The 'postcode lottery' with inquests causes me incredible distress each and every day. So so so many people thought that once we had Jasmine's inquest verdict, that was it, and that quite clearly her death had been sad and unfortunate, but there had not been any wrongdoing. This is simply not true. I think the inquest failed to uncover the truth, and I will tell you how that happened.
It drives me insane! Jasmines care occured over 4 and a half weeks, she was seen by a vast number of people and different specialities. My barrister made it clear to the coroner that Jasmines inquest needed to be an 'in depth' thorough investigation in order to determine the true facts. He told her an 8 day inquest was required, he listed 21 relevant witnesses, and he said she would need to be advised by 'independent' neurologists and radiologists.
The coroner replied and said 'no'! We had a one day inquest, only 8 witnesses, and NO INDEPENDENT OPINION! Therefore the coroner asked the actual doctors involved in Jasmines appalling care what their thoughts were, and these were not thoroughly cross examined or questioned in any way, as there were no independent experts there to provide alternative opinion! On many occasions she even told my barrister to cease with his current line of questioning (It was clear she wanted to get through all the witnesses and wrap it up in one day)
My legal team had reassured me that despite the coroners reluctance to hold a sufficient enquiry, on the day it would become obvious there was no way the inquiry could be sufficiently held in one day. I don't think they were expecting her to cut off lines of questioning or rush through in the manner she did either.
We ended up with a verdict where EVERYONE in the room, My family and friends, legal teams, and press, were SHOCKED that the failures discussed throughout the day were not mentioned in the summing up, and the narrative verdict completely 'missed the point'.
Quite simply, the true facts of Jasmines case could NEVER have been ascertained in a 1 day inquiry, with very few witnesses and no independent opinion.
I have attended another inquest which would have also failed to identify the severity of the situation had the barrister not been given the freedom to ask whatever questions he wanted and an independent expert not stood up and totally disagreed with the evidence of the clinicians responsible for the care at the end.
So this is what I mean by postcode lottery. It depends which coroner you get, and then it depends what they feel like doing. There are no rules!
Oh, and reasons why the coroner might have been in such a rush? Could it have anything to do with the fact our actual coroner, who had been working on the case for a year, had to resign from his job because he had employed his wife as a deputy coroner without her having the adequate qualifications? So therefore her caseload had doubled as she had her own work to get on with, and now had to 'get through' all of his cases too? So she had inherited Jasmines case very late in the day anyway, and she had a lot of work to plough through.. Did she give it the time and attention my little girl deserved? I for one say MOST CERTAINLY NOT!
It all makes me sick.
