0:00:02 > 0:00:04The inquest is the final chapter.
0:00:04 > 0:00:06For that moment, you live that case
0:00:06 > 0:00:09and you live that life and death of somebody.
0:00:09 > 0:00:10West London.
0:00:10 > 0:00:15One of the busiest coroner's jurisdictions in the country,
0:00:15 > 0:00:16with over 4,000 cases a year.
0:00:16 > 0:00:20Today, coroner Alison Thompson is about to enter court
0:00:20 > 0:00:25to solve the mystery of a young woman who was found dead at her flat.
0:00:25 > 0:00:28Sometimes we are looking more at that person's life
0:00:28 > 0:00:30than anyone else would ever have looked at.
0:00:30 > 0:00:36It's the culmination of a five-month investigation by the coroner's team.
0:00:36 > 0:00:40We are going to have to treat her as a cyanide case.
0:00:40 > 0:00:44Do we know anything about where this potassium cyanide came from?
0:00:44 > 0:00:47In court, Alison must establish the facts.
0:00:47 > 0:00:50Who was the deceased?
0:00:50 > 0:00:54When, where and how did she die?
0:00:54 > 0:00:57We're ready to go. OK, that's absolutely fine.
0:00:57 > 0:00:59When life's end is unexplained,
0:00:59 > 0:01:02the answer falls to Her Majesty's Coroner.
0:01:02 > 0:01:05Please rise for Her Majesty's Coroner.
0:01:17 > 0:01:19It's a Tuesday morning in March,
0:01:19 > 0:01:23when the coroner's investigation into Jessica's death begins.
0:01:25 > 0:01:29At Uxbridge mortuary, the technicians are preparing her
0:01:29 > 0:01:32for a routine postmortem examination.
0:01:32 > 0:01:35Coroner's office, good morning.
0:01:35 > 0:01:37In the office next door,
0:01:37 > 0:01:41Coroner's Officer Diane Whiting is following up on existing cases.
0:01:41 > 0:01:43Thank you, Doctor. Bye-bye.
0:01:46 > 0:01:49Home Office pathologist Dr Ashley Fegan-Earl
0:01:49 > 0:01:52will try to establish how Jessica died.
0:01:53 > 0:01:58Here we have a lady with bipolar, which is a risk for suicide.
0:01:58 > 0:02:01It's believed she's taken a medication overdose.
0:02:01 > 0:02:05We're going to look for any unnatural potential causes,
0:02:05 > 0:02:10any injuries to the neck, any signs of deliberate self-harm,
0:02:10 > 0:02:13any injuries to the wrists.
0:02:13 > 0:02:18If we look at this lady's arms, there are multiple healed scars.
0:02:18 > 0:02:22It's not uncommon to see a few marks on the inner aspect of the wrist,
0:02:22 > 0:02:25but in this lady, they're very extensive.
0:02:25 > 0:02:29They're passing from wrist up to the crook of the arm.
0:02:29 > 0:02:33They're also on the back and, more unusually,
0:02:33 > 0:02:36over the front of her thighs, but all indicative
0:02:36 > 0:02:41of a history of previous acts of deliberate self-harm
0:02:41 > 0:02:44and this is a relatively common finding
0:02:44 > 0:02:47with a number of suicides that we deal with.
0:02:47 > 0:02:52The other issues we're looking for is whether there's any evidence
0:02:52 > 0:02:56of third party violence. There's nothing externally of note,
0:02:56 > 0:03:00so we'll move to the internal examination now.
0:03:00 > 0:03:03Yes, OK.
0:03:03 > 0:03:07Dr Fegan-Earl is about to begin the examination
0:03:07 > 0:03:13of Jessica's internal organs when Diane calls him out of the mortuary.
0:03:13 > 0:03:15I literally put the phone down,
0:03:15 > 0:03:17scribbled the note and brought it out.
0:03:17 > 0:03:20Do you want me to get the police to go and fetch it?
0:03:20 > 0:03:22Yeah, we're not opening her today until we know.
0:03:22 > 0:03:26We will leave that and we need to find out a bit more because...
0:03:26 > 0:03:28What's the implications of potassium cyanide?
0:03:28 > 0:03:30It'll give off cyanide. We'll leave it
0:03:30 > 0:03:32and say we need more info.
0:03:32 > 0:03:36Right, would you like me to get the police to fetch the container or...
0:03:36 > 0:03:37Yeah, I want to know if it's open.
0:03:37 > 0:03:39Because if it's not open, fine.
0:03:39 > 0:03:45But if it's open, you're going to have to treat her as a cyanide case.
0:03:45 > 0:03:48It's the first time the coroner's team in west London
0:03:48 > 0:03:51has had to deal with a suspected poisoning like this.
0:03:53 > 0:03:56We had a phone call from someone who lived at the house
0:03:56 > 0:03:58to say that a pot of potassium cyanide
0:03:58 > 0:03:59had been found in her bedroom.
0:03:59 > 0:04:03They immediately stopped the postmortem examination
0:04:03 > 0:04:06because there's a real risk with certain chemicals
0:04:06 > 0:04:10that gasses might be given off, and that this could be very dangerous
0:04:10 > 0:04:13to the pathologist and the mortuary staff.
0:04:13 > 0:04:17If there is cyanide inside her, this young lady's body ought to go
0:04:17 > 0:04:20to a very special unit at St Thomas' Hospital
0:04:20 > 0:04:23where they deal with chemical deaths and that kind of thing.
0:04:23 > 0:04:26The family have booked a funeral in three days,
0:04:26 > 0:04:29so we really are racing against time on this one.
0:04:29 > 0:04:33Until a full postmortem examination can be carried out
0:04:33 > 0:04:37to establish how she died, the coroner will retain Jessica's body.
0:04:43 > 0:04:45Alison Thompson has been the coroner
0:04:45 > 0:04:48for the 1.5 million people of west London
0:04:48 > 0:04:49for the past 12 years.
0:04:51 > 0:04:54I've got a strange-shaped patch.
0:04:54 > 0:04:57I would say about 40 miles, top to bottom.
0:05:00 > 0:05:03We've got prisons, detention centres, motorways,
0:05:03 > 0:05:07big hospitals, main railway lines, airports,
0:05:07 > 0:05:11so lots of scope for people dying, I suppose, and certainly enough
0:05:11 > 0:05:16to keep us busy with just over 4,000 reported deaths a year.
0:05:16 > 0:05:18You can still get some violent crime here.
0:05:18 > 0:05:21We had an excellent Detective Chief Superintendent who used to,
0:05:21 > 0:05:22in the good old days,
0:05:22 > 0:05:25drop in for coffee and doughnuts early in the morning
0:05:25 > 0:05:27and tell me about the latest murders.
0:05:27 > 0:05:28He was great fun.
0:05:28 > 0:05:30And he said, actually,
0:05:30 > 0:05:34there's quite a lot of domestic stuff around here,
0:05:34 > 0:05:38domestic murder, and I always remember he gave me advice that,
0:05:38 > 0:05:41if you ever, by any chance, do kill your partner -
0:05:41 > 0:05:44without meaning to, of course - the best thing you can do
0:05:44 > 0:05:47is to actually ring and say you've done it as soon as you can.
0:05:47 > 0:05:50Once you start prevaricating, you've had it.
0:05:50 > 0:05:52To be fair, I'm simply not at the sharp end,
0:05:52 > 0:05:56so I don't have the difficult things to do, and I'm very thankful that
0:05:56 > 0:06:00there are other people in the system doing the difficult and dirty tasks.
0:06:00 > 0:06:03That role falls to her Coroner's Officers.
0:06:06 > 0:06:10They are, essentially, investigators of that death,
0:06:10 > 0:06:12from start to finish.
0:06:12 > 0:06:16We have at the moment ten Coroner's Officers working for us
0:06:16 > 0:06:18and I feel very fortunate to have them all.
0:06:18 > 0:06:20They are my eyes and ears.
0:06:20 > 0:06:23You need a strong stomach.
0:06:23 > 0:06:27Having to go and deal with bodies,
0:06:27 > 0:06:30sometimes bodies not in a very good condition,
0:06:30 > 0:06:31I think it's a difficult job.
0:06:34 > 0:06:35It's Monday morning,
0:06:35 > 0:06:38often the busiest day of the week for Alison's team.
0:06:41 > 0:06:45The badly decomposed body of a man has been found at a flat.
0:06:45 > 0:06:49At the scene one, of the Coroner's Officers is gathering evidence
0:06:49 > 0:06:52to help determine when he died.
0:06:52 > 0:06:56Morning, it's John Mitchell from the Coroner's Office here at Fulham.
0:06:56 > 0:07:00One of your patients, unfortunately he's passed away,
0:07:00 > 0:07:03and I need to get some medical history.
0:07:08 > 0:07:13Yes, at home. No, it's fine, thank you.
0:07:13 > 0:07:17At the court in Fulham, Coroner's Officer John Mitchell
0:07:17 > 0:07:20is trying to piece together details of Fred's life.
0:07:20 > 0:07:24It looks like he'd been there for some time.
0:07:24 > 0:07:27There are plenty of clues in Fred's fridge,
0:07:27 > 0:07:31where the food is nearly three months old.
0:07:34 > 0:07:38And he's got no other history apart from the blood pressure?
0:07:38 > 0:07:42Thank you very much. Thanks for your time. Goodbye.
0:07:42 > 0:07:45Well, he hasn't been seen at the GP since 2007.
0:07:45 > 0:07:49He's an unknown quantity as far as the doctor goes.
0:07:49 > 0:07:53Looks very much as if he probably has been there since late November.
0:07:53 > 0:07:57The police broke in, noticed the bad smell, found him,
0:07:57 > 0:08:00informed the on-call Coroner's Officer last night
0:08:00 > 0:08:01who took the details
0:08:01 > 0:08:05and organised him being bought into our mortuary in Fulham.
0:08:05 > 0:08:08There's no next of kin.
0:08:08 > 0:08:11He is 69 years of age.
0:08:11 > 0:08:15We'll organise a postmortem for him tomorrow.
0:08:18 > 0:08:21It's five o'clock the following morning at Fulham Public Mortuary.
0:08:21 > 0:08:26Manager Dave Colvin and deputy manager Lenny Browse are preparing
0:08:26 > 0:08:30for the morning's postmortem examinations.
0:08:30 > 0:08:33Visceral bag for containing the internal organs
0:08:33 > 0:08:37when they have been dissected.
0:08:37 > 0:08:40Shroud - no-one goes out naked.
0:08:40 > 0:08:43Always go out with a shroud.
0:08:43 > 0:08:48Let's see. Block, which goes under the shoulders,
0:08:48 > 0:08:50or under the head.
0:08:52 > 0:08:55Just preset everything, have it ready.
0:08:55 > 0:08:59Like anything else, the secret is in the preparation.
0:08:59 > 0:09:03Fred is one of four routine examinations to be carried out today
0:09:03 > 0:09:05by Dr Olaf Biedrzycki,
0:09:05 > 0:09:08who followed his father into forensic pathology.
0:09:08 > 0:09:13I do really enjoy coming to work, which I think I'm very privileged.
0:09:13 > 0:09:16I'm a very morning person anyway and it's a quite morning-suited job,
0:09:16 > 0:09:20so when the alarm goes at five, I do genuinely think,
0:09:20 > 0:09:22"Great, I wonder what we'll have today."
0:09:22 > 0:09:26There appears to be a beard and moustache on the face.
0:09:26 > 0:09:28The ears are not obviously pierced.
0:09:28 > 0:09:32Fingernails are 2-3mm.
0:09:32 > 0:09:34I really enjoy doing postmortems.
0:09:34 > 0:09:38And I quite enjoy the Coroner's Court side of it.
0:09:38 > 0:09:41I just enjoy doing the practical side of things.
0:09:41 > 0:09:45Parchmented abrasion to the back of the right hip measuring some 6cm
0:09:45 > 0:09:49and parchmented black abrasions to the front of each knee,
0:09:49 > 0:09:51measuring six on the left and five on the right.
0:09:51 > 0:09:54'It can be quite exciting.'
0:09:55 > 0:09:59When you're looking through bowel at lots of poo,
0:09:59 > 0:10:01all the glamour fades away very quickly.
0:10:04 > 0:10:07Having lain undiscovered for two months,
0:10:07 > 0:10:09Fred's body may present Dr Biedrzycki
0:10:09 > 0:10:11with a unique set of problems.
0:10:11 > 0:10:15When their body is decomposed, you're just trying to make sure that
0:10:15 > 0:10:18nothing horrendously untoward has happened,
0:10:18 > 0:10:21because the cause of death is probably going to be unascertained.
0:10:21 > 0:10:24When you do do a very decomposed body,
0:10:24 > 0:10:27even when you're wearing two and three pairs of gloves,
0:10:27 > 0:10:31you still have part of that smell on you for a while afterwards.
0:10:31 > 0:10:32It's very hard to get rid of.
0:10:32 > 0:10:36The eyes are partially destroyed by the decomposition process,
0:10:36 > 0:10:38but appear brown.
0:10:38 > 0:10:43I've even done a case where the body was very mummified, very desiccated,
0:10:43 > 0:10:47lots of decomposition-related holes in the body and, actually,
0:10:47 > 0:10:51when we opened up the chest there was a dead mouse within the chest.
0:10:51 > 0:10:54That's not unusual.
0:10:54 > 0:11:00The examination moves on to Fred's internal organs.
0:11:00 > 0:11:03You can just see part of the liver which,
0:11:03 > 0:11:06instead of being a lovely mahogany brown colour,
0:11:06 > 0:11:08is a very pale yellow colour.
0:11:08 > 0:11:11So this, to me, already says that this man
0:11:11 > 0:11:14is suffering from cirrhosis of the liver.
0:11:14 > 0:11:17Now, lots of causes for that but, unfortunately, in this country,
0:11:17 > 0:11:21by far the most common cause is drinking alcohol to excess.
0:11:23 > 0:11:28At Fred's flat, there was plenty of evidence of sustained alcohol use.
0:11:28 > 0:11:31So I've just started the internal examination,
0:11:31 > 0:11:34I've had a couple of helpful findings.
0:11:34 > 0:11:35I've opened the stomach,
0:11:35 > 0:11:38there's a lot of black, altered blood in there.
0:11:38 > 0:11:43It's all looking very good for a significant gastric bleed
0:11:43 > 0:11:45due to cirrhosis of the liver.
0:11:47 > 0:11:50Unusually in cases of severe decomposition,
0:11:50 > 0:11:54establishing a cause of death is looking possible.
0:11:54 > 0:11:57Fred will remain in the mortuary team's care
0:11:57 > 0:12:00while the search for his next of kin continues.
0:12:00 > 0:12:04Deep freeze at minus 20...
0:12:05 > 0:12:07..can hold a body for...
0:12:09 > 0:12:11..indefinitely.
0:12:11 > 0:12:15The longest I think we've ever held onto an individual
0:12:15 > 0:12:16was about two years.
0:12:29 > 0:12:34Over 600 inquests a year are held at West London Coroner's Court.
0:12:34 > 0:12:39These cases are the formal record of how, when and where people died.
0:12:39 > 0:12:42She was aged only 28
0:12:42 > 0:12:45and she had been found in a state of collapse at her home.
0:12:47 > 0:12:49A note found near to her
0:12:49 > 0:12:53suggested that she'd taken an overdose of medication.
0:12:53 > 0:12:57Today, Alison is hearing the inquest of a young woman
0:12:57 > 0:12:59who appears to have taken her own life.
0:13:04 > 0:13:07More than one in seven of our verdicts in west London
0:13:07 > 0:13:10is one of suicidal self-harm,
0:13:10 > 0:13:14and it has been as high as one in five.
0:13:14 > 0:13:15Hello, ma'am.
0:13:15 > 0:13:19Thanks very much for doing all this extra work on it.
0:13:19 > 0:13:22It's really very helpful. And we've got the original note now,
0:13:22 > 0:13:25- found by her dog-walker...- Yes.
0:13:25 > 0:13:27..saying, "Do not resuscitate."
0:13:27 > 0:13:32Now she has Petra's suicide note, the coroner will able to decide
0:13:32 > 0:13:36not only how she died, but whether she meant to take her own life.
0:13:41 > 0:13:45Petra was the second-youngest of Peter's four daughters.
0:13:45 > 0:13:48She died just before Christmas.
0:13:48 > 0:13:53She was a lovely little, friendly girl, very sharp.
0:13:53 > 0:13:56Several people wrote to us at the time of her death.
0:13:56 > 0:13:58They said she brought joy into a room.
0:13:58 > 0:14:00And she did. She was that sort of girl.
0:14:00 > 0:14:04Very, very much loved.
0:14:04 > 0:14:05By all of us.
0:14:07 > 0:14:10At the age of 13, she contracted anorexia,
0:14:10 > 0:14:13which is a form of depression.
0:14:13 > 0:14:15Finally, at the end of last year,
0:14:15 > 0:14:18she'd had enough of trying to get better.
0:14:18 > 0:14:21She'd managed to get, through the Internet,
0:14:21 > 0:14:25some pretty nasty antidepressants,
0:14:25 > 0:14:28to the tune of 300.
0:14:28 > 0:14:32One morning my wife was rung up, to be told that
0:14:32 > 0:14:36she'd been found in her bedroom, on the floor, totally unconscious.
0:14:39 > 0:14:43She was in the Charing Cross resuscitation unit,
0:14:43 > 0:14:46absolutely fantastic doctors who did all they could.
0:14:46 > 0:14:50Unfortunately, one could tell she was braindead
0:14:50 > 0:14:53and one would have had to make a decision then
0:14:53 > 0:14:55whether to cut it off or not.
0:14:55 > 0:14:58Thank goodness she died, actually, from heart failure.
0:14:58 > 0:15:01But...not easy.
0:15:08 > 0:15:11It's interesting looking at the poisons information
0:15:11 > 0:15:16that the hospital were able to get, because it shows that this other drug
0:15:16 > 0:15:19is very difficult to deal with in overdose.
0:15:19 > 0:15:22So, really, from the outset, I think she was in difficulty
0:15:22 > 0:15:26and I think she was obviously an intelligent woman who knew that would be the case.
0:15:26 > 0:15:31I mean, she's giving clear instructions to people here, isn't she?
0:15:31 > 0:15:34- Is Tomasina the... - Tomasina's the dog?
0:15:35 > 0:15:39To even sort of say, whoever takes the dog gets some money
0:15:39 > 0:15:41to look after the dog for insurance and stuff.
0:15:41 > 0:15:44Even mentioning the dog being due for a haircut.
0:15:44 > 0:15:47I mean, down to the nth degree of detail here.
0:15:47 > 0:15:51And giving money to whoever's going to look after the dog,
0:15:51 > 0:15:57and giving the PIN number for her bank account even.
0:15:57 > 0:16:01- That's the thing, isn't it, that really makes it so convincing. - Shows it's final.
0:16:01 > 0:16:03I think it leaves us with a clear intention,
0:16:03 > 0:16:09and circumstances suggesting that she intended the outcome to be fatal.
0:16:09 > 0:16:14But, obviously, I'll look at all the evidence.
0:16:14 > 0:16:18John's going to take me into open court now, so I'm afraid
0:16:18 > 0:16:23the rules require me to respectfully ask you to leave.
0:16:24 > 0:16:29The coroner will make her final verdict on the death alone.
0:16:29 > 0:16:33Petra's family have chosen not to attend the hearing.
0:16:33 > 0:16:36I did determine that she had intended to take her life,
0:16:36 > 0:16:38and so I recorded a verdict.
0:16:38 > 0:16:40We don't tend to use the word "suicide".
0:16:40 > 0:16:44We actually write down, "The deceased took their own life."
0:16:46 > 0:16:49John now has to pass on the coroner's decision
0:16:49 > 0:16:50to Petra's family.
0:16:53 > 0:16:57We've just come out of court, having held the inquest.
0:16:57 > 0:17:00The coroner felt she had no option
0:17:00 > 0:17:04but to arrive at a verdict that Petra took her own life.
0:17:06 > 0:17:09For Petra's family, the conclusion of the coroner's investigation
0:17:09 > 0:17:13might do more than simply mark the end of this tragedy.
0:17:13 > 0:17:18I do feel there could be some benefit at the end of it,
0:17:18 > 0:17:20if there is such a word.
0:17:20 > 0:17:24And no child or... I call her a child - she's 28 -
0:17:24 > 0:17:30is able to just have available the access to taking her own life
0:17:30 > 0:17:32in this manner.
0:17:32 > 0:17:37If you want to buy any prescription drug through the Internet,
0:17:37 > 0:17:39you can do so.
0:17:39 > 0:17:41It's not legal in the European Union,
0:17:41 > 0:17:43but you can do it
0:17:43 > 0:17:46from outside anywhere.
0:17:46 > 0:17:50I will consider whether or not there is anybody I could report it to.
0:17:50 > 0:17:53I think the difficulty is regulating overseas sites.
0:17:53 > 0:17:59But it might be worth me contacting the regulatory body in this country.
0:17:59 > 0:18:03I think it's probably one of the most important features
0:18:03 > 0:18:06of what we do, actually, is prevention of other fatalities.
0:18:06 > 0:18:08It's something tangible.
0:18:17 > 0:18:21Another day is coming to an end at Uxbridge Mortuary.
0:18:21 > 0:18:25Technicians Cheryl and Cassie are tending the deceased
0:18:25 > 0:18:29and preparing the mortuary for tomorrow's cases.
0:18:33 > 0:18:36My other half, he thinks it's brilliant
0:18:36 > 0:18:37that we do this type of thing.
0:18:37 > 0:18:41He thinks it's really good. He certainly couldn't do it.
0:18:41 > 0:18:45My son's got more of an idea now about what I do,
0:18:45 > 0:18:48but my daughter thinks I send people to heaven!
0:18:48 > 0:18:51Sometimes you do get quite involved, say if it's a suicide,
0:18:51 > 0:18:54and you start feeling sorry and you really shouldn't, maybe, do that.
0:18:54 > 0:18:58You should just get on and do the job.
0:18:58 > 0:19:01You're aware that there's a family,
0:19:01 > 0:19:05that their parents are going to bury their child,
0:19:05 > 0:19:07and that's awful,
0:19:07 > 0:19:11even from a young child, to a teenager, 20s.
0:19:11 > 0:19:13And that's horrible, because life dictates
0:19:13 > 0:19:15that a parent shouldn't bury their child.
0:19:15 > 0:19:18It's meant to be the other way round.
0:19:21 > 0:19:24Coroner's Officer Diane Whiting has travelled to Fulham
0:19:24 > 0:19:27to brief the coroner on Jessica's unique case.
0:19:27 > 0:19:31- Diane, come in.- Ma'am.
0:19:31 > 0:19:34We've got a young lady of 27 years of age,
0:19:34 > 0:19:41living with her boyfriend, who was found dead in bed, with notes left,
0:19:41 > 0:19:45and a tub of potassium cyanide was found in the room.
0:19:45 > 0:19:50Although I have to say that wasn't found until later,
0:19:50 > 0:19:54after her body had been moved over to us at Uxbridge.
0:19:54 > 0:19:57None of us realised what the dangers were.
0:19:57 > 0:20:00They're dangerous, suicides, in a sense.
0:20:00 > 0:20:05- You never...- Fully know. - ..fully know what someone has got.
0:20:05 > 0:20:08So you just got to treat every body exactly the same
0:20:08 > 0:20:10and take precautions.
0:20:10 > 0:20:13We had one young lady who swallowed razor blades.
0:20:13 > 0:20:18I mean, that could be really dangerous if you're not aware.
0:20:18 > 0:20:21I think with the Internet, you're hearing of more and more cases
0:20:21 > 0:20:24where people are getting stuff online
0:20:24 > 0:20:27and mixing up concoctions and gassing themselves.
0:20:27 > 0:20:30And, of course, anyone else that then goes into that environment,
0:20:30 > 0:20:33be it the scene where the suicide's been committed,
0:20:33 > 0:20:35or the body itself, is at risk.
0:20:35 > 0:20:39The situation is at the moment that we were advised to move her up
0:20:39 > 0:20:42to one of the London hospitals for a postmortem examination
0:20:42 > 0:20:44Guy's and St Thomas', I think.
0:20:44 > 0:20:48They had a detector which would have detected cyanide gases
0:20:48 > 0:20:52had they been present, and there weren't any.
0:20:52 > 0:20:55The chemical probes used to detect cyanide gas
0:20:55 > 0:20:58at the specially-arranged postmortem failed to reveal
0:20:58 > 0:21:01whether Jessica had taken the poison.
0:21:01 > 0:21:07But, at the scene, a spoon and glass were also recovered.
0:21:07 > 0:21:11The glass had traces of potassium cyanide on it.
0:21:11 > 0:21:15The coroner wants to know if Jessica herself
0:21:15 > 0:21:18left any information about what she'd taken.
0:21:18 > 0:21:20Did the note give us any clues?
0:21:20 > 0:21:21Did she say anything in the note?
0:21:21 > 0:21:27No, they were, basically, sorry to family members.
0:21:27 > 0:21:30They weren't indicative of what was in her mind.
0:21:30 > 0:21:32Do you know what the note on the door said?
0:21:32 > 0:21:34Don't come in, call the police.
0:21:34 > 0:21:36Because otherwise her partner would have come in.
0:21:36 > 0:21:41- Did the police look at her computer? - She had used her computer
0:21:41 > 0:21:44to research the use of potassium cyanide.
0:21:44 > 0:21:48So we still haven't got a final cause of death yet.
0:21:48 > 0:21:51We are still awaiting toxicology.
0:21:51 > 0:21:54They're doing quite extensive tests.
0:21:54 > 0:21:56Lovely, and I'll be in touch with you about that.
0:21:56 > 0:21:58We'll speak again in three weeks.
0:21:58 > 0:22:01- Yeah, thanks, Diane. - Thanks. Bye-bye.- Bye.
0:22:01 > 0:22:06Jessica's blood samples may hold the key to how she died.
0:22:06 > 0:22:09But, because cyanide cases are so rare,
0:22:09 > 0:22:12the tests must take place in France.
0:22:13 > 0:22:17It'll add another six weeks to the coroner's investigation
0:22:17 > 0:22:20and keep Jessica's family waiting.
0:22:23 > 0:22:28Yes, hello, it's John Mitchell from the Coroner's Office at Fulham.
0:22:28 > 0:22:30Yes, plastic bag over his head.
0:22:31 > 0:22:33How many witnesses do you have?
0:22:33 > 0:22:37At Fulham coroner's office, things are proving more straightforward
0:22:37 > 0:22:40in the case of Fred, who died alone.
0:22:40 > 0:22:43Morning, John. Good news.
0:22:43 > 0:22:46He's not as decomposed as we thought
0:22:46 > 0:22:49and, actually, I managed to get a cause of death on him.
0:22:49 > 0:22:50He's got cirrhosis of the liver
0:22:50 > 0:22:54and a significant bleed in his bowel due to a oesophageal varices.
0:22:54 > 0:22:57So we won't need an inquest in this case. I'm sure you'll be pleased.
0:22:57 > 0:23:01- Brilliant news, Olaf. Super. - Excellent.- Thanks very much.
0:23:01 > 0:23:04- Nice when it happens like that, occasionally.- Exactly.
0:23:04 > 0:23:09As Fred died of natural causes, his case won't need an inquest.
0:23:09 > 0:23:13Establishing how he died has been surprisingly easily.
0:23:13 > 0:23:17But locating friends and family has proved impossible.
0:23:17 > 0:23:21I've been here five years. I think I've only had two people
0:23:21 > 0:23:23who we've never been able to put a name on.
0:23:23 > 0:23:26But we've had plenty of people who we've had to sort of
0:23:26 > 0:23:29put in the hands of the local authority
0:23:29 > 0:23:31because they've got no next of kin.
0:23:31 > 0:23:34Can you give me a cause of death?
0:23:34 > 0:23:36'Nine million people in London,
0:23:36 > 0:23:40'but it can be a very lonely place if you've got no friends or family,'
0:23:40 > 0:23:43and you're sort of, you know, you're getting on a little bit,
0:23:43 > 0:23:45and you're holed up in your little flat with your cat,
0:23:45 > 0:23:48and you never go out, your neighbours get your shopping,
0:23:48 > 0:23:51and things like that, that's all too common.
0:23:53 > 0:23:56They were walking, living, talking, breathing.
0:23:56 > 0:24:01To us now, you know, with the most of respect, they are just shells.
0:24:01 > 0:24:04But you still got to treat them as though they're one of your own.
0:24:04 > 0:24:10Even if that person does not have so much as one single living soul
0:24:10 > 0:24:12to shed a tear for them,
0:24:12 > 0:24:15here they will be treated well.
0:24:15 > 0:24:19So having respect for everyone, no matter what colour,
0:24:19 > 0:24:21no matter what gender,
0:24:21 > 0:24:25no matter what they've done in their lives, we never judge.
0:24:25 > 0:24:31So, basically, you do the best you can, when you can.
0:24:31 > 0:24:35Hello, it's Neil Sherry at the funeral directors.
0:24:35 > 0:24:39I'm just ringing up about the funeral arrangements for Frederick
0:24:39 > 0:24:42from the London Borough of Hammersmith and Fulham.
0:24:42 > 0:24:47Right, excellent. We'll come along later on today to collect him.
0:24:47 > 0:24:49The council have an obligation to arrange a funeral
0:24:49 > 0:24:52if no-one else will take responsibility.
0:24:52 > 0:24:55It's a statutory duty of every local authority.
0:24:57 > 0:25:00It does happen quite a lot.
0:25:00 > 0:25:07We probably do 150 local authority funerals a year
0:25:07 > 0:25:13and out of that, I would say maybe 15-20%, there's no-one there.
0:25:13 > 0:25:16We don't necessarily know anything about the person,
0:25:16 > 0:25:20so we can't celebrate their life.
0:25:20 > 0:25:24At least there is the vicar and us there for their funeral service.
0:25:31 > 0:25:34It's the end of the day at her court in Fulham,
0:25:34 > 0:25:38and Alison Thompson has some good news in Petra's case.
0:25:38 > 0:25:42I'm always surprised at how many families say to us after a death,
0:25:42 > 0:25:46you know, we just would love something good to come out of this.
0:25:46 > 0:25:48We'd like lessons to be learned.
0:25:48 > 0:25:52Petra took her own life by exploiting a loophole
0:25:52 > 0:25:57to buy antidepressants on the Internet without a prescription.
0:25:57 > 0:26:00I wrote with good effect, I think,
0:26:00 > 0:26:05to the Medicines and Healthcare products Regulatory Agency.
0:26:05 > 0:26:08They're monitoring the Internet for websites operating in the UK,
0:26:08 > 0:26:11they're making test purchases from the Internet
0:26:11 > 0:26:13so they can monitor more effectively,
0:26:13 > 0:26:16and they say that, really, they've got two jobs.
0:26:16 > 0:26:20One is enforcement to prevent the sale from illegal websites,
0:26:20 > 0:26:22but also education.
0:26:22 > 0:26:26It's not bringing anybody back, but it does help families to know
0:26:26 > 0:26:31that it's been taken seriously and that some good may come of it.
0:26:36 > 0:26:38Four months after her death,
0:26:38 > 0:26:41and the mystery of Jessica's suspected cyanide case
0:26:41 > 0:26:43is still unfolding.
0:26:43 > 0:26:47At Uxbridge Coroner's Office, pathologist Dr Ashley Fegan-Earl
0:26:47 > 0:26:52has finally received the toxicology results.
0:26:52 > 0:26:54We've got the reports from France
0:26:54 > 0:26:58that has showed the presence of cyanide.
0:26:58 > 0:26:59So I think that's quite interesting
0:26:59 > 0:27:01that the chemical probes were negative,
0:27:01 > 0:27:05and yet in the blood, which is obviously the most sensitive
0:27:05 > 0:27:07and the most important area, it's positive.
0:27:07 > 0:27:11So your cause of death is cyanide toxicity or something like that?
0:27:11 > 0:27:13We will go for 1a, cyanide intoxication.
0:27:13 > 0:27:18Hello, there, it's Diane Whiting from the Coroner's Office.
0:27:18 > 0:27:22Diane now has to pass the news to Jessica's family.
0:27:22 > 0:27:27We have confirmed cyanide intoxication.
0:27:27 > 0:27:29I know from what I've heard, you know,
0:27:29 > 0:27:33that your daughter was a very kind and caring person,
0:27:33 > 0:27:37and the likelihood is that she may have looked at the levels
0:27:37 > 0:27:39and made sure that she took a level
0:27:39 > 0:27:43that wasn't going to be injurious to people around her.
0:27:43 > 0:27:47This does mean now that we can go to inquest.
0:27:47 > 0:27:50Well, we appreciate hearing that news.
0:27:50 > 0:27:54I suspected all along, so it's not a surprise to us.
0:27:54 > 0:27:56Yeah, OK.
0:27:56 > 0:28:00Thanks so much, Diane. We appreciate the information you've given us.
0:28:00 > 0:28:02You're very welcome.
0:28:02 > 0:28:04And please feel free to call me any time
0:28:04 > 0:28:07if there's any other way in which I can help you,
0:28:07 > 0:28:10or if there's anything else you need to know. Bye.
0:28:12 > 0:28:16Well, Mum and Dad are now...
0:28:16 > 0:28:21you know, they, they have the answer,
0:28:21 > 0:28:27which...they, they knew they were going to get, I think, anyway.
0:28:27 > 0:28:32But they did say it had been a long time waiting, which of course it is,
0:28:32 > 0:28:38but we had to go through quite a long process to be sure.
0:28:38 > 0:28:41There were times when we weren't sure and now we are,
0:28:41 > 0:28:43and now they are,
0:28:43 > 0:28:48and...we can start wrapping things up.
0:28:50 > 0:28:54The coroner finally has Jessica's medical cause of death,
0:28:54 > 0:28:58but her case file may provide clues about her background,
0:28:58 > 0:29:02which could help to determine her state of mind when she died.
0:29:02 > 0:29:04In the time I've been in west London,
0:29:04 > 0:29:07I haven't come across a cyanide poisoning case before.
0:29:07 > 0:29:11Sometimes, as part of an inquiry into the death,
0:29:11 > 0:29:14we learn an awful lot about the person.
0:29:15 > 0:29:19I notice from looking at the file and at the photographs,
0:29:19 > 0:29:22that this lady created a very nice home environment,
0:29:22 > 0:29:25the flowers and artwork in the apartment.
0:29:25 > 0:29:29And I gather she was also a very keen photographer.
0:29:31 > 0:29:35It's apparent that she had a close, loving relationship,
0:29:35 > 0:29:38which, again, sometimes makes one think,
0:29:38 > 0:29:42well, if that was such an important part of their lives,
0:29:42 > 0:29:45it's difficult to understand how they can necessarily do this.
0:29:45 > 0:29:51But, of course, I'm not naive enough to think that the two can't go together.
0:29:51 > 0:29:54All of that background is really very important to us
0:29:54 > 0:29:57in concluding how she died.
0:30:06 > 0:30:09It's the morning of Fred's funeral.
0:30:11 > 0:30:14He died alone and his body lay undiscovered for two months.
0:30:18 > 0:30:21Without family or friends, it's been left to the local authority
0:30:21 > 0:30:24and undertakers to arrange the service.
0:30:30 > 0:30:34But the pews at Mortlake Crematorium are not entirely empty.
0:30:36 > 0:30:40Fred's neighbour, Novlette, who lived upstairs,
0:30:40 > 0:30:43and her mother are here to pay their respects.
0:30:43 > 0:30:49We've come to say farewell to...
0:30:49 > 0:30:52..you called him Fred, your neighbour?
0:30:52 > 0:30:55To trust him to God.
0:30:55 > 0:30:57Let's do so by starting with a prayer.
0:30:59 > 0:31:03The thing is, I didn't really know him that well.
0:31:03 > 0:31:06We was neighbours, so he lived downstairs from me,
0:31:06 > 0:31:10so I'd see him in passing, really.
0:31:10 > 0:31:13Once I hadn't seen him for maybe about a week or so,
0:31:13 > 0:31:17so I rang the doorbell, and when he opened the door he said,
0:31:17 > 0:31:20"Oh, no, don't worry about me, dear. I'm fine."
0:31:20 > 0:31:25You told me how he used to pick up your mail in the morning so,
0:31:25 > 0:31:30although he has no relatives, he has people that knew him.
0:31:30 > 0:31:33Once in a while, I would hear that he's on the phone,
0:31:33 > 0:31:37so I always used to think, "Oh, that's nice, he's speaking to his family."
0:31:37 > 0:31:39But it was actually probably just,
0:31:39 > 0:31:41you know, somebody from the electricity company.
0:31:41 > 0:31:44Now we say goodbye.
0:31:44 > 0:31:46It was over the Christmas period,
0:31:46 > 0:31:50so I'd noticed his post was sort of piling up.
0:31:50 > 0:31:54Every day I would ring the doorbell, just at different times,
0:31:54 > 0:32:00just to see if he had come home, but he wasn't answering the door.
0:32:00 > 0:32:04One evening I came home, and there was just this horrendous smell,
0:32:04 > 0:32:07you know, the worst smell I've ever experienced in my life.
0:32:07 > 0:32:11You know, I just knew something wasn't right there.
0:32:14 > 0:32:18I even felt really guilty because, you know,
0:32:18 > 0:32:22I was here in my front room, you know, just living life,
0:32:22 > 0:32:25just going about my daily business, really and, you know,
0:32:25 > 0:32:29having friends and family round, and things like that.
0:32:29 > 0:32:33And all the time he was just down there, it's just horrible to think.
0:32:33 > 0:32:35It's just not right.
0:32:38 > 0:32:41To me, it was a beautiful send-off.
0:32:41 > 0:32:44I don't know much about him personally,
0:32:44 > 0:32:49but I could only imagine he could be happy with that.
0:32:49 > 0:32:52And I feel as though his dignity,
0:32:52 > 0:32:55that, you know, that was actually...
0:32:57 > 0:32:59..regained if anything, you know.
0:33:08 > 0:33:10Thursday, 14th July.
0:33:11 > 0:33:15The West London Coroner's five-month investigation
0:33:15 > 0:33:19into the sudden death of Jessica is reaching its conclusion.
0:33:19 > 0:33:22Today, the inquest is being heard in court.
0:33:22 > 0:33:26It's a legal process steeped in history.
0:33:26 > 0:33:29Things have changed gradually over the last 800 years.
0:33:29 > 0:33:33For example, we now can't hear inquests in public houses,
0:33:33 > 0:33:34which is rather a shame.
0:33:34 > 0:33:37We don't go through the whole palaver of,
0:33:37 > 0:33:38"Oyez, oyez, all those people
0:33:38 > 0:33:42"having anything to do with the sitting of the Coroner's Court,
0:33:42 > 0:33:45"draw nigh and give your attendance, God save the Queen."
0:33:45 > 0:33:47We don't do that any more.
0:33:47 > 0:33:50When I come in, I set up the court.
0:33:50 > 0:33:53I make sure the sound equipment's working.
0:33:53 > 0:33:57The coroner has summoned six witnesses to testify...
0:33:57 > 0:34:00We've asked everyone to come for 9.45am.
0:34:00 > 0:34:02..including police and chemical specialists,
0:34:02 > 0:34:04along with pathologist Ashley Fegan-Earl.
0:34:04 > 0:34:07- Hello, Ashley.- Hi, John. How are you?- Good, thanks.
0:34:07 > 0:34:09They have to promise to tell the truth
0:34:09 > 0:34:11or swear on a holy book to tell the truth.
0:34:11 > 0:34:15We have the Koran, a Bible of course,
0:34:15 > 0:34:17an Old Testament for people of the Jewish faith.
0:34:17 > 0:34:19The Sikhs have a special holy book
0:34:19 > 0:34:23which is always kept wrapped in a cloth so that we don't touch it.
0:34:23 > 0:34:25You know, it's only for believers.
0:34:25 > 0:34:27We're ready to go. OK, that's absolutely fine.
0:34:27 > 0:34:31Please rise for Her Majesty's Coroner.
0:34:31 > 0:34:35Under English law, cameras are banned from filming in open court.
0:34:35 > 0:34:40What follows is taken from the court's own transcripts.
0:34:43 > 0:34:46The purpose of the hearing is to determine and record
0:34:46 > 0:34:50when, where and how this young lady died.
0:34:50 > 0:34:53Though the images are representative, the words are real.
0:34:53 > 0:34:56I swear by Almighty God, the evidence I shall give shall be
0:34:56 > 0:34:59the truth, the whole truth and nothing but the truth.
0:34:59 > 0:35:01Do sit down.
0:35:01 > 0:35:05The key to establishing if Jessica's death was an intentional act
0:35:05 > 0:35:08lies in understanding her state of mind.
0:35:08 > 0:35:12Her partner, who found her, is here to testify.
0:35:14 > 0:35:18I do apologise, because I know this is something of a sad reminder
0:35:18 > 0:35:19of all the events in February,
0:35:19 > 0:35:22but your evidence is very important to us.
0:35:24 > 0:35:28Obviously, you knew her well and you saw something of the illness.
0:35:28 > 0:35:32A lot of effort was required to remain
0:35:32 > 0:35:34at what normal people would consider...
0:35:34 > 0:35:36An equilibrium?
0:35:36 > 0:35:39Yeah, it was, it was difficult for her.
0:35:39 > 0:35:43And that morning I was concerned at her level of calmness,
0:35:43 > 0:35:45because that was unusual.
0:35:45 > 0:35:48Did you have any contact with her during the day?
0:35:48 > 0:35:52Yeah, she was texting me up to about 2 or 3pm.
0:35:56 > 0:36:01The night before she said, "Keep in touch tomorrow."
0:36:01 > 0:36:06As I walked through the door of the flat,
0:36:06 > 0:36:09on the door there was a note, something along the lines of,
0:36:09 > 0:36:13"Don't come in, just call the police," or something.
0:36:13 > 0:36:17And I ignored that, and...
0:36:17 > 0:36:18I think, greatly to your credit,
0:36:18 > 0:36:21you made attempts, didn't you, to resuscitate her.
0:36:21 > 0:36:22Yeah.
0:36:25 > 0:36:28And at this point it's a bit of a haze.
0:36:28 > 0:36:30Um, it-it just remains for me
0:36:30 > 0:36:33to formally record a medical cause of death,
0:36:33 > 0:36:35a brief narrative and a formal verdict.
0:36:39 > 0:36:42She had battled valiantly for many, many years
0:36:42 > 0:36:44with this devastating illness.
0:36:48 > 0:36:53So I'm going to formally record a verdict that she took her own life.
0:36:56 > 0:36:59It's not for me too presume but people are left thinking,
0:36:59 > 0:37:02"Well, was there anything we could have done to prevent it?"
0:37:02 > 0:37:04And I think the answer is no.
0:37:04 > 0:37:07In a case like this, it wasn't an impulsive gesture.
0:37:07 > 0:37:11She'd lived with a degree of unhappiness for a long, long time.
0:37:11 > 0:37:15And she was tired. And I think she made it clear.
0:37:15 > 0:37:19But she nicely made it clear also in her notes that she loved them all
0:37:19 > 0:37:21and that they must not grieve for her
0:37:21 > 0:37:24or think that they could have done any more.
0:37:24 > 0:37:27And she was at pains to point that out.
0:37:27 > 0:37:30Hello. My name is David.
0:37:30 > 0:37:33I'm Jess's younger brother and I'm speaking on behalf of all of her siblings.
0:37:33 > 0:37:38Big sisters are truly one of a kind, and Jess was no exception.
0:37:39 > 0:37:43Good morning. I'm Pat, also known as Aunt Weedy.
0:37:43 > 0:37:46Jess was a stubborn little Munchkin
0:37:46 > 0:37:48and she had no problems standing, hands on hip,
0:37:48 > 0:37:50looking up at her dad.
0:37:50 > 0:37:53It didn't faze her a bit that he was five feet taller
0:37:53 > 0:37:57and well over 200 pounds heavier.
0:37:57 > 0:38:01I will forever cherish my memory of Jessica sitting in my office
0:38:01 > 0:38:03right over there, saying,
0:38:03 > 0:38:08"Bridget, um, no-one likes boring."
0:38:10 > 0:38:13You claimed that you were no role model, but we all looked up to you.
0:38:13 > 0:38:16You taught us the definition of perseverance
0:38:16 > 0:38:19as you confronted adversity time and time again,
0:38:19 > 0:38:22and showed us the meaning of courage.
0:38:24 > 0:38:27I think this is very useful for families to know
0:38:27 > 0:38:30that we've pursued things
0:38:30 > 0:38:33and that we may be making things safer for other people.
0:38:35 > 0:38:38"I was hoping that be writing to you, I may be able to highlight
0:38:38 > 0:38:42"the dangers and try to prevent future fatalities."
0:38:45 > 0:38:47I'm writing a general letter
0:38:47 > 0:38:51to all distributors of cyanide-based products in the UK.
0:38:51 > 0:38:55I would hope that they will look at it and make more stringent checks
0:38:55 > 0:38:58about the people who are asking for it.
0:39:00 > 0:39:03I should have taken my father's advice.
0:39:03 > 0:39:05He said that I should never learn to type,
0:39:05 > 0:39:08otherwise I might find myself working as a secretary
0:39:08 > 0:39:13and he wanted to encourage me to do science or engineering of some sort, or medicine.
0:39:20 > 0:39:23Subtitles by Red Bee Media Ltd
0:39:31 > 0:39:34But he hadn't foreseen the word processor
0:39:34 > 0:39:37and how we'd be required to type anyway,
0:39:37 > 0:39:40but I'm still a two-finger typist!