Coroners inquest

I'm really sorry for your loss, I can't comprehend how you must be feeling.

Having been to Coroners court a few times, it's not uncommon for families to have engaged a lawyer so I would echo what others have said.

I hope you get the closure that you are looking for.
 
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
a review has been mentioned by children’s services (the care proceedings over the baby) but not sure if it’s a formal serious case review, also not sure if that would spread across the different agencies involved (Social care, housing, mental health services) and the cracks gaping chasm between them. something specifically warned about in the guidelines.
 
@labrat, our condolences for your tragic loss from both myself and Mrs H_M; can I suggest both SSAFA and the RBL as a source of advice and support? Also, it would be well worth engaging the services of someone legally-qualified to represent both you and your late daughter in court. Their job is to speak for someone who can no longer speak for themselves. H_M.
 
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.

Pity he wasn’t the coroner for the other lads the USAF brasses up in 91.
 
a review has been mentioned by children’s services (the care proceedings over the baby) but not sure if it’s a formal serious case review, also not sure if that would spread across the different agencies involved (Social care, housing, mental health services) and the cracks gaping chasm between them. something specifically warned about in the guidelines.
labrat, I think it may go to a serious case review. The Local Authority has no choice in the matter as it may be part of their statutory duties.
It’s been said before, but have a talk with a lawyer. Your house insurance could cover it (please check your policy). It can help (really, it can).
I cannot begin to think what you are going through, but please seek help if you are puzzled.
Like lots on here, I have been a copper, and unfortunately things get businesslike. There are lots of bereavement services out there. Seek help; someone will guide you through an awful time.
 

rifleair

War Hero
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?
First off my condolences for your loss.

What you need to do in the first instance is to address a formal letter of complaint to the trust.
Address it to the chief executive of the mental health trust. Research the person and use the name.
Ensure that you bullet point your concerns, with the evidence that you have.
Also ensure that the letter is endorsed with a CC to the Senior Coroner for the district that you are in, again research that persons name, address it to him/ her. This shows the trust that the coroner is informed of your concerns.
include in the letter two questions
1. Is consideration being given to whether this is being classed as a maternal death, this is due to the fact that death is within 1year of the birth of the child.
2. Is an RCA bring undertaken ( root cause analysis).
To reiterate send a copy of that letter to the coroner. The coroner will not respond to you as the letter is addressed to the trust, however they will monitor the information coming to them from the trust and deal with anything that is in their remit.
 

jarrod248

LE
Gallery Guru
a review has been mentioned by children’s services (the care proceedings over the baby) but not sure if it’s a formal serious case review, also not sure if that would spread across the different agencies involved (Social care, housing, mental health services) and the cracks gaping chasm between them. something specifically warned about in the guidelines.
Isn’t a serious case review after the death of a child? I’ve been involved with them regarding children and babies but never adults?
 
i@labrat -

Some good advice about but with a caveat:

Before you write any letter to the officials involved discuss this with counsel to ensure that you do not omit significant facts and that you do not introduce anything irrelevant to possible claims

There is talk about having someone representing you and your daughter. Possibly the most important possible claim would be by her son/daughter.
Not clear how the nomenclature works in the UK but civil actions might be filed by Mr Labrat, Mrs Labrat, the estate of Miss Labrat and by Mr &Mrs Labrat as guardians and next friends of Baby Labrat.

No idea how you lawyer shop in the UK but here some of the best plaintiffs attorneys for Med Mal cases are attorneys who previously were registered nurses, paramedics etc. They understand medical records. A lawyer who was a psychiatric social worker would be great. Get someone you can trust to handle the matter from beginning to end.

As I said, I have dealt with litigation at all levels of the courts here, from local state courts to the Supreme Court of the US*, you need someone who cares and who you trust.

Best of luck to you and the baby


*full disclosure - I only had one case before the US Supreme Court and I lost before SCOTUS 8 to 1 Mr Justice Rehnquist was the dissenter.
 
Isn’t a serious case review after the death of a child? I’ve been involved with them regarding children and babies but never adults?
I’m told that the correct current term is ‘safeguarding adult review’ - we have asked the question and the council havesaid this is likely but will take time.

I spoke to the head of children’s services (who she was engaged with over care proceedings) The other day and made it absolutley clear that we regarded this as down to breaches of protocol and multi-agency failings.

we’ve also asked a number of other questions of thr council including support packages available if my ex became special guardians for the baby, (which obviously would be a huge step for her) and a few other questions about practicalities, which have all been referred upwards.

thnks to everyone for the advice so far. Thanks @rifleair and @DavidBOC for those latest comments, I’ve been referred to a charity that are going to put us in touch with a specialist solicitor, so I’ll speak to them before sending any letters.

her mum and I went to view a natural burial site, it’s was really tranquil. nature always helped her calm down - she’ll be at peace there. Personally, I’m an utterly broken man, completely destroyed, she was so wonderful, she struggled so much at times, but at other times she was just so delightful - witty and insightful. Such a waste.
 
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ancienturion

LE
Book Reviewer
My oldest daughter, aged just 22, committed suicide last week.
I'm really sorry to hear about your loss.
It might be better if you contact a solicitor as to how to go about the problems you encountered because I don't think the Coroner's court is the place for you to try and sort things out.
 
Polite update, initial meeting with large London legal firm today, and it looks like they will be representing us at inquest.
 
I don't know your work circumstances but I would consider going to your GP (difficult to do at the moment I know) and get signed off. Two years ago a number of problems hit me simultaneously and I went to my doctor for help. His response was that he couldn't make the problems go away, but he could make work go away for six weeks so that I could find the time and energy to deal with it.
 

Grownup_Rafbrat

LE
Book Reviewer
Polite update, initial meeting with large London legal firm today, and it looks like they will be representing us at inquest.
Excellent news. Wishing you the very best of luck.
 
Polite update, initial meeting with large London legal firm today, and it looks like they will be representing us at inquest.
As an old retired US attorney I am glad t hear that. Just having counsel present will ensure those testifying are more careful as to what they say.

Hard time for you I know but if you could update post hearing I would be interested.
Best of luck in dealing with this.
 
A very sobering and difficult read. I am so sorry for you and family at this dreadful time and can only hope that you all come through this.

RIP to your daughter, and condolences to family and friends.
 

Rooper

War Hero
A coroner can make a decision for an inquest to be considered as under article 2 of the ECHR (Right to Life), a key component of which is that a state has a positive obligation to take appropriate measures to safeguard life. A 'so what' from this is that this can lead to legal aid being granted for the proceedings.

Whilst a coroner is not there to apportion blame they do have wide ranging powers to establish the facts and dependent upon their findings they can issue a Regulation 28 report with the aim of preventing future deaths.

None of this will bring your daughter back but there may be some solace in doing something towards stopping it happening again.
 
None of this will bring your daughter back but there may be some solace in doing something towards stopping it happening again.
a lot of people have said this to me

Unfortunately, the pessimistic side of me is resigned to knowing that a report saying ‘lessons will be learned’ will be issued, and inevetably forgotten about as the same mistakes get repeated time and again.

on a more practical basis, for me at least, there’s going to be a child who needs to know why her mum died, so as not to spend the whole of her life feeling abandoned or not wanted, or thinking that she might have ‘inherited’ problems from her mum and worry about doing the same (a potentially self-fulfilling prophecy). So I feel that if I can at least give her a proper understanding of the failures that led to the loss of her mam, I need to.
 
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