GIST: "A woman says she has not been able to grieve for her father after an inquest into his death was held without her or her family knowing.
Robert Darby, from Epsom, died in July 2020 aged 68 after being diagnosed with a terminal brain tumour.
Surrey Coroner's Court has since admitted "administrative errors" accounted for the hearing being held without the family's consent in March this year.
Robert's daughter Hannah, who only wishes to give her first name, said: "It stops you having closure and being able to grieve because you're waiting for things to be aired [in court].
"We never got a chance to be included in that process. It's really upsetting. It feels like we were cheated out of a fair process."
After Robert's diagnosis in October 2019 he underwent surgery, chemotherapy, radiotherapy, and a trial drug treatment in the months that followed.
After a stint in Epsom Hospital to treat an infection in April 2020, his family say he returned home "much weaker and with a strong possibility of suffering from Covid".
Hannah's family had specific questions they wanted answering at the inquest about Robert's treatment in April and July at Epsom Hospital and were advised by their barrister it should have been a witness not a summary hearing.
In an email from the coroner's office received in February 2021, the family were told to look at the documents and raise questions if they had any.
The email also sought confirmation of the family's consent for a non-witness hearing to take place on March 3.
The family responded with queries, comments and corrections on the inquest bundle and made it clear they wished to challenge some of the evidence.
But this was never passed on to the coroner and there was never a follow-up from the coroner's office.
The family chased the court a number of times for a reply, including on March 3, when they were stunned to hear the inquest had gone ahead without them.
Hannah said: "I was shocked and burst into tears on the phone. It didn't even enter my head that they would continue with it on March 3 without getting back to us on our queries and without giving us information about the actual hearing."
Hannah said the process has been "distressing and exhausting" having had the one opportunity to challenge certain evidence about her dad's death being taken away.
There were inaccuracies in the inquest documents and the family has been told these cannot be changed retrospectively.
She said: "It is hard to move on and grieve without resolving this and without feeling that my dad's inquest followed the correct legal process.
"Whilst individual officers have been mostly kind the system has been muddled, confused, ineffective and lacking empathy. We feel that bereaved families deserve so much better."
Hannah also raised concerns about the court's use of a discredited pathologist, Michael Heath.
At the time he was carrying out work on behalf of the coroner despite previous questions over the reliability of his evidence, including leading to one man having his murder conviction quashed in 2005.
Hannah's family, and Robert's oncologist and clinical trial team, required post-mortem testing and sampling to get specific answers about Robert's brain tumour and potential Covid positivity. They feared they may not be conducted correctly by Dr Heath.
Hannah said: "When we found out that Dr Heath would be carrying out the autopsy we researched him and were extremely concerned by what we learnt about his conduct - a litany of issues, medical blunders and disciplinary proceedings - we were very concerned about him performing it."
When the family asked Surrey Coroner's Office for a different pathologist, they were told this was not possible.
Hannah said: "We felt that the coroner was not very sympathetic to our concerns."
Despite only given a day's notice by the court that Dr Heath would be performing the post-mortem, the family managed to arrange a private pathologist to watch the examination take place to "give reassurance that at least somebody else's eyes were on Dr Heath", Hannah said.
No major issues were raised by the private pathologist.
But since then, complaints against Dr Heath, so serious that he could pose a threat to patients or the public, have seen him referred to an interim orders tribunal with the Medical Practitioners Tribunal Service.
Hannah added: "We are obviously now even more concerned and upset that he was allowed to place his hands on our dad or husband and carry out such an important and delicate job."
Dr Heath's fall from grace:
The General Medical Council (GMC) found Dr Heath guilty of serious misconduct in 2009 but found his fitness to practise was not impaired.
The interim orders tribunal in March this year saw Dr Heath, who has carried out numerous examinations as part of high-profile cases, become subject to seven interim conditions, including that he must only work on reports of his previous examinations (prior to March 10, 2021).
Meanwhile, the GMC is examining evidence brought against Dr Heath which could lead to a referral for a full tribunal hearing.
At present although Dr Heath is under investigation, he remains GMC registered with a licence to practise – subject to the conditions.
A Surrey's Coroner Service spokesperson said: "The Coroner has written to the family to explain that once an inquest is closed, a coroner cannot amend or change their findings or conclusions, and that the only way forward for the family is to challenge the coroner's findings/conclusions in the senior courts by way of an appeal.
"Dr Heath is not currently employed or instructed by the Surrey Coroner. He is subject to an investigation by the GMC. Once the GMC has concluded their investigation, the Court will act appropriately.
"We have apologised to the family for the administrative errors that were made."
An Epsom Hospital spokesperson said: "The Trust would again like extend its deepest sympathies to Mr Darby's family for their sad loss. A complaint was raised and responded to by the Trust in July 2021.
"We take such matters with the utmost seriousness and lessons have been learned. In the Trust's response to the family, opportunities were offered to review any outstanding concerns and discuss options available for progressing these further, and that offer remains open."
'I felt absolutely sick':
Since SurreyLive revealed one family's worry that they had laid the wrong body to rest due to errors in a post-mortem report carried out by Dr Heath in August 2020, others, as well as Hannah, have come forward with concerns.
Rebecca Rees' mother Deirdre Davidson Hicks, from Reigate, died in East Surrey Hospital on July 6, 2020.
A post-mortem examination was conducted by Dr Heath on July 10, the report of which resulted in Rebecca spotting errors and missed opportunities.
The 55-year-old West Sussex nurse and health visitor said: "[Given Dr Heath's history] I felt absolutely sick that this person had been anywhere near my mother."
She added: "Heath said that my mother had a normal healthy gallbladder, but I knew my mum didn't have a gallbladder.
"This and other aspects of the report raised my suspicion that perhaps Heath uses a generic or template PM report rather than producing a bespoke report for the body he had supposedly examined."
Doubting the reliability of Dr Heath's post-mortem, Rebecca was forced to delay her mother's funeral by six months until a second examination by a different pathologist could take place.
In light of this, Dr Heath conducted a third post-mortem on Mrs Hicks on February 17, 2021, which Rebecca described as "extremely distressing".
In his second report, Dr Heath refuted the findings of the other pathologist.
The two doctors have concluded different causes of death, and Rebecca is unsure how this will be resolved before her mother's witness inquest is held in December.
'It just didn't sound like my dad at all':
Steve Goodenough, from Banbury in Oxfordshire, died aged 68 on September 11, 2020.
The post-mortem was carried out swiftly and by September 28 the funeral was held. It wasn't until around one month later, in November, that the family received Dr Heath's report.
Mr Goodenough's daughter Amy Dickson, 43 and from Reigate, said: "This post-mortem dropped into my inbox and it all kicked off. It just didn't sound like my dad at all."
The report mentioned a well-built man and did not flag problems with the liver, but Mr Goodenough had been a heavy drinker all his life, an alcoholic for many years and "was so tiny and frail", Amy said.
Dr Heath also concluded "alcohol withdrawal syndrome" contributed to his death, apparently ignoring the family's understanding he had been drinking up until he died.
The cause of death of Mr Goodenough has since been revised by the Oxford Coroner after a review by another pathologist in the county.
Amy said: "I cannot believe this happened. You have the shock of an unexpected death of a parent, the utter horror of how he died, and you then aren't getting straight answers and then see alcohol withdrawal. "To see that and think the one time he was going to give up, we weren't there to support him. Initially it made us feel really guilty."
As did the family of Ann House, Amy said her family went through a period of time where they thought they had cremated the wrong person.
"You feel guilty you weren't there, you feel guilty you couldn't help, you feel wretched that person has gone from your life in awful circumstances. Then you have to deal with the fact that even in death you still weren't there to protect them," she said.
Amy said when she came across Mrs House's case it was "like reading the same story".
The entire story can be read at:
PUBLISHER'S NOTE: I am monitoring this case/issue. Keep your eye on the Charles Smith Blog for reports on developments. The Toronto Star, my previous employer for more than twenty incredible years, has put considerable effort into exposing the harm caused by Dr. Charles Smith and his protectors - and into pushing for reform of Ontario's forensic pediatric pathology system. The Star has a "topic" section which focuses on recent stories related to Dr. Charles Smith. It can be found at: http://www.thestar.com/topic/charlessmith. Information on "The Charles Smith Blog Award"- and its nomination process - can be found at: http://smithforensic.blogspot.com/2011/05/charles-smith-blog-award-nominations.html Please send any comments or information on other cases and issues of interest to the readers of this blog to: hlevy15@gmail.com. Harold Levy: Publisher: The Charles Smith Blog;
