Gaia Pope-Sutherland was an expressive, sensitive, charismatic young woman with a brilliant sense of humour. She was a much loved daughter, granddaughter, sister, twin, cousin and friend to many. You can learn more about Gaia in the series of blogposts below.

Gaia’s inquest was opened shortly after her death, there were delays as other investigations including two by the Independent Office of Police Conduct were held, and then further delays due to Covid19.

Her inquest took place over 12 weeks from April – July 2022 at Bournemouth Coroners Court, in front of Senior Coroner Rachael Griffin who sat with a jury. I reported the first 10 days, blog posts linked below.

The inquest concluded with the jury finding Gaia’s death was caused by hypothermia, and that on the balance of probabilities she died between 15.59pm on 7 November 2017 and 10am the following day.

In a narrative conclusion, the jury found:

• Gaia’s mental health and mental state on 7 November 2017 probably caused or contributed to her death.
• Gaia’s acute situational crisis and an epileptic seizure contributing to her psychosis possibly caused or contributed to Gaia’s death.
• Gaia not being referred to either the community mental health team or the crisis team when discharged from hospital on 22 October 2017 was a factor that possibly caused or contributed to her death.

The coroner did not allow the jury to decide on whether failings with the police search or calls caused or contributed to Gaia’s death, despite the critical evidence heard. However, there were admitted failings by Dorset Police, recorded in the record of inquest, including:

• Police should have treated Gaia as a missing person earlier.
• As soon as Gaia was reported missing she should have been graded as a high risk missing person.
• Dorset Police’s response in the first 24-48 hours was disorganised and lacked clear strategy, leadership and focus. It was accepted that the response was deficient.

There were additional failings admitted by Dorset Healthcare University Trust (DHUFT), also recorded on the record of inquest, including:

• There were missed opportunities to refer Gaia for mental health support following her discharge from hospital on 22 October 2017 when she had been in mental health crisis.
• There was a missed opportunity following Gaia’s discharge from hospital on 22 October 2017 to communicate with the neurology/epilepsy team involved in Gaia’s care.