Inquest – a family’s perspective

My much loved daughter in law Mariana Pinto died, aged 32, on 16 October 2016.  The Coroner, issued a narrative verdict at the end of the inquest, on 13 March 2017: 

 “Mariana Pinto died on Sunday, 16 October 2016, when she stepped over the balcony of her home, fell from the third floor, and after some minutes rolled off the glass roof on which she had landed to the ground below.

Her actions were deliberate, but she did not have the understanding necessary to categorise these as suicide.  She was in a confused state with features of psychosis.  This was a consequence of cannabis withdrawal and the unmasking of an underlying anxiety by the cannabis cessation.

Following an uncharacteristic and florid episode, Ms Pinto had undergone a Mental Health Act assessment in hospital the day before her death.  After treatment with lorazepam, she was assessed as not detainable.  She did not want to be admitted as a voluntary patient, and so was discharged with medication and an arrangement for the crisis resolution and home treatment team (the crisis team) to visit the following day between 5 and 7pm.

At 3.32pm on the day of her death, Ms Pinto’s husband rang the crisis line, asking for help on an urgent basis because his wife was deteriorating rapidly.  The home visit was not brought forward.  He was advised to call the police, but no call was made by the crisis team to the police or ambulance services, to confirm that he had been able to call them and that help was on its way.  The police and ambulance services were not called to attend.

At 4pm, Mariana Pinto broke away from her husband and jumped.”

Just after Mariana was pronounced dead (at 5 pm), the police explained to us that this was an ‘unexplained death’ and so would be referred to the Coroner.  There would be an inquest.  We had absolutely no idea what this would entail. 

I cannot begin to explain the impact of the trauma of Mariana’s death on my entire family.  I won’t even try.  This blog attempts to tell you what an inquest process is like if you have to go through one.  We were lucky. 

Our Coroner was kind, respectful, authoritative, brave and forensic in her approach.  I’ve met many other families who had a much worse experience. 

When we hear there will be an inquest, we are terrified.  We hear the word court.  We think we are going to be judged.  (Wrongly).  We think (correctly) that we will have to re-live it all in public.  We have to wait until 13 March.  This is so that the Coroner can request statements, review them, and request more if required.  Apparently, it can often take much longer for an inquest to take place. 

A few days after Mariana’s death we get a letter from the Coroner, a leaflet explaining her job, a temporary death certificate, and invited to ring if we need information.  We are treated with courtesy and sympathy.  We ring to ask when we can view Mariana’s body at the morgue.  Her family have arrived from Brazil, distraught and desperate to see her.  There is a delay because of the post-mortem.  When we do see her, I get it into my head that when her father kisses her, she will wake up.  She doesn’t.  I think well of course not, my son, Camilo, needs to kiss her.  He does.  She stays dead.  My legs almost give way.  The pain floors me.  This is the state we are in when trying to deal with the inquest, the complaints process and the Serious Incident Review.  All these processes run concurrently. 

Camilo is required to make a statement to the police for the inquest.  And to provide his own statement if he wishes.  He does.  I help him with both statements.  It is horrific as we re-live and recount the events prior to her death.  The police officer who comes to take the statement cannot get her head around the events of the day of Mariana’s death, and we have to correct aspects of the statement several times.  It’s horrible but also reassuring.  It doesn’t make any sense to us either. 

I take on all the liaison with the Coroner and the hospital because Camilo can’t manage it.  To this day he’s not been able to read any of the documentation.  I have no idea how someone could cope alone.  If this is you, please get help. 

I ask my friends if they know of any charity that might help us.  I’ve been in the charity world so long I know there will be one if we can just locate it.  There is.  Action against Medical Negligence.  They are brilliant.  They tell us exactly what we should do.  And put it in writing to me.  They explain that we can’t get legal aid but tell me that if at all possible, we should be represented at the inquest as the hospital will as a minimum have their own legal department.  They tell us how to choose a suitable lawyer.   We start the process to ask for the medical records and we make a complaint as advised.  We select a lawyer.   Then we have experts who advise and support us and are alongside us.  We were lucky.  We got taken on a no win no fee basis.  This is often not possible.  I don’t know how we could have paid for a lawyer and I don’t know how we could possibly have managed without one.  Our lawyer and barrister explained every step of the process to us, made sure every one of our questions was answered, challenged experts, found their own experts. 

On 7 January we get the statements made to the Coroner and the medical records and are aghast.  There are statements from the two psychiatrists who conducted the assessment on Mariana, from the A&E doctor who conducted the physical examinations, from the junior psychiatrist who first saw Mariana, from the police who got Mariana to hospital, from the ambulance crew and fire crew, and air ambulance crew who attended the day she died.  From Camilo, from Mariana’s close friends who were at A&E with us.  From me.  From her GP, from the crisis team. 

Camilo can’t read them – I do and summarise them for him.  They don’t accord with our experience.  I liaise with Mariana’s sister Mafalda in Brazil who wants to understand what is happening.  She asks to see the statements and I email them to her, making her promise she will not be alone when she reads them.  She is desperately upset by the language of the statements to the Coroner.  She feels that it dehumanizes her beloved sister.  It does.  She feels that this demeans the people who wrote the reports and it demeans us all.  She is right. 

I contact the Coroner’s assistant, who reassures us – it’s a court of truth not of blame.  For the family.  And it is. 

On the day we are accompanied by family and friends.  It’s an old building.  There’s only 1 set of toilets so we meet staff and lawyers from the hospital trusts queuing for the loo.  The Coroner is forensic in her questions and incredibly respectful and thoughtful.  But we do have to re-live the experience.  In public.  The press is there.  The Coroner starts the proceedings by taking evidence from the fireman who attended.  In this way she makes sure that everyone who attends knows what happened and also makes sure that our re-living of events is somewhat eased.  The witness list includes the police, the 2 crisis team members who spoke with Camilo, the 2 psychiatrists who assessed Mariana, the A&E doctor, the consultant overseeing the Serious Incident Report. 

The Coroner asks every witness what they would do differently if another Mariana were to present.  Mostly they say they would do nothing different.  The Coroner does not relent.  We notice that all the witnesses for the Trust look over to their legal team when answering.  We notice someone from the trust team nods and smiles at them.  This turns out to be the senior consultant in charge of the Serious Incident Review, who we have never met and never do meet.  She leaves early, despite not having asked permission to leave from the Coroner, who does not hide her displeasure.  The psychiatrist says she cannot help but be affected by this case.  We are relieved.  The Coroner quizzes the attending psychiatrist about why he has copied and pasted 3 paragraphs of his statement from the psychiatrist’s statement.  As does our Barrister.  He had forgotten the details he says.  The Trust want to play the recordings of the calls made by Camilo to the Crisis team in the court.  The Coroner tells Camilo he can leave if he would prefer but he sits it out.  The Coroner hears the panic in his voice during the last call.  She hears that the person answering the last call is not kind.  And tells this person.  We are grateful for this.

The Coroner issues the narrative verdict at the end of the inquest and tells everyone she will be writing a Prevention of Future Deaths Report.  She says

“I should say to Mariana’s family, one thing I don’t know is if things had been different in terms of how her crisis was handled as to whether her outcome would be different. All I can say is there is an opportunity to do things differently.”

This form of words is incredibly helpful.  Please don’t tell someone a death was preventable.  It’s happened.  It can’t unhappen.  A future one might perhaps be prevented and for this reason I continue to lobby and push for change. 

We are told we have behaved with incredible dignity throughout.  This masks our pain and distress.  We wonder if had we acted out our feelings in cubicle 7 of the Acute Hospital Trust A&E department on the evening of 15 October 2916 things might have been different.  We wonder what it would take for someone from the Mental Health Trust to look us in the eye and say they could have done better.  We are still wondering.

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