Tag: Coroner

05 he didn’t know how he was going to live

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No witnesses gave evidence
at the inquest,
only the coroner read out
written statements
from the man’s doctor, the first paramedic
to attend him after he collapsed,
a police sergeant who investigated
his death, the pathologist
who carried out
his post-mortem.
The day he died
he was awaiting the results of an appeal
against being found fit for work.
He visited the jobcentre,
and was asked to climb some stairs.
Heart disease, sarcoidosis,
diabetes, cirrhosis,
depression, anxiety,
agoraphobia and high blood pressure;
he had been referred to a respiratory clinic; had been diagnosed
with Asperger’s syndrome.
He had previously lost his job because of depression;
he was falling asleep at work; serious breathing difficulties.
Despite a ‘fit note’ from his doctor
he had started a new job within a few days;
he wanted to work.
But his employer realised how unwell he was, and was worried.
He lost the job.
He told the jobcentre staff
he would have a heart attack
if he climbed the stairs.
Told he could use the lift,
he asked if someone could accompany him
because of his claustrophobia.
He was told this was not possible.
It was agreed that someone would come down
to speak to him.
After leaving the Jobcentre
he went to see a friend,
who calmed him down.
He was worried about work, about
money.
They weren’t going to give him disability benefits.
He didn’t know how he was going to live.
Hours later
he collapsed in the street
and died.

[Disability News Service, 11/08/2022, Shock after inquest ignores ‘fitness for work’ and jobcentre concerns]

07 the decision-maker

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The coroner concluded
at the end of the inquest:
‘The anxiety and depression
were long term problems
but the intense anxiety
was caused by his recent assessment
by the Department
as being fit for work
and his view
of the likely consequences.’
A former orthopaedic surgeon
employed by the contractor
had carried out the assessment,
concluding that he
was ‘at no significant risk
by working.’
The decision-maker
did not request
any reports or letters
from his doctor
his psychiatrist
or his clinical psychiatrist
had failed to ask him
if he had suicidal thoughts.
Six months later
he took his own life.

[Disability News Service, 02/12/2019, DWP: The Case for the Prosecution]

18 Dirge 1: for when you think you will be well again

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The dispatcher noted on the call log that the patient wanted to die,
but this particular piece of information was not conveyed.
The information which the crew were given was:
Psychiatric/Abnormal behaviour/
Suicide attempt;
trying to slit wrists; Armed with a weapon –
glass.
Therefore
the crew were given adequate information
of the patient’s intent.
She was due to attend the Jobcentre on the fourth
to make her declaration of unemployment
in order to remain eligible for her benefit payment.
However, she contacted the centre that day
to say she was sick.
She subsequently attended on the seventh
where she explained that she had not come in on the fourth
because she was ill.
She was asked to complete a form
to formally declare her sickness.
She completed and returned the form,
then immediately left.
This meant that the Work Coach
was unable to discuss
the details of the statement she had made:
‘I was busy trying to kill myself,
drinking non-stop.’
There is a space on the form
for the date when you started being unwell
(she put the fourth)
and another
for when you think you will be well again
(she put the seventh).
The coach discussed his concerns with his line manager, and
recorded the incident
in accordance with Department procedures.
Policies state
that employees are empowered
to take any reasonable steps,
including contacting the emergency services,
if they feel the customer
faces clear and significant risks to their welfare
or safety. In this case,
based on the information he had,
the Work Coach made a judgement
that there was no immediate risk to the customer’s safety.
She died later that same day.
On the morning of the sixth,
she reported that a man had attempted to rape her in her home.
One of the first-responding officers,
on encountering her outside her address,
noticed blood on her clothing, and,
quite properly,
attempted to persuade her
to allow police to seize the clothing
for forensic examination,
and to dissuade her from immediately returning to her home,
the apparent crime scene.
A third party witness
expressed surprise at the intrusiveness of the questioning,
conducted by a male officer
in a public area;
a less than ideal situation.
The witness added that,
although the officers’ questions were not in any way inappropriate,
and they had explained why they needed to ask them,
she would herself have felt
uncomfortable
answering such questions
in such a way.
The second attending officer sought advice
from the Team Detective Sergeant
regarding how best to proceed with the agitated woman
who informed the officers that she had been
drinking throughout the preceding night. In line with best practice
a female Sexual Offences Investigation Trained (SOIT) officer
was tasked to attend.
Despite difficulties,
officers obtained
sufficient detail
to circulate a description of the suspect,
who was promptly arrested nearby.
(He was later released.)
It was clear that there was some tension
between the desire on the part of the initial attending officers
to achieve best evidence
and the manner and location of the communication
between the woman and those officers,
necessitated by the character of contact
between the parties.
She walked off towards her flat;
an officer followed
trying to prevent her from entering.
Once outside the address he and another officer
tried to explain to her
why the scene needed to be preserved
but she continued to be obstructive.
She continued to demand that she be allowed to enter her flat
and threatened
to kick her own door down. Eventually
she used her keys to enter the address
and closed the door.
Research indicated she was capable
of being volatile and violent
when intoxicated.
Reports for example
indicated she had assaulted police in her home
five months earlier
when they attended there
to check on her welfare.
The Detective Sergeant
decided that
in her present state of mind
she was no longer suitable
for an immediate SOIT officer deployment,
and instead arranged for an officer
to re-attend the address
with a colleague
the following day,
which was the seventh.
On arrival
the front door was closed.
The officer knocked several times
before a female voice from within said ‘Who
is it?’
It’s the police. Can you open the door please?
The voice
replied ‘Everything
is fine. There is
no crime here.’
Can you open the door?
I don’t want to force it open.
We just need to speak to you
that’s all.
The door was opened.
She said
‘I don’t need
you lot. You can
fuck off.’
The officer explained
they were asked to attend
on behalf of the ambulance service
as they had been contacted
by someone threatening
to harm themselves
with a piece of broken glass.
‘Well it’s not me. I don’t need
you lot here. I
never asked you
to come so can
you please fuck
off.’
Have you hurt yourself with some glass?
She replied
‘No.’
What’s your name?
‘You don’t need
to know my
name it’s all
on your systems.’
The officer stated he saw a letter
and a bank card
on the sofa
which confirmed her name.
He said
Have you called for an ambulance?
She replied
‘No. I don’t need
an ambulance and I don’t know
why
you are here.’
Could anybody else
have called an ambulance for you?
Have you phoned a friend or
anybody to say
you were going to hurt yourself
with some glass?
She replied
‘No. Look
I never
called
you lot
please
fuck
off.’
The ambulance crew arrived,
and took over the lead in continuing attempts
to rapport-build,
only to experience
similar difficulties.
It was during this period that the SOIT officer and a colleague arrived
having postponed their initial visit
from the previous day, the sixth.
No officer present briefed the ambulance crew
regarding the alleged sexual assault.
On this occasion too, having been briefed by the first officer
on the woman’s state of mind
and volatility,
and by the ambulance crew
regarding her
nevertheless
evident mental capacity
and lack of immediate welfare concerns,
all parties decided
once again
to leave.
About forty minutes later, she left her home.
She is seen on CCTV entering the station.
The train was not driver-operated.
It was travelling at only 15 miles per hour.
It happened so quickly, commuters
continued reading their papers.
They had no idea
what she was doing.
The proximate cause of death was injuries sustained
when she stepped in front of the train.

[Responses from the Metropolitan Police (17/03/2016), London Ambulance Service (11/03/2016) and the DWP (undated) to the Prevention of Future Deaths report made by Coroner ME Hassell, 20/1/2016; added details from The Guardian, 06/02/2016, Faiza Ahmed: how one woman’s cries for help were missed by every authority]

41 a second, unopened letter

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She received a letter
from the Department
saying she should go back to work.
She suffered chronic breathlessness,
pulmonary disease,
depression;
she was a recovering methadone addict.
The letter also told her
her incapacity benefit
would be stopped.
She was so distressed
she took a cocktail of drugs.
She recovered
after treatment in hospital.
She regretted trying to take her own life
and vowed to fight the decision.
She died two days later.
A suicide note had been left in a sealed envelope
some medication was around the floor.
A post-mortem examination revealed
she only had a small amount of drugs in her system –
mostly from the suicide attempt
two days previously.
The coroner was satisfied
that she died
of natural causes.
After her body was found
a second, unopened letter
was also discovered
indicating she would not
lose her benefit after all.

[Evening Standard, 14/08/2013, Suicide bid of woman who feared losing her incapacity benefit]

44 he may have been successful

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His former wife
gave evidence at the inquest.
They had been married for twelve years,
separating in 1995,
although they still saw each other
on a regular basis.
During the first half of their marriage
he suffered a brain haemorrhage,
leaving him paralysed down one side.
She had last seen him when he called to see her
at work.
He wanted help to go through his benefit papers.
He was worried he was going to be sent back to work.
His doctor made a statement,
said they had spoken on the phone
two weeks before he was due to attend
an appeal hearing.
He had been upset
because his benefits were being stopped
after an annual assessment.
His neighbour
was sat in his front room
watching the television
when he heard a loud bang.
He went outide and saw the man, his neighbour,
slumped in a chair.
He also saw there was a gun on the floor.
He ran inside and phoned 999.
‘Had he attended the appeal
he may have been successful’
the coroner said.
‘It is evident that the matter
was concerning him greatly.’

[Gazette and Herald, 17/04/2013, Benefits withdrawal led to man’s suicide]

57 how all seemed normal

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In a statement read by the Coroner’s Officer,
her husband of 36 years
told how all seemed normal
when he went to work,
but when he returned home
the following morning
with their son
his wife was in the back room, lying half
on the bed.
They phoned 999.
The operator talked them through CPR
until the parademics arrived.
She had been unable to work for about ten years
due to a dengerative back disease.
She had depression for about five years.
She had started suffering from stomach pains
and had also been extremely upset
due to a tribunal regarding her incapacity benefit
which had taken from her.
The pathologist who carried out the post-mortem
said she had eight times the lethal dose
of dothiepin, a prescribed anti-depressant,
and four times the dose of propanolol,
a beta-blocker
which stabilises the heart,
in her system.
He also found codeine and paracetamol
in her body.
The coroner said
‘Her husband had gone
to work,
she was alone.
Things must have just
swept over her,
suddenly
she found her life
intolerable.’

[Blackpool Gazette, 09/12/2008, Back problems led to fatal dose; via Web Archive at 19/04/2016]