Initial revelations following Sally’s death
Following Sally’s death we were informed by Humberside Police that as this was an unexplained death there was to be an inquest. Humber NHSFT informed us that it intended to carry out a Serious Incident (SI) investigation. Towards the end of August 2014 we had an initial meeting with the Trust’s appointed lead investigator.
Six weeks after Sally’s death we were shocked to learn from our local paper, the Hull Daily Mail (6 September 2014) that there had been serious failings with the ambulance response to Sally’s final call after she was sent home with the police by the Crisis Service.
Although it had been agreed between Humber NHSFT and YAS that they would carry out a joint SI with Humber NHSFT as the lead organisation and therefore responsible for communicating the scope of the SI to us, no-one had done so and neither was it mentioned to us at the August meeting with the lead investigator.
SI Investigation Process
At the outset of the investigation process, we were sent a letter by the Head of Nursing from Humber NHSFT indicating the name of the lead investigator. Strangely, we thought, both the author of this letter and the investigator shared the same surname, not one that was particularly common. On enquiry, we learnt that the lead SI investigator appointed by the Trust was in fact the husband of the Head of Nursing at the Trust. We had considerable concerns over this with regards to probity and impartiality and communicated these to the Chief Executive who agreed eventually to suspend the ongoing SI process and appoint an investigator independent of the Trust. This was in September 2014. Lack of availability of a suitably qualified and experienced external investigator and team, meant that the process did not re-start until late November 2014. The SI report was finally completed in mid-April 2015, nine months after Sally’s death.
Following the above aborted initial joint investigation with Humber NHSFT, YAS met with us and shared their own internal SI investigation which had already been completed.
This confirmed that Sally had rung 999 at 17.35 on 25 July 2014 and that the call had been categorised as a Green 2 with a target response time of 30 minutes. In the end a paramedic in a Rapid Response Vehicle was the first to arrive at 19.14, a 99 minute response time, confirming the article in the local paper that the response was very late.
The report also admitted to an error in process of that last call in that after 13 minutes Sally asked if she could put the phone down and the call was disconnected. It was stated that due to the nature of the call it was an error to disconnect and the operator should have kept Sally on the line in order to monitor her condition. She was also at additional risk as she was alone.
Sally’s inquest commenced fifteen months after her death on Wednesday 14th October 2015. It was an Article 2 inquest under the Human Rights Act 1998 and followed three Pre Inquest Reviews (PIR’s).
Although we were well prepared for the inquest and had the support of an excellent barrister, Bridget Dolan (now QC) of Sergeant’s Inn Chambers, in reality, nothing could have prepared us for the actual process itself. Humber NHSFT had engaged in endless delaying tactics and obfuscation, in the fifteen months since Sally’s death, refusing to hand over Sally’s notes, despite us having provided all appropriate paperwork and failing to provide or deliberately withholding crucial information. These tactics continued immediately prior to and during the inquest with the Trust admitting liability the day prior to the commencement of the inquest in order, we believe, to encourage us to abandon our legal representation at the eleventh hour by claiming it was unnecessary in the light of their admission and/or to ensure that subsequently they would not be held responsible for our legal costs.
Because of our anxiety about the potential cost of legal support for the inquest and in the light of the fact that there is no public funding for families at inquest, we decided to dispense with the more usual route of engaging a solicitor who would then engage and instruct a barrister on our behalf and we opted for a direct access arrangement. This meant that we were able to engage a barrister who was prepared to work with us directly, known as a Direct Access Agreement. We knew that representation in court was essential as other interested parties, particularly public bodies such as the Trusts were certain to be represented out of the public purse.
At his final summing up at the end of the inquest, the Coroner Professor Paul Marks, recorded a narrative verdict stating:
“Had admission occurred after her initial assessment or following the two further missed opportunities, she would have survived and not have died when she did. The failure to admit her to an inpatient psychiatric bed constitutes neglect and this neglect bears a direct causal relationship to her death later that evening. A further missed opportunity to save her life probably presented itself when she was associated with the Ambulance Service and her call was not categorised appropriately and to compound this, a delay of 69 minutes over and above the intended 30 minute arrival of the ambulance occurred. “
The Coroner issued a narrative verdict at the end of Sally’s inquest which indicated clinical negligence and a breach of Article 2 of the Human Rights Act by Humber NHSFT. He issued a Preventing Future Deaths (PFD) notice to YAS.
Coroner’s Findings of Fact
The final mental health assessment of Sally on 25th July 2014 comprised two phases, the first lasting 14 minutes and the second occurring thereafter when Sally started banging her head against a wall and subsequently placed a ligature in the form of a shoe lace from her trainers around her neck and tightened it.
Quotes from the Coroner’s Summing Up:
“I have found that the quality and thoroughness of the first phase was lamentable and was not associated with any appropriate preparatory study of Sally’s records and no weight was given either to her past medical history or to her care plan in which short term admission was set out as a recommendation and useful technique for managing increasing risk that she might exhibit.”
“Following refusal of admission the second phase with involvement by the Crisis Team occurred. Sally was clearly demonstrating extremely worrying behaviour and self-harm both by banging her head and self-strangulation with her shoe lace. During this phase I found that she was restrained in a prone position. Following such restraints it is mandatory for an individual to be assessed by a Medical Practitioner with the episode to be documented and for the staff involved to be de-briefed. None of these actions in fact occurred. I have found as fact that if due protocol pertaining to restraint had been followed a further opportunity for reassessment by the involving medical team would have occurred and on the balance of probabilities this would have led to her admission. I have found that this represented a missed opportunity which, had it been taken would have resulted in Sally not dying at the time and place she did.”
“I have also found that during the assessment there was a failure to treat Sally with appropriate dignity and respect by members of the Crisis Team involved.”
“The police officers acted with thorough professionalism in the face of an illogical quixotic and unconscionable decision not to admit Sally Mays to hospital by the Crisis Team. The decision was underpinned by the slipshod and peremptory assessment. Crucially I have found as fact that if Sally Mays had been admitted after the Crisis Team’s assessment she would not have died where and when she did. I would regard this as a gross failing in her management and following on from this stems causation. For the avoidance of doubt had Sally been admitted she would not have died that day. Bearing in mind the strict test for neglect in the coronial jurisdiction as set out in the dictat of Lord Bingham I have found that the test is satisfied and there was neglect associated with Sally’s death.”
Late arrival of the ambulance
“Sally’s call to the ambulance service was allocated a Green 2 status which meant that an ambulance should arrive within 30 minutes of the call being taken. It in fact transpired that it took 99 mins for the ambulance to arrive.”
On the afternoon of the 25th July 2014
“I have found that there was an inappropriate predetermination not to offer admission to Sally.”
“The initial gate keeping assessment was not appropriately conducted.”
“I have found that it was not appropriate to refuse admission to Sally at that time.”
“It is my finding that she was at substantial risk of fatal self-harm and the gatekeeping team failed to recognise this.”
“Whether given the decision to refuse admission to Sally the care plan then recorded of “await contact over the weekend was appropriate” – I have found that this was not an appropriate response.”
“Whether or not the refusal of the admission was provocative and escalated Sally’s distress and contributed to her reactive self-harm behaviour – I have found as fact that this was the case as clearly demonstrated by her attempt at head banging and self-strangulation following the refusal of admission.”
“Whether or not it was appropriate to fail to consider breaching confidence and informing Mrs Mays of Sally’s elevated level of risk – I have found that consideration should have been given to breaching confidentiality and informing Mrs Mays of Sally’s elevated level of risk. Firstly, Sally’s consent should have been sought but failing that the team should have appreciated that the making of confidentiality is subordinate to the protection of the patient and the public under certain circumstances.”
Humber NHS Trust Systems
“Whether the Trust systems regarding the use of updating of risk assessment tool were adequate – at material times they were inadequate.”
Last Yorkshire Ambulance Service call on 25 July 2014
“Whether or not the call by Sally to YAS was appropriately coded given she was alone – it is my finding this was not appropriately coded and greater priority should have been afforded to Sally.”
“Whether or not the call taker failed to take appropriate steps to keep Sally on the line – I have found that the call taker failed to take appropriate steps to keep Sally on the line.”
Hull Daily Mail articles relating to the inquest
The links below to reporting in the Hull Daily Mail describe the events of the inquest as they happened on a day-by-day basis. These initially were available on that papers’ website but have now been deleted, hence the need to reproduce them here. We are grateful to Allison Coggan the journalist, then working for the Hull Daily Mail, for her accurate reporting of the events of the inquest.
Police and Crown Prosecution Service
Initial police investigation – perjury and perverting the course of justice
Less than two weeks post inquest we were contacted by the coroner who said that it had come to his attention via Humber NHSFT that information which should have been disclosed at inquest had not been and that this information indicated that following the final “assessment” at Miranda House there may have been another opportunity to save Sally’s life. He had handed this information to Humberside Police who, when they met with us a few days later, said that they were investigating an accusation of perjury and perverting the course of justice. That investigation took just over a year to complete and at the end of November 2016 we were informed that there was insufficient evidence to enable the CPS threshold to be reached. Consequently there was to be no charge.
Subsequent police investigation – perjury, perverting the course of justice, clinical negligence manslaughter and corporate manslaughter
Two months after the conclusion of the initial police investigation, we were contacted once again by the Humberside Police in January 2017 to inform us that a decision had been made to carry out a major investigation into all aspects of Sally’s care which, in addition to their previous remit, would also be extended to include any potential criminal charges with specific focus on criminal negligence manslaughter and corporate manslaughter.
Followng a further two years of investigation, in November 2018, we received the CPS decision not to charge on any of the potential offences which had been investigated together with an explanation of this decision. Close examination of the report revealed, we believed, that there were procedural flaws in the CPS decision-making process and we therefore requested a Victims’s Right to Review (VRR). This review, confirming the original decision, was completed in March 2019.
Humber NHSFT Complaint process
At the same time as the initial police investigation was being undertaken we lodged a complaint with the Humber NHSFT, early in 2016, regarding an event which took place on 22nd July 2014 (3 days before Sally died). This related to the fact that Sally had told her mother that she was asked by her senior CPN to engage in a training exercise with a student and to act as if in crisis on the telephone in order to test the student’s reactions. The student was not to know that Sally was acting and not actually in crisis and was to be under the false impression that Sally’s alleged crisis was real. This request, the handling of the exercise and its aftermath raised serious issues of professional practice and was of considerable concern to us.
Although these issues were raised at inquest (Day 3), it was not covered in appropriate detail and undue weight was given to the accounts of the professionals involved, who were those actually involved in the incident itself. In brief they claimed Sally had not been asked to act “as if in crisis” and that it was a legitimate clinical intervention, despite there being no clinical notes whatsoever of the event.
We were thus, advised by Humber NHSFT to submit a complaint about the incident. The outcome of the complaint, five months later, was that Humber NHSFT concluded that it was a valid clinical interaction (even without any notes to support this) and that either Sally had misunderstood the purpose of the ‘phone call or her mother had misunderstood what Sally had told her. As we knew that neither of these scenarios were true, we therefore decided to escalate the complaint to the Parliamentary and Health Service Ombudsman (PHSO) for them to investigate.
Parliamentary and Health Service Ombudsman (PHSO)
We submitted our complaint to the PHSO in mid-June 2016, who agreed to investigate. We were subsequently disappointed and alarmed when, following an eighteen week wait for an appropriate investigator to be appointed, our request to meet with the Case Investigator was refused. We raised this issue with their manager who subsequently appointed a new Case Investigator. On contact the new investigator again promptly stated that the PHSO do not normally meet with complainants, that he personally had never met with any complainant in the ten years he had worked there and that he did not believe there would be any benefit in such a meeting. Even Skype was out of the question! This, understandably, set alarm bells ringing for us. We had already had an extremely poor experience of Humber NHSFT’s complaints process, and it appeared to us that the PHSO viewed their review as merely a ‘desktop’ exercise, not a great deal of use in our case in the light of the total absence of documentation by the Trust for the day in question.
The final irony was that the PHSO’s report, when produced, supported the same claim that the Trust made regarding Sally misunderstanding the purpose of her interaction with the student even though the chronological facts do not support that. Additionally, the investigator had made a fundamental error (which could have been avoided by an early meeting with us) of misunderstanding what we were asking the PHSO to investigate. There were also a significant number of factual errors and the report was extremely poorly written.
We were left with no choice but to challenge the decision and the process of investigation and finally after numerous emails, telephone calls and letters, we met with Rob Behrens, the then newly appointed Ombudsman, 53 weeks after submitting our original complaint (June 2017).
The Ombudsman apologised unreservedly for the poor service we had received and agreed that post police investigation the PHSO will undertake a new investigation of our complaint. Prior to the new investigation commencing in June 2018 we requested that the previous report be formally quashed. This request was refused.
In April 2020 we received the final report of the PHSO’s second investigation, a partial uphold.
Post inquest we submitted a claim against Humber NHSFT for civil (clinical) negligence and a breach of Sally’s, her parents and her brother’s Human Rights (HRA 1998) under Articles 2 and 3 (ECHR).
Article 2 (HRA Act 1998) is defined as:
“Everyone’s right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which the penalty is provided by law.”
Article 3 (HRA Act 1998) is defined as:
“No one shall be subjected to torture or to inhuman or degrading treatment or punishment.”
Additionally we submitted a claim for litigant in person and counsel costs.
Humber NHSFT had admitted clinical negligence the day before the inquest started and ultimately, over the course of the following year, settled on the negligence claim, the Article 2 breach on behalf of Sally and her family, the Article 3 breach on behalf of Sally and the reimbursement of our costs.
In November 2015 Humber NHS Foundation Trust referred two senior psychiatrists to the GMC on the grounds that they had been excluded from work pending a police investigation into perjury and perverting the course of justice. Following extensive investigations, in January 2020, the Case Examiners closed both cases with no further action.
Following the inquest, in late 2015, we referred two nurses, Patrick McKee and Gemma Pearson (now Marsh), to the NMC. These nurses were responsible for the final assessment of Sally, and worked in the Crisis Service at Miranda House, Humber NHS Foundation Trust.
We made a further referral of Laura Elliot, one of Sally’s CPN’s to the NMC in December 2016. The regulatory concerns related to her record-keeping and dishonesty. The NMC Decision Letter in her case, dated July 2020, reported that the Case Examiners found “no-case to answer.”
In January 2021 the NMC concluded their investigation of Gemma Pearson (Marsh), one of the two nurses from the Crisis Service responsible for the final mental health assessment of Sally on 25 July 2014. The regulatory concerns identified were:
- Failure to carry out an adequate clinical/gatekeeping assessment
- Failure to adequately reassess Sally when her risk increased after the initial clinical/gatekeeping assessment
- Contribution to Sally’s death
- Failure to adequately record the assessment and/or the clinical rationale for not admitting Sally
- Failure to treat Sally with dignity and respect.
On concerns 1, 2, 3 and 5 the Case Examiners found on the basis of the evidence: “We consider that there is a realistic possibility that the facts alleged would be found proved. As such, we consider that there is a case for you to answer on the facts of this regulatory concern.” On concern 4, the Case Examiners found that there was no case to answer.
Overall, the NMC ruled there was “no case to answer” citing remediation and six years subsequent safe practice as mitigating factors.
The second nurse, Patrick McKee, involved in the final assessment of Sally, was the subject of a 12-day NMC Fitness to Practice hearing held in October 2021 and January 2022. The panel considered more than thirty charges. All were found to be proved. The overarching charges related to: failure to carry out an adequate clinical/gatekeeping assessment and that the decision to refuse Sally admission to hospital that day, as per her Care Plan contributed to her death. In arriving at their decision on the sanctions to be applied, six aggravating factors were taken into account and there was no mitigation. The panel made a Striking Off Order.
The hearing was heard in the registrant’s absence. He refused to co-operate with the investigation during the 6+ years it took the NMC to consider his case.
Non-disclosure of the relevant information deliberately withheld from Sally’s inquest and details of the subsequent Trust and police investigations, left us no option but to resort to a formal legal route involving an application to the High Court for the quashing of the original inquest and the ordering of a fresh inquest.
This application to the High Court for a re-inquest is a two-stage process. Firstly, permission (a fiat) must be obtained from the Attorney General to bring proceedings in the High Court under s.13 of the Coroners Act 1988. This initial process, for a lay person, is onerous and requires considerable legal expertise. We submitted our application in October 2020 and a fiat was granted and issued to us on 18th February 2021.
On 1 December 2021 our application under s.13 of the Coroners Act 1988, requesting that the outcome of Sally’s orignal inquest in October 2015 be quashed and a fresh inquest ordered, was heard in the High Court and was successful. The case was heard before Lady Justice Simler, Mrs Justice May and HHJ Thomas Teague, QC, Chief Coroner of England and Wales. We, Sally’s family were represented by Bridget Dolan, QC, Serjeants’ Inn.
The application was brought on the grounds that:
(1) the discovery of new facts and evidence since the original inquest makes it both necessary and desirable in the interests of justice that a fresh investigation and inquest is held.
(2) the state’s procedural (investigative) obligations under Art. 2 ECHR are engaged but have not been met, in that the full facts and circumstances of Sally Mays’ death have not been subject to an effective investigation compliant with the Claimants’ Art. 2 rights.
The circumstances leading to the application are, that shortly after Sally’s original 8-day inquest concluded, in October 2015, it came to light that information relevant to how she came by her death had been knowingly withheld from the NHS Trusts’s internal investigation and the Senior Coroner. It was also withheld from us, Sally’s parents. The new information indicated that following what the Senior Coroner described as an, “illogical, quixotic and unconscionable decision” not to admit Sally to hospital that afternoon, there was a clear opportunity for a Consultant Psychiatrist, who spoke with Sally’s CPN after she had been turned away from Miranda House and refused admission, to intervene and reverse that decision. The Senior Coroner found that had Sally been admitted to hospital, as she was requesting, her life would probably have been saved.
This revelation, two weeks post inquest, led to a 3.5 year police investigation, ending in 2020. Following this, we were in protracted correspondence with Humber NHS Foundation Trust, Humberside Police and the Senior Coroner in order to obtain further information about the events withheld at inquest. However, although the detailed evidence was made available to all of these persons/organisations, it continues to be withheld from us, Sally’s parents.