Louis is the latest young person whose inquest was covered by George Julian. Her posts include family photos of a beautiful young cheeky chappy who looks like he’s on the cusp of taking on the world. Except he can’t. Because a dereliction of anything resembling “health care” led to his death before he could enjoy his 18th birthday trip to the US.

Louis’s inquest lasted one day. There were four witnesses; two doctors from the hospital, a GP and an expert witness. Louis was taken to A&E in January 2023 after being pale and out of sorts to an extent that alarmed his parents, Jackie and Ian. Once there, he was seen by Dr Morelli who was ‘unable’ to do a blood test as Louis did not cooperate. Given he’d sat for 5 hours on a chair in A&E clearly feeling like shite, this is no big surprise. Dr M arranged for him to go home and come back in the morning.

Louis was then seen by Dr Therabandu. He looked at Louis and made the judgement he didn’t look unwell. He did no observations other than ‘looking’ because Louis was sitting on the floor in the corridor. Quite some medical practice there; the monstering of Louis happening in full view and offered as an excuse for medical failings. Monstering underlined by Dr T referring to Louis’s ‘adult size’. It was time for Louis to go home (again) and get the blood sample done in the community.

We knew in Louis’s case many children or adults with learning difficulties, being out of their own surroundings is more harmful than good. 

Louis was very distressed, we were having to hold a big strong man.

Got to keep these people in the wild, in their own surroundings. Not in an emergency hospital department.

So, Dr T, asked the coroner. What would you say the cause of death was? Well natural causes of course. I have a lot of medical experience.

As witnesses were questioned, Jackie occasionally intervened with questions screaming in my head.

I don’t understand the blood tests should have happened, I know I’m just his mum, don’t have any legal background or medical background, but this is just common sense. I’m telling them he’s not well, these are consultants practically, they are very serious doctors. I’m sorry I’m ranting.

Hush now.

Next witness was Dr Ryba, a GP who did a home visit a few days after the failed blood tests. By now, Louis was not well enough to leave home. She described how;

He was placid, he was silent, he didn’t speak to me throughout my visit. He was docile and compliant and seemed at ease and not too anxious or distressed in any way.

Docile and compliant comments again pointing to monstering and fear. Dr R said Louis was “clinically stable” and off she went into the night. He was dead 12 hours later.

What do you think the cause of death was, asked the coroner. Difficult to say without a blood test, Dr R said. Anything else?

I’ve given it an enormous amount of thought, stress how difficult it must have been for his parents, would like to stress what a warm and loving environment he was being cared for in.

Just a reminder, this is a 17 year old school boy, not a rescue chimp from Senegal. Anyway, over to questions from other interested parties:

SD [counsel for the family]: When you saw Louis did you see he was jaundiced?

PR: No.

Jackie: there was no light on.

SD: Did you see him with the light on?

PR: Yes, the bedroom light was on.

Jackie: It wasn’t the big light

The coroner said it was important not to confuse the witness.

This exchange highlights how the coroner leaned into medical witnesses across the day, dismissing Jackie’s expertise. Witnesses were protected while Jackie was left to flounder, trying to correct inaccuracies in evidence. The main light was not on. The GP could not see if Louis was jaundiced just as Dr T could not make informed judgements without formal observations. We are back in the familiar land of nonsense and absurdities. A weaving of a tale about the boy and impossible blood tests. Dr T’s next answer underlines this beautifully. She was asked about a photo showing Louis’s skin colour:

I wouldn’t make a diagnosis of jaundice from looking at those photographs.

And yet three medics made a range of judgements asserting Louis was well based on looking (in the dark).

Finally, expert witness. Dr Habibi. We reached the pinnacle of absurdity with Dr H’s evidence. Dr H stated blood tests would have offered an opportunity to explore why Louis was clearly unwell. He had been fit and well a few weeks before and there was nothing in his postmortem to suggest nasties that could not be recovered from. The absence of blood tests closed this avenue.

You can’t say that, Dr H. There were no blood tests. We cannot know what they would have shown! Er, well yes. Exactly. Without the blood tests we can only assume Louis died of natural causes, there is no other plausible reason. Yes. So blood tests should have been taken. But they weren’t and we’ve heard from three MEDICAL witnesses that Louis didn’t seem unwell.

We should start from the fact obviously tragically Louis did die. Final illness, even though it appeared not particularly concerning, it obviously was because it led to his illness in the end.

When you hear sense among the absurdity it is like watching a single raindrop on a spring bulb.

Louis died. He was clearly ill.

The coroner moved to submissions. Jackie had been told she could ask questions after witness evidence. She splurged a devastating ‘why?’ filling in the answers herself.

Why didn’t he get a blood test? Because he presented as difficult in different settings, have to remember all doctors said what they said because they don’t want to say what didn’t do. Lots of what was said was factually incorrect as we saw at the time. Dr Morelli made the decision to send him home, we did not want to leave. We wanted to stay in the hospital until, pointless going back and coming back, we knew would be more difficult next day to start the process again. It needed to be done. Hospital is the place where blood tests are done, nowhere else to go. […] I think that’s because Louis is boy with Down’s Syndrome, they couldn’t ask him questions, we had to present as best we could, hoping they’d listen to us. He was very, very unwell. Louis would rely on us as his parents, he trusted us more than anyone else. We were the people who he looked at and wanted to help him.

There was no answering these questions because the witnesses were released. The coroner concluded Louis died of unascertained and natural causes. Move on now, nothing to see here.

There was nowhere to take your beautiful and clearly unwell boy to keep him alive.

Imagine.