Category Archives: Inquest

Privately-run prison’s officers ignored pregnant teenager in labour – so the baby died

Bronzefield prison: the death of baby Aisha happened after at least four other incidents involving pregnancy there.

WARNING: DISTRESSING CONTENT

This is what happens when you let your government put people’s lives in the hands of a private corporation that exists only to make a profit: PEOPLE DIE.

That is exactly what happened at privately-run Bronzefield Prison, on the outskirts of Ashford in Surrey, which is run by Sodexo Justice Services.

An inquest has found that teenage mother Rianna Cleary was found in her cell, covered in blood, her dead baby Aisha cradled in her arms, after she had twice called for help after going into Labour during the night – and both calls were ignored by staff. She had to bite through the umbilical cord.

She should have been monitored five times during the day before the birth but the nurse who had been on duty at the time admitted that this had not happened. A nurse had tried to get Ms Cleary moved to the prison’s healthcare facility but no bed was available.

When she went into Labour, Ms Cleary used the cell’s intercom system to tell an officer she needed a nurse or an ambulance – but the officer on duty did not call for any help. About half an hour later, in what was described as “unbearable” pain, she repeated her request – but the call was disconnected in the guard’s control room. This meant the call bell from her cell was disabled from that point onward.

The senior coroner for Surrey, Richard Travers, said systematic failings at both the prison and the hospital that looked after the mother meant Aisha died; she might have survived if Ms Cleary had been discovered in Labour and transferred to hospital.

These events occurred in September 2019 and the inquest has only just happened – taking a month to be heard.

A glance at the prison’s history shows that this outrage is far from unique: at least four times in the two years to 2019, women gave birth in upsetting and potentially dangerous conditions.

A report by The Guardian in November that year states that in addition to Ms Cleary’s case, “On at least four occasions in this period, women held at the privately run Surrey prison have given birth in distressing and potentially unsafe circumstances, including one woman who gave birth in her cell and another who was left in labour at night-time supported only by another pregnant prisoner.

“In December 2017, one woman suffered a stillbirth and another baby was admitted to neonatal intensive care, in both instances after women were transferred from Bronzefield to hospital at a late stage of labour. In the latter case, it is understood that the woman alerted the prison to concerns two days before she was eventually taken to hospital.

“Board meeting minutes from Ashford and St Peter’s NHS trust, from July 2018, refer to the two incidents, stating: “Adverse outcomes were reported in both cases … significant learning and process change were identified for both hospital and prison teams.”

“The minutes state that Bronzefield, Europe’s largest female prison, intended to review its policy concerning the transfer of pregnant women to hospital and its criteria for risk assessment.

“Sodexo Justice Services, which runs the prison, said that following the December 2017 incidents it had worked with Ashford and St Peter’s Hospital and changed arrangements with its midwives.”

So there can be no excuse for what happened.

But: “The Guardian also heard of a woman who alerted prison staff that she was in labour in July 2018. She was not seen by a midwife and was left in labour during the night, supported only by another pregnant prisoner.

“In March 2019 a woman, understood to have been in the prison on remand, gave birth in her cell with no midwife or doctor present. A nurse reportedly delivered the baby.”

The Ministry of Justice, contacted in November 2019, said that Sodexo had not incurred contractual penalties relating to the levels of care to pregnant women in custody in the previous three years – and declined to comment on then-recent incidents at HMP Bronzefield.

Former prisoners, including one from Bronzefield, said midwife appointments and scans were frequently missed as a result of prison staff shortages.

It all adds up to a failure of service caused by privatisation, in This Writer’s opinion. Private corporations, brought in to run a service like a prison, do so in order to make money and cut corners in order to achieve those profits.

Even when they are found to be at fault, those failings continue to go unremedied, meaning more – and worse – tragedies are likely to happen.

And what is done by the government that hired these – call them what they are – incompetents? It turns a blind eye.

One final point: if you think what happened at this privately-run prison is a traumatically-shocking outrage, ask yourself what will happen to the National Health Service when it is given to private firms like Sodexo.


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Government’s role in death of benefit claimant to be examined in new inquest

Jodey Whiting: death by DWP?

The role of the Department for Work and Pensions in the death of former Employment and Support Allowance claimant Jodey Whiting is to be examined after the Court of Appeal approved a second inquest.

The decision follows representations by solicitors Leigh Day, and I’ll let them explain:

Jodey’s mother, Joy Dove, has been fighting for five years to have a second inquest into Jodey’s death to examine the role of the DWP.

The Court ruled that it is desirable in the interests of justice for a new inquest to be held to investigate how Jodey came by her death in light of new evidence Joy obtained after the first inquest into Jodey’s death.

The Court found that it was not only desirable for Joy and her family to have an inquest into Jodey’s death at which they could invite a Coroner to make findings about the role of the DWP’s failings in Jodey’s death, but also that the public at large has a “legitimate interest” in this investigation being carried out.

On the specific facts of the case, the Court of Appeal rejected the argument that the DWP owed Jodey a legal obligation to protect her life (within the meaning of Article 2 of the European Convention on Human Rights) under the Human Rights Act.

Jodey took her own life aged 42 on February 21, 2017. She had multiple physical and mental illnesses which left her housebound and entirely reliant on welfare benefits. She died a fortnight after her benefits were terminated because she did not attend a Work Capability Assessment. At the time of the assessment, Jodey was housebound with pneumonia, had been in hospital, and had found out that she had a cyst on the brain.

Since Jodey’s death, her mother, Joy Dove, has fought tirelessly for a second inquest into her death so that the role of the DWP can be examined. The first inquest into Jodey’s death lasted only 37 minutes and the coroner refused to consider the role of the DWP.

In the years since the first inquest, new evidence has come to light, including an investigation into the handling of Jodey’s benefits by the DWP and a report from an independent consultant psychiatrist, who concluded that it is likely Jodey’s mental state would have been substantially affected by the DWP’s failings.

The Court of Appeal judgment notes that it is accepted by the DWP that its failings in Jodey’s case “were extensive, both before and after it stopped her benefits with effect from 7 February 2017.” It went on to explain that the Court’s ruling that the DWP did not owe Jodey a legal obligation under Article 2 is “not to ignore the multiple failings on the part of the Department. The Department accepts that individuals within the Department failed to follow the relevant systems and policies at crucial points.”

The judgment explains that the new evidence which was crucial to the decision to order a new inquest was Dr Turner’s evidence that “Jodey would have experienced shock and distress at the withdrawal of her welfare benefits and that the effect would have been heightened by her current difficulties, her isolation and her pain”. It explains that a new inquest is desirable because it is appropriate for a coroner consider, based on Dr Turner’s evidence, whether it is appropriate to record “any link or connection between the withdrawal of the welfare benefits and her mental state in the period leading up to Jodey’s death”.

It is hoped that a date for the new inquest will be set soon and that the DWP will be made an Interested Person in the inquest. The family hope that the inquest will consider the failings of the DWP, as identified by the independent investigation, and the effects of these failings on Jodey’s mental state, including whether or not the failings more than minimally contributed to Jodey’s death.

Joy Dove said:

“I am so pleased and grateful to the Court of Appeal and I would like to thank the Court of Appeal judges that considered Jodey’s case. We buried Jodey just over six years ago and finally my family and I have the chance of getting justice for Jodey.

“Jodey is never going to be forgotten and her death was not in vain, she’s helping others and her legacy will live on. We have always believed that the DWP wrongly stopping Jodey’s benefits caused her death and the High Court’s refusal caused such disappointment not just for me and my family, but others too who have lost loved ones after DWP mistakes and who continue to fight for accountability from the DWP. This is a victory not just for us but for all those families and others still on the receiving end of awful treatment by the DWP. I hope the DWP learn from their tragic failings.”

Merry Varney, partner at Leigh Day, added:

“Today’s unanimous ruling from the court of appeal means finally Joy and her family have the opportunity for the role of shocking failings by the DWP in the death of much loved Jodey to be publicly investigated, and the Court of Appeal has rightly underlined the importance of this not just to Jodey’s family, but to the wider public.

“Inquests play a vital role in exposing unsafe practices and risks to future lives, and today’s Judgement, rejecting arguments made by the Coroner and overturning the decision of the High Court, makes it abundantly clear that Coroners can and indeed sometimes should be investigating more than the immediate cause of death regardless of whether the right to life is engaged.”

Joy is represented by Jeremy Hyam KC of 1 Crown Office Row and Jesse Nicholls of Matrix Chambers and her case is funded by legal aid.

Timeline

  • In late 2016 the DWP began to reassess Jodey’s entitlement to Employment Support Allowance (ESA). Jodey requested a home visit as she rarely left the house due to her health and she made clear in her reply that she had “suicidal thoughts a lot of the time and could not cope with work or looking for work”.
  • Despite this, the DWP decided that Jodey should attend a work capability assessment in January which Jodey did not attend and on 6 February 2017 the DWP decide to stop the fortnightly ESA payments which Jodey relied on from 17 February.
  • Jodey with the help of her family wrote to the DWP explaining the severity of her health conditions and asking them to reconsider their decision to terminate her ESA, but this did not happen until after her death.
  • Jodey also then received letters to inform her that her housing benefit and council tax benefit would be stopped because they were linked to her ESA.
  • Just three days after her last ESA payment, on the 21 February, Jodey took her own life.
  • On 24 May 2017 an inquest was held into Jodey’s death at Teesside Coroner’s Court.
  • Jodey’s family initially wrote to the Attourney General in January 2020 to seek his permission to apply to the High Court for a second inquest.
  • This was granted and the application to the High Court was submitted in December 2020.
  • In June 2021 the DWP was given permission to have a limited role in making submissions to the court about the second inquest application.
  • In September 2021 the High Court ruled that that the new evidence that had come to light since the first inquest did not require a fresh inquest to be held in the interests of justice.
  • Joy sought permission to appeal that decision on 1 Oct 2021 but this was refused on 11 October 2021
  • An application to the Court of Appeal for permission to appeal was submitted on 2 November 2021 and permission was granted on 5 October 2022
  • On January 31 and February 1 2023 the Court of Appeal heard Joy’s arguments for the appeal.

So: no date for the new inquest – yet. This Site will try to keep you informed.


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Jodey Whiting had an incurable condition. Why did the DWP try to force her into a benefit reassessment?

Death by DWP: Jodey Whiting.

This is a good question – triggered in This Writer’s mind by a reference to a different case.

Please read the following Twitter thread, which was prompted by a tweet referring to the death of DWP benefit claimant Philippa Day:

Yes, why does the DWP force people with incurable or terminal conditions to prove that they still have a lifelong disability or are still dying?

Reading those words, I thought about Jodey Whiting. She had a number of disabilities, including scoliosis which – as far as I can tell – is an incurable condition that requires constant treatment for the length of the sufferer’s life. If untreated, it could be life-threatening.

So it was pointless to demand that she attend a work capability assessment, because it was impossible for her condition to have improved. It could only worsen.

There is an argument that a WCA could take place to ascertain whether a claimant’s payments should increase – but that cannot be used as justification in Ms Whiting’s case because her benefits were stopped.

The DWP’s Green Paper on Disability, released in July this year (2021), acknowledges that it is pointless to keep reassessing people with lifelong and/or terminal conditions and proposes the creation of a Severe Disability Group (SDG). People put in this group would not have to face reassessment.

If the DWP is admitting that it is unreasonable for people with lifelong conditions to face constant reassessment now, then it would also be unreasonable to suggest that they should have faced constant reassessment in February 2017, when Ms Whiting took her own life.

Strangely, this does not seem to have been considered by the High Court when it rejected an appeal for a second inquest into Ms Whiting’s death, last month (October).

I wonder why the court did not consider that the absence of necessity for the assessment that led to Ms Whiting’s benefits being cut was a material consideration in her case.

There’s now a second appeal for another inquest. Perhaps the point could be made this time around?

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Fresh application lodged for second Jodey Whiting inquest. What does the DWP have to hide?

Death by DWP: Jodey Whiting.

A second application has been lodged for permission to appeal against a decision not to allow a second inquest into the death of Jodey Whiting.

Mother Joy Dove has made the application after an earlier attempt was refused by the High Court on October 11.

The High Court had previously found that new evidence that had been discovered since the first inquest did not require a fresh inquest to be held in the interests of justice.

Ms Whiting died in February 2017 after the DWP withdrew her benefits for not attending a Work Capability Assessment.

At the time of the assessment, she was housebound with pneumonia after having been in hospital, and had found out that she had a cyst on the brain.

The permission to appeal application is brought on the grounds the High Court was wrong in that finding, and that it was also wrong to find that Article 2 of the Human Rights Act, the right to life, was not engaged by the circumstances of Ms Whiting’s death.

Ms Dove said:

“It seems to me that there were obvious failings in the way the DWP treated Jodey, which were proved and documented by the Independent Case Examiner, and it is ridiculous that this has not been fully and publicly investigated.

“How can lessons be learned, and future tragedies prevented, if no one examines this properly?”

Merry Varney, of law firm Leigh Day added:

“The possible link between the DWP making repeated errors in the handling of Jodey’s welfare benefits claim shortly before her death, which left her without income, housing benefit and council tax benefit, and her death has never been publicly investigated.

“Having obtained the Attorney-General’s permission to apply to the High Court for a second inquest, it is disappointing the High Court rejected our client’s application on all grounds and we hope the Court of Appeal will allow her the opportunity to overturn this decision.”

Ms Whiting took her own life on February 21, 2017, after being told that her Employment and Support Allowance payments would stop, along with associated Housing Benefit and Council Tax benefit payments, because she had not attended a work capability assessment.

Ms Varney, commenting on the case earlier, had said: “Jodey had requested a home visit for the WCA as she rarely left the house because of her severely poor health. She suffered multiple physical and mental health difficulties, took 23 tablets a day and was entirely dependent on welfare benefits.

“She had made in clear in her request for a home WCA that she had “suicidal thoughts a lot of the time and could not cope with work or looking for work”.

“After Jodey’s death, an inquest was held three months later, 24 May, 2017, which lasted less than an hour. The coroner declined to consider the potential role of the DWP and their acts or omissions in Jodey’s death. Jodey’s family were unrepresented and were unaware that they may have been entitled to publicly funded legal representation.

“After the inquest a report by an Independent Case Examiner concluded that the DWP had made multiple significant errors in how it treated Jodey. Some of the failings had not been known to Jodey’s family, who were horrified to learn how many failings had occurred in the handling of Jodey’s benefits.

“The opinion of an independent Consultant psychiatrist, sought by Jodey’s family, confirmed that the DWP’s failings would probably have had a substantial effect on Jodey’s mental state at the time she took her own life.

“Joy argues that the manner in which Jodey was treated by the DWP, and in particular the withdrawal of her ESA, caused or materially contributed to her death and that, had this not occurred, Jodey’s death would not have occurred when it did.”

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Inquest hears nursing home resident died ‘dehydrated and malnourished’

Inquest: Dorothea Hale.

This not only raises questions about social care in the UK, but also about the deaths of others for whom the authorities have a duty of care.

Dorothea Hale, it is alleged, suffered neglect at a Welsh nursing home where she had been admitted after suffering two strokes that left her entirely paralysed down one side of her body.

In a stay of around four months, she developed dehydration, malnourishment and pressure sores before being transferred to hospital due to fast-declining health, where she died, aged 75.

The inquest is ongoing so we have yet to hear the coroner’s verdict on the cause of her death.

It featured in Operation Jasmine, a police investigation into the neglect of elderly residents at several care homes in south Wales.

That inquiry lasted nearly a decade and cost £11.6 million, with detectives examining 63 deaths potentially caused or abetted by inadequate healthcare treatment.

The suggestion of failures in social care indicate that reform is desperately needed – and has indeed been promised by successive Tory governments for many years, although we have yet to hear a single policy proposal.

Here’s my question:

If 63 deaths in social care can lead to a lengthy – and costly – inquiry, why do 150 deaths in the benefit system not merit the same treatment?

Source: Welsh nursing home resident ‘died after becoming dehydrated and malnourished’ | The Independent

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What will the DWP do if a coroner says this mum died because her benefits were cut?

Inquest: did Philippa Day take her own life in despair after benefit assessment provider Capita cut her benefits and demanded that she attend an assessment centre – which was impossible due to her disability?

We’ve been here before, I think. As I recall, coroners tend to back away from criticising the Department for Work and Pensions when disabled benefit claimants die.

But – again, as I recall – questions have been asked about the validity of such inquests after claims were made that some of the relevant evidence was omitted.

This time, it seems very thorough preparations are being made to prevent this from happening; several pre-inquest reviews have been held to discuss the case of Philippa Day.

The mother, from Mapperley, Nottingham, is believed to have taken her own life after a long struggle to have her benefits restored.

When her Disability Living Allowance was converted to the new Personal Independence Payment in January 2019, the government slashed the amount she received from £228 per week to £60.

The most recent pre-inquest hearing centred on discussions between Ms Day, the DWP and private assessment provider company Capita before her death, and the decisions about her benefits that followed.

It seems Capita had demanded that she must attend an assessment centre in person – an impossibility due to her ill-health.

Ms Day was admitted to hospital in August last year – in a coma, according to her family. She never revived and died in October 2019, aged just 27.

The full inquest is due to take place in January.

Let’s hope it makes more sense than some others we have heard recently.

Source: Coroner to examine death of Mapperley mum who died after her benefits were cut – Nottinghamshire Live

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