The Coroner (37 page)

    Hartley
said, 'Then on what basis did you telephone Nurse Raven and insist that he be
seen by a psychiatrist?'

    'Because
of what his mother had told me.'

    'Is
Mrs Wills medically qualified?'

    'Of
course not.'

    'Did
she take him to her GP to express her concerns about his mental health?'

    'She
had six children.'

    'And
the oldest was about to go into custody for the first time. You'd think if her anxiety
was that great she would have made him a priority?'

    'We
hoped the Youth Offending Team would have him seen.'

    Hartley
was the soul of patience. 'That does rather suggest your concern was more to keep
him out of custody than for the actual state of his mental health.'

    Hesitant,
Ruth Turner said, 'In hindsight perhaps I should have made her take him to the
doctor.'

    'But
you didn't. And nor did you persist with your request to have him seen by a
psychiatrist after the one telephone call you had with Nurse Raven. You rather
gave up on him, didn't you?'

    She
paused for a long moment. 'I have a very heavy caseload. I wish I had followed
it up, but technically Danny was no longer my responsibility once he was in
custody.'

    'Such
was your concern for his fragile state of mind that you washed your hands of
him?'

    'No.
I did what I could in the time I had available.'

    Hartley
nodded and said, 'I'm sure we can all relate to that.'

    As Ruth
Turner stepped, deflated, from the witness box, Jenny felt as if she were
staring into an abyss. It had never for a moment crossed her mind that the
social worker's evidence could be used to bolster UKAM's position, but that was
what had happened. Hartley had accused her of sentimental opportunism, of
bleating about a psychiatrist without actually having the belief that Danny was
ill. His point had even got home to the jury: there had been accusing looks in
Simone's direction when they'd heard she didn't take Danny to the doctor. The
weeping woman now wore a disapproving frown that said,
What sort of mother
was she?

    Jenny
took a gulp of water and called for Nurse Linda Raven to be sworn, telling
herself that while Hartley was shaving the odds he still couldn't get around
what happened in the house unit. There could be no excuse for not finding the
body before morning.

    Linda
Raven read the oath with the same dispassionate, untouchable expression Jenny
had observed in the reception centre. She answered her preliminary questions in
a deadpan and unapologetic voice, confirming that she was the chief nursing
officer at Portshead Farm, with overall responsibility for the medical
assessment of trainees on reception. She had held the position for three years,
since the facility opened, and prior to that had spent thirteen years working
in the NHS, her last four as a senior staff nurse in the Vale Hospital's
A&E department. When asked her reasons for leaving the NHS, she said she
was attracted by the salary and the opportunity to enter management.

    Jenny
said, 'Could you describe the nature of the assessment you carried out on Danny
Wills?'

    'It
was a standard medical questionnaire approved by the Department of Health and
the Prisons Service. We take a basic history, ask if they're suffering from any
physical or mental symptoms, whether they have any allergies. We also cross-
reference with NHS records - if we can't get them online we call their surgery
and talk to a practice nurse or doctor.'

    'Is
psychiatric assessment part of this process?'

    'No.
If there are any medical issues we get them seen by a doctor - we have
surgeries twice a week. If it's more urgent there are on-call arrangements.'

    'But
there was no arrangement for psychiatric care at that time.'

    'The
company I work for has a contract with the NHS to provide a range of services.
At that time, the local primary care trust withdrew funding for psychiatric
services outside certain clinics. There was a dispute that lasted several weeks,
during which time they refused to provide cover. We couldn't have had a
psychiatrist if we'd asked for one.' Her answer was polished and well
rehearsed, phrased in a way she wouldn't have come up with herself:
during
which time.

    'Would
you have liked Danny to be seen by a psychiatrist?'

    'No.
He didn't present with any particular problems - you can see from his file. It
was a borderline decision whether to keep him under observation at all.'

    'What
led you to make that decision?'

    'All
trainees with a history of drug abuse are strip-searched to make sure they have
no narcotics on their person. When my colleague attempted to examine him, Danny
was obstructive and violent.'

    'In
what way?'

    'Do
you want me to repeat the exact language that was used?'

    'Yes,
please.'

    'When
my colleague, Nurse Hamilton, warned him that force could be used to carry out
the search, he said, "Go ahead, you can fucking kill me. I'll fucking kill
myself before I let you white niggers touch me." Once he'd said those
words it amounted to a threat to self-harm. Our procedure was to keep him under
seventy-two hours' observation.'

    'Was
he strip-searched?'

    'Yes.'

    'Was
force used?'

    'Two
secure care officers contained him while Nurse Hamilton conducted the search.'

    'Did
that include an internal search?'

    'It
did.'

    'And
how did Danny respond?'

    'Once
the search was complete he was detained in an observation cell, where he continued
to shout and swear for several hours before he calmed down.' Nurse Raven turned
her head to the jury and said, 'I'd like to stress that after the search he did
not make any further threats to kill himself.'

    'But
you took his initial threat seriously enough to dress him in a padded,
knee-length sleeveless gown designed to prevent self-harm.'

    'He'd
been violent. It was a standard response.'

    Jenny
made no further progress. Nurse Raven's carefully prepared story, in which
there were no obvious holes, was that Danny ended up under observation merely
because he uttered a threat to harm himself which, although technically it made
him a suicide risk, was in fact a hostile response to the indignity of having
his rear end searched by a male nurse.

    When
he cross-examined, Hartley emphasized this point several times over, getting
Nurse Raven to confirm that there was nothing else in Danny's behaviour which
suggested he was a danger to himself.

    When
he had finished, Jenny asked: 'If there had been a psychiatrist available at
the time, would you have had Danny assessed?'

    'I
doubt it. After the initial couple of hours he was perfectly cooperative. You
can see that from the observation log.'

    'But
you had received a call from Ruth Turner, the family's social worker, saying
that she wanted him seen by a psychiatrist.'

    'Most
trainees have got psychological problems, that's why they offend. We could keep
ten psychiatrists busy. And in my experience of suicides, they tend to keep
their plans to themselves.'

    There
were nods of recognition in the jury. In the public gallery Simone Wills was
being comforted by a woman with 'Porn Star in Training' written in glitter
across her tight top.

    Jenny
thanked Raven for her evidence and let her stand down, feeling the ground
slipping further from under her feet. Hearing her last answer, she remembered
how crafty her friend Cathy had been all those years ago. After being drunk for
a solid week in which she claimed to have slept with ten men, she had spent
several days in sober, self-imposed purdah, emerging from her bedroom in their
shared flat neatly dressed, quietly spoken and repentant. That was the night
she stepped under a train.

    Jenny
called the lunch adjournment and retreated to the charmless office at the back
of the court grandly named the 'Judge's Chambers'. She couldn't face making
small talk in the judicial dining room to which she had a pass for the duration
of her inquest, and instead picked at a mini packet of shortcake biscuits which
had been left for her on a trolley along with hotel-style sachets of coffee and
a one-cup electric kettle.

    The
morning had moved her investigation no further forward. She felt naive and
foolish for ever having imagined it could have turned out differently. Harry
Marshall, who had been in the job for years, hadn't made a dent on UKAM. Less
than two months ago he must have sat in a similar room coming to the same
depressing conclusion: the system was geared so everyone got to avoid
responsibility. That was why it worked it all. If a child or two died, what did
it matter? Most didn't.

    Alison,
still frosty and maintaining her distance, came in with a message from Hartley.
Elaine Lewis had been unavoidably detained and sought the court's permission to
be excused attendance until tomorrow morning. Jenny said she would have
preferred more notice, but could work around it. Privately, she was glad she
wouldn't have to face her this afternoon. She was already feeling spent.

    Alison
said, 'That nurse was more confident than last time. I think they've been
working on her.'

    'I
should say so.'

    'Maybe
the way Mr Marshall handled this case doesn't seem quite so strange to you
now?'

    She
gave Jenny a look and left the room.

    The
afternoon started on a more promising note. A man named Vince Mason, an
operations manager for Sectec Ltd, was next in the witness box. Producing a
sheaf of computer printouts taken from the customer service log, he was adamant
that his company hadn't been informed of any camera malfunction at Portshead
Farm until nine a.m. on 14 April, a few hours after Danny's body had been
discovered. Part of their contract with UKAM, he explained, was a regular
three- monthly system check. His engineers had been in a fortnight before and
found everything in full working order. What's more, they guaranteed that
equipment would be fixed or replaced within forty-eight hours of a fault being
reported. It was inconceivable that a camera reported broken would be down for
a week.

    Unfazed
by Mason's certainty, Hartley asked him if it was possible that the security
staff at Portshead Farm had reported the fault but his company had missed it,
or simply not got around to responding. Mason said no, he could look at the
log, there was no fault report prior to the 14th.

    'Customers
report faults by email as well as telephone, don't they?' Hartley said.

    'Some
do.'

    Hartley's
solicitor handed him two sheets of paper which he asked Alison to pass to
Mason. Another copy was produced for Jenny.

    'Do
you see that these are email messages reporting a fault in the camera in the
main corridor of the male house unit?'

    'Yes,
sir.'

    'Were
they sent to your correct address?'

    'They
seem to have been.'

    'Perhaps
you would be so kind as to tell the jury the send dates.'

    Mason,
troubled, squinted at the documents. 'They say 9 and 14 April, but I'm not sure
I believe it. They're not on our log.'

    'Are
you saying your customer service desk didn't receive those emails?'

    'I
don't think we did.'

    Hartley
turned to Jenny. 'Ma'am, could the witness be allowed a few minutes to clarify
the situation? It may be that a few phone calls could shed some light.'

    Jenny
saw Tara Collins catch her eye from the public gallery, her look saying they
both knew what was coming next.

    Jenny
said, 'See if those emails were received, Mr Mason.'

    It
was no surprise, when, less than five minutes later, he came back to the box
looking baffled with the news that the emails did seem to be on the system
after all. He had no explanation for why they weren't logged or actioned. It
had never happened before.