Joanna Bailey’s inquest finished today. Joanna, 36, died at a private Jeesal Group ‘hospital’, Cawston Park in April 2018. A day after her parents warned staff they thought she was about to have a seizure. ‘We’ll take care of her’ they were told. Joanna wasn’t observed that night, her sleep apnoea machine wasn’t working and when she was found unconscious in the early hours of the morning, four staff members stood by bickering about CPR until the paramedics arrived.
After a week of chilling evidence the coroner this morning told the legal counsels she would direct the jury to determine that Joanna died of natural causes. There was no budging on this. The family’s barrister Oliver Lewis asked if the jury could be shown a photo of Joanna.
The virtual air across the Microsoft Teams court platform became frosty. The coroner talked about this practice happening in criminal courts. It spilled into her courtroom sometimes [‘prison suicides’] and there was apparent agreement between her and the Jeesal Counsel, Mr Walsh, about underhand motives and the emotiveness of photo sharing. The coroner said:
“I really don’t know what purpose there would be unless it’s to register the fact she’s a human and I think the jury know that,”
After a week of being viscerally dissected in front of her family and wider public with a focus on deficit and deceit, fake seizures, allegations of abuse and troublesomeness, this seemed a stretch.
Mr Walsh insisted if the jury had to see the photo [howl], it should be after the jury had delivered their determination. Hmm, that’s not relevant given the jury has just been told exactly what to write. The coroner made this point to him but Mr Walsh would not budge.
“In my submission Ma’am, the usual practice in this court is not to do so. The only concession would be if it’s still required after the jury return to deliver the determination.”
Joanna’s parents were present during this tussle. Witnessing their daughter being treated with the contempt she was treated with in life.
“Could you show us the photo Mr Lewis?” asked the coroner.
A beautiful photo of a young woman appeared on our screens.
“When was this taken?”
“I’m not sure of the exact date Ma’am, it was within the last six months of Joanna’s life.”
The coroner was visibly surprised. Six months? She looks so different. The small photo she had in her bundle was difficult to see but Joanna looked so, so different [from what she’d imagined? Human even?] She decided that the jury could see the photo briefly.
The jury returned. Joanna’s photo was shown on the screen behind the coroner for about 20 seconds.
The blame
The stench of blame is never far from families of people who die in the hands of the state. As consistent and persistent as the production and content of a Big Mac. The photo exchange was horrible to witness. It highlighted the insidious practices of ‘defence’ barriers in dehumanising the dead to serve the agenda of their clients. It further revealed the assumptions and judgements of the coroner which had dripped across the proceedings like a slightly faulty tap. Why the sea change on seeing the photo?
An A4 photo of Connor stood on the coroner’s desk during his inquest. We even swapped it in week two. The coroner’s assistant made sure it was facing the jury daily. Swapping not swaying. We wanted the various, random members of public sitting in witness to our beautiful son’s preventable death to be able to see and hear about him as a person not a composite of revolting records.
As today unfolded and after Joanna’s photo was fleetingly shown, the coroner faced resistance among jury members to her instruction. The jury had asked informed, engaged questions across the week and were rightly puzzled as to why they were suddenly being told exactly what to write. The coroner’s answers were thin and full of holes. When asked why there was a jury, she gave a classic ‘because’ answer. It’s the law.
They eventually produced a list of eleven concerns about the ‘care’ Joanna received and wrote additional detail on the Record of Inquest form. Bloody legends.
A Jeesal medic, Dr Oyefesu, then continued with evidence about improvements the company had made since Joanna’s death. A tough listen in the context of the deaths of a patient both before and after Joanna. During a fantastical account of the glowing Cawston Park focus on health and wellbeing (despite a very recent CQC failing inspection review) Dr Oyefesu mentioned that Joanna’s family had brought her a McDonalds the day before she died.
“Yes… I saw that’, said the coroner.
For some (many?) of us there’s constant rage around these atrocity stories. A rage, deep sadness and despair. Thomas Rawnsley’s inquest also finished this week with a determination of natural causes. His mum, Paula, fighting every step of the way for her son’s rights in life and death while facing brutal resistance. The coroner’s casual and careless apparent agreement with Dr Oyefesu was devastating. The ‘them’ and ‘us’ the discussion had descended into. The worthy and unworthy. The blameworthy and judgemental response in front of Joanna’s parents.
“It’s patient and families fault,” said Oliver Lewis.
Pantomime swiftly ensued. Oh for senior figures to get as angry about the treatment of marginalised people. The coroner and Mr Walsh jostled for position on the outrage stage: “Such an inappropriate comment!” “How very dare you!” “You must apologise to Dr O.” “Mr Lewis you must apologise now!” “I can’t make you apologise Mr Lewis but I certainly invite you to…” The term abuse was even used.
Oliver Lewis apologised if he’d come across as ‘rude and ungracious’ and suggested there was little to be gained from continuing with the evidence.
This evening Joanna’s dad Keith said:
“We have listened in the last five days to a catalogue of mistakes, system problems and poor care provided by Jeesal Group to our vulnerable daughter. We desperately wanted the jury to be able to consider that our daughter’s death was contributed to by neglect because of the gross failure by the Jeesal Group to provide basic medical care. We are disappointed that the coroner refused to permit the jury to consider that Joanna died of SUDEP contributed to by neglect. We are grateful to the jury who took the time and care with the evidence and raised eleven concerns about the services of Jeesal Group which we fully endorse. We have lost our loving, funny and fabulous daughter and, in our opinion, there were so many missed opportunities to avoid her premature death.”
mydaftlife 
I had just left a comment about Joanna Bailey’s Inquest on Sara’s last blog post when this one went live! My comment sets out the 11 concerns expressed by the jury and names the Coroners’ Court – if anyone wants to write.
Thanks, Sara, for this, and for reminding the world that our children are real people. Incredible that that should come as news to anyone.
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As mum and mother-in-law of middle aged learning disabled people who live in ‘supported living’, I have decades of experience of the many obstacles to getting speedy, or safe health care.
Constant oversight is needed to anticipate infections say, and to or ensure routine checks.
If admitted to hospital constant oversight is needed. For not all hospitals have LD where present they make huge difference in health care and safety,
In spite of my oversight both carry additional disabilities caused by avoidable mistakes and early delays in accessing health care.
I believe that without my oversight both would be dead.
Families who have supported the right of LD son/daughter to marry and or have own home, are never off duty.
LA’s can vary in the amount and quality of care they commission, and if or how they monitor this agency care
This can be good and caring for a time – provide an independent happy, safe life for son – daughter, and give family a brief respite. But neither agency or LA welcome pleas for better or safer support, far less welcome complaints. Interventions by families can make a neglectful or dangerous situation worse.
And although families fear this, we have no choice but keep watching.
All families of LD people living away from home carry this, plus the nightmare of being seen a nuicance rather than as partner – dismissed as an array of negative, soul destroying adjectives.
All obstacles to happy safe care – or a full life span for son or daughter.
In community, respectful concerns raised with an agency can result in their withdrawal, leaving LD individual with no support – other than family for months, while LA trawls for cost effective replacement.
How much worse then if son ordaughter is placed in institutional care, however shiny the promise. Where love is seen as an insult to the staff or organisation; as theft of independence – over weaning at best. Family can only watch – and imagine – fear from afar. In terror ….of the inevitable.
All of which means that families though enthusiastic to encourage independence, have no choice but reject this for son or daughter; keep them at home and be unfairly blamed for guarding out of date attitudes – of denying son daughter the right to their independence.
And all the while the same parents live with soul grinding fears of what will happen to son / daughter when they are too old to protect them from –
…….so called, Care.
.correction .. ‘not all hospitals have LD nurse, where present….’
Weary Mother you have wonderfully outlined the fears and worries of parents with learning disabled loved ones. I relate to it all. Thank you.
You are welcome Pauline. The conundrum is that micro and macro details on the lives of people with learning disabilities and their families has provided very profitable careers for increasing number of people.
Effect, Issues and evidence, freely, and movingly offered by tired, desperate and grieving people. Same info been minutely scrutinised, researched, studied and broadcast using every possible medium – by paid others. For decades –
– with not a blink of improvement – it seems?
If there was ever a time for a new way, it is now and this story is just one of the many examples of what I mean. As the public we have to remember that we cannot and must not break our experiences down into a targeted group. Wrongful and preventable deaths happen across all groups. The deaths are the same and they are all as wrongful as the other. The best way I can describe what I mean is: “Read this story and its comments without the adjunct of it happening to learning disabled people.” Wrongful deaths will never be seen for what they are if they are overshadowed by a seemingly “larger” issue of happening to this group or that group. In Canada recently, a Native woman died a wrongful death in a hospital but to the relief of the hospital the neglect she suffered was covered over by the fact that she was spoken to in a racially discriminatory way as she lay dying. This became the story. I am waiting for the cause of death but it never comes. The protections the doctors and nurses need are all nicely held at bay by some other issue which is bad but certainly not as bad as death. It is terrifying to me that no one sees past this distraction. Wrongful death is wrongful death. It has to do with everyone’s right to life. None is more regrettable than another. If we want equality we have to check exactly how we ask for this. Be careful. It may be the lesser of two evils for those we are asking to respond and they are really pleased about being given the choice. They must be so happy that people are so naive and get so caught up in the frills.