My daughter Jess was 27 and worked as a civil engineer for the environment agency. She died by suicide in Link House a crisis house in Bristol on 16th October 2020.
Jess was unwell with depression and had been referred by her GP to the care of the community MH team. Over about six months her mental health declined steeply with severe depression and increasing suicidal ideation. The community mental health team were aware of this, and while believing she did not need hospital admission, they acknowledged that they were unable to help her adequately at home. They suggested a referral into a local crisis house (commissioned by the then PCT and therefore funded by the NHS) and which was part of the mental health pathway for the Bristol area. This sort of crisis accommodation is outside of CQC regulation and there are no minimum standards for staff training or for the fabric of the premises.
We were totally unaware of her admission (we live in London). Jess hid her illness from us because she was ashamed of it, and wished to protect us, her family, from worry. She last came home to visit two weeks before her admission but told us nothing about the plan. Five days after entering Link House Jess took her own life. She had made disclosures to the crisis house staff (who are not MH professionals) in the days leading to her death. She described her increasingly alarming and vivid thoughts of suicide and the method she planned to use to end her life. The staff did not seek to remove the means of her suicide; they did not keep her in sight where she would be safe, and they failed to escalate her obvious decline to the mental health team who had referred her into the crisis house. Avon and Wiltshire Partnership, the Trust, had failed to prepare a safety plan for Jess when she was admitted to Link House. There was no clinical oversight while she was at Link House and no documented route for escalation of clinical safety concerns in the event her health deteriorated further while she was there.
The Trust investigation into her death took almost a year.
The inquest was held almost two years after her death.
The coroner did not engage Article 2 at the inquest into her death as it had happened outside a formal hospital environment. This meant we were not entitled to funded legal representation at the inquest, which was eventually scheduled for two weeks in Bristol at the end of June 2022. Amid the bewilderment and devastation of our loss, we found ourselves having to navigate a lengthy legal process we knew nothing about.
We didn’t know we would need legal help to prepare for the inquest and a barrister to represent us at the hearings. Even if we had known this, we would have had no idea how to find that help. A chance enquiry to the organisation INQUEST opened a door for us. We were assigned a case worker who introduced us to a solicitor and a barrister from the INQUEST lawyers’ group who had previously worked on cases like Jess’s.
We were entitled to limited legal help funding to prepare for the inquest but, in the absence of Article 2 the right to life being engaged, not to funded representation at the Pre Inquest Review Hearings or at the inquest itself.
The mental health trust, the crisis house, the police and the ambulance service all had state funded legal teams at the Pre Inquest Review Hearings and at the inquest. I remember being absolutely horrified by the numerous lawyers who all seemed intent on trying to persuade the coroner to limit the scope of the inquest, and to encourage him not to engage Article 2. We felt outnumbered, overwhelmed and helpless at the tide of defensiveness, the disinterest both in our loss and in the failures in the system that had allowed Jess’s death to happen.
The months went on.
There was a drip, drip of disclosure of documents.
Dates were set for the inquest, which at the last minute were changed to short Pre Inquest Review Hearings for legal argument. We booked accommodation in Bristol which we had to cancel at short notice on several occasions. The legal aid funding of legal representation had been turned down early in the process. However, it was later approved following legal submissions on the grounds that Article 2 was ‘arguably engaged’. At the final Pre Inquest Review Hearing , A2 was definitively refused by the coroner. At this point it seemed our access to legal aid would be lost, and we would need to find many thousands of pounds (we were told £5-10K) for representation at the two-week inquest (that was on top of our accommodation and other costs). Our legal team made a late submission to the Legal Aid Agency on the grounds that - despite the coroners final ruling – Article 2 could still be said to ‘arguably’ apply. In their opinion the inquest was Article 2 ‘in all but name’. We didn’t understand the legal argument, to us the system appeared opaque and subjective. However, the upshot was that shortly before the inquest, and despite the coroner’s ruling, we were definitively granted legal aid. The arguments put forward by our solicitor and barrister had been successful. They were delighted and seemed genuinely surprised. We were confused and bemused by the whole process, but we were extraordinarily grateful. We realise now that we were extremely fortunate to be granted this funded legal aid in the absence of an Article 2 inquest. It was a lottery. Most families in our situation would not have received legal aid.
Our barrister had represented us pro bono at the early Pre Inquest Review Hearing. This included hours of reading disclosure documentation, formulating legal argument, and even paying her own travel expenses, because she believed we had the right to be represented. Other families would not necessarily have found such dedicated lawyers.
I agree with her, we should have had the same automatic right to skilled legal representation as all the other organisations involved.
The energy of our lawyers would have been better spent preparing our questions and concerns around the death of our daughter for the coroner, and exploring what went wrong, so as to avoid future similar tragedies, rather than in chasing funds which were automatically being granted to the organisations that let Jess and us down so badly.
Adele Zeynep Walton is an online safety campaigner, journalist and member of Bereaved Families for Online Safety and Families and Survivors to Prevent Online Suicide Harms. Adele’s sister Aimee died in 2022 after visiting a forum that promotes and encourages suicide.
Firstly, thank you to Inquest for inviting me to speak and for the incredible work you do to advocate for bereaved families. I’m here as a sister, as in 2022 I lost my incredible sister Aimee when she was 21.
After the pandemic, Aimee was struggling with her mental health, she failed by mental health services and not safeguarded by university or police, despite us constantly raising our concerns that Aimee was a suicide risk and needed safeguarding.
In the police investigation that followed, we found out that Aimee had been on a forum that promotes and encourages suicide, and an American man flew to the UK to be in the hotel room when she died. She bought the poison from a Canadian supplier who is responsible for at least 90 UK deaths.
Research by MRF has revealed the website run by two American men, has so far taken at least 133 UK lives. Despite this, there has been no change to poisons act or ambulances equipping antidote. I’m telling you all of this, to give you an insight into the multiple intersecting systematic failures that exist in my sister’s case, as we believe these factors all need to be looked into in order to prevent this from happening to anyone else. These are things we believed an inquest would look into.
My family is yet to have our inquest, but we’ve been through the process of having to seek and apply for legal aid, and I cannot put into words how stressful and painful that process has been. We’ve had to battle to get legal aid for our inquest, to have our coroner acknowledge our concerns about systematic failings, which has led to a need for judicial review.
When invited to speak today, I also asked other bereaved families I’m connected to, to share their thoughts on why legal aid is so important.
David Parfett, father of Tom, told me “no family should be expected to engage in a coronial inquest without legal support paid for by legal aid. The process is unfit for a family who aren’t represented by an expert solicitor and barrister.”
Pete Aitken, father of Hannah said “legal representation at inquests is vital for bereaved families, particularly in the case of suicides where there are wider issues that are relevant and need proper investigation. Without legal aid, our families and more importantly the loved ones we have lost would be denied justice.”
Allison, mother of teenager Lucas, had a gruelling experience of the inquest process. She was told she didn’t qualify for legal aid, and with no experience of the justice system didn’t realise why she might need it. With the savings she had put aside for Lucas to go to university with, she hired a barrister, represented herself, but got nothing, and feels things would have been totally different had she had legal aid.
I also asked my mum to share her reflections with me on our experience, this was what she told me. “Have you ever had a dream in which you couldn't speak? You were talking, shouting, even screaming but no noise was coming out. I imagine this is how not having legal representation must feel like. You are voiceless, you are unheard, you are unseen. How can someone with no legal training, at the most traumatic time of their life, be able to represent themselves in a daunting process such as an inquest. To expect such a thing would be like asking a patient with complex health issues to find a cure for their illness.
Thankfully, we were very lucky to be recommended an excellent law firm who assisted us with applying for legal aid. İnitially, our application was refused. We would have given up at this stage but thanks to our legal team's determination and expertise, we were granted legal aid following our appeal.
But for far too many, this isn’t the case. Many of the bereaved families I know are going through the painstaking process of waiting for their legal aid applications to be approved or denied, and fighting to challenge those decisions, something my family also had to do and would not have been able to without our legal team.
We’ve met families who’ve had to represent themselves, resulting in inquests where they felt humiliated and alienated by the entire process. In the meantime, public bodies, be it schools, mental health services, social media, companies social services, police departments, have evaded accountability, and instead gone through the inquest process as an exercise of self-defence, ignoring families concerns and denying their involvement in a person’s loss. Too many families experience inquests only further exacerbate the trauma we’ve already been through.
I know that if families felt represented and heard within the inquest process, we would not have to spend our grief campaigning and going public with our most traumatic battles to get justice.
A bereaved family, no matter how willing and capable they might be, would not be able to do what a legal team could do for justice for their loved one. A decent inquest should be a right that all families can access. It should not be a postcode lottery left up to the whims of individual coroners.
This expansion will mean that bereaved families are empowered and have a chance of justice for their loved ones. And that's just the start. We, as bereaved families, have many more fights to fight, not for ourselves, not for our loved ones who are long gone but for the future of our children and our young people so the decision to grant legal aid is welcomed. İ am sorry for those who had been unfairly treated by the system and had to go through the legal processes without it.
Our sole goal, and I would argue the goal of inquests and their recommendations, is to prevent future deaths. Legal aid for families is what makes that a tangible reality, and it’s vital that the expansion of legal aid under the Hillsborough Law is made swiftly, so that no family has to go through the turmoil of being excluded from a system that is meant to serve the purpose of getting answers and accountability.
Without Leigh Day’s representation that legal aid allowed, we would have probably already had an inquest, probably that lasted a day. We would be totally in the dark, navigating a system that is equal parts intimidating, emotionally intense and laborious.
We sadly had a coroner who was dismissive - the only way we could challenge that was by threatening judicial review, which was not funded by our legal aid. Thankfully our firm were able to do this work, but this isn’t something all firms can do, which leaves families without any redress to get justice. Ensuring that this legal work is also able to be funded with legal aid is just as vital.
The difference that legal aid made for my family cannot be put into words. Leigh Day have been an immeasurable source of support and strength throughout the hardest thing we’ve ever experienced as a family. This is a right that every bereaved family deserves to access, and I believe this expansion will be life changing for those affected by injustice.
Thank you.
Moira Durdy and Adele Zeynep Walton speeches
Moira Durdy is the mother of Jess Durdy who died in 2020 following failures of the mental health services caring for her. Jess was 27 and worked as a civil engineer for the environment agency. She died by suicide in Link House, an NHS funded crisis house in Bristol, on 16 October 2020.
My daughter Jess was 27 and worked as a civil engineer for the environment agency. She died by suicide in Link House a crisis house in Bristol on 16th October 2020.
Jess was unwell with depression and had been referred by her GP to the care of the community MH team. Over about six months her mental health declined steeply with severe depression and increasing suicidal ideation. The community mental health team were aware of this, and while believing she did not need hospital admission, they acknowledged that they were unable to help her adequately at home. They suggested a referral into a local crisis house (commissioned by the then PCT and therefore funded by the NHS) and which was part of the mental health pathway for the Bristol area. This sort of crisis accommodation is outside of CQC regulation and there are no minimum standards for staff training or for the fabric of the premises.
We were totally unaware of her admission (we live in London). Jess hid her illness from us because she was ashamed of it, and wished to protect us, her family, from worry. She last came home to visit two weeks before her admission but told us nothing about the plan. Five days after entering Link House Jess took her own life. She had made disclosures to the crisis house staff (who are not MH professionals) in the days leading to her death. She described her increasingly alarming and vivid thoughts of suicide and the method she planned to use to end her life. The staff did not seek to remove the means of her suicide; they did not keep her in sight where she would be safe, and they failed to escalate her obvious decline to the mental health team who had referred her into the crisis house. Avon and Wiltshire Partnership, the Trust, had failed to prepare a safety plan for Jess when she was admitted to Link House. There was no clinical oversight while she was at Link House and no documented route for escalation of clinical safety concerns in the event her health deteriorated further while she was there.
The Trust investigation into her death took almost a year.
The inquest was held almost two years after her death.
The coroner did not engage Article 2 at the inquest into her death as it had happened outside a formal hospital environment. This meant we were not entitled to funded legal representation at the inquest, which was eventually scheduled for two weeks in Bristol at the end of June 2022. Amid the bewilderment and devastation of our loss, we found ourselves having to navigate a lengthy legal process we knew nothing about.
We didn’t know we would need legal help to prepare for the inquest and a barrister to represent us at the hearings. Even if we had known this, we would have had no idea how to find that help. A chance enquiry to the organisation INQUEST opened a door for us. We were assigned a case worker who introduced us to a solicitor and a barrister from the INQUEST lawyers’ group who had previously worked on cases like Jess’s.
We were entitled to limited legal help funding to prepare for the inquest but, in the absence of Article 2 the right to life being engaged, not to funded representation at the Pre Inquest Review Hearings or at the inquest itself.
The mental health trust, the crisis house, the police and the ambulance service all had state funded legal teams at the Pre Inquest Review Hearings and at the inquest. I remember being absolutely horrified by the numerous lawyers who all seemed intent on trying to persuade the coroner to limit the scope of the inquest, and to encourage him not to engage Article 2. We felt outnumbered, overwhelmed and helpless at the tide of defensiveness, the disinterest both in our loss and in the failures in the system that had allowed Jess’s death to happen.
The months went on.
There was a drip, drip of disclosure of documents.
Dates were set for the inquest, which at the last minute were changed to short Pre Inquest Review Hearings for legal argument. We booked accommodation in Bristol which we had to cancel at short notice on several occasions. The legal aid funding of legal representation had been turned down early in the process. However, it was later approved following legal submissions on the grounds that Article 2 was ‘arguably engaged’. At the final Pre Inquest Review Hearing , A2 was definitively refused by the coroner. At this point it seemed our access to legal aid would be lost, and we would need to find many thousands of pounds (we were told £5-10K) for representation at the two-week inquest (that was on top of our accommodation and other costs). Our legal team made a late submission to the Legal Aid Agency on the grounds that - despite the coroners final ruling – Article 2 could still be said to ‘arguably’ apply. In their opinion the inquest was Article 2 ‘in all but name’. We didn’t understand the legal argument, to us the system appeared opaque and subjective. However, the upshot was that shortly before the inquest, and despite the coroner’s ruling, we were definitively granted legal aid. The arguments put forward by our solicitor and barrister had been successful. They were delighted and seemed genuinely surprised. We were confused and bemused by the whole process, but we were extraordinarily grateful. We realise now that we were extremely fortunate to be granted this funded legal aid in the absence of an Article 2 inquest. It was a lottery. Most families in our situation would not have received legal aid.
Our barrister had represented us pro bono at the early Pre Inquest Review Hearing. This included hours of reading disclosure documentation, formulating legal argument, and even paying her own travel expenses, because she believed we had the right to be represented. Other families would not necessarily have found such dedicated lawyers.
I agree with her, we should have had the same automatic right to skilled legal representation as all the other organisations involved.
The energy of our lawyers would have been better spent preparing our questions and concerns around the death of our daughter for the coroner, and exploring what went wrong, so as to avoid future similar tragedies, rather than in chasing funds which were automatically being granted to the organisations that let Jess and us down so badly.
Adele Zeynep Walton is an online safety campaigner, journalist and member of Bereaved Families for Online Safety and Families and Survivors to Prevent Online Suicide Harms. Adele’s sister Aimee died in 2022 after visiting a forum that promotes and encourages suicide.
Firstly, thank you to Inquest for inviting me to speak and for the incredible work you do to advocate for bereaved families. I’m here as a sister, as in 2022 I lost my incredible sister Aimee when she was 21.
After the pandemic, Aimee was struggling with her mental health, she failed by mental health services and not safeguarded by university or police, despite us constantly raising our concerns that Aimee was a suicide risk and needed safeguarding.
In the police investigation that followed, we found out that Aimee had been on a forum that promotes and encourages suicide, and an American man flew to the UK to be in the hotel room when she died. She bought the poison from a Canadian supplier who is responsible for at least 90 UK deaths.
Research by MRF has revealed the website run by two American men, has so far taken at least 133 UK lives. Despite this, there has been no change to poisons act or ambulances equipping antidote. I’m telling you all of this, to give you an insight into the multiple intersecting systematic failures that exist in my sister’s case, as we believe these factors all need to be looked into in order to prevent this from happening to anyone else. These are things we believed an inquest would look into.
My family is yet to have our inquest, but we’ve been through the process of having to seek and apply for legal aid, and I cannot put into words how stressful and painful that process has been. We’ve had to battle to get legal aid for our inquest, to have our coroner acknowledge our concerns about systematic failings, which has led to a need for judicial review.
When invited to speak today, I also asked other bereaved families I’m connected to, to share their thoughts on why legal aid is so important.
David Parfett, father of Tom, told me “no family should be expected to engage in a coronial inquest without legal support paid for by legal aid. The process is unfit for a family who aren’t represented by an expert solicitor and barrister.”
Pete Aitken, father of Hannah said “legal representation at inquests is vital for bereaved families, particularly in the case of suicides where there are wider issues that are relevant and need proper investigation. Without legal aid, our families and more importantly the loved ones we have lost would be denied justice.”
Allison, mother of teenager Lucas, had a gruelling experience of the inquest process. She was told she didn’t qualify for legal aid, and with no experience of the justice system didn’t realise why she might need it. With the savings she had put aside for Lucas to go to university with, she hired a barrister, represented herself, but got nothing, and feels things would have been totally different had she had legal aid.
I also asked my mum to share her reflections with me on our experience, this was what she told me. “Have you ever had a dream in which you couldn't speak? You were talking, shouting, even screaming but no noise was coming out. I imagine this is how not having legal representation must feel like. You are voiceless, you are unheard, you are unseen. How can someone with no legal training, at the most traumatic time of their life, be able to represent themselves in a daunting process such as an inquest. To expect such a thing would be like asking a patient with complex health issues to find a cure for their illness.
Thankfully, we were very lucky to be recommended an excellent law firm who assisted us with applying for legal aid. İnitially, our application was refused. We would have given up at this stage but thanks to our legal team's determination and expertise, we were granted legal aid following our appeal.
But for far too many, this isn’t the case. Many of the bereaved families I know are going through the painstaking process of waiting for their legal aid applications to be approved or denied, and fighting to challenge those decisions, something my family also had to do and would not have been able to without our legal team.
We’ve met families who’ve had to represent themselves, resulting in inquests where they felt humiliated and alienated by the entire process. In the meantime, public bodies, be it schools, mental health services, social media, companies social services, police departments, have evaded accountability, and instead gone through the inquest process as an exercise of self-defence, ignoring families concerns and denying their involvement in a person’s loss. Too many families experience inquests only further exacerbate the trauma we’ve already been through.
I know that if families felt represented and heard within the inquest process, we would not have to spend our grief campaigning and going public with our most traumatic battles to get justice.
A bereaved family, no matter how willing and capable they might be, would not be able to do what a legal team could do for justice for their loved one. A decent inquest should be a right that all families can access. It should not be a postcode lottery left up to the whims of individual coroners.
This expansion will mean that bereaved families are empowered and have a chance of justice for their loved ones. And that's just the start. We, as bereaved families, have many more fights to fight, not for ourselves, not for our loved ones who are long gone but for the future of our children and our young people so the decision to grant legal aid is welcomed. İ am sorry for those who had been unfairly treated by the system and had to go through the legal processes without it.
Our sole goal, and I would argue the goal of inquests and their recommendations, is to prevent future deaths. Legal aid for families is what makes that a tangible reality, and it’s vital that the expansion of legal aid under the Hillsborough Law is made swiftly, so that no family has to go through the turmoil of being excluded from a system that is meant to serve the purpose of getting answers and accountability.
Without Leigh Day’s representation that legal aid allowed, we would have probably already had an inquest, probably that lasted a day. We would be totally in the dark, navigating a system that is equal parts intimidating, emotionally intense and laborious.
We sadly had a coroner who was dismissive - the only way we could challenge that was by threatening judicial review, which was not funded by our legal aid. Thankfully our firm were able to do this work, but this isn’t something all firms can do, which leaves families without any redress to get justice. Ensuring that this legal work is also able to be funded with legal aid is just as vital.
The difference that legal aid made for my family cannot be put into words. Leigh Day have been an immeasurable source of support and strength throughout the hardest thing we’ve ever experienced as a family. This is a right that every bereaved family deserves to access, and I believe this expansion will be life changing for those affected by injustice.
Thank you.
Make a Donation
Every year, INQUEST supports hundreds of families bereaved by deaths involving the state. We are independent of government and entirely reliant on grants and donations to continue our vital work.
Support us and bereaved families in the fight for truth, justice and accountability by becoming a regular donor today.
Donate now
Subscribe to our newsletter
To receive the latest news from INQUEST straight into you inbox please subscribe. For examples of what you will receive, see our previous newsletters.