumonitis’.
The Coroner corrected her and said “aspiration pneumonia.”
But Miss S corrected the Coroner firmly and said “aspiration pneumonitis.”
The distinction was crucial as pneumonia would suggest an infection whereas pneumonitis – damage to the lungs caused by aspiration of bowel contents – would be an injury.
And such injury would be the underlying cause of death – and not a natural one.
We knew this was significant testimony.
(Perhaps that is why this passage of testimony disappeared from the inquest recording.)
The Missing Microbiology records
We had been asking for these missing reports for the last 4 years as they were crucial to establishing my mother’s cause of death.
The Coroner asked the NHSLA advocate to arrange for a witness who had access to the Trust’s electronic Microbiology system to bring these in on the following day.
But, on the following day, the witness said the NHSLA advocate had not contacted her and she had not been asked to bring these in.
The Coroner did not call for an adjournment to locate the reports, but just carried on regardless without the evidence that was needed.
Events in ITU: Avoiding the Issues
Since he had been the Duty Consultant for the last 3 days of my mother’s life, it might be thought that this would have finally brought to light the facts that had been hidden for the previous 4 years such as:.
But Dr Y was not able to answer any of these questions.
He said he could not identify the doctor on his team who had been working under him that day –
even though he had the doctor’s signature and initials on the medical chart
even though this doctor had handed over to him
even though this was just an 8 bedded unit.
So much for the Coroner’s assertion that Consultants could speak on behalf of the junior members of their teams.
Instead, the Coroner was treating him as an expert, asking him to give an overview of the overall care on ITU, deferring to his greater expertise.
Dr Y replied, making a number of startlingly false statements about sepsis.
When I questioned these, the Coroner backed him up.
This was so blatantly wrong that it took my breath away.
After the end of evidence
Their expert emailed back confirming the errors in it.
I emailed this to the Coroner along with a booklet on sepsis.
So she told us she had ruled out Dr Y’s evidence on sepsis.
With Dr Y’s testimony discredited, there had been no evidence given about the last two days of my mother’s life.
The Reading of the Narrative Conclusion
It came as a shock to us when he started to make these arguments, which were full of highly disputable statements.
We asked the Coroner to allow us to give our opposing arguments as we believed there SHOULD be a rider of neglect.
The Coroner heard our arguments with the appearance of grave attention then, as soon as we finished, picked up her pre-prepared statement and read out her Conclusion in which she said she had found against adding a rider of neglect.
It found that she had died of aspiration pneumonia, for which there was no medical evidence at all.
Aside from the testimony of the Surgical Registrar, Miss S, it had brought no new facts to light.
As far as Dr Y was concerned, it had not allayed our suspicions. If anything, these had intensified.
The Recordings of the inquest
I asked him for the discs of the inquest.
I knew that the Chief Coroner’s guidance was that these could be obtained by relatives for £5 a disc.
I had worked as an audio medical secretary and so planned to transcribe the inquest recordings myself.
But now, he said that these could not be de-encrypted except by specialist lawyers.
He said we could get the discs transcribed by a transcription service which would cost us around £900 plus VAT.
He emailed me the next day, repeating that the discs couldn't be de-encrypted and quoting a 'guesstimate' of £1,500.
He copied his answer to the Coroner’s AOL email account so I assumed he was telling me this with the Coroner’s knowledge and approval.
However he emailed me back again, apologising that he had been 'inadvertently misled'.
He had now been advised that it was not technically possible to burn a copy of the master disc.
I couldn’t imagine what use it would be to a court to have a master disc that could not be copied.
When I contacted her, she too said that the recordings were ‘encrypted’ and that the court did not have the facility to copy discs.
She said if we wanted access to the recordings, we would need to commission a transcript from a firm called Kellie Transcribers.
By now, the quote had gone up to £3,400. She said she was about to go off on leave.
We only had 2 months if we wanted to refer the conclusion to Judicial Review. There was only a week to go before we would be out of time to refer doctors to the GMC.
My sister reasoned that time was slipping away and, since the only way we could access the evidence of our inquest was to pay for the transcript, we should borrow the money and commission it from Kellie Transcribers.
She instructed us to send a cheque to Kellie Transcribers at an address in North East London.
I looked the company up online. It had no entries. It had no website and was not registered with Company House. The postcode appeared to be a house in a residential area.
Track and Trace showed the cheque was delivered to the home of the ‘Coroner’s PA’.
We were planning to challenge the Coroner’s conduct of the inquest. We, therefore, did not want her PA typing up the transcript.
The PA might alter it or leave chunks out and since we couldn’t access the discs, we wouldn’t be able to check this.
It seemed to us that some people at the court were operating a scam to rip off bereaved relatives when they were at their lowest ebb.
The JCIO advised us to inform the Senior Coroner.
It was news to us that there WAS a Senior Coroner. I sent her an urgent message.
She said she would be instigating 2 investigations – one at the court, and another corporate fraud investigation managed by the Local Authority.
To compensate for distress and inconvenience, she offered to commission a transcript of our mother’s inquest recordings from transcriptionists Merrill Legal at no cost to ourselves.
The Senior Coroner invited me to the court and gave these to me, saying that they were not encrypted, could be easily copied and could be played on free downloadable software on any PC.
She said she didn’t know why the Senior Coroners Officer and the ‘PA’ had told me differently.
It turned out that the ‘Coroner’s PA’ had been typing the transcript from copies of our inquest discs on a computer in the Coroner’s court.
Evidence missing from the discs
I took a while for this to sink in.
This loss left us feeling utterly bereft.
But when we checked the 700 pages of the transcript against the copy disc, we found a crucial 15 minute passage missing from the Consultant Surgeon’s testimony.
There was also a crucial 5 minute passage missing from the Matron’s testimony.
The system seemed quite informal and insecure. The recordings were not saved to the Cloud but archived manually to disc by anyone who was passing.
He wrote in his report that:
‘It is technically possible that the system could be modified to alter recorded content although this would be a very complicated process which we believe would leave a footprint.’
Off the record, he told us ‘anything was possible’ if someone had the skills.
On 28 July 2015, he wrote to the London Borough lawyer:
‘The fundamental issue is that the correct process is for recordings to be archived at the end of a session in order to create a master record.
In the absence of the archive media against which we can compare the recordings on the PC and the CD copies, we cannot 100% state the integrity of the recordings.’
This was because of the inquest triumvirate –
Coronial office staff answerable only to the Local Authority
Coroner answerable only to the JCIO
Coroners’ Officers answerable only to the Police Authority
This meant the issue got tossed between the 3 authorities until it was conveniently lost.
The Local Authority offered us £300 compensation which we refused. We wanted someone to investigate the lost evidence from the court recording but this did not happen.
And that was because none of these 3 authorities were prepared to ask the relevant staff members the obvious questions.
This sent us into an anxious frenzy, ringing round, asking lawyers and medical support charities to give us a list of Coroners with a reputation for being fair.
We were shocked by the cautious response to this and the very small number of names of ‘fair’ Coroners being put forward to us.
There were only about 3 or 4 and some of those were outside London.
But the second inquest is unlikely to be plain sailing.
It is now 10 years since our mother’s death, and this time lag is wholly due to the Trust’s successful tactics of delay, deny and defend.
We find, at the new inquest, that the Trust is still at its old tricks of delaying, denying and failing to deliver - in the hope that they can stretch this out for another ten years.
The Coroner has a team of high powered lawyers managing the case for him and the Trust’s new high powered lawyer introduced herself to us at the hearing.
The only party at the inquest with no power is us.
Because of the paucity of the funding available, we see little prospect of being represented and, that being so, we contemplate the second inquest with dread.
It should not be that an inquest further traumatises already traumatised people.
All pretence that inquests are inquisitorial not adversarial should be abandoned.
Coroners have too much power in too much isolation and there is the risk that such power leads to shortcuts in the name of value for money and institutional bias in favour of NHS Trusts.
02 September 2020
 NHS Litigation Authority – now NHS Resolve
 The Ombudsman personally quashed our 2012 Ombudsman’s report in 2018 following a review which identified that the Trust had provided them with a set or edited and misleading medical records.