Six and a half years since Sally’s death, in practical, as opposed to emotional terms, where are we now?
Attorney General: Application for permission to apply to the High Court for a reinquest (s. 13 Coroners Act 1988)
Following Sally’s 8 day Article 2 inquest in October 2015 it came to light that information was intentionally withheld from the Senior Coroner by three members of staff from Humber NHS Foundation Trust regarding a missed opportunity to intervene and take steps to save Sally’s life on the day of her death. It was this revelation, post inquest, which triggered the three and a half year police investigation mentioned below.
Following the completion of the police investigation, during the period 2019 – 2020 we have been 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 has been made available to all of these persons/organisations, it continues to be withheld from us, Sally’s parents.
In October 2020 we submitted a s. 13 Application to the Attorney General requesting permission to apply to the High Court for a quashing of the original inquest and a fresh inquest. The Attorney General granted this permission on 18th February 2021.
NMC: Following the inquest, in late 2015, Humber NHS Foundation Trust referred three nurses to the NMC regarding their fitness to practice.
In the case of the nurse who was one of Sally’s Care Co-ordinators, and the investigation into the regulatory concerns regarding her record-keeping and dishonesty, the Decision Letter dated July 2020 reported that the Case Examiners found “no-case to answer.”
In January 2021 the NMC reported on one of the two nurses from the Crisis Service based at Miranda House who was 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 third nurse referred to the NMC, also working in the Crisis Service at Miranda House and involved in the final assessment of Sally on 25 July 2014, has been referred by the Case Examiners to a Fitness to Practice hearing/meeting which is scheduled for later this year.
GMC: 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.
Police and Crown Prosecution Service (CPS): Three years of police investigations into Humber NHS Foundation Trust relating to perjury, perverting the course of justice, criminal negligence manslaughter and corporate manslaughter resulted in the decision to make no charges. In December 2018, following the CPS report outlining the reasons for this decision, we requested a Victim’s Right to Review (VRR) and a new senior CPS prosecutor was appointed to examine the case afresh. This was commenced in January 2019 and completed three months later. The original decision, not to prosecute on any of the charges, was upheld.
PHSO: In June 2016 we submitted a complaint to the Ombudsman regarding the conduct of nurses from Humber NHS Foundation Trust in an incident which occurred three days before Sally’s death. The PHSO issued their findings into this complaint in a report dated December 2016. The report, which failed to uphold our complaint, was fundamentally flawed in that it failed to address the issues we raised and was factually incorrect. We challenged both the procedure and the outcome with the PHSO and met with the Ombudsman, Rob Behrens, in May 2017, who apologised unreservedly for what we had experienced in our dealings with the PHSO and agreed that our complaint would be re-investigated following the completion of the police investigation. Prior to the new investigation commencing in May 2018 we requested that the report from the initial investigation be formally quashed. This was refused.
In April 2020 we received the report into the outcome of the PHSO’s second investigation, a partial uphold.
Adult Safeguarding: In June 2016 a Safeguarding Adult Review in relation to Sally’s death was commenced, finally reporting in May 2019. The agencies involved included: Humber NHS Foundation Trust, Yorkshire Ambulance Service, Hull Clinical Commisioning Group, Humberside Police, City Care Health Partnership and Hull and East Yorkshire NHS Hospital Trust. The report made seven recommendations highlighting timescales for actions within a three to twelve month period.