Before lunch on Day 9 the coroner summed up the evidence in Jessie’s inquest. She explained to the jury what their role entailed, what findings they needed to make and talked them through the record of inquest.
The coroner told the jury that their findings must be based solely on what they heard in court and that if she expressed a particular view on evidence they must ignore it, unless of course they agreed with it.
She reminded the jury that this is not a trial, it is an inquest into a death. A fact finding inquiry to find out how Jessie died. She told them that they are not concerned with attributing blame, and that they were simply there to establish the facts.
She said in order to decide the facts they must make an assessment of the evidence. She said it was up to them what they make of each witness, in terms of credibility and reliability. It was up to them what evidence they accept or reject. She also told them that it was open to them to accept part of the evidence of a witness and reject another part of it.
She told them that they had to answer four questions: who the deceased was, where, when and how and in what circumstances did Jessie come by her death. The coroner told the jury that they must also reach an overall conclusion about the death. She said she would come to conclusions later.
The coroner told the jury that they must not express an opinion about other matters, or make any recommendations. She talked them through the record of inquest and what agreed details it should contain.
The coroner told them that when it comes to medical cause of death in Section 2, they should consider the pathologists evidence, and that of the court’s expert. She reminded them that Dr Beber’s opinion was that Jessie’s medical diagnosis was likely to have caused or contributed to her death. She said the jury would recall that Dr Beber said “all the conditions Jessie suffered from were so intricately linked, she could not say if any one of them was more likely to be the main condition linked to her tying the ligature”.
The coroner explained that if they thought Jessie’s medical diagnoses were more likely than not to have caused Jessie to tie the ligature, directly causative, it should be recorded in 1b, if they find it did not cause but more than likely contributed then they should put it in Part 2.
The coroner explained that in Section 3 the jury would record where, when and how Jessie came by her death. She said what they write down in Section 3 was a matter for them. It should be brief, neutral and factual, expressing no judgement or opinion, without naming any individual. She said that they should restrict their findings there to answering three questions: when, where and how did Jessie come by her death.
She gave an example not related to Jessie’s case.
The coroner told the jury as this was an Article 2 case, the wider circumstances should be included, unless they will conclude them in their final narrative conclusion.
The coroner said that a list of questions had been prepared to assist them. The coroner said that they do not have to address each of the questions, they may include other issues that they consider important, providing they are relevant to the circumstances of Jessie’s death.
The coroner told the jury:
This is your record of inquest, I am not trying to tell you what you should say, what you find and how you express it is entirely a matter for you, merely giving some structure for you to consider when drafting your narrative.
The coroner told the jury that the law states that they must not make recommendations, or express opinions, in answering how Jessie came by her death. She said findings of fact must be brief, neutral, clear and based on the evidence heard in court.
She said once the jury had agreed the facts, only then should they move to consider their conclusion, in box four. The coroner explained that they could use just a narrative conclusion, or they could include a short form conclusion within the narrative.
What do I mean by a narrative conclusion?
A short factual account of how the death came about. It must be factual, neutral and as I said can’t name any indvidiual. It is possible to include short form conclusion within your narrative.
The coroner gave an example not related to Jessie’s case.
Narrative conclusions must be directed to issues central to the cause of death, and nothing more, or to disputed factual issues at the heart of the case.
Remind you, conclusion should be brief and concise. When come to your decision of facts, need to consider what was relevant at the time. You shouldn’t apply the benefit of hindsight.
You should consider whether any act or omission on its own, or in combination with other acts or omissions, contributed to Jessie’s death.
An act or omission has contributed to death only if directly causal link between the act or omission and the death.
To the extent you find an act or omission of someone other than Jessie contributed to her death, you may use words to describe that factor such as failure, inappropriate, omission, unsuitable. Can also use words such as because of or contributed.
You must not use words which imply civil or criminal liability such as carelessly, negligently, recklessly, foolishly, guilty or breach of duty.
Standard of proof should apply is balance of probabilities, that is something more likely than not to have happened.
The coroner left three short form options to the jury to include in their narrative, and explained each one: suicide; accidental death; misadventure.
The coroner then read the questions to the jury, and reminded them that they were only there to assist them, they can dismiss them or bring their own questions.
- At the time of Jessie’s death was she detained under Section 3 Mental Health Act 1983 on the Caburn Ward at Mill View Hospital?
- From what diagnosis or health conditions did Jessie suffer?
- On 16/17th May 2022 did Jessie tie a ligature around her neck ?
- If so was this a deliberate act?
- By tying the ligature did the tying of this ligature lead to her death?
- Did Jessie have a settled intention to die, when and by tying the ligature?
- If not was Jessies death an unintended consequence of a deliberate act or omission?
- Is it probable (more likely than not) that these events (either individually or collectively) caused dysregulation in Jessie on the 16th/17th May
- The visit by the social worker on the afternoon of 16th May 2022?
- The fact that an IMC locum worker was present on the ward that night?
- The impact of the existence of, or process of the safeguarding enquiries on Jessie’s state of mind?
- The fact that she was on general observations and did not have full access to her craft materials in her room?
- What was Jessies presentation after (a) and (b) in question 8?
- Do you consider that the level of Jessie’s observations should have been changed on 16th May 2022 following the events (a) and (b) in question 8?
- Were the observations carried out on the 16-17 May 2022 carried out adequately?
- Were the staff from Caburn Ward, Mill View Hospital aware of the safeguarding concerns relating to (i) Jessie’s father, (ii) Provision of care provided by IMC Locums.
- Were staff from Caburn Ward aware of the subject matter that the Social Worker was to discuss with Jessie?
- Do you consider that at the time of Jessie’s death that Caburn Ward, Mill View Hospital was the best place for Jessie when presenting with her current diagnosis?
- Was there other suitable accommodation available to her? If not why not?
- Are there any other matters which you consider where probably causative of her death?
The coroner then reviewed the evidence the court had heard. I’ll not report it here, because I’ve reported it all week. She was clear that the jury had to be aware of the safeguarding concerns in order to understand the chronology of events that had taken place, but she directed them that they are not able to form a view as to the allegations, and whether or not the allegations themselves were causative of Jessie’s death.
She also directed them that whether or not carers provided intimate personal care to Jessie, or whether or not the agency was CQC regulated, is not a matter for them.
She told them that they could consider the suitability of accommodation, whilst being aware that nothing else was available, and there is a lack of suitable placements nationally. She told them that they had heard that from a number of witnesses.
The coroner at the end of summing up the evidence told the jury that they would be given Jessie’s communication passport and an extract from the TCAT report, together with the directions and a list of questions to help guide them.
The jury bailiff was sworn at 12:35 and the jury retired at that point.