After I published this piece about a Bath man who died in police custody and whose family waited two years for an inquest I was contacted by another couple also waiting for answers.
Carol Bagg's son Christofer Walker died in 2008. He'd taken an overdose of pills and rung the police. It then took an hour for the emergency services to find him and get him to hospital - despite the fact he lived just a few minutes away. The Bagg's grief was compounded by the fact that it took months for an inquest to be held.
I wrote the story below for Private Eye back at the beginning of the year, but it was never published. I couldn't find anyone else who was interested in the story either. The good thing was that, after making inquiries an inquest was miraculously scheduled. See reports on the outcome here and here. This week the BBC's Inside Out programme and news outlet covered the story - well done to them.
The Avon coroner debacle has now been resolved but Carol says the things which went wrong and led to her son dying still need fixing.
Carol and Alan Bagg whose son, Chris Walker, died in Weston-super-Mare in February 2008.
The 27-year-old rang the police at 1.27am to say that he had been drinking and had accidentally taken a number of pills. Walker, who had learning difficulties, lived by himself. The overdose was from pills prescribed to manage a heart problem.
Despite living just four minutes drive from a hospital he did not arrive there until 2.46am – more than an hour after his 999 call. A consultant cardiologist estimated that he needed to have had a stomach pump within an hour to stand any chance of survival.
As it was he suffered a cardiac arrest before he even got in the ambulance and was effectively dead by the time he got to hospital.
In the absence of any investigation by the coroner Mrs and Mrs Bagg have turned detective amassing a huge amount of information.
An internal police investigation has criticised the call handling while the Baggs have serious concerns about how Great Western Ambulance dealt with their son.
Carol Bagg said: “It was like peeling back an onion and just finding more and more rotten bits. It was a sequence of events that could have been avoided.”
Frustrated at not even being given a date for an inquest the Baggs wrote to the Lord Chancellor, Ken Clarke, asking for help. They received a reply two months later from an official apologising because “the Ministry of Justice has had a serious backlog of public correspondence”.
In that letter, dated December 23, 2010, the official said that the coroner’s office had yet to even review the case file. He promised that the OJC would be in touch with a “substantive reply” addressing their concerns.
Three weeks later the OJC, also apologising for the delay in replying, said: “I am unable to provide you with a substance response at this time.”
The Bagg’s MP, John Penrose, who is the Minister for Tourism and Heritage, said: “I’m extremely concerned that such a large backlog of cases has built up at the Coroners Court. Some of the families have been waiting a very long time, which clearly isn’t fair when they’re having to deal with the grief of losing someone they love.
“I’m going to write immediately to the Coroners Court pushing them to clear the backlog quickly, and urging they get moving on Ms Bagg’s particular case as fast as possible.”
Mrs Bagg said: “What is important to me is that what happened to Chris does not happen again.
“Somebody needs to be held to account so the system can be changed.”