Less than two months, after Bill Johnson’s death, Kristian Thompson, a 19 year old talented cricket player, was found unconscious in a shower, in St Andrews Hospital, Northampton, where he later died.
His mother, had raised concerns about the effects of his medication.
His death, shortly afterwards, made her even more concerned, particularly, when she found out, that four other men, on similar medication, had died at St Andrews in the previous 10 months.
Kristian was a fit healthy young man, who found himself in St Andrews, after an assault, just 10 months before his death, which left his behaviour, ‘unpredictable’, and allowed him to be detained under the Mental Health Act.
At Kristian’s inquest, experts gave evidence, that Kristian’s death, may have been caused by sudden adult death syndrome, or, epilepsy.
The Coroner recorded an ‘open verdict’.
A spokeswoman for St Andrews said Kristian’s death had been investigated, in accordance with their procedures.
And St Andrews managers, dismissed claims by Bill Johnson’s solicitor, that the 5 deaths, could, be linked by the use of, the anti-psychotic drug clozaphine.
Merely on the basis of the logistics, that, they had occurred on different wards, and were treated by a different teams of nurses.
Still, not knowing why, her physically fit young son, had died at 19, Kristian’s mother contacted David Miliband MP, who wrote to the coroner, asking to discuss his unexplained death.But the Coroner, replied that he thought there was no need for such a discussion..
So Kristian’s mother spoke to the coroner, and, asked to speak to the pathologist, but, who refused to meet her.
Desperate for answers, she then wrote to David Cameron, Prince Harry, the head of the CPS, and the Attorney General, and many other people, who all came back with lots of sympathy, but said, there was nothing they could do.
But four years after Kristian’s death, two High Court Judges quashed the inquest’s verdict.
On the grounds, that without Kristian, having being diagnosed with epilepsy, before his death, an inquest, could not, have safely concluded it might be a cause.
And, this showed, there had been an ‘insufficiency of inquiry’, and there should be a fresh inquest into the matters put forward by Kristian’s legal team.
As there was insufficient evidence, Kristian was in fact, an epileptic at the time of his death.
The potential effect of his medication, and dosage before his death, were also not considered.
As was, no toxicology report done on Thomas Rawnsley, and his mother had to crowd fund to pay for one.
The High Court ruled, that this fresh inquest, should take place, ‘as soon as can be reasonably practicable’.
That was in May.
None of this would not have happened, but, for Kristian legal team.
And legal Aid, is not available for inquests, even under the government’s ‘exceptional funding’.
Bill Johnson’s inquest was re opened by family lawyers, after an initial finding of death by ‘natural causes’.
The only other inquest, into the 3 other deaths in St Andrews, recorded a finding of ‘natural causes’, but was not reopened.
In May this year, there was a successful application, under Article 2 European Directive, for ‘exceptional funding’, to cover legal representation in inquests.
But, there is still, no legal requirement, as exists in prisons, for independent investigations into deaths in hospitals, or residential care facilities.