Grieving families left to wait as inquests delayed

Coroner Caroline Sumeray called the chief executive of the Isle of Wight NHS Trust, Maggie Oldham, to the Isle of Wight Coroners' Court on Tuesday, and fined the trust £500 for its failings.

The summons followed a 15-page letter Mrs Sumeray sent to Mrs Oldham, documenting her concerns at a string of hold-ups that had led to several inquests being delayed.

Inquests are ideally opened and closed within 14 weeks but many were taking around 20 weeks. Of the 13 inquests listed this week, only around six are likely to go ahead.

Mrs Sumeray told Mrs Oldham: "This is a really unhappy situation and I deeply regret that you attend before me again. It is embarrassing for you.

"I am coming under pressure from the Chief Coroner. He wants to know why my stats are so out.

"It is miserable. There has been a catalogue of woe. I wrote to you with steam coming out of my ears."

Mrs Sumeray said she had been having to issue notices requiring compliance for every inquest, when they should only be used as a last resort.

There was also an ongoing problem with numerous late notice Serious Incident applications.

She said the trust should notify her office within 24 hours of a death, but this wasn't happening. Families had been ringing the office after a few days, to be told there was no record of the deceased.

She also said doctors had sent through"pretty silly" causes of deaths, showing a fundamental lack of knowledge on what condition causes what outcome.

One key criticism was that important documents were coming through too late to be included in the evidence. In some cases, bodies had been cremated and documents only come to light afterwards, when it was too late for further tests on the bodies.

In the case of one drug-related death, documentation was emailed to the Coroner so late, it arrived after the inquest had been heard and it was too late to do anything about it.

Mrs Sumeray told of a widower who phoned the Coroner's office almost daily, trying to establish what is happening and when the inquest will be heard. The office have no update available as they are awaiting paperwork from the trust.

One inquest had to be adjourned this week due to several outstanding pieces of evidence, including the vital statement which pronounces life extinct.

Mrs Oldham said in response: "I am extremely disappointed and frustrated to find myself in this position, that my office is continuing letting your office down.

"I share your frustrations. We have to get a team that's equipped with the relevant skills. Sadly we have not got the right level of skill."

Mrs Oldham offered to spend a day with the Coroner and said she would make some immediate changes.

She also pledged to be personally involved with every Serious Incident case until the matter improved. A new inquest lead person is due to start work at the trust on March 11.

Case study: David Nurse had been a "massive drain on resources" as he had called the ambulance on 200 occasions, many because he wanted them to make him a cup of tea or get him out of his armchair.

One day he told a delivery boy he was going to take a suicide pill, and if that didn't work he would shoot himself.

The boy told his mother who informed the ambulance service the man was suicidal.

Ambulance staff made contact with Mr Nurse but didn't visit him or take any further action, and he was later found dead, having shot himself twice in the head.

Mrs Sumeray said: "The ambulance service had no protocol in place in case of firearms and they hurriedly drafted one."

Case study: A 99-year-old woman was discharged from St Mary's Hospital at 1am in the morning, and taken home in a taxi. She was then re-admitted but the Coroner has not been able to find anything out about her condition, and why she was discharged in that way. She has requested further information and the inquest, which was meant to take place this week, has been adjourned.