At the end of March 2019 we received the final decision regarding the three and a half year investigation by Humberside Police and the CPS into the issues of perjury, perverting the course of justice, criminal negligence manslaughter and corporate manslaughter relating to staff at Humber NHS Foundation Trust. This decision was a result of a second consideration of the case by the CPS following our request for a Victim’s Right to Review (VRR) in December 2018. The outcome confirmed the original decision that there was insufficient evidence to reach the criminal threshold for prosecution.
Up until this time we had been kept in the dark about what the matters were which were concealed from the inquest and what happened on the day of Sally’s death after she had been “assessed” and refused admission by the Crisis Team. However, the CPS VRR report sets out a brief account of the facts.
It indicates that the CPN who accompanied Sally to this “’quixotic’ gatekeeping assessment” (Coroner’s words), met by chance with the Senior Consultant Psychiatrist with responsibility for Adult Admissions, immediately after the “assessment”, in the car park outside Miranda House. This was not revealed at inquest, but it is now apparent that she had a conversation of some sort with this psychiatrist about the events which had taken place during the gatekeeping assessment and that several other persons within the Trust subsequently were aware of this.
This nurse, later, sought advice from another Consultant Psychiatrist, with responsibility for Sally’s care, regarding the relevance of her encounter and discussions with the first psychiatrist. This psychiatrist concealed his own knowledge of that meeting from the Trust internal investigation, the Senior Coroner and from ourselves.
From the above it appears clear to us that the full circumstances of the events on the day of Sally’s death were not revealed at her 8 day Article 2 inquest. It appears that there may have been relevant matters brought to the attention of, at very least, a consultant psychiatrist, before Sally died and hence a real opportunity to intervene and reverse the decision of the gatekeeping assessment before she died later that evening. There are, in our view, reasonable grounds to suspect that this presented a further opportunity to avert Sally’s death which was not revealed at the inquest.
It appears to us that the Senior Coroner’s conclusions, that there was not:
“a deliberate attempt to obfuscate failings on behalf of the Trust and its employees,” is not now sustainable.
We are now seeking to find out all the information omitted from the inquest regarding the full circumstances of Sally’s avoidable death of which several public bodies and individuals are now aware. To this end we have written to Humberside Police and Humber NHS Foundation Trust seeking their assistance in this matter.
As the police and CPS investigations are finally completed investigations instigated with the GMC and NMC will now proceed.
The PHSO have actioned our previous agreement made at a meeting with the Ombudsman, Rob Behrens in June 2017, to undertake a reinvestigation of our complaint regarding Humber Trust, following the conclusion of the police investigation. We have also requested that the previous complaint report dated December 2016 be formally quashed and are waiting to hear the outcome of this request.
Additionally, we are about to again meet with the Chair and Manager of the Adult Safeguarding Board regarding the publication of the final report into Sally’s case, which it is expected to happen in the next few weeks.