Jessie’s Inquest: Conclusion

The coroner called the jury back to court shortly before 5pm to see what position they were in and how much more time they thought they needed for deliberations.

Coroner: Members of the jury I wonder if the foreman or forelady could stand please

They do

Coroner: Members of the jury you’ve now been deliberating for 4.5 hours, don’t want to put you under any pressure, but it’s 5pm and members of the jury may have their own commitments this evening. Are you able to give us any info as to whether you’re near to completing your deliberations?

The foreperson said that they had completed them

Coroner: Have you completed the record of inquest?

Foreperson: Yes

The coroner said that she’d take a look at it first.

Coroner: Thank you very much. I’ll ask the foreperson to stand please.

They do

Coroner: Will ask you a series of question. Have you completed your discussions and reached agreement on the record of inquest?

Foreperson: Yes we have

Coroner: Are you all agreed on the record of inquest?

Foreperson: Yes, thank you.

The coroner asked them to read out the record of the inquest.

They confirmed in Box 1 Jessie’s name in full.

In Box 2 they recorded Jessie’s medical cause of death as:

a) compression of the neck by a [withheld] ligature and

b) mental health.

In Box 3 they recorded:

At 01:16 on 17 May 2022 the deceased was pronounced dead at Caburn Ward, Mill View Hospital, Hove. The deceased was found with a ligature tied around their neck.

In Box 4 they recorded:

It is the conclusion of the jury that systemic systematic*** failures in health and social care led to a series of events which caused the deceased periods of dysregulation culminating in regular bouts of self-harm, which ultimately ended in her death by misadventure.

They then confirmed other details about Jessie required for the registration of deaths. I’ll not share them here.

The foreperson ended by saying that they had yet to sign this agreement. The coroner thanked them, asked them to take a seat and to pass around the record of inquest for everyone to sign.

The coroner then addressed the court:

This concludes your involvement in this case. I just want to advise you one of my responsibilities is prevention of future deaths.

I will be making a Prevention of Future Deaths Report.

Sadly this case, yet again, exposes the totally inadequate community provision for those suffering with autism.

This is a national problem as you have identified, and sadly leads to to many experiencing admissions to inpatient wards and A&E attendances [think she said].

Despite a report from the Health and Social Care Committee in 2021, there does not seem to be any improvement and more lives are likely to be lost.

The conclusion of this report, and I quote, was that “autistic people and people with learning disabilities have the right to live independent, free and fulfilled lives in the community and it is an unacceptable violation of their human rights to deny them the chance to do so”.

The report goes on to say that community support for autistic people and people with learning disabilities and financial investment in those services is “significantly below the level required to meet the needs of those individuals and to provide adequate support for them in the community”.

Very disappointing to hear from expert witnesses you heard in court, two years on there does not seem to be any improvement in this position.

We heard how East Sussex County Council tried over 30 providers… [missed]

I fear there was not much else they could have done in the circumstances, but the lack of facilities nationally, as you identified members of the jury, have contributed to Jessie’s death and changes need to be made.

The coroner said that she would be addressing that Prevention of Future Death Report to the Secretary of State for Health and Social Care, Victoria Atkins**.

The coroner said that she was sure the case had had an impact on the members of the jury, and she is sure that they would like to join with her in expressing condolences to Ms Eastland and Mr Seares.

She thanks counsel, Mr Downs, Ms Walker, Ms Nicolaou and Ms Agnew for all their assistance with the case.

The coroner formally closed proceedings at 17:10.


With thanks to those who have followed my reporting, shared and discussed it. None of it would happen without my crowdfunders. If you’ve found the reporting useful and can afford to financially support it, please do so here. If you can’t please don’t worry, but please do tell someone about Jessie and what happened. We need to shine a light on these repeated failings.

I will share a family statement in due course once one is available.

** An earlier version of this report had a typo saying the coroner would be sending a PFD to Victoria Adams, to be honest Posh Spice is probably worth a try at this point, but the coroner did indeed say Victoria Atkins. Apologies

*** Have had confirmed by the court that the final conclusion said systematic not systemic. Apologies. Sound was difficult.

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