I’ve followed the inquests of over 30 people with learning disabilities for a decade now through George Julian’s meticulous reporting. These began as live tweets, magnificent threads dripping with horror then shifted to lengthy daily summaries of proceedings. Each inquest, involving a much loved person who was revoltingly failed, is a difficult read, sometimes wincingly so. Daniel Lindsay’s inquest which ended on Friday was near impossible to follow. Daniel was a quiet, gentle 41 year old man who loved playing on his Playstation. George has written a comprehensive commentary about his inquest here.

In my book about social murder I write about a loose collective of people (health and social care professionals, politicians, policymakers, national charity staff, sometimes family members etc) who are implicated in these premature deaths. Loose collective members have varying layers of ignorance which relate to misunderstanding, ignoring or refusing to know what is happening, and where failings lie. The collective is loose because people can move in and out of it. Enlightened people who remove themselves from the collective are probably some of the best allies and activists in this area.

Daniel’s inquest had quite the cast of collective members. The most important being the coroner whose ignorance about people with learning disabilities made the skin on the back of my hands prickle. She insisted Daniel could not communicate despite evidence he was trying to communicate about his throat pain and discomfort over time from various witnesses. She accepted woeful evidence from a range of ‘experts’ who knew nothing about people with learning disabilities all of whom said nothing could have been done to change what happened.

That someone can die from choking because their undiagnosed throat cancer is so advanced is grotesque and can only be a massive red failure flag in terms of the provision of health and social care. The coroner went on to record her ignorance on public record by determining the cause of Daniel’s death as 1a) choking 1b) locally advanced oesophageal cancer and 2) Down syndrome and learning disabilities.

People cannot die from Down Syndrome and learning disabilities. That would be like dying from having curly hair or size 6 feet. Gruelling, unacceptable ignorance which blames Daniel for his death and absolves the myriad failings that led to it.

The government states coroners must ensure relevant facts are fully and fairly investigated and are the subject of public scrutiny during the inquest hearing. Coroners can’t be an expert in everything. That is why they call expert witnesses, to fill gaps with knowledge and experience. The coroner did not call an expert in learning disabilities despite stating she knows little about this area. She is an example of refusing to know which comes with chilling consequences given her role. Daniel’s family are devastated and crucial failings in his care have been left unchallenged.

Yet more evidence in the bulging evidence bank of social murder.

One of the action points of our recent Social Murder Festival is to contact the Chief Coroner about ignorance among coroners which urgently needs addressing. That this inquest unfolded at the same time as the festival speaks to how far we have to go. The festival itself, however, was a force for change, empowerment, hope and anger.

Onwards and upwards.