Treated with callous disrespect: A bereaved mother’s tale of institutional apathy from the Coroner Service

Summary

A story of a bereaved mother’s experience with the Coroner's Service in the aftermath of her previously well 25-year-old daughter Gaia’s unexpected and unexplained death and why she set up TruthForGaia.com in her search for the truth. 

This case demonstrates systemic failings in the Coroner Service: the dismissive way that bereaved family members are treated through the inquest process and a lack of clinical curiosity to determine the primary cause of death. 

This inconclusive inquest prompts wider questions about who speaks up for the dead. Just as we have Martha’s rule in life, should there be a Gaia’s rule in death to help families be heard about failed inquests?

Gaia’s death and failed inquest are chilling reminders that this could happen to any one of us and our families.

Content

It was a beautiful sunny summer’s day. Twenty-five year old Gaia Young had been out for a gentle bike ride to do some shopping, came home and had an ice cream in the garden in north London that afternoon. Just hours later she was dead . 

Gaia, the only daughter of Dorit Young, died of an unexplained brain condition after an emergency admission to a London teaching hospital on a Saturday night in July 2021. 

I spoke to her mother Dorit about what happened and how she has had to embark on her own search for the truth. Dorit said:

“Although her death sent shockwaves through the hospital, it remains unexplained despite hospital investigations and an inconclusive Coroner’s inquest.

“I have had to do my own investigation. I set up TruthForGaia.com for medical crowdsourcing and in the hope it may contribute to wider learnings."

The inquest was held in February 2022, six months after Gaia died. Dorit said:

 “I was treated with callous disrespect through the inquest process.

“I was in no way treated in line with the stated goal of 'placing bereaved families at the heart of the Coroner Service' [1]. My experience was the very opposite – it has added to the pain of my grief.

“What I experienced should not be allowed to happen to any bereaved family. There were a series of failings which show the Coroner Service for Inner North London is not fit for purpose.”

Dorit added: 

“I rightfully published my daughter’s medical records and coronial documents on my website despite heavy resistance by the hospital Trust and the Coroner."

The Times reported that the inquest was "uninformed and uninformative".[2]

 Dorit told me the facts of what happened:

• The court hearing lasted less than a day. She believes this is insufficient for the unexpected and unexplained death of a healthy 25-year-old woman in hospital with a brain condition.
• The inquest was about complex medical issues which she found emotionally draining. She gladly accepted the 10 minute break for lunch the coroner offered! 
• Her questions to the Coroner's court in advance of the hearing were proportionate and relevant to finding out the cause of her daughter's death.
• She asked in advance of the hearing about a differential diagnosis of metabolic encephalopathy (brain condition), but her submission[3] was disregarded. There was also striking lack of curiosity by the hospital  – the Trust includes the UK's leading neurology hospital – in the investigation of how Gaia died. 
• There were no independent experts giving evidence other than the two pathologists; there were no independent clinicians to give evidence on the care provided. The hospital was permitted to investigate itself in an independent judicial process; there was no external scrutiny. The coroner and the hospital opposed her request for a neurologist and other experts to attend. See her submission.[3]
• Dorit’s questions at the inquest about fundoscopy and Gaia’s brain “coning” (being squeezed down) due to raised intracranial pressure (high pressure inside the skull) could not be answered properly because the witness chosen by the hospital was an Accident & Emergency (A&E) consultant, so not best able to answer her neurological questions. 
• At the inquest itself, Dorit says the Coroner shut her down when she tried to ask questions. She felt she was shown little empathy and was stopped from telling her side of Gaia’s story.
• Dorit said the Coroner did not allow her to read out her personal statement. You can read for yourself how this happened in pages 31 –34 of the Coroner’s transcript.[4]

If anyone reading this article knows a bereaved family who has had a poor experience with the Coroner Service, let them know they can share their story with the public inquiry into The Coroner Service: The Follow-Up. The window is open until 15 January and submissions will be published on the government website.  

Dorit has made her submission to the government inquiry and you can read it in full on her campaign website.[5]

References

1. UK Parliament. Justice Committee launches new inquiry into the Coroner Service to examine progress; 20 November 2023.
2. Catherine Baksi and Jonathan Ames. Mother may win new hearing into headache death. The Times; 16 October 2023.
3. Dorit’s investigation – memorandum submission January 2023.
4. Approved transcript of Coroners Inquest 14 February 2022.
5. House of Commons. Justice Committee inquiry. The Coroner Service: follow-up Submission of Dorit.

About the Author

Dr Annabel Bentley originally trained as an NHS surgeon. She’s worked as a chief medical officer and a medical director across a range of healthcare organisations for over 30 years, spanning London teaching hospitals, large medical insurers and diagnostics providers and health tech start ups.

She’s provided evidence to the government’s Paterson Inquiry 2020 and was a member of the Department of Health’s Expert Working Group for the Information Standard, the first certification scheme for high quality health content.

She has been a Responsible Officer for seven years; established and chaired clinical risk committees. Her interests include evidence-based healthcare and patient safety. She is an independent healthcare consultant and charity trustee.