Down like waters

I’m a pretty tough person. I’ve survived a lot in my life.  But Nico’s inquest nearly broke me.  Even now, 10 months later, I find it difficult to think about and even harder to write about.  We are still very much living with the repercussions of the inquest.

Every day, every long, long day of the Connor Sparrowhawk inquest I had planned to read every message of the live Twitter stream from the coroner’s court. It seemed like the very least that I could do to support his family and friends, but I failed.

Within a day of the inquest starting and the live twitter stream beginning I was in pieces and unable to continue. The words and expressions used in the court were just so familiar to me.  The same coroner’s court, the same coroner, just made it all come back and I was forced to retreat into checking the tweets at the end of each day and sending a daily message of support.  Not much, but all I could manage, so it had to do.

But I’ve been thinking about that coroner a lot and I wonder if he’s been thinking about us too. About all that has changed from the first day of our inquest to the final day of Connor’s inquest.

It seems to me that he has learned a lot (A LOT) from Connor’s inquest. His summing up and his verdict seemed to suggest that he’s learned a lot about our world and about Southern Health since the first day of Nico’s inquest.  I’d like to think that both Nico and Connor’s inquests have informed him, but truthfully I think it’s probably Connor’s.

But I really do have a feeling that if that coroner was to preside today over another case of a young disabled person dying in care (or next week, next month or next year) what he says and does will be far more informed. It must have been a very interesting journey for him.  I wonder if we had our inquest today – would the verdict be the same?  Does the coroner still hold Katrina Percy and Southern Health in such high esteem?

On the first day of Nico’s inquest the coroner opened the inquest by praising the work of Southern Health. In his words “they do a job that not everyone would want to do”.  The job of caring for our young people.  Our apparently un-lovable young people.  All praise Southern Health!

We sat there on the opening of Nico’s inquest; the coroner had not offered us a PIR (pre-inquest review) as he didn’t feel it necessary. Our “team” was literally myself, my partner, my daughter, Beverley Dawkins (who furiously scribbled post it notes and passed them to our young barrister) and my friend who had tried so hard to help us with Nico’s care at Barrantynes, Charlotte Sweeney.

The coroner put everyone from Southern Health in seats directly behind us. So close we could feel their breath on our necks.  We were forced to hear the senior staff member snicker at a comment made about Nico by one of their witness.  We heard their whispers and their giggles.

Our young barrister, Graeme, was working for free. He hadn’t represented a family at an inquest before and was keen to gain experience and was interested in our case.  He thought we “really had something” and was convinced that he could make the coroner see this.  He stood up after the coroner’s opening remarks and formally applied for Article 2*.  The coroner flatly turned him down.

We heard 2 witnesses that day, both from the Southern Health care team. One spoke honestly and directly.  He spoke fondly of Nico and was clearly filled with sorrow and regret.  The second witness told Graeme that they had got into the habit of giving Nico his last feed in the evening when he was in bed.  Graeme asked if they were checking on him regularly while he was having his feed.  She replied that they were in the kitchen and no, they couldn’t hear him from there. Then she made one of the many statement given by Southern Health witnesses which will stay with me forever………she said that they didn’t check on him regularly, just looked in on him whenever they “wafted down the corridor”.

At the end of the first day Graeme asked the coroner for Article 2. The coroner refused and said that he was NOT to ask him again.

Then he closed by apologising to “the parents” for having to continue the inquest as he realised we’d like it all over as soon as possible. He also apologised to Southern Health, but thought a longer inquest necessary as he wanted to call more witnesses.

But he was wrong. We didn’t want it over as soon as possible, we wanted justice.

He granted a PIR. It was conducted as a conference call between the barrister from Bevan Brittan working for Southern Health, Graeme and the coroner.  Someone from Southern Health was listening in, so was our solicitor and so were we, but we’d been told that we shouldn’t speak.  The barrister from Bevan Brittan told the coroner that he hadn’t received several of the witness statements from our side which had been sent to him, so hadn’t had a chance to read them.  But he still objected to those witnesses being called and the coroner upheld his objection (it turned out he hadn’t read the witness statements either).  We just had to listen in horror.  Graeme asked for Article 2.  The coroner turned him down.

Day two of the inquest had a different atmosphere. The courtroom looked like one of those weddings where they bride has hardly any friends or relations and over on the other side, the groom’s lot are so numerous they can hardly fit into their side of the church and so they’ve filled their side and spilled into the back of the bride’s empty seats at the back.  We were the bride’s side.

The only addition to our team from day one was my “daughter from another mother”, my own daughter’s nearly sister, who insisted on being there to support us.

On the other side there were over 10 on their legal team, plus numerous unidentified Southern Health management types, plus their many witnesses and their supporters. I didn’t count them, but it was a lot of people, enough to fill up their side.

Day two began with Graeme asking for Article 2 and being turned down.

Of the rest of the day I can only say that I found the lying very shocking. I honestly wasn’t expecting them to lay their hands on the bible and swear an oath and then lie.   I found the coaching very shocking too.  Our barrister had warned us that witness coaching by the barristers is allowed at inquests, you can even “correct” a witness and say “No, I think what you meant to say was…..” and they did this.  Southern Health had brought in a ringer, a top flight barrister for our inquest and frankly the amount of coaching he did would not have disgraced any football team.

So much of what the Southern Health witnesses said was based on knowing that the coroner wouldn’t fully grasp the finer points of disability and care. So they told him with a straight face that it wasn’t necessary for Nico to have a risk assessment for his early morning vomiting.  They told him that the staff had no training around how to deal with his vomiting but it didn’t matter. They said they had no memory of the additional funding or discussion of the funding which had been committed by the local authority for extra staffing to safeguard Nico if he was sick in the morning.  The corner didn’t comment.  He didn’t mention these things in the final summing up.

In his closing remarks at the end of day 3, the coroner upheld the doctor’s statement that if Nico had been found within 20 minutes he could have been saved. He noted that in Nico’s care plan he should have been checked every 20 minutes.  He felt sure, in spite of various conflicting statements by care staff, that this hadn’t been done.  He thought this was because there was only one staff member awake to care for all four young people.

He granted Article 2.

The coroner began Nico’s inquest with the perception that he was dealing with the death of a non-verbal, small and delicate looking young man in a wheelchair. The inquest had this perception running thought it like a thread which bound up all the proceedings, all the witness statements, all the written statements and all the coroner said.  This was a young man who was poorly in some unexplained way, a young man who would die soon anyway.  So nothing much to see here and no need to look too deeply into matters.

But perception is not reality.

Nico had hardly ever been ill a day in his life. Non-verbal doesn’t mean you can’t understand, a wheelchair doesn’t mean that you can’t think for yourself, have your own dreams and desires.  Nico was a whole person and he deserved to have his life. He was needed and loved and wanted by his family and friends.

By contrast it’s far harder to cast young Connor Sparrowhawk in the mould of “poor little Tiny Tim, waiting to die”. With his good looks, wise cracking sense of humour and big personality; it’s harder to perceive him dying young.  His disabilities were less obvious. The strength, knowledge and understanding of his family and friends  around him, both in his life and in the fight for justice made him harder to cast in the role of helpless little chap, just waiting for a merciful death.

The neglect verdict stunning and wonderful. A game changer perhaps. But all game changers come at a cost and this inquest was dearly bought by those who loved him.

On our final day, at the end of our inquest we sat in the family room, stunned, speechless.  Graeme practically danced around the room, overcome with the excitement and joy of having procured that so important Article 2 decision.  We were completely caved in and felt years older by the end of that day.  Our daughter from another mother left almost immediately, needing to get away from that place, to be able to breathe.  Our own daughter went outside into the corridor so she could cry without us seeing.  My partner and I mumbled to the camera, utterly spent, utterly exhausted.  Our support team went home.  Beverley had to leave before the verdict came in.

There was no feeling of justice. No feeling of victory.  Only the knowledge of trust betrayed and the knowledge that our beloved son could have, should have been saved.  Then we walked in the dark to the station and caught the train home.

Southern Health CEO, Katrina Percy issued no statement, there was no apology and instead we received a letter from their director of learning disabilities a month later. You might recognise her name from the LB inquest tweets – Lesley Stevens.  She wrote “whilst I was not able to be in attendance at the inquest, I am aware of the findings and of the Coroner’s verdict.  I recognise that this has been a very difficult time for you and your family and that the Trust could have done more after Nico’s death to engage in you the investigation process.  I would like to take this opportunity to say how sorry I am that this was not done at the time” 

Not sorry he died, not sorry for the lack of risk assessment, lack of therapy, lack of appropriate staff training, lack of funding (as his additional funding to safeguard him had disappeared) – no, sorry that her boss Katrina Percy had written to us saying that they had decided not to let us know how Nico had died as it would be upsetting for us to know.

All I have to say in reply to this is – Independent Investigation. Yes, we’re coming for you Southern Health.

“Let Justice roll down like water and righteousness like an ever flowing stream”.


*Article 2 of the European Convention on Human Rights (ECHR) concerns the right to life. There are several parts to this article, which have been interpreted over time: first, the obligation not to deprive a person of life except in certain, limited circumstances; secondly, the positive duty to protect life where appropriate; and, thirdly, the duty to investigate suspicious deaths.

It must be shown that the death was caused by failures that were not only systematic but sufficiently serious as to breach the obligation of the state to maintain safe structures and rules to protect life. One of other the key requirements of an Article 2 inquest is that the authority must be aware of the failings and fail to act upon them – this is one of the criteria for separating ‘mere’ negligence from failings amounting to a breach of Article 2.

The principle behind Article 2 is that the State should take all practical steps to safeguard the safety of its citizens.

Information from Michelmore’s (solicitors) newsletter on Article 2 inquests.


7 thoughts on “Down like waters

  1. Rosi I have been thinking of you over the last 2 weeks – yes it must have been very raw for you. This twisted dark side from SHT sadly is normal, I too have witnessed many lies, and from that the frustrating inner rage that comes from any interaction from certain management/staff. They are well practiced – have no heart or conscience & yes Ive even witnessed smirks and gloating. So it would seem being soulless is standard for some, I say some as I have met some genuine staff – but I don’t think they have it easy as they dont fit in. An independent investigation is just what you and Nico need and deserve. XXX

    • What can I say Deb, apart from YES! Until you see it for yourself, hear it for yourself, you just wouldn’t believe it. But we know. So much wrong here and it worries me that people may think that them getting kicked in the goolies on the very high profile LB case may have taught them something but I think (and I bet you do too) that all it’s really taught them is to be more clever, more thorough and to not get caught out!

      • Totally – in fact I see it all the time even now after every successful complaint. But like you I am not easily fooled or impressed.

  2. Rosi I think the words” a job not everyone would want to do ” are unforgiveable. The ‘ job’ is simply the provision of care giving and specialist services as appropriate in a setting other than home. Standards should be exemplary . Nico deserved the bar set high for safeguarding as did LB. It is clear your inquest had a completely different dynamic to LB’s. I sincerely hope you have all the support you need for your independent investigation. I am guilty of seeing LB’s inquest as ‘ the way you should do it ‘. I was caught up in quite a celebratory mood to see all the news coverage , thoughts of well nothing like that will ever happen again. Clearly the support of a legal team/others is invaluable and most people are lacking those resources. I agree totally that it is much easier for a young physically disabled person without speech to be seen as sickly and failing akin to a little old person regardless of their actual health status. My daughter was light in body weight and with little independent movement towards the end of her life it undoubtedly drew parallels with old age for those health professionals who visited. No one said how tragic it was, everyone acted as though grandma was slipping away in the sitting room. I am not convinced about the apology from Southern Health , there was a very obvious disconnect between the mind/eyes and lips of that lady. LB’s inquest verdict was feel good, the news coverage was feel good, it even made me remember laughter shared. The reality is LB died, Nico died in the care of that Trust.

    • Thanks for another great, thought provoking comment Nic. I think we all know that every single case, every single inquest, is different. As ours and Connor’s were in the same court and with the same coroner, it becomes very easy to draw parallels, but really we shouldn’t – because there are none. The two inquests were very, very different beasts. But the fact remains that, whatever the case and whoever’s child has died, the type of inquest you get seems to still be so dependent on the type of legal support you are able to afford. If you either have a lot of money or have a team who are able to fundraise heavily, then you can afford a really good legal team, if not – you will end up at a real disadvantage in the courtroom. However, it’s worth remembering that in some cases, in Connor’s case for example, where they die can affect who can represent the family. The wonderful charity INQUEST.ORG was able to support the Ryan family and made such a tremendous difference to the legal side of things, but a lot of people, like us, wouldn’t be eligible for their help. They run on a shoestring and a lot of good-will and frankly should be better funded so they’re able to help more people.

      What you have written about your own daughter is a “knowledge bomb” to me and that phrase “as though grandma was slipping away in the sitting room” will stay with me for a long time.

  3. The comment, ‘a job that not everyone would want to do’, reflects the Magistrates comment, when he sentenced, the carer, who had continually, over 2 months, bent Thomas Rawnsley’s fingers back, threatening and trying to break them, but couldn’t, as he was double jointed.

    On sentencing him, to community service, the magistrate remarked,’ Its not easy dealing with these disadvantaged youngsters’.

    The same ‘understanding’/discrimination,/ disabled disrespect, is not extended, to parental care, where incapacity, and abuse is sought, and parents permanently vilified.

    This was a process, cold, clinical, impersonal, as is the care of the disabled now and getting worse as it is now mainly privatised and run for maximum profit.

    Yet, the carer institution, is paid up to £4,000 for specialist treatment/care, but the vulnerable receive, less than basic care, and inadequate services.

    Why ?

    Because the service provider is accountable to no one, but it appears, can charge what they like.

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