Reporting on inquests
Eight and a half years ago I attended my first inquest. Connor Sparrowhawk was 18 when he died in an Assessment and Treatment Unit run by Southern Health NHS Foundation Trust. The jury at his inquest found:
Connor Sparrowhawk died by drowning following an epileptic seizure while in the bath, contributed to by neglect.
The jury went on to identify a number of “very serious failings”, “errors and omissions”, “contributory factors” and “other failings” in the care and support provided to Connor.
There were eight sets of legal representatives in court throughout Connor’s inquest, and his family were represented by a legal team, some acting pro bono and some paid for by funds raised by the JusticeforLB campaign. It was definitely not inquisitorial.
I attended court throughout Connor’s two week inquest, and at the suggestion of a member of the family’s legal team, Caoilfhionn Gallagher KC, live-tweeted proceedings on social media.
I never anticipated the level of interest there would be in the detail of the court process. After Connor’s inquest, other families and lawyers started to contact me, to ask if I would report from their relatives’ or clients’ inquests.
I have now reported from a further 25 inquests into the deaths of learning disabled and/or autistic people. I focus on this group because it has been reported for decades that they are dying prematurely, often from preventable causes, and they rarely make the mainstream media headlines.
For the last four years I have been working as a crowdfunded journalist, and that has enabled me to report from other courts too, namely the Court of Protection, the High Court, the Court of Appeal and the criminal courts.
About half the inquests I have covered to date I reported in real time on social media (as a courtesy, always with the agreement of the family). The other half I have reported in long form, posting daily reports on the blog on my website.
I am regularly contacted by bereaved families whose loved ones have died. I try to speak to them early on in their inquest process, and will attend and report from pre-inquest review hearings, if possible. I will always try to write a profile of the person before their inquest hearing is heard in full. If I am practically able to report from court, I will always do so. I will then share any statement from the bereaved family after the inquest has concluded.
I routinely monitor Prevention of Future Death reports as they are shared on the MOJ website, collating and analysing them for common themes and potential learning.
I report in the hope that it will raise awareness, and provide a degree of external scrutiny, into why so many learning disabled and autistic people continue to die from preventable causes such as drowning, constipation, unwitnessed seizures, malnutrition and neglect.
The Voicing Loss findings in many ways accord with what I’ve witnessed in recent years. I hope they will prove useful to all those involved in coronial processes and serve as a reminder of the centrally important role they play, and how small things can make a huge difference.