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    Evelin Chacko – Notes from the Inquest

    10:08, 27/1/2025

    Home » News & Knowledge » Evelin Chacko – Notes from the Inquest

    Last week saw the opening of the Inquest touching on the death of Evelin Chacko.

     

    We represent the family in this case which surround the admission of a child patient onto a complex care geriatric ward following an overdose.

    Whilst awaiting further assessments and a decision about her future care Evelin absconded from the Ward and sadly took her own life.

     

    Notes from the inquest

     

    20/01/2025 – Inquest Day One

    The Coroner opened the Inquest setting out the scope of the inquiry. Having already ruled that Article 2 of the ECHR is not engaged, the Coroner had made it clear that this would not affect the scope and that ‘there will be a rigorous inquiry into all the circumstances of Evelin’s death’.

    The Coroner also noted that Article 2 will be kept under review as the evidence is heard.

    There are over 30 witnesses who are to give evidence over the course of the next two week. Unusually in this case, some of the witness evidence will be read. Some witnesses will be giving evidence by video link, but the majority will give evidence in court.

    On day one we heard from the mother of the deceased and the Consultants who ran the Complex Care Ward where Evelin was resident in the days leading up to her death.

    The Inquest continues.

     

    21/01/2025 – Inquest Day Two

    Day two of the Inquest for Evelin Chacko saw many witnesses called to the stand by Coroner, Bronia Hartley, including a Ms. Jones who was called up first. Ms. Jones was a patient at Royal Bolton at the same time as Evelin.

    The pair struck up a friendship and bonded over their similar experiences. Ms. Jones and Evelin often met up during their time at the hospital to play football and go for walks around the hospital grounds.

    Ms. Jones stated that Evelin wanted to get better and they made a promise to each other to meet up after their stint in hospital was over to maintain their new found friendship.

    On the day of Evelin’s death, Ms. Jones stated that Evelin had messaged her to say she was going to give her football back. She said that there seemed to have been a change in Evelin’s persona, and she had not seen Evelin like this before and how it seemed to her that Evelin had “given up”.

    Ms. Jones recalled messages that Evelin had sent her on how Evelin would try her best not to run and how Ms. Jones had told hospital staff of her concerns over Evelin.

    The Coroner read out a witness statement from Heather Mackay, a student nurse at the time of Evelin’s hospital stay, and it was heard that Ms. Mackay said Evelin was a little quiet but “did not seem overly upset” on the day of her death, and further denied Ms. Jones telling her Evelin would run away.

    Many of the healthcare assistant/nurse witnesses that were heard had agreed how it was unusual and surprising for a patient as young as Evelin to be in the C2 Ward giving her age and vulnerability.

    Nurse Mary Hart did express concerns over Evelin and how the C2 Ward was not appropriate for her. She escalated her concerns to the mental health practitioner and also the security team at the hospital on the 13th July 2020 when she had learnt that Evelin had not returned to the ward.

    It was apparent that there had been a series of miscommunications between colleagues at the hospital and also a lack of review of Evelin’s hospital notes, mostly put down to the ward being extremely busy and simply “not having the chance” to do so.

    The Inquest continues.

     

    22/01/2025 – Inquest Day Three

    The inquest of Evelin Chacko continued for the third day and further witness evidence was presented to the coroner.

    The majority of the witnesses heard today were the Mental Health Staff including witnesses from the Mental Health Liaison Service, Ward management and Evelin’s psychiatrist.

    There was contention between the witnesses as to whether Evelin was suffering from Suicidal ideations, when questioned by Counsel representing the family it transpired that the reality was that many of the witnesses ‘could not recall’ and multiple witnesses had not documented events sufficiently within the medical records.

    For example, there was multiple occasions where Evelin’s earlier suicide attempts had not been recorded within the mental health reviews leading to questions as to whether these were taken into account or to the validity of the mental health reviews.

    The witnesses who presented evidence at the inquest today confirmed that multiple people were involved in the events leading up to Evelin’s death and each witness tried to pass the blame.

    By the end of the day, it was very clear that serious actions were not taken to keep Evelin safe and multiple alarm markers were not acted on ever or quickly enough.

    It was also clear there was a huge lack of communication between the different services. One of the witnesses even confirmed he did not follow NICE guidelines and complete a full review before increasing Evelin’s medication which contributed to the feelings she had, and it was extremely devastating to learn this.

    The inquest continues.

     

    23/01/2025 – Inquest Day Four

    The inquest of Evelin Chacko continued for the fourth day on Thursday 23/01/2025.

    Further witness evidence was presented to the Assistant Coroner Bronia Hartley from Karen Dalley (Mental Health Liaison Practitioner – GMMH), Katie Twist (Care Coordinator – GMMH) and Bernadette Brown who was providing testimony in lieu of Ian Watson (Assistant Director Social Care and Early Help Bolton Council).

    Both Karen and Katie had first-hand experience with dealing with Evelin and stated that although she had her difficulties she also had positive encounters with them, they both commented that Evelin was a clearly bright and articulate young lady, who had a good sense of humour.

    The witnesses gave visibly emotional testimonies and it was very clear that Evelin’s suicide had come as a shock to them and they will forever remember this bright young lady.

    Bernadette Brown did not have any direct interactions with Evelin (I believe), however it was admitted that there had been failings when it came to inter agency communication and too much short-term thinking, the long-term mental health of Evelin and the reasons behind her issues should have been explored in more detail.

    Ms. Brown stated that there was clearly a lack of professional curiosity when it came to Evelin’s complex mental health needs and the causes behind them. Ms. Brown had recently moved from Bolton Council, however she was aware that there had been some learnings and plans implemented since Evelin’s tragic passing.

    Ms. Brown advised that there has now been more lobbying for resources, so patients that do not quite fit the Tier 4 criteria are provided with sufficient and adequate help and don’t just slip through the cracks.

    The inquest continues.

     

    24/01/2025 – Inquest Day Five

    Today we heard the witness testimony from Helen Williamson; Claire Wallwork; PC Marsden; Dr Freeman; Mr Noonan; and, Fiona Farnworth. Helen Williamson and Claire Walwark discussed their roles and involvement when working for agencies relating to Evelin’s social/childcare.

    Constable Marsden discussed the police’s involvement when Evelin had been reported missing, and the steps taken in their investigation.

    Dr Freeman had written the internal ‘root cause analysis’ report on behalf of the hospital. This report was written to identify what had happened and lessons to learn from any perceived faults in Evelin’s care.

    Fiona Farnworth (RGN and named nurse for safeguarding) advised that the actions taken following Dr Freeman’s report had been completed or were now underway.

    Mr. Noonan was commissioned by the CQC to write a report, further investigating whether Evelin’s treatment was negligent and, if so, had it led to Evelin’s death.

     

    27/01/2025 – Inquest Day Six

    Day six saw conclusion of the witness evidence and the Coroner heard from the Co-Chair of the Serious Investigation Report, including that there was a failure to deliver the comprehensive management. Therefore, this was not in line with trust policies.

    The inquest continues.

     

    28-01-2025 – Inquest Day Seven

    After hearing 31 witnesses over 7 days, the coroner reached a finding of suicide. We will now be looking carefully at the witness evidence with a view to advising the family on respect of a civil claim in the hope that we can bring the matter to a final conclusion.

    This matter has taken an unusually long time in terms of the Inquest being heard. This was for a number of reasons, but largely due the amount of evidence and number of witnesses that the Coroner felt must be heard in order to have a complete picture.

     

    Relevant reading

    The inquest into the death of Evelin Chacko – Oakwood Solicitors Ltd

    Hospital negligence – Oakwood Solicitors

     

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