But that would be a lie

Perhaps if we turn a blind eye to the gaps in our system the Suicide epidemic will just go away, right?- the words written on the faces of the Senior Coroner and her Officer.

This article is not about the death of Martin Gallier or the missed opportunities to save his life, of which there were many.

This piece will focus on the series of events that followed and the way in which they affected our vulnerable, grieving family whilst doing nothing to prevent future deaths.

February 8th 2017,  00:25, Bristol Temple Mead Hospital

Our already little family’s lives changed forever as our fathers body shut down one organ at a time in front of us. His fingernails muddy, his neck marked and his brain activity minimal.

A terrible car accident or terminal illness hadn’t put Dad in this intensive care bed where machines were breathing for him, his demons had.

Dad had hanged himself at a local canal 12 hours prior and the strong man who once upon a time danced with us stood on his feet and belted out terrible 80’s music at the top of his lungs was now weak, frail, and ultimately gone.

February 8th, 00:26, Bristol Temple Mead Hospital


July 6th 2017, 08:30,  Somewhere between Merseyside and Gloucestershire on a busy train

I opened up the inquest search page on the government website, the same website that I had been obsessively refreshing since Dad’s death. There it was, a verdict (correctly and more widely known as a conclusion).

The words hit me in the face like a ten tonne truck “DRUG/ALCOHOL RELATED”“Why is there a verdict, we haven’t had the hearing yet” I questioned over and over in my busy little head.

“How can such a false conclusion be recorded on a public forum prior to the investigation taking place? Surely this is a mistake?” questions flooded my mind and I was no longer the calm, well put together young lady who wanted to make her father proud at the hearing, I wanted answers.

July 6th 2017, 10:30, Gloucestershire Coroner’s Court

My teenage sisters and I arrive at the Coroners Court, blissfully unaware of the injustices that lay ahead. We were seated in a small family room, the harsh lights stinging our tear filled eyes.

Little did I know that this would be the last time I would be able to cry for 7 long months. A tall man in his early sixties walked in, dominating the room.

He was the Coroner’s officer in charge of Dad’s inquest. I advised him that my siblings and I had not received a copy of the file and questioned the presence of a conclusion on the website.

His face registered his instinctive dislike of being questioned like this, he couldn’t bear me…He assured me that the verdict/conclusion was a mistake and nothing had been decided as yet.

I didn’t believe this ex police officer who towered over me, nor did I trust him.

July 6th 2017, 10:50, Gloucestershire Coroner’s Court

We were ushered into the court room, a space that would become a second home to us over the coming months.
As the eldest and our family’s representative I sat on the front bench, directly in front of the Coroners Officer who, I felt, disliked my sheer presence. 

A seat that may as well have had my name written on it, my bottom would grace this chair repeatedly over the coming months.

The file of evidence was sparse and prepared without care which made me question how much of a picture these “professionals” had of Dad’s final movements and quite frankly, how much they actually cared.

After all, an inquest is a fact finding mission to answer four questions and four questions only; who died, when they died, where they died, and how they died.

The next 30 minutes were a blur of legal jargon and clinical accounts of Dad’s death.

July 6th 2017, 11:20, Gloucestershire Coroner’s Court

There they were again, those words, “DRUG/ALCOHOL RELATED” they echoed in the sound of silence.

The following minute felt like a lifetime as the Senior Coroner explained her decision to conclude Dad’s death as alcohol related despite his alcohol levels being only 338 milligrams per 100 millilitres, a figure that’s low for a seasoned alcoholic like Dad.

“How is this happening, Dad ultimately died of a Hypoxic Brain Injury caused by the starvation of oxygen to the brain, starvation of oxygen that had been caused by the ligature around his throat.

“How can this be anything other than Suicide?” my thoughts were muddled and confused but every inch of my being was screaming that this was wrong! I looked back to the second row of seats where Dad’s children were seated. I saw their already broken faces as they bit back tears.

I saw the 5 months they had just spent trying to come to terms with Dad’s suicide.  I saw the lives they had ahead of them dealing with this lie. And my instincts kicked in, my body took over and launched me into the air.

Words were spilling out of my mouth with little regard for the consequences. “is it too late to speak?” I questioned.
The Senior Coroner and her officer, with blank shock on their faces invited me to take the stand. My heart felt like it was going to beat right out of my chest and my legs felt as though they could no longer take the weight of my body.

July 6th 2017, 12:10, Gloucestershire Coroner’s Court

“This is no longer an inquest hearing, this is now a Pre Inquest Review, I would like further evidence” The Senior Coroner quickly changed what was set to be the first and final hearing into a Pre Inquest Review pending further evidence. 

My revelations of statutory services being aware of Dad’s suicidal intent, namely the police force, had caused quite a stir.

I explained that I had written evidence of the police being informed of Dad’s suicide risk only weeks prior to his death and that the reason I had access to this evidence was due to me being the author of such pleas. 

I questioned why a man who was so heavily involved with upwards of 5 services in his final weeks had a file of evidence so sparse. An opinion that riled the Coroners Officer who had clearly been tasked with preparing said file.

I returned to my soon to be familiar seat and the Coroner left the court. The Coroner’s Officer walked towards me, I presumed he was about to offer some sort of an apology or support, I could not have been more wrong!

Like a giant, he towered over all five foot 1 of me, at a time when one would usually call upon her father for protection.

His words haunt me until this day. “Young lady, I do hope you realise that you have dragged this out for your family for a very long time now. Do you want a suicide conclusion?!” he snarled as he looked me up and down. I had two choices, I could run away and cry or I could stay and fight for what I believed in. What would my Dad do?

July 6th 2017, 12:15, Gloucestershire Coroner’s Court

“ABSOLUTELY I DO, it’s the truth” I had decided to stay and fight, and what a battle I had taken on to my sheltered 27 year old shoulders.

“I have spent the last 5 months teaching these children that suicide is ok, that they speak about it as they would any other death, and that they have absolutely nothing to be ashamed of.

What kind of message would I be sending to them if I allowed you to brush this under the carpet for the sake of your counties’ statistics? Yes I do want a Suicide conclusion because that’s what happened!”

September 7th 2017 10:30, Gloucester Coroner’s Court

2nd Pre Inquest Review Hearing.

December 8th 2017 10:30, Gloucester Coroner’s Court

3rd Pre Inquest Review Hearing.

January 23rd 2018 16:30, Gloucester Coroner’s Court

The Senior Coroner requested a 45 minute break to consider the evidence heard throughout the day. The hearing had started at 10.30am and witnesses had been called one by one.

The family, Probation service, Police, Social Services, Change Grow live (alcohol treatment),were amongst the witnesses called, other evidence was heard orally.

Steven Powels, our family Barrister by this stage, looked at me with warm eyes as the Senior Coroner began to sum up the case.

I glanced back at Joy Hibbins from Suicide Crisis who had supported us throughout;

I could see the defeated look in her eyes. We all knew that the last 7 months of fighting had been in vain. January 23rd 2018 16:40, Gloucester Coroner’s Court-“There was no note…” One of the Coroner’s many arguments against changing her conclusion.

We waited with baited breath, all hope had evaporated from our bodies by this stage, we were exhausted. Broken. Lost.
The coroner continued “The threshold to conclude that an individual intended to take his or her own life is extremely high, beyond reasonable doubt in fact……………… I DO believe that this threshold has been reached and therefore my conclusion is SUICIDE”. Her words seemed to touch my skin.

My body was no longer my own as tears violently yet independently erupted down my face and once again my legs went from under me and I was upheld by what I can only describe as a cloud of relief. 

It wasn’t happiness, it wasn’t sadness. I like to believe it was justice that kept me standing at that moment. Or my Dad. You see, the previous two hearings were different; our application for funding had been rejected as Human Rights Article 2 had not been engaged, yet we desperately needed the legal funding to engage Article 2.

Unrepresented, in the depths of our grief, our vulnerable family were represented by……the curly haired, five foot one, squeaky voiced, blonde girl-me.

I did my utmost to hold my own against the five legal teams sent by the agencies we had trusted with Dad’s care. My pride and passion for justice in my father’s name made up for my not so legal mind.

Yet I would not allow them to see me cry.

I was unwilling to show that weakness in a court of law, against individuals who were paid to be there. Individuals who had no personal or emotional attachment to the case. 

In the most difficult and painful months of my short life thus far, I did not cry. Imagine that. I would love to tell you that following on from this painful, heart breaking experience changes were made, that the failings identified by our family, the Senior Coroner and the services themselves were all rectified.

That a Prevention of Future Deaths report was published ensuring these mistakes were never made again.

But that would be a lie.