I told myself I’d take the weekend off, to decompress, spend time away from a screen, try and release some of the anger and tension that is searing through every sinew of my body. Couple hours into the weekend and I’ve given in to the rage and am sat banging away at my keyboard. I can honestly say that this week was the worst week in my Open Justice journey so far.
Coming up to six years ago Thomas Rawnsley died, as a result of a chest infection, in a ‘specialist’ service in Sheffield run by Lifeways. Thomas’s inquest was adjourned on Day 2 of what should have been a 5 week inquest, in September 2019. The adjournment at the behest of Lifeways, the ‘care’ provider looking after Thomas who objected to the Coroner’s social work expert evidence and wished to commission additional expert social work evidence of their own.
Coroner Dorries retired in the intervening period, and the replacement coroner, Assistant Coroner Combes, decided a year later that the jury didn’t need to hear any expert social work evidence.
You can learn more about Thomas and his life in this post here. This photo was taken the first time he met his niece, and the last time his Mum, Paula, saw him alive.
Thomas’s inquest was reconvened on November 2nd, and evidence was heard on various days over three weeks. I was not in court due to coronavirus and that fact that the court had limited phonelines available. They did manage to arrange access via Teams for members of the public and press for the final day, this Wednesday, and the coroner’s summing up.
In legal discussions before the jury were bought back in the Coroner confirmed that she would be instructing the jury to find that Thomas died from natural causes. She has ruled that Article 2 no longer applied.
Following all the witness evidence, Assistant Coroner Combes considered legal submissions made on behalf of Lifeways, Bradford Council, Yorkshire Ambulance Service and a number of GPs involved in Thomas’s care, that argued the investigative duty imposed by Article 2 of the European Convention on Human Rights was not engaged.
These submissions broadly followed the case of R (Maguire) v HM Senior Coroner for Blackpool and Fylde  EWCA Civ 738 where the Court of Appeal determined that the fact that Jackie Maguire had been placed in a private care home run by United Response, by the Court of Protection, was not in and of itself sufficient to engage Article 2 (and thus trigger the wider investigation).
The Court of Appeal decided that it must either be arguable that the death arose from a situation of danger created by the state, or from a systemic failure by the state in the provision of services where the authorities knew or ought to have known of the risk and failed to take measures to prevent that risk. I’ll try to blog more about this another time but there’s a great blog by Stephen Cragg and Frederick Powell about the implications of the decision on the Doughty Street website here.
Assistant Coroner Combes stated that:
The challenge with Article 2 is you start with a wide funnel and questions are asked… you can’t shy away from the evidence being heard.
There was much discussion about whether giving examples to the jury would confuse them and someone, I think legal counsel for the care provider [at least I think it was legal counsel for the care provider but I couldn’t 100% say because the camera didn’t show anyone other than the coroner] stressed:
‘where we are now is a small picture from the whole, better to keep fixed on that’.
Indeed. Isn’t that where we always find ourselves when it comes to the deaths of learning disabled and autistic people.
When pushed for her view the family’s barrister Emily Formby simply observed:
‘They’ve spent three weeks listening to information and are now being told there’s very little they can do with it, bluntly’.
In summing up the evidence to the jury the coroner pointed out that the pathologist couldn’t say with any certainty when Thomas became ill, recalling that there was ‘significant findings of consolidation in the lungs… the pneumonia had been there for some time, but he could not give precise timings’ .
A second pathologist couldn’t find sufficient pathological evidence to determine whether Thomas’s chest infection, that led to pneumonia, was viral or bacterial. They also couldn’t determine specifically when it was contracted or developed, but thought anything between three and ten days before Thomas’s collapse.
I wasn’t in court for the evidence so am unsure whether the pathologist decided that three days was ‘commensurate with the history provided’ or whether that was the coroner’s assessment.
Either way, the jury were instructed to find that Thomas died from natural causes, because there was no definitive evidence about whether his illness was bacterial or viral, and therefore it couldn’t be stated for sure whether earlier treatment with broad spectrum antibiotics would have saved his life.
The jury returned a while later after lunch finding what the Coroner had told them, that Thomas died from hypoxic ischemic encephalopathy (when the brain doesn’t receive enough oxygen), due to cardiac arrest as a result of a chest infection. Thomas’s Down Syndrome was also mentioned as it was felt it had led to an increased risk of chest infection.
The jury recorded that Thomas collapsed and was given CPR on 2/2/15 after being diagnosed with a chest infection on 29th January. They also recorded that he was admitted to hospital where he died on the 3rd February.
Conclusion: natural causes.
I literally felt sick hearing this. I’ve known Paula for a couple years now, I’ve attended a number of the eight pre-inquest review hearings in Thomas’s case and was in court last year when his inquest should have been held. I don’t know Paula well but I’ve always been struck by her tenacity and her iron core.
I spoke to Paula regularly over the course of this year’s inquest and could feel her morale slipping down almost daily, as the walls of the ‘wide funnel’ closed in. I received a message from her on the final day where she shared she hadn’t gone to court because she just couldn’t face it. She attended for the jury returning their verdict but didn’t need to hear any more. You can read their family statement in response to Thomas’s inquest verdict in full here, it includes:
It is coming up to 6 years since Thomas died. We trusted in the coronial process but as time has passed the scope of Thomas’s inquest has been narrowed further and further. His inquest didn’t examine any of the wider failings in care, the abuse he suffered, the lack of trauma support or why Thomas couldn’t live in his local community. It just looked at the last 5 days of his life. The first coroner promised a thorough Article 2 inquest, this started last year and was put on hold due to Lifeways wanting more expert evidence. The experience of this year’s inquest was very difficult for us, with the focus narrowing even further, and the expert evidence we waited for not even being heard.
The jury were instructed that the only safe finding they could reach was that Thomas died from natural causes. We are left wondering how it can be natural for a fit and healthy 20 year old to die from a chest infection.
We feel Thomas’s voice has been dismissed in death, as it was in life.
I literally bounced straight from Thomas’s inquest into Joanna Bailey’s, it felt like bouncing, my head was reeling. Then followed two and a half days of evidence about what happened to Joanna. I’d already read a little earlier in the week, and seen some tweets of what had been heard in court.
This is Joanna.
Joanna’s family described her as loving, funny and fabulous. I hope to speak to them at some stage and will share more about who she was if I’m able [**Edited** I did speak with Joanna’s father, Keith, and you can learn more about her here] .
Joanna had a learning disability, and some physical health problems including epilepsy and sleep apnoea. Joanna became mentally unwell in 2014 and at the time of her death she was detained under Section 3 of the Mental Health Act. Joanna was living in a ‘specialist’ hospital, Jeesal Cawston Park.
Joanna was just 36 when she died.
On the first two days the court heard from a number of support workers who had found Joanna, unconscious in her bed, and had failed to conduct CPR, and they’d also heard from the paramedics who arrived to find her still warm, and commenced CPR, unsuccessfully. I joined on Day 3, part way through the evidence of Annita Nyabunze, a Learning Disability Nurse who was working overtime on the night of Joanna’s death because they were short staffed. You can read my tweets from Joanna’s inquest Day 3 here and Day 4 here and Day 5 here.
On Day 5 we were initially told that members of the press and public had to leave court while the Coroner heard legal submissions. This had happened earlier in the week too, but is not actually legal. An email to the court rectified this error fairly quickly, and there followed an awful hour of legal argument. Sara has summarised some of it here.
I can’t believe in 2020 anyone would object to a photograph of the person whose inquest it is being shown in court. So much for keeping the person and their family at the centre of the process.
There was also extensive efforts from the barrister for Jeesal, Micheal Walsh of Serjeants Inn, to persuade the Coroner that it would be unsafe to leave a neglect verdict to the jury. He felt it would be unsafe on the grounds of causation. Laura Bayley, counsel for Annita Nyabunze, claimed to be neutral but supported Mr Walsh.
The jury heard extensive evidence of numerous failings in Joanna’s care, including crystal clear evidence from the microchip in Joanna’s CPAP machine (a machine to help with breathing and prevent any complications of sleep apnoea) that it had only been used on 29 occasions in the last 209 nights, the last being in January. Joanna died in the early hours of 28 April 2018.
So despite Joanna being held under Section 3 of the MHA and not able to leave, despite her care clearly being sub-standard, despite a record of over 60 seizures in the 18 months she was at Jeesal Cawston Park and no referral to neurology, despite the known correlation between SUDEP and sleep apnoea, and despite her parents not being informed about her seizures or her apparent refusal to use her CPAP machine, the Coroner ruled that it would be unsafe to leave neglect to the jury on causation grounds, and that they had to find natural causes.
The Coroner made much of the fact that Sudden Unexplained Death in Epilepsy (SUDEP) can occur at any time, with or without any seizures. Pretty much the perennial ‘poor care get out of jail free’ card.
The jurors couldn’t quite believe what they were being told and questioned the coroner in an attempt to understand:
I’ll blog about the Prevention of Future Death arguments another time. I have to confess to being completely confused as to why the jury were told that they couldn’t record their thoughts on the Record of Inquest. They were bought back in and re-directed because I think there was agreement that this had been very unclear.
The jury had been told the cause of death that they had to find: 1a) sudden unexplained death in epilepsy (SUDEP) 1b) primary generalised epilepsy and 2) obesity and obstructive sleep apnoea.
Despite the limitations the jury returned the following in Box 3:
In the early hours of 28 April 2018 Joanna Sarah Bailey was found unresponsive in her bed at Jeesal Cawston Park, later confirmed as death by natural causes (SUDEP).
They also highlighted in Box 3 facts surrounding the case:
- CPR not administered prior to emergency services arriving
- inconsistent observations
- careplan not accessible to staff
They then read an additional statement which the coroner had permitted them to write and be read onto the record in open court, but not recorded on the record of inquest form. This stated:
The jury expresses concerns regarding the following:
- Availability of radios and communication tools
- Quality of audits and spot checks
- Quality of training and competency, including regular follow ups
- Communication, comprehension and understanding e.g. language barriers with staff and patients
- Staff shortages
- Communicating effectively with family
- Training on relevant and patient specific equipment
- Fear of blame culture stopping adequate care of patients in response to emergency situation
- Management information
- Relevant patient information to be accessible to all staff
- Governance and control
Conclusion: natural causes.
In a statement issued by Joanna’s family, they stated:
‘We have listened in the last five days to a catalogue of mistakes, system problems and poor care provided by Jeesal Group to our vulnerable daughter.
At no point were we made aware that Joanna wasn’t using her CPAP machine, which she had regularly been doing with prompting, encouragement and assistance, since 2012.
Now we are having to come to terms with the loss of our loving, funny and fabulous daughter and, in our opinion, there were so many missed opportunities to avoid her premature death.
We desperately wanted the jury to be able to consider that our daughter’s death was contributed to by neglect because of the gross failure by the Jeesal Group to provide basic medical care. We are disappointed that the coroner refused to permit the jury to consider that Joanna died of SUDEP contributed to by neglect.
We are grateful to the jury who took the time and care with the evidence and raised eleven concerns about the services of Jeesal Group which we fully endorse’.
Thomas and Joanna.
Two learning disabled people’s lives.
Two devastated families.
Two self proclaimed ‘specialist’ services.
Two Article 2 jury inquests.
Two natural causes conclusions.