Attended 3rd PIR of 2nd inquest into death of Elsie Brooks today. Her daughters Janet and Maggie @daisypearldaisy represent themselves.

Families are up against it in inquests w/out legal representation. They've managed to quash one inquest and secure Article 2 for the 2nd 1/21

I mentioned them in my blogpost: Inquisitorial Trauma http://www.georgejulian.co.uk/2020/09/29/inquisitorial-trauma/

At today's PIR the discussion focused on three key issues: disclosure, witnesses and the instruction of experts. I attended by audio on MS Teams and the call was mostly clear and trouble free

2/

The Coroner, Dr Julian Morris, seemed fair and reasonable, and genuinely keen to ensure that Mrs Brooks' family had a chance to be heard and input into proceedings.

I've been musing the hearing for the past hour or two and our societal deference to all things NHS

3/

The Coroner was decisive and keen to instruct experts asap to ensure their advice is received in good time ahead of the inquest (listed for March 2021).

He was mindful not to be delayed by future pandemic developments (which are a mystery to us all)

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One exchange went something like this:

Coroner: I’m also anxious, I’ve not read the news today but things are likely to change and they may change again; I’m anxious the medical witnesses or experts may get caught up in the next wave of covid coming up to the new year

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Trust legal representative: I’m concerned about creating more work for some who may, I simply don’t know... be under the pressures of dealing with the pandemic such as it is

[Elsie died 10yrs ago. Her family feel the NHS have delayed them getting answers for this long]

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Family: We’ve said a number of times that we think Ms Sing’s [??] witness statement had a page missing from it and it would be good to find out if there was a page missing from it

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The conversation continues and it is agreed the Coroner will request that the trust legal representative will ascertain if anything is missing.

Clearly this had been asked many times before. Why have the NHS Trust not answered the question on the first time of asking?

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The discussion continues, the family had requested that the Head of Governance (now retired) and Head of Microbiology were called as witnesses. They were asked to explain their reasoning and this was their response:

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'The Head of Governance attended court in the first PIR of the first inquest in 2012. She was knowledgeable about the policy at the time, and knew where documents could be found, which the Trust has denied since that it has, stored or archived...' 10/

'It seemed unlikely that a hospital trust would have no organisational memory… that’s how we saw it' @daisypearldaisy

The coroner asks what else they think this witness could provide and the family make a couple of suggestions.

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It seems that the hospital claim they can not trace, or identify, a member of staff Dr M who according to an investigation report was on duty [I got a little lost at this point having not seen the paperwork in question]. The family commented:

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'The fact they’re not able to name these members of staff, they did an 11mth investigation into the events. Why was the investigation not involving the staff present at events? That has led to the fact we’re here 10yrs later....'

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'It has taken 10yrs because there simply wasn’t a proper investigation done at that stage'

Not sure I can imagine what it must be like to wait ten years for answers as to why your elderly mother died. And to then hear about the challenges faced by the NHS as result of covid

14/

Trust legal rep replied:

'Sir the difficulty we have is the witness Mrs Brooks is asking for retired in 2014/15. If the request is for the person who knew that position at the time I’m not sure how we can assist further'

Anyone know whether the coroner can call them?

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An almost carbon copy discussion continues around the Head of Microbiology. It appears that some medical records are missing.

The trust legal representative points out:

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'Is asking the Head of Microbiology now to comment on something that happened ten years ago... I can’t see how that is going to assist your investigation sir'

Which is a fair point, but doesn't speak to why the Coroner can't find the former Head of Microbiology.

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The Coroner asks 'In relation to the missing documents, or the alleged missing documents, do you know whether any previous investigations or attempts have been made to see whether those are available?'

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The Trust legal representative responds: 'Sir I don’t know the answer to that question but I can certainly ask Ms Gallant [??] to make those inquiries'

[I think I gathered that the legal representative on the call was a stand in as Ms G was in court on another matter]

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It seems to me that the NHS Trust who the family feel have 'dragged everything out for the longest possible time' continue to benefit from such delay, and are still to some extent doing the same, albeit politely and under the cover of a global pandemic.

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I hope the Coroner sticks to his timescales and insists on answers to Elsie's family's questions. I also hope that he is able to call retired witnesses if it seems they have something to offer the inquest.

Elsie's inquest is tabled for Mar 2021. I'll be watching this space /END