I’ve been reporting from coroner’s courts for almost a decade now, and it is very rare to see more than a couple of journalists in attendance. Walking into Surrey Coroner’s Court yesterday there were lots of people, including numerous members of the media. However, when I was asked to sign the media list, I was the only journalist heading for Court 2.

It left me wondering whether there would be any difference in the care provided to, or the life expectancy of, learning disabled youngsters, if their inquests received a high degree of media scrutiny (or any media coverage really). In this post I will report on the evidence heard by the court on Day 1 of the inquest into the death of Mia Louise Gauci-Lamport.

Mia’s parents and sister were in court, together with family friends and a bereavement support worker from the ICB (who her family spoke very highly of). Mia’s family did not have legal representation.

Alongside Mia’s family, there were two other Interested Persons. Bracknell Forest Council commissioned the care that Mia received and were her corporate parent. They were represented by Carwyn Cox of Farrar’s Building Chambers. The Children’s Trust, Tadworth is where Mia lived, and they provided her healthcare and support and education. They were represented by Michael Walsh of Serjeants’ Inn Chambers.

There were a number of witnesses and members of the public in court too.

The coroner, Dr Karen Henderson, opened with introductions of those in the room and an outline of her plan for the day. She said that there had been a number of pre-inquest review hearings, that Mia’s family were happy for her to refer to Mia by her name throughout, and that the court would be hearing from 4 witnesses in person, and there was some Rule 23 evidence that would be adduced as and when.

The coroner said that she’d some photos of Mia that she would show to the court and then she’d leave them by her side so she had them throughout. She stood up and showed two large poster size collages of photos of Mia, and thanked Mia’s family for bringing them to court. She also thanked them for bringing Mia’s scrapbook that she’d had a look at and said that it was important to put a personality to the person.

The first evidence was read by Coroner’s Officer Josh. He read a statement written by one of his colleagues, who had spoken with Mia’s dad and confirmed registration details. Mia was born in November 2006 in Frimley, Surrey. Her home address was in Tadworth and she died on the 11 September 2023 at 07:25 in the morning, and he told the court that she was 16 years old when she passed away.

Pen Portrait

The coroner then read a pen portrait written by Mia’s sister Paige. You can read it in full here.

Post-mortem reports

The coroner read extracts from a post-mortem report compiled by Dr Simi George that was reported on 4 December 2023. She said that there was a neuropathology report within the post-mortem that had been written by Dr Nicki Cohen (later referred to as Professor Cohen).

Prof Cohen’s report observed that Mia was a 16 year old with global developmental delay and epilepsy, including daily tonic clonic seizures.

She referred to a known mutation of the STXBP1 gene and said Mia’s death was not expected. Mia’s neuropathology showed “long standing features in keeping with her condition” and found “no evidence of any acute pathology or any significant period of hypoxia before death”.

The pathology report concluded that on the balance of probability, in her opinion, it would be entirely reasonable to suggest that the death was sudden and related to epilepsy (Early Infantile Epileptic Encephalopathy).

Dr George gave the cause of death as 1a STXBP1 related encephalopathy with epilepsy.