Category Archives: Inquest stuff

A letter to the Ministry of Justice

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Dear Ministry of Justice,

I’m writing because I’m pretty concerned about this statement you issued to BBC Radio Oxford a couple of weeks ago when asked why there was no legal aid for families to cover representation at inquests:

An inquest is aimed at helping families find out the circumstances behind the death of their loved one. Lawyers are not usually required as the hearings are specifically designed so people without legal knowledge can easily participate and understand what is happening.The coroner is there to investigate the death and can put questions on behalf of the family during proceedings.

This has a touch of the In the Night Garden about it. Naive, meaningless fluff. You present a version of the inquest coated with parma violets, butterscotch and cream soda. Devoid of context. You suggest that families put their trust in the coroner. Yes. Maybe. But they should also be aware that other interested parties (such as the NHS, the prison service, police, local authority) may well turn up mob handed with barristers and the like. Determined to close down questions and limit the investigatory process.

And it ain’t just about what happens at ‘the inquest’. The inquest is a process not an event that happens within a set space at a particular time, as I’m sure you know. It’s a process that involves evidence gathering and submissions. Without legal representation, how can families be sure that the questions they want answered are going to be asked? I ain’t being funny, but coroners are only human and can’t go through the mountains of paperwork associated with a particular death in the level of detail necessary. And a family who are experiencing the gut wrenching and devastating despair associated with bereavement aren’t best placed to (and shouldn’t have to) trawl through records and documents.

If, as you also suggest, the inquest is inquisitorial and not adversarial, why have Sloven Health been arguing for the narrowing of our son’s inquest to one with no jury and no Article 2 engagement? In your sunshine version surely the Slovens would be there cheering on in the sidelines for an inquest best placed to answer questions? With openness, candour and transparency. Not fighting the toss on these points. With spurious, insensitive and offensive arguments that include death by drowning is neither unnatural or non-violent.

Their choice of barrister, Gerard Boyle, also speaks to a fairly weighty adversarial inclination:
image

Gerry is in huge demand by the police and medical defence organisations to appear at Article 2 inquests? In huge demand?? How does this fit with your bland statement that families need no legal representation? It makes no sense at all. You must be completely distanced from the reality of the process, or worse.

I don’t know how to convey to you how we felt on the morning of LB’s pre-inquest review meeting. Back in November. When, three hours before the meeting, we found out who was representing the Trust. Such a blatant sign of their determination to fight. To fight about the circumstances of the death of our son they’d previously accepted was preventable. I really don’t know how an NHS Trust can possibly defend the death of a patient with epilepsy in the bath but that’s clearly not stopping them. I’m just relieved we have a legal team that shine a fierce light on human rights issues. A team drenched in integrity. And no whiff of parma violet pong.

Advising families they don’t need legal representation at inquests is simply wrong. Each situation is different. And clearly in some contexts legal representation is a necessity. I can’t imagine what it’s like to end up with an unsatisfactory inquest outcome. Other than making the worst thing you could ever imagine so much worse. This is unforgivable. And who funds this representation needs examination and reform. It isn’t fair that families have to pay.

It strikes me it might be helpful to send a few of your bods out to attend some inquests involving deaths in NHS Trusts. To get an idea of how it works in practice. Our next pre-inquest review meeting is on January 13th in Oxford if that’s any help.

Yours,

Sara

The Sloven Book of Dirty Tricks

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Pre-Inquest Hearing yesterday. And Sloven added a new chapter to their Book of Dirty Tricks. Delay, as always, was a Sloven feature. They circulated their submission 3.5 hours before the meeting started. Classy little technique. Reading it at home, and weeping, I thought back to the meeting we had with David Nicholson where he said something about the Trust not contesting LB’s death (I mean how can you, really?)

How can you? Well Sloven, turning up en masse with a barrister, a solicitor, their in house legal person and the now too familiar medical director, gave it a go. In an obscenely offensive move. They argued that there should not be a jury at the inquest because LB’s death wasn’t – wait for it – violent or unnatural.

Yep. I ain’t joking.

It’s indescribable how awful it is to read such dirty little, lying, contradictory, game playing, rubbish about the death of your child. This is the NHS?

Note to Sloven and team. If you fully accept the findings of a report stating that a patient died a preventable death, don’t pitch up in a courtroom setting six months later and claim he died of natural causes.

Complete scum of the earth stuff.

The coroner dismissed it straightaway.

The Pre-Inquest Review

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Seventeen months after LB’s death, the pre-inquest review hearing is taking place tomorrow afternoon. In a room in County Hall, Oxford. The building where I used to attend meetings about provision for disabled kids in Oxford. Transport issues and cuts. The Parents Advisory Group.

There’s not much to say at this point. I’ve said it all on these pages. In various ways. Pretty relentlessly.

A tiny part of me still thinks ‘Really? The NHS? Behaving like a bunch of bullyboy thugs? Nah. Our beautiful dude died. He was young, fit and had his adult life ahead of him… Such a terrible, terrible preventable death would lead to care and concern, not cover up, delay, crap and deceit. Surely?’

A tiny part the size of a pin head now.

Tonight, we’ll be thinking about LB. In all his legendary awesomeness. And the comfort he felt in doing things his own way. Before he grew older and stuck his toe in a new and empty world of ‘adult services’. Where one size fits all and he wasn’t allowed to be.

Like so many young people like him.

old pics (8)

I bloody love and miss you. xxxxxxxx

State of play

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Nearly 16 months now since LB died. 16 long months. Nothing’s happened really in terms of change or accountability. The preventable death of a fit and healthy young man in the ‘care’ of the state. In an NHS unit. In the UK. In the 21st century. A young man who was victim of a system that simply doesn’t recognise learning disabled people as human. Can you imagine?

LB’s death has crushed our lives. The damage caused by 16 months of fighting, campaigning and raging is unknown yet. But given I feel pretty shit on a daily basis, probably substantial. Standing up to an NHS trust that bullies, deceives and demonstrates complete disrespect/disregard for us, is pretty relentless. The Sloves throw money at reputation repair and focus on protecting staff (a selective protection given a staff comment here). The experience, for us (an irrelevant, irkesome family), is the equivalent of a daily battering. An experience documented by other parents like James Titcombe, Anne Dixon, Rosi Reed and siblings like @waketheworld. How can this be?

So where are we at? In no particular order, as always:

    • One staff member so far is being investigated by their professional body after a referral we made. Sloven staff disciplinary proceedings are like a stuck record; continually finishing in the ‘next few weeks’ or ‘ongoing’.  Shameful, shameful delay and prevarication. The Verita report makes clear individual staff failings. It should not have been our responsibility to do this.
LB 1 million

CEO, Sloven Health, 24.2.14

  • The Death Review is out to tender and will take 4 months.
  • The police investigation is ongoing.
  • The second review into LB’s death, covering transition, mental capacity, restraint, why he went into the unit and broader governance issues, is underway by Verita. Due to be completed early next year.
  • The pre-inquest review meeting is on November 25th.
  • The Slade House site is shut to patients. A problematic silence about what will happen to this prime chunk of land continues. And what is happening to people who would have been admitted to the units there. Nothing like allegedly sweeping in to take over known problematic provision in a different county, allowing it to worsen (till something serious happens), closing it and flogging the land. Nope. Nothing like it.
  • On a brighter note… the #LBBill is going at a pace that Sloven should take lessons from (no vimeo in sight). The easy read version of the draft bill is being produced and will be blasted out for discussion in a week or so. Complete energy, commitment and passion.
  • The LB Fighting Fund total so far, after remarkable efforts is £24, 267.77. Wow. Wow. Just wow. So many people, many of whom we’ve never met and who never met LB, have contributed to this amount. Just brilliant.

We’re heartened by the remarkable solidarity #justiceforLB demonstrates. We ain’t got a vimeo budget but there are countless people willing to step up and do all sorts at the drop of a hat.

We’re also fucking delighted that our quirky dude, who loved buses and laughter, seems to have touched, and even impacted on, people’s lives. What a legend. LB bus museum

The inquest

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Justicequilt
Received the pre-inquest review meeting (Nov 25th) paperwork from the coroner’s office this morning. (Sob). Thought it would be useful to outline the process here. (This is my sloppy version. For superb information the INQUEST Handbook is your baby.)

The inquest establishes who and where, when and how they died.  An inquest is held when the cause of death is unnatural or uncertain. There are bog standard inquests and article 2 (of the European Convention of Human Rights) inquests. The latter happen when there’s a question mark over state failure to protect someone’s right to life. Article 2 inquests are more in-depth and can involve a jury. Juries are required when someone dies in state ‘custody’.

The inquest isn’t about blaming people but the coroner can issue a critical verdict. Article 2 inquests can lead to narrative verdicts which expose problems or mistakes made.  A rule 43 report is where the coroner writes to the relevant person/ authority who has power to take action to prevent further deaths. Getting a rule 43 report is a chunky old dent in the reputation of an organisation (basically flagging up their shiteness publicly) and should lead to action.

When things are complicated pre-inquest meetings are held to thrash out the scope of the inquest (type, how wide a focus on what happened, whether there will be a jury and what witnesses to call, etc).

Phew. Think that’s pretty much it. Some other snippets… The coroner makes all these decisions. Inquests are public events. LB’s inquest can’t happen until the police investigations have finished. Sloven will have a legal team present defending them at the taxpayers expense. We have to fund our own legal costs (around £25,000) which thanks to  legendary efforts by the great British (and further afield) public we’ve pretty much raised now. This is bloody brilliant. Though so wrong.

Inquest and inequity

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Had a meeting at lunchtime with Deborah Coles and Selen Cavcav from INQUEST and Andrew Smith, our MP, today as part of #107days. The meeting was at Portcullis House. A building with a random, mini airport type security gig going on that is breathtaking. Bags scanned. Bodies scanned and ordered in out, in out, shake it all about. Patted down by serious, super silent, severe security people. Wow.

Instead of leaving on a jet plane (sadly), we went through to an enormous atrium to grab a drink from the heavily subsidised cafe and up to Andrew Smith’s office. Wow. I’m clearly in the wrong business. An office/room/corner space with a view that captured the London Eye, the Thames, parliament buildings, Big Ben… Wow.

It turns out Andrew Smith has lived in Blackbird Leys for years (thirty four years). I bloody love this fact and I bloody love his office. But this wasn’t about spaces. It was about what he could do to help #justiceforLB. We had a fairly action packed 40 minutes or so, in which Deborah demonstrated INQUEST magic and (policy) knowledge in buckets. Key issues were discussed and plans made. These will be reported elsewhere. I just wanted to focus on one part of the discussion. The inquest and inequity that exists around inquest funding.

I got a real taste today, through hanging out with Deborah and Selen, of the centrality of the inquest. I sort of knew this but hearing it talked about made it clearer. The inquest is the mechanism by which families are able to find out exactly what happened and to explore the circumstances surrounding this. And it’s crucially important to have the right questions asked. If, as we hope, LB’s inquest comes under Article Two of the European Convention of Human Rights (he died in the care of the state), the inquest will be broader and involve more witnesses and, possibly, a jury.

The inequity kicks in when it comes to legal representation for this. The NHS (Slovens) are able to bring out the big solicitors/barristers for the inquest funded by, er, you and me. If social care are required to be there, they will be able to draw on a legal team funded by, yep, you and me. If the Oxfordshire Clinical Commissioning Group, likewise. So health and social care can draw on the public purse to provide top level representation to defend themselves against families of patients who have died (howl).

And families? They have to foot their legal representation. To stand firm in the face of the NHS legal team and get someone other than themselves to ask the questions, they have to fund the legal costs themselves. There is some Legal Help that is means tested and covers the costs of pre-inquest preparation and early advice but representation in the inquest is unfunded outside of the exceptional fund.

I’m not going to go into the nitty gritty of the hoops involved in trying to crack the exceptional fund. I just wonder how it can be possible that LB died a preventable death in the care of the Slovens, and they can effortlessly draw on unlimited legal support to defend the indefensible while we have to stump up, or fundraise (thank you everyone who has contributed) £1000s?

?

It’s so wrong, it almost takes your breath away. And. Where, in any of this vile, hideous, inhumane process is there any consideration of the compete and utter pain we are experiencing?

I left the meeting pleased it was positive. And, within moments, so blinking sad that LB never got to see the newly designed Routemaster buses pretty much nose to nose along my walk back to the coach stop.

 

Our Charlotte

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In my last post I outlined the way in which we were launched into the world of legal representation via twitter and got ourselves a solicitor highly recommended by our new caseworker from INQUEST. Charlotte Haworth Hird from Bindmans. Charlotte was very highly recommended. Being completely unfamiliar with any of this new world we wanted no part of, we just held on and ran with it.

Before the relationship was officially sealed, Charlotte spent some time on the phone with me, talking through some extremely upsetting and uncomfortable things (autopsy details, potentially delaying LB’s funeral, the enormous costs involved in having legal representation at an inquest and what we could realistically expect to happen). Again, I can’t describe what it’s like to have these sorts of conversations days after your child has died, but Charlotte was sensitive, thorough, kind and comprehensive.

We dropped out of touch with her for a couple of weeks then picked up the communication after LB’s do. We arranged to meet her at her offices a few days later. Before the meeting, she emailed about various bits and asked us to send a photo of LB so she could “put a name to a face and see who we are fighting for”. That kind of sealed it for me but you don’t know anything in the world of the completely unfamiliar.

We met that first time for about four hours. We were hopelessly late as we pounded up and down Gray’s Inn Road with me getting the office number completely wrong. It was boiling hot and beyond stressful. I’d wanted to scream at everyone on the train from Haddenham where we going and why but of course, you don’t. Charlotte was an oasis of calm. She talked us through excruciating and agonising details and memories and thoughts. With compassion and sensitivity.

Since then we’ve largely interacted by email. Typically, very short, two liners from me and essay length responses from her. The kind of emails you need to read a couple of times to grasp all the content but, at the same, emails that contain everything you need to know. Including all the stuff you had no idea you needed to know.

I hope very, very few of you are ever in the position of doing what we’re doing. But if you are, a brilliant solicitor you can completely trust is priceless (not only because they costa del fortune). We’re delighted Charlotte just won the ‘Inquests/actions against the state’ award at this year’s Legal Aid Lawyer of the Year Awards. Wow. So deserved. And so blinking brilliant that her remarkable work to try and get justice for LB contributed towards this.

charlotte

I’m pretty sure she’ll cringe her socks off at this post (she most definitely doesn’t do twitter or social media) but Charlotte, from one of your clearly many satisfied (not the right word… Grateful? Desperate? Heartbroken..) punters, you’re fighting the fight in a way that’s restorative, reassuring, heartwarming and bloody exceptional.

And keep asking to see those photos…