If someone you love is killed due to neglect or harm by institutions and you can prove it at the inquest into their death, you should at least be sure that the state will do what it can to prevent that same thing from happening to someone else.
We shouldn’t have to fight for that certainty, but at the moment, the prevention of future deaths is essentially optional – and that puts everyone at risk.
I spent three months of 2022 in court for the inquest into the death of my cousin, Gaia Pope. Gaia was a kind, bright and brave young woman whose struggles with epilepsy and post-traumatic stress inspired her to pursue a career in healthcare. She died aged 19 within two years of reporting to Dorset Police that she had been a victim of child sexual exploitation.
She went missing during an acute mental health episode just as it was getting dark on 7 November, 2017 and was without her coat, wallet, phone or epilepsy medication. The inquest found this was caused by what they called a “situational crisis”: a polite way of saying she wasn’t getting support for her mental health, had suffered ongoing threats and sexual harassment and had been met with continued discrimination and apathy from the police. She was missing for 11 days until her body was found
As soon as Gaia reported what had happened to her, psychiatrists were making notes about her “delusions of sexual assault”. Despite recurrent mental health crises, in those two years, she spent less than two months under the care of community mental health services which she was still trying to access on the day she went missing. She even called for an ambulance that day but not for the first time, none were sent.
Hers was one of the longest individual inquests in British history. It exposed the devastating impact of austerity cuts and a culture of misogyny within the police, social care and NHS services, unearthing over 50 failings as well as police officers who tampered with evidence.
The Independent Office for Police Conduct (IOPC) identified serious failings in the rape investigation and mental health experts said that had Gaia not been traumatised by this, she would probably still be alive. We also uncovered shocking failings in the police investigation into Gaia’s disappearance.
Calls Dorset Police initially denied the existence of revealed that the officer she spoke to – not trained to recognise signs of a mental health crisis – had hung up on her, telling colleagues she was “taking the piss” and playing a hoax. When she went missing shortly afterwards they failed to log her as a missing person or identify her as high risk. The sergeant in charge that night was disciplined for misconduct because he did not take or order any action to search for Gaia that first night when she was lost and dying of hypothermia.
Even so, Dorset coroner Rachael Griffin banned the jury from even considering whether police failings contributed to Gaia’s death, taking eight weeks of evidence off the table.
So ended the investigation we had waited and struggled five years for. With no hope of justice for Gaia, our only comfort was that we had revealed systemic issues which could cause more deaths and acknowledging this, Mrs Griffin wrote to an unprecedented 10 institutions with recommendations for lifesaving change.
These included one to the Royal College of Psychiatrists, for better and more joined-up care for people with complex needs like survivors of sexual violence; and one to the College of Policing for better training on physical and mental health conditions that might affect behaviour or risk – ignorance of which most often contribute to the deaths of Black men in custody.
But what happens to prevention of future death reports? Institutions respond, sometimes with outright refusal to implement the recommendations, like the College of Policing in Gaia’s case; or sometimes saying “this would save lives, but we have no funding for it”, like the Royal College of Psychiatrists. In some cases, bodies claim to have made changes that are hard to monitor, often leaving people with no choice but to take their word for it because no-one is responsible for making sure those claims are legitimate.
The recommendations and responses just sit there online, gathering proverbial dust and piling high as more families are broken forever by the loss of someone who needn’t have died, if only lessons had really been learned last time around. Perhaps if they had been, Gaia would still be here, making the world a better place just by being in it.
The inquest system is broken beyond belief. That is not only a stunning waste of public money, it endangers anyone who might someday need police or care services in the event of illness or injury. So this isn’t a matter of private grief but of public concern.
Even pre-pandemic, government austerity cuts had been linked to at least 130,000 preventable deaths with some estimates as high as 300,000. The vast majority of these were not even investigated. Inquests that did take place found over 700 failings causing over 270 deaths between 2012 and 2017 in healthcare settings alone.
No wonder, then, that there is top-down ambivalence about calls for a National Oversight Mechanism – an independent public body which would be answerable only to parliament, ensure inquest recommendations are implemented, have powers to sanction institutions that refuse them without good reason and raise the alarm of systemic and recurrent threats to life while involving bereaved survivors.
We shouldn’t need the No More Deaths campaign to fight for that certainty, but then again, public awareness of how many people are dying and why would cause a political crisis for this Government overnight. So justice must come the only way it ever has: not from lawyers and politicians but from the demands of ordinary people.
The law may be complex but the truth is simple. As long as inquests give only the illusion of accountability, the state saves face and it is people like Gaia who pay with their lives.
The prevention of future deaths should not be optional, it should be legally enforceable and the National Oversight Mechanism is a vital step towards this, towards a time when preventable killings can no longer be swept under the carpet and at last, “lessons will be learned” becomes a practice, not a platitude.
Marienna Pope-Weidemann is a writer, journalist and social justice advocate. She led the grassroots Justice For Gaia campaign and her upcoming book, The State of Britain is Killing Us (Trapeze, an imprint of Orion Books) is out in 2025
