Written evidence submitted by Ms Moira Durdy (TCS0024)

My inquest experience.

I lost my daughter who was 27 years old, 5 days after she was admitted to a crisis house by the NHS community mental health team, who were treating her for severe depression. She died by suicide in Oct 2020. The inquest was finally held at the end of June 2022. It was allocated 2 weeks at the coroner’s court in Bristol, but in the end, it was completed in 8 days. We were not allowed to have A2 or a jury because, even though the services of the crisis house were commissioned by the local ICB, and largely NHS funded, the coroner ruled that it was a ‘community’ placement. There was a lot of legal argument about this, over the course of 2 PIRs, before the inquest eventually took place. There were lawyers for the NHS Trust, crisis house, police, and ambulance trust. We were fortunate to have skilled and supportive legal representation, thanks to the direction provided by our caseworker at INQUEST. Had we not had the support of our caseworker who knew the system, we would not have known where to start to find a lawyer to represent us. I don’t think we would have realised that we needed a lawyer. I don’t think we should have needed a lawyer, but we certainly did.

Before our inquest, I became aware, through on-line support groups, that our coroner did not have a good reputation among bereaved families locally. He was known for being particularly uncritical of NHS organisations, when things had gone wrong. When I did my own research, I found that many families had voiced concerns (one had crowd funded for a judicial review), and that it was many years since he had issued a PFD report, while his fellow coroners, working in the same locality, were issuing them.

I did not feel that, as a family, we were put at the heart of the inquest into our daughter’s death. The PIRs, were primarily conversations between the coroner and the lawyers. Our barrister interpreted what was going on for us, but the coroner did not address us directly regarding to explain the decisions he was making.

At the inquest we asked if we could display a photo of our daughter, we were told that the coroner did not like to see photos in his court, but it would be OK for us to have one on our desk, facing us, so long as he couldn’t see it. When I read a short pen portrait, I had to take an oath which I thought was ridiculous. It was my recollection, my chance to speak about my love for my daughter.

The coroner was courteous on the very few occasions he addressed us (2 or 3 times throughout the whole process), but he was grand and pompous, regularly reminding our lawyer that it was his court and his rules. He did not appear even handed in terms of his challenge of the lawyers. He seemed to want to limit our representative exploring the issues, without being similarly challenging to the other lawyers, representing the state organisations.

The state lawyers were very defensive. They seemed to be primarily concerned with limiting the scope of the discussion, regardless that this could lead to relevant facts not being exposed or the distress it was obviously causing us. We had lost our beloved daughter and simply could not understand why this was happening. We had worked so hard with the NHS Trust after her death to have a thorough investigation, where the things that went wrong were identified, lessons were learned, and actions put into place to stop anything like this happening again. During the inquest none of this seemed to matter anymore. Learning lessons and demonstrating any degree of candour was not the priority, it was about damage limitation. It felt as though the state lawyers had no conscience. They objected continually to questions from our lawyer, they could be reasonably sure that the coroner would support them, while they glossed over the failings identified in the Trusts own internal investigation. They had no care or compassion for our loss.

We received no PFD, yet an independent expert review of our daughter's case (post inquest) has been extremely scathing and very clear in opinion that she would not have died when she did, had adequate care been in place.  We remain convinced that the coroner was biased, he did not want to see a reason either to comment on what had happened or to issue a PFD report. We believe a PFD relating to training on clinical risk management, and to the level of clinical oversight of vulnerable people who are referred into residential crisis house accommodation was needed. He took no notice of the critical internal serious incident investigation and did not remark on issues that had been raised by the Trust’s patient safety investigators. We have no idea why this is. We were advised that there was no realistic route to challenge the inquest outcome, as so much comes down to opinion. In any case pursuing a review would be extremely expensive. The inquest did not treat us or our daughter fairly.

We found the inquest process to be extremely stressful. On top of the devastation of our loss and grief, the impending inquest dominated our lives to a greater or lesser extent for the 20 months following our daughter’s death. We were given 3 dates before the inquest finally happened on the 4th. The first was delayed early on, at the request of our INQUEST case worker because the Trust investigation had barely started. The 2nd and 3rd became PIRs for reasons relating to the lack of disclosure of evidence and on-going argument over A2 being engaged or not. The uncertainty relating to dates was difficult as we were juggling work, caring responsibilities, and having to find (and then cancel) affordable accommodation (the inquest was being held in a distant city). The on-going argument over A2 meant that we did not know if we would have funded legal representation, and how much it would cost if we had to pay for it. Attendance at the PIRs and the inquest was expensive as we had to cover the costs of travel and accommodation.

We were extremely fortunate and grateful to (eventually) get funding for legal representation at our daughter’s inquest. Even though our coroner would not engage A2, our solicitor, who is very experienced, managed to convince the Legal Aid Board that, despite what was happening in the court, there were grounds for A2, so in the end they granted us funding. I believe this is very unusual, public funding for bereaved families at inquests should be equitable-it felt like a lottery.

January 2024