The Inquest & The Missing Letter

The Inquest into Jake’s death was scheduled for 3rd December 2015. The support and guidance I received from the Coroners Office was professional, informative and sensitive. Despite this, nothing can really prepare you for an Inquest into the untimely death of your only child. You want that day to come, but at the same time you want to fast forward and for it to all be over.
I was interviewed by a Police Coroners Officer in the first few weeks after |Jake’s death and was disappointed when told that the interview would be conducted over the phone. I was expecting face to face, so this just felt like the assumption had been made, that Jake would be just another young male suicide. One of the 6,188 suicides of 2015, a statistic. However, I have to say that this Police Coroners Officer was very thorough, our phone call lasted over an hour and a half and when I received the written statement for me to check and sign, I was impressed and felt reassured by the detail.
I was feeling incredibly anxious and nervous during the build up to the Inquest. I knew that Journalists, could attend and report on the Inquest. I was told that it just depends on what else is of interest to them on the day. I had no idea if Jake’s suicide note would be read out. I was asked by the Coroner’s Office if I wanted to know what it said, I was unsure. She hinted that it was along the lines of the phrases that Jake would often use like “There is a future that is calling, but I don’t see it coming”. How very, very sad.
I received a letter notifying me of who was to be called to the Inquest as a witness – myself, my brother, Detective Inspector, Toxicologist, Trafford Aim. Phoenix Futures, GMW Mental Health Foundation Trust. We were all expected to give evidence. The Pathologist, GP, CMHT & RAID were only required to submit statements to the Coroner.
So, the day came and I felt sick to the core. I arrived at the Coroner’s Court and waited in reception until all witnesses had arrived and signed in. I spoke to a member of staff from Trafford Aim and she started crying, which set me off. Then the Detective Inspector introduced himself, the room was filling up quite quickly now and then a lady came over and introduced herself as, the Police Coroners Officer who had interviewed and supported me. I had never actually met her and I thought that this was such a lovely touch.
The last witness to arrive was the person who carried out the Serious Incident Report. If you have been following my blogs then you will be aware that after the SIR was written I raised an important question about a ‘missing letter’ just one week before the Inquest. She came over to me and appeared to want to share some information with me, she looked quite anxious. There wasn’t time to talk, as we were all ushered upstairs to the court room.
It took me a while to fully take in the room. There was a long table with microphones and name cards for the 7 of us who had been called to give evidence. There were a number of seats behind our table for anyone else who was attending. The room was full and I kept scanning it to work out who was who. Every witness other than the DI and Toxicologist had brought at least one other person with them i.e. their manager, area manager, other representatives. I managed to work out who everyone was or at least who they were with, so I felt relieved that there were no journalists.

We all had to stand whilst the Coroner Joanne Kearsley entered the room. When I need to stay focused, I can do it, and on this day, I was determined not to be tearful, but instead keep my wits about me and listen to every word. |I felt very strongly that I had to represent Jake and expose the shortfalls that he had experienced. I had to make sure that no stone was left unturned.
I was the first witness to take the stand and I was nervous. The Coroner took me through the statement that I had submitted, starting with what Jake was like as a child etc. and then she jumped to the final few months of his life and then to the final day. Then she stopped and said ‘do you have any questions?’. I looked around the room in disbelief thinking you have missed out the most important elements of my statement. I looked at her puzzled and said ‘you haven’t asked me anything about Trafford Aim’. She looked at me very sternly and then around the room which was silent and said in what seemed a patronising tone ‘you will get the opportunity later to ask questions’. Well, that was me told. It took me about an hour to realise just how the role of a Coroner works. I worked out what she was doing and was very impressed.
The other witnesses were called to the stand. The DI went through the facts regarding the day and the scene of Jake’s death. I learned of the planning and the sophistication that went into how Jake hung himself using ratchet straps. The Pathologists summarised on Jake’s post mortem report that Jake had died very quickly. The evidence for this was the fact that there was very little bruising to the neck which meant that his heart stopped very quickly. I guess that means he didn’t struggle.
The Toxicologist was up next. She faced the Coroner when being asked a question, but she then turned around and directly faced me when giving her answers. This way of communicating in such a formal environment is something that I will never forget. She also explained the toxicology results in a way that I could understand.
When Jake’s case worker from Phoenix Futures took the stand the Coroner actually smiled at her (I think this was the only time that she did smile) and went on to outline the fantastic relationship that she had built with Jake as his case worker and the work that Phoenix Futures had done with Jake.
Next to take the stand was a representative from Trafford Aim. This witness did know Jake, but only for a short time as there had been staffing issues/changes. I hold an awful lot of negativity towards Trafford. The Coroner did expose everything that I thought of them and more. However, I have to say that I felt for this witness, as in my opinion she was ‘pushed under a bus’ by Trafford Aim. She was not prepared or supported, she was pulled apart by the Coroner and although Trafford Aim deserved this, she didn’t.
So now we come to the Head of GMW Mental Health Foundation Trust who had carried out the Serious Incident Review. This person is experienced at giving evidence at Inquests, but \I must say she seemed nervous. To cut to the chase she was given a very hard time by the Coroner and things were about to get worse. THE MISSING LETTER.
So, rewind to the SIR report and the fact that only a week before the Inquest |I pointed out that a very important piece of correspondence was nowhere to be seen in the report. There had only been about 4 working days for this person to look into this and only the day before the Inquest had she found out that a very important letter had indeed been faxed from a GP to Trafford Aim. It had been faxed to the correct number and had been logged as sent successfully. However, Trafford Aim had no record of this fax/letter. This was what she wanted to talk to me about when she arrived at the Coroners Court but we were ushered upstairs.
This witness had to inform the Coroner during her time on the witness stand that it would appear that there is a ‘missing letter’ that does not feature in the SIR report.
Well, if the Coroner could have done a vertical take off then I think she would have. Her face became even more serious than the serious expression she had already shown throughout this Inquest. You could have heard a pin drop in that room. I was on the edge of my seat. The Coroner asked for more detail and she allowed me to speak and briefly explain even though I was not in the witness stand (only those on the stand are allowed to speak).
The Coroner looked this witness in the eye and said “are you telling me that a significant letter was sent in June by a GP to Trafford Aim that should have resulted in Jake receiving a safe prescription for benzodiazepines and there appears to be no record of it?”
“Yes” was the reply.
The Coroner ordered an immediate investigation into the missing letter with a short time frame to feedback and then issued a Regulation 28 which is a report to prevent future deaths. She bowed and left the room.
I am proud of Jake for fighting so hard to live whilst battling with suicidal thoughts. If he had not have shared all his thoughts, his feelings, his behaviour and his appointments with me then this Inquest would have been an open and shut case and the Coroner would not have known the half of it and changes would not have come about since Jake’s death
The Court Clerk came over to me at the end and said “you did really well, well done”
I guess I managed my goal which was to stay focused and fight Jake’s corner.
This experience was quite exhilarating which may not seem like the most appropriate word, but I was running on adrenaline for a couple of weeks after this Inquest from the sheer relief at how well it actually went.
Much Love.x