I wish to bring to the attention of the Justice Select Committee Hearing on Coroners, how the coroners conducted the inquest into my deceased mother and subsequently how they treated her bereaved family.
The Coroners involved were Dorries (Sheffield) and McLoughlin (Wakefield).
My mother died on 8th May 2018. On the 11th May 2018 an official from the Sheffield Coroners (Maggie Bennett) telephoned me out of the blue to say my mother’s death had been referred to the coroner. I was advised by Ms Bennett that my mother’s death had been referred to the coroner because of the documented concerns my family had made to the hospital. At that stage no such concerns had been lodged with the hospital. Ms Bennett then asked me to describe at length what my concerns were, I duly divulged my concerns in great detail to Bennett. With hindsight I realise now that this was the wrong thing for me to do. I should have asked Bennett to get the documented concerns from the hospital and then let me have a copy.
The Ministry of Justice “guide to coroners’ services section 3.2” details the reasons when a death should be reported to the coroner. Bereaved family concerns about the treatment of the deceased in hospital is not included in the reasons for referral. 3.2 also states that “The coroner does not become involved in the many cases when the deceased’s own doctor, or a hospital doctor who has been treating him or her during the final stages of an illness, is able to diagnose and certify a natural cause of death.”
There is government legislation in GUIDANCE No.22 PRE-INQUEST REVIEW HEARINGS which describes the complete process of a coroners hearing. Part of this guidance states that any submissions made by any party to the coroner should be made 14 days in advance of any coroners hearing and distributed to all parties. The coroners at Sheffield and Wakefield did not follow that legislation in the following instances: -
i) Bob Crookes an official of the Sheffield Coroner’s court telephoned me to try and arrange a hearing for 4 days on from his phone call. At this stage I had not received any submissions from the hospital nor an agenda from the coroner. Mr Crookes was also aware I was going on holiday on the day of his phone call and that I was not due back until the day before his proposed hearing date. Furthermore I did not receive an agenda for the PIR meeting held at Sheffield Coroners Court on 9th July 2018.
ii) I did not receive the submissions made by the hospital until 4 days prior to date of the original PRE-INQUEST REVIEW. This was despite my many calls to the coroner’s office requesting that the hospitals submissions be sent to me.
iii) Mcloughlin the Wakefield coroner allowed the hospital to present a further submission 3 days before my mother’s inquest. He then allowed the hospital solicitor to question me about this new submission at the inquest itself.
When challenged about not adhering to the legislation regarding inquests. Mcloughlin dismissed me by saying the legislation was only there for guidance. My view is that “what is the point of legislation if it is not followed to the letter?”
Dorries the Sheffield coroner also dismissed the non-adherence to legislation by his staff. He did however acknowledge a breakdown in trust between my family and his court. He subsequently agreed to have the case transferred to a different coroner (Wakefield). The transfer of the case to another coroner’s court was unprecedented as far as I was aware. However, this move to the Wakefield Coroner did not see any change in the way certain elements of legislation were being ignored and the way the coroner’s court system were treating the bereaved family.
At the inquest the hospital submitted their own reports into my mother’s care from the nurses and doctors involved in the care. Prior to the inquest I had received a letter from the chief executive of the hospital trust in which she described her own staffs reports and record keeping as “unacceptable”. I brought this view of the chief exec to the attention of the coroner (He had had a copy of the same letter), Mcloughlin stated he would be disregarding the chief executives view on her staff reports. Mcloughlin did not explain his rationale for taking this stance, but proceeded to use the same reports as evidence for his court.
At this stage I had lost any hope of getting justice for my mother from Mcloughlin’s court. Also in his summing up Mcloughlin stated that he believed a witness statement that directly contradicted my statement to the court. The only conclusion I can draw from this is that Mcloughlin thought I was a liar.
On conclusion of the inquest I set about trying to challenge the way the coroners had ignored parts of their own legislation, which left my bereaved family feeling that we were at a disadvantage at the Inquest hearing. However, every organisation I approached on the official escalation path said that the coroner’s actions that formed the basis of my complaint was outside of their remit. The organisations I approached were the Local Police authority, LGO, JCIO and JACO. In the final decision from JACO, they refer to legislation in Judicial Conduct Rules 2014. JACO pointed out that the guidance excludes the following items from its remit namely
I) A coroner refusing to allow a witness to give evidence or admit certain documents.
II) A coroner appearing to react more favourably to one person’s evidence than another’s.
It appears that under the current regime that coroners
i) see themselves as being bullet proof, especially in the way they treat the bereaved.
ii) they should be allowed to ‘cherry pick’ which areas of parliamentary legislation they adhere to.
This needs addressing at the earliest opportunity.
I took my issues to my local MP and through them I contacted the chief coroner’s office and the Justice Minister at the time, Both these parties also washed their hands of my complaint.
Further details of each issue addressed along with documentary evidence of what occurred will be provide by me on request should you wish it.