London Eye: Accountability

A second London trust has been rapped by a coroner for having its staff present evidence in court that was “not credible”.

The inner north west London coroner Fiona Wilcox said Central and North West London Foundation Trust’s engagement with the inquest into the death of one of its patients was so poor it amounted to “a failure of the duty of candour”. A breach of the duty of candour can prompt Care Quality Commission intervention or, with fatalities, criminal prosecution.

Roberto Bettello was 44 when he died in 2020. The court found confusion between the police and the trust’s Hillingdon team may have caused or contributed to his death, with the court concluding the Hillingdon team breached trust protocol multiple times.

Professor Wilcox wrote in her prevention of future deaths report: “The court had experienced immense difficulty in getting evidence from CNWL in relation to the Hillingdon issues despite repeated requests, such that the evidence was not clarified until the last day of evidence and after further directions had been give live in court.”

The judgment added: “It was clear to the court and jury that the evidence of [CNWL Hillingdon] witnesses was at times not credible despite recordings of the calls they made and transcripts of these calls being used as part of the evidence.”

This is the second time in a year a coroner has questioned the truthfulness of staff testimony from a London mental health trust.

In May a coroner at the other end of the city issued about as damning a verdict as you can get in the case of a man who died of neglect under the care of North East London FT.

Graeme Irvine is quoted in the Barking and Dagenham Post as saying: “I think witnesses who have given evidence to me in this inquest have not told the truth.

“It seems to me that this remarked upon a culture of impunity and that, unless someone sees there are consequences to their actions, nothing is going to change.”

He also said he had “no faith” in the observations documents presented to the court and noted they appeared to have been cut and pasted. “Two trust witnesses declined to answer questions put to them regarding whether their observation records were truthful”, he wrote.

Asked about the coroner’s criticism in the Bettello proceedings, a CNWL spokesperson said: “We are very sorry for any mistakes that were made and opportunities missed whilst he was under NHS care. We are reviewing the findings of the coroner’s report and will respond formally in due course.”

Let’s see whether this formal response addresses the specific criticism of its staff’s credibility in court proceedings.

Being called to give evidence to a coroner is one of the scariest things that can happen to staff.

Inquests exist to determine the cause of death in cases where there is some doubt and are an important way to warn professionals and the wider public about safety issues.

But to the staff giving evidence in the case of someone who has died under their care the case can feel like you, the clinician, are on trial.

As with so much, mental health trusts bear the brunt of this. Because of the high volume of suicides they deal with, their staff give evidence in a disproportionate number of inquests.

And there often is a case to answer. Mental health trusts can’t cope with demand at the moment so terrible things can happen.

What might be new is trusts simply not cooperating with the inquest process.

University College London Hospitals FT also came in for criticism recently about its conduct at an inquest.

In evidence given to the House of Commons Dorit Young, a member of the House of Lords, said the trust had only presented specialist evidence to the inquest into the death of her daughter Gaia a day before proceedings.

Lady Young said this was disrespectful and that the statement “did not contain any differential diagnosis of Gaia’s illness.

“There was no neurologist in court. There was no independent clinician in court. The witness from the trust ‘best able to assist [the court]’ was unable to answer many of my questions.”

UCLH has now commissioned reports from a range of specialists after Lady Young contacted the Attorney General.

She wrote: “My experience of the inquest was unsatisfactory. It was uninformed and uninformative: a waste of time and money. The provision by the trust of an important (neurologist) statement less that one working day before the inquest hearing was unacceptable. It showed disrespect for the court, for Gaia, and for her relatives.

“There was insufficient inquiry. The evidence before the court was not capable of addressing the issue of how Gaia died. Such evidence was always available to the trust but was not provided to the court by the trust. The court’s inquiry was based mainly on the trust’s evidence, particularly its superficial, unsatisfactory investigation report.”

Prosecution

NELFT also faces prosecution in the spring over another death, this one from 2015.

A band seven ward manager and the trust itself are due to enter pleas to manslaughter charges in May.

The trust faces a charge of corporate manslaughter and the manager one of gross negligence manslaughter – prosecutions for this are very rare in the NHS.

Legal director at Kingsley Napley Sophie Wood wrote last year that for the corporate charge to be proved “the prosecution must provide evidence, so that the jury is sure, that the way in which an organisation managed or organised its activities not only caused an individual’s death but also amounted to a gross breach of a duty of care owed to that individual (and the way in which senior management organised/managed its activities was a substantial element of that breach)…

“‘Senior management’ is defined as people who play a significant role in making decisions about how all or a substantial part of the activities are to be managed or organised.”