Coroners inquest

it’s a pretty hard time to be writing this, looking for some help and advice about where we go and what happens next.

My oldest daughter, aged just 22, committed suicide last week.

She had Asperger’s syndrome (as do I) and OCD, and was subject to an EHCP since her early teenage years

she had struggled for some years with suicidal ideation and overdoses/threats but in my opinion this was mainly ‘cry for help’ stuff as she had the communication difficulties caused by Autism and didn’t know how to express her need for help and reassurance - however this time was different and very clearly planned as a way end It.

All this was tied to a complete failure in social services and mental health services engagement, despite numerous requests for help and repeated appeals for assessment of needs and a package of support with housing etc. All repeatedly rebuffed, over a period of years.

On top of this, she had a baby in January, and social services launched care proceedings against her (This is undoubtedly what pushed her over the edge) - but, importantly, the situation here involved repeated and numerous documented breaches of statutory guidance and caselaw, particularly in the availability and types of support, support with ongoing child contact, and advocacy/counselling that was repeatedly promised. Failure to carry out required assessments both before and during the court proceedings, etc.

As an example of the level of failings involved, just a few weeks ago, even after years of social services and mental health services involvement, they gave her the keys to a new flat, with no managed transition, no care needs assessment, no support or referral to support agencies - this vulnerable and disabled young girl was handed keys to an empty flat and expected to move in to an unfurnished flat with no gas or electric and fend for herself. She spent the first night there with no furniture or electricity until we Stepped in and took her back out of it.

Please don’t think for one second that the family were not supporting her - we absolutely have been, but she was both intelligent, and fiercely independent - she didn’t want to rely on us for help, and thus lots of things were happening whereby we repeatedly only found out after the event (again, largely down to a lack of proper engagement and communication by the professionals involved who were not supporting her the way the guidelines said they should)

I think it’s also important to say that none of this came out of the blue, as a family her mum and myself had been warning them repeatedly in writing about the ongoing failings in support and failures to put In place independent advocacy as the guidelines said they should (which to many autistics is pretty much equivalent to not providing a Deaf person with a sign language translator). We literally have emails Warning them that if they didn’t pull their act together it was going to end in a tragedy, and we are proved right.

So, after that cathartic bit.

has anyone had experience of dealing with Coroners inquests and how to get this type of information and background over to them. We are terrified that council will close ranks and play the ‘minor procedural errors, much regretted, lessons learned’ approach,, and try to push all the blame onto mental health services (and, of course, vice versa). How can we ensure that a proper investigation happens?
 
it’s a pretty hard time to be writing this, looking for some help and advice about where we go and what happens next.

My oldest daughter, aged just 22, committed suicide last week.

She had Asperger’s syndrome (as do I) and OCD, and was subject to an EHCP since her early teenage years

she had struggled for some years with suicidal ideation and overdoses/threats but in my opinion this was mainly ‘cry for help’ stuff as she had the communication difficulties caused by Autism and didn’t know how to express her need for help and reassurance - however this time was different and very clearly planned as a way end It.

All this was tied to a complete failure in social services and mental health services engagement, despite numerous requests for help and repeated appeals for assessment of needs and a package of support with housing etc. All repeatedly rebuffed, over a period of years.

On top of this, she had a baby in January, and social services launched care proceedings against her (This is undoubtedly what pushed her over the edge) - but, importantly, the situation here involved repeated and numerous documented breaches of statutory guidance and caselaw, particularly in the availability and types of support, support with ongoing child contact, and advocacy/counselling that was repeatedly promised. Failure to carry out required assessments both before and during the court proceedings, etc.

As an example of the level of failings involved, just a few weeks ago, even after years of social services and mental health services involvement, they gave her the keys to a new flat, with no managed transition, no care needs assessment, no support or referral to support agencies - this vulnerable and disabled young girl was handed keys to an empty flat and expected to move in to an unfurnished flat with no gas or electric and fend for herself. She spent the first night there with no furniture or electricity until we Stepped in and took her back out of it.

Please don’t think for one second that the family were not supporting her - we absolutely have been, but she was both intelligent, and fiercely independent - she didn’t want to rely on us for help, and thus lots of things were happening whereby we repeatedly only found out after the event (again, largely down to a lack of proper engagement and communication by the professionals involved who were not supporting her the way the guidelines said they should)

I think it’s also important to say that none of this came out of the blue, as a family her mum and myself had been warning them repeatedly in writing about the ongoing failings in support and failures to put In place independent advocacy as the guidelines said they should (which to many autistics is pretty much equivalent to not providing a Deaf person with a sign language translator). We literally have emails Warning them that if they didn’t pull their act together it was going to end in a tragedy, and we are proved right.

So, after that cathartic bit.

has anyone had experience of dealing with Coroners inquests and how to get this type of information and background over to them. We are terrified that council will close ranks and play the ‘minor procedural errors, much regretted, lessons learned’ approach,, and try to push all the blame onto mental health services (and, of course, vice versa). How can we ensure that a proper investigation happens?
Jesus H C. My condolences, this must be an awful time. Coroners mainly deal with the facts, and nowt else. If you have questions, engage a lawyer soonest. Sounds just like all the things we all hate, but an initial chat can be useful.
None of the above can convey my condolences in such a sad time. Stay strong for her child, and you. Difficult times ahead, focus on the nipper.
 
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Grownup_Rafbrat

LE
Book Reviewer
it’s a pretty hard time to be writing this, looking for some help and advice about where we go and what happens next.

My oldest daughter, aged just 22, committed suicide last week.

She had Asperger’s syndrome (as do I) and OCD, and was subject to an EHCP since her early teenage years

she had struggled for some years with suicidal ideation and overdoses/threats but in my opinion this was mainly ‘cry for help’ stuff as she had the communication difficulties caused by Autism and didn’t know how to express her need for help and reassurance - however this time was different and very clearly planned as a way end It.

All this was tied to a complete failure in social services and mental health services engagement, despite numerous requests for help and repeated appeals for assessment of needs and a package of support with housing etc. All repeatedly rebuffed, over a period of years.

On top of this, she had a baby in January, and social services launched care proceedings against her (This is undoubtedly what pushed her over the edge) - but, importantly, the situation here involved repeated and numerous documented breaches of statutory guidance and caselaw, particularly in the availability and types of support, support with ongoing child contact, and advocacy/counselling that was repeatedly promised. Failure to carry out required assessments both before and during the court proceedings, etc.

As an example of the level of failings involved, just a few weeks ago, even after years of social services and mental health services involvement, they gave her the keys to a new flat, with no managed transition, no care needs assessment, no support or referral to support agencies - this vulnerable and disabled young girl was handed keys to an empty flat and expected to move in to an unfurnished flat with no gas or electric and fend for herself. She spent the first night there with no furniture or electricity until we Stepped in and took her back out of it.

Please don’t think for one second that the family were not supporting her - we absolutely have been, but she was both intelligent, and fiercely independent - she didn’t want to rely on us for help, and thus lots of things were happening whereby we repeatedly only found out after the event (again, largely down to a lack of proper engagement and communication by the professionals involved who were not supporting her the way the guidelines said they should)

I think it’s also important to say that none of this came out of the blue, as a family her mum and myself had been warning them repeatedly in writing about the ongoing failings in support and failures to put In place independent advocacy as the guidelines said they should (which to many autistics is pretty much equivalent to not providing a Deaf person with a sign language translator). We literally have emails Warning them that if they didn’t pull their act together it was going to end in a tragedy, and we are proved right.

So, after that cathartic bit.

has anyone had experience of dealing with Coroners inquests and how to get this type of information and background over to them. We are terrified that council will close ranks and play the ‘minor procedural errors, much regretted, lessons learned’ approach,, and try to push all the blame onto mental health services (and, of course, vice versa). How can we ensure that a proper investigation happens?
I am really sorry for your loss. I can't imagine what it must be like to lose your child. I do hope that you are able to take your grandchild into your home if you can .

I really think you should consult a specialist lawyer over this, rather than the arrserati, to be sure to get accurate advice.

Good luck with your case, and my deepest condolences for your loss.
 
@labrat

Deepest condolences

God Bless
 

MoleBath

LE
Kit Reviewer
Book Reviewer
Welcome to The Coroners’ Courts Support Service
The Coroners’ Courts Support Service (CCSS) is an independent voluntary organisation whose trained volunteers offer emotional support and practical help to bereaved families, witnesses and others attending an Inquest at a Coroner’s Court.

Note they are not working face to face at present
 

Helm

MIA
Moderator
Book Reviewer
As the others have said get specialised help. Deepest condolences on a terrible loss.
 

Arte_et_Marte

ADC
Moderator
@labrat

Jeezus, that's tragic.

I'm sorry I cannot offer advice regarding the Coroner other than they deal with facts (as has been said) and they are not there to apportion blame, but as others have also said, there are pros out there that specialise in the medical negligence side of the law. I wish you well.

My thoughts are with you and your family.
 
No one should have to bury their child. Sincerest condolences to you.

Have you looked at MH charities such as Mind? They may be able to offer some guidance.

Regarding the coroner’s themselves, there is this.


It may also be worth booking an appointment with your MP to highlight the systematic failures you have encountered.

Good luck.
 

jarrod248

LE
Gallery Guru
it’s a pretty hard time to be writing this, looking for some help and advice about where we go and what happens next.

My oldest daughter, aged just 22, committed suicide last week.

She had Asperger’s syndrome (as do I) and OCD, and was subject to an EHCP since her early teenage years

she had struggled for some years with suicidal ideation and overdoses/threats but in my opinion this was mainly ‘cry for help’ stuff as she had the communication difficulties caused by Autism and didn’t know how to express her need for help and reassurance - however this time was different and very clearly planned as a way end It.

All this was tied to a complete failure in social services and mental health services engagement, despite numerous requests for help and repeated appeals for assessment of needs and a package of support with housing etc. All repeatedly rebuffed, over a period of years.

On top of this, she had a baby in January, and social services launched care proceedings against her (This is undoubtedly what pushed her over the edge) - but, importantly, the situation here involved repeated and numerous documented breaches of statutory guidance and caselaw, particularly in the availability and types of support, support with ongoing child contact, and advocacy/counselling that was repeatedly promised. Failure to carry out required assessments both before and during the court proceedings, etc.

As an example of the level of failings involved, just a few weeks ago, even after years of social services and mental health services involvement, they gave her the keys to a new flat, with no managed transition, no care needs assessment, no support or referral to support agencies - this vulnerable and disabled young girl was handed keys to an empty flat and expected to move in to an unfurnished flat with no gas or electric and fend for herself. She spent the first night there with no furniture or electricity until we Stepped in and took her back out of it.

Please don’t think for one second that the family were not supporting her - we absolutely have been, but she was both intelligent, and fiercely independent - she didn’t want to rely on us for help, and thus lots of things were happening whereby we repeatedly only found out after the event (again, largely down to a lack of proper engagement and communication by the professionals involved who were not supporting her the way the guidelines said they should)

I think it’s also important to say that none of this came out of the blue, as a family her mum and myself had been warning them repeatedly in writing about the ongoing failings in support and failures to put In place independent advocacy as the guidelines said they should (which to many autistics is pretty much equivalent to not providing a Deaf person with a sign language translator). We literally have emails Warning them that if they didn’t pull their act together it was going to end in a tragedy, and we are proved right.

So, after that cathartic bit.

has anyone had experience of dealing with Coroners inquests and how to get this type of information and background over to them. We are terrified that council will close ranks and play the ‘minor procedural errors, much regretted, lessons learned’ approach,, and try to push all the blame onto mental health services (and, of course, vice versa). How can we ensure that a proper investigation happens?
Firstly I’m so sorry for your loss.
I’ve been to coroners court many times over the years, mainly suicides and overdoses.
It very much depends on the coroner as to how relaxed these proceedings can be.
I mean to say some don’t wear wigs, gowns and have a jury.
It’s not easy to get any sort of satisfaction in any of this.
Don’t forget it’s to determine cause of death.
A coroner can send witnesses with police officers to get information if he deems it necessary. The old I left that in my office at work scam ‘fine, officer go take him to get it’.
Services often have some form of risk assessment to determine whether a person is deemed high risk. I expect the forms will say as they want them to. More services are now on computer so it’s often impossible to delete things without a trail.
A patient I thought as a mental health nurse was high risk of suicide, his GP thought he was and a ward sister thought he was, the mental health team did not. The chap had a suicide plan, had train timetables and had been down to the train lines, recently lost his brother and grandmother and had nothing to live for.
The nurse who assessed him actually got promoted.
Don’t forget it’s about cause of death and you no doubt know that.
I was very angry about that case, now I see mental health services decimated and nobody seems to care.
Again I’m so sorry.
Do get support, do talk to friends and family.
 
This, my brother killed himself, after a long battle with PTSD.
The corner is there to determine cause of death, Nothing more nothing less.
 
Thanks for the kind words above

My understanding was that a coroner can (should?) go beyond simple cause of death where future deaths could be prevented. As I say, this whole thing tracks back to services not following existing caselaw and guidance.
 

diverman

LE
Book Reviewer
it’s a pretty hard time to be writing this, looking for some help and advice about where we go and what happens next.

My oldest daughter, aged just 22, committed suicide last week.

She had Asperger’s syndrome (as do I) and OCD, and was subject to an EHCP since her early teenage years

she had struggled for some years with suicidal ideation and overdoses/threats but in my opinion this was mainly ‘cry for help’ stuff as she had the communication difficulties caused by Autism and didn’t know how to express her need for help and reassurance - however this time was different and very clearly planned as a way end It.

All this was tied to a complete failure in social services and mental health services engagement, despite numerous requests for help and repeated appeals for assessment of needs and a package of support with housing etc. All repeatedly rebuffed, over a period of years.

On top of this, she had a baby in January, and social services launched care proceedings against her (This is undoubtedly what pushed her over the edge) - but, importantly, the situation here involved repeated and numerous documented breaches of statutory guidance and caselaw, particularly in the availability and types of support, support with ongoing child contact, and advocacy/counselling that was repeatedly promised. Failure to carry out required assessments both before and during the court proceedings, etc.

As an example of the level of failings involved, just a few weeks ago, even after years of social services and mental health services involvement, they gave her the keys to a new flat, with no managed transition, no care needs assessment, no support or referral to support agencies - this vulnerable and disabled young girl was handed keys to an empty flat and expected to move in to an unfurnished flat with no gas or electric and fend for herself. She spent the first night there with no furniture or electricity until we Stepped in and took her back out of it.

Please don’t think for one second that the family were not supporting her - we absolutely have been, but she was both intelligent, and fiercely independent - she didn’t want to rely on us for help, and thus lots of things were happening whereby we repeatedly only found out after the event (again, largely down to a lack of proper engagement and communication by the professionals involved who were not supporting her the way the guidelines said they should)

I think it’s also important to say that none of this came out of the blue, as a family her mum and myself had been warning them repeatedly in writing about the ongoing failings in support and failures to put In place independent advocacy as the guidelines said they should (which to many autistics is pretty much equivalent to not providing a Deaf person with a sign language translator). We literally have emails Warning them that if they didn’t pull their act together it was going to end in a tragedy, and we are proved right.

So, after that cathartic bit.

has anyone had experience of dealing with Coroners inquests and how to get this type of information and background over to them. We are terrified that council will close ranks and play the ‘minor procedural errors, much regretted, lessons learned’ approach,, and try to push all the blame onto mental health services (and, of course, vice versa). How can we ensure that a proper investigation happens?
My sincere condolences to you your family and most importantly the little one. First thing to do is find a good solicitor who deals in family and maybe criminal law. You will need one afterwards as well in regard toi care proceedings. The law regarding the care of your daughter may have been broken in numerous ways and you need a solicitor to present the case at least in the Coroners court. There are legal specialists who deal with this. As your daughter commited suicide talk to the Coroner's officer as well about proceddings and put forward your fears regarding any information which will be witheld by the authorities.

If you can reach out to families who have gone through similar things through mediums like Facebook (yeah I know) Look for places where there have been care scandels, local political blog sites which shine a light behind coucil activities. Also a local journalist maybe very helpful at digging things up.

And, cases like this.


If the NHS is involved then the CQC is a port of call and for social services Ofsted are the regulators.
 

diverman

LE
Book Reviewer
This, my brother killed himself, after a long battle with PTSD.
The corner is there to determine cause of death, Nothing more nothing less.
But by rendering a verdict of corporate manslaughter or manslaughter or neglect, he can open a whole can of worms for the authorites.

Remember the Chief Croner I think Andrew Walker who demanded USAF pilots give evidence after a major blue on blue attack in Iraq and the death of LCploH (Lance Corporal of Horse) Matty Hull. caused all sorts of problems for the government. A verdict of unlawful killing was returned.

 
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jarrod248

LE
Gallery Guru
Thanks for the kind words above

My understanding was that a coroner can (should?) go beyond simple cause of death where future deaths could be prevented. As I say, this whole thing tracks back to services not following existing caselaw and guidance.
These things can take a very long time. I’d like to reassure you that things improve but unfortunately I can’t.
Tiers of mental health teams were done away with, funding cut, it’s hard to get people seen when I refer them so it’s often back to us in general practice to offer what we can.
It’s nowhere near good enough. I’ve prescribed antipsychotic medication when I just couldn’t get anyone else to do it. I shouldn’t do it but had little option.
 
I am horrified at what you and the family are going through.

I am not a UK barrister or solicitor so cannot give you any real legal advice based on UK law. I am however a retired US attorney and am familiar with legal systems in general and urge you to get a lawyer on board before the coroner hearings begin.

You could begin by contacting groups who help families of persons on the autism spectrum. They might provide names of solicitors who deal with this sort of wrongful death. The coroner's finding of fact could have a major effect on any future claims.

You now have a six month old grandchild who will need care throughout childhood. I sincerely hope the baby has been placed with family that will love her and care for her.

As I explained I am not a UK lawyer but I presume any finding of fact by the coroner would have a major impact on what follows. You should look for a lawyer with medical malpractice experience to ensure that the baby has the resources for his/her upbringing. Again, check with autism support groups for advice on counsel in the matter, not just for you but for the baby.

I wish you all the best in dealing with this. I am sure you are not alone in this. It does sound like your daughter's care was what we in the US, colloquially, term a "complete clusterfcuk"

Here in the US we get similar problems. The younger sister of a lifelong friend was murdered by her son 4 years ago. They lived in New York where the legal system generally limits involuntary commitments to 30 days. Her son was at home between commitments for his schizophrenia and was not taking his meds. He got angry when his mother told him he had to take his meds, dragged her across the lawn to the pool and held her under until she drowned. He then got dressed and took the train to NYC, went to his sisters house and told her what he had done. A sad death of a woman I really liked. All due to a mental health system in NY.
 
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it’s a pretty hard time to be writing this, looking for some help and advice about where we go and what happens next.

My oldest daughter, aged just 22, committed suicide last week.

She had Asperger’s syndrome (as do I) and OCD, and was subject to an EHCP since her early teenage years

she had struggled for some years with suicidal ideation and overdoses/threats but in my opinion this was mainly ‘cry for help’ stuff as she had the communication difficulties caused by Autism and didn’t know how to express her need for help and reassurance - however this time was different and very clearly planned as a way end It.

All this was tied to a complete failure in social services and mental health services engagement, despite numerous requests for help and repeated appeals for assessment of needs and a package of support with housing etc. All repeatedly rebuffed, over a period of years.

On top of this, she had a baby in January, and social services launched care proceedings against her (This is undoubtedly what pushed her over the edge) - but, importantly, the situation here involved repeated and numerous documented breaches of statutory guidance and caselaw, particularly in the availability and types of support, support with ongoing child contact, and advocacy/counselling that was repeatedly promised. Failure to carry out required assessments both before and during the court proceedings, etc.

As an example of the level of failings involved, just a few weeks ago, even after years of social services and mental health services involvement, they gave her the keys to a new flat, with no managed transition, no care needs assessment, no support or referral to support agencies - this vulnerable and disabled young girl was handed keys to an empty flat and expected to move in to an unfurnished flat with no gas or electric and fend for herself. She spent the first night there with no furniture or electricity until we Stepped in and took her back out of it.

Please don’t think for one second that the family were not supporting her - we absolutely have been, but she was both intelligent, and fiercely independent - she didn’t want to rely on us for help, and thus lots of things were happening whereby we repeatedly only found out after the event (again, largely down to a lack of proper engagement and communication by the professionals involved who were not supporting her the way the guidelines said they should)

I think it’s also important to say that none of this came out of the blue, as a family her mum and myself had been warning them repeatedly in writing about the ongoing failings in support and failures to put In place independent advocacy as the guidelines said they should (which to many autistics is pretty much equivalent to not providing a Deaf person with a sign language translator). We literally have emails Warning them that if they didn’t pull their act together it was going to end in a tragedy, and we are proved right.

So, after that cathartic bit.

has anyone had experience of dealing with Coroners inquests and how to get this type of information and background over to them. We are terrified that council will close ranks and play the ‘minor procedural errors, much regretted, lessons learned’ approach,, and try to push all the blame onto mental health services (and, of course, vice versa). How can we ensure that a proper investigation happens?
I have zero advice and just wanted to offer my condolences- Stay strong Brother.
 

BratMedic

LE
Book Reviewer
I'm so sorry to hear your sad news, our eldest daughter has Asperger's so I know how difficult it all can be. Condolences.
 
I'm so sorry for your loss

Has the Local Authority indicated that they will be holding a serious case review, also any failings in local authority provision of care you can involve your local councillor and Member of Parliament

Archie
 

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