Episode 1 Death Unexplained


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The inquest is the final chapter.

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For that moment, you live that case

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and you live that life and death of somebody.

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West London.

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One of the busiest coroner's jurisdictions in the country,

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with over 4,000 cases a year.

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Today, coroner Alison Thompson is about to enter court

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to solve the mystery of a young woman who was found dead at her flat.

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Sometimes we are looking more at that person's life

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than anyone else would ever have looked at.

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It's the culmination of a five-month investigation by the coroner's team.

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We are going to have to treat her as a cyanide case.

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Do we know anything about where this potassium cyanide came from?

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In court, Alison must establish the facts.

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Who was the deceased?

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When, where and how did she die?

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We're ready to go. OK, that's absolutely fine.

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When life's end is unexplained,

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the answer falls to Her Majesty's Coroner.

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Please rise for Her Majesty's Coroner.

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It's a Tuesday morning in March,

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when the coroner's investigation into Jessica's death begins.

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At Uxbridge mortuary, the technicians are preparing her

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for a routine postmortem examination.

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Coroner's office, good morning.

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In the office next door,

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Coroner's Officer Diane Whiting is following up on existing cases.

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Thank you, Doctor. Bye-bye.

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Home Office pathologist Dr Ashley Fegan-Earl

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will try to establish how Jessica died.

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Here we have a lady with bipolar, which is a risk for suicide.

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It's believed she's taken a medication overdose.

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We're going to look for any unnatural potential causes,

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any injuries to the neck, any signs of deliberate self-harm,

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any injuries to the wrists.

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If we look at this lady's arms, there are multiple healed scars.

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It's not uncommon to see a few marks on the inner aspect of the wrist,

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but in this lady, they're very extensive.

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They're passing from wrist up to the crook of the arm.

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They're also on the back and, more unusually,

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over the front of her thighs, but all indicative

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of a history of previous acts of deliberate self-harm

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and this is a relatively common finding

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with a number of suicides that we deal with.

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The other issues we're looking for is whether there's any evidence

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of third party violence. There's nothing externally of note,

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so we'll move to the internal examination now.

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Yes, OK.

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Dr Fegan-Earl is about to begin the examination

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of Jessica's internal organs when Diane calls him out of the mortuary.

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I literally put the phone down,

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scribbled the note and brought it out.

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Do you want me to get the police to go and fetch it?

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Yeah, we're not opening her today until we know.

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We will leave that and we need to find out a bit more because...

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What's the implications of potassium cyanide?

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It'll give off cyanide. We'll leave it

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and say we need more info.

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Right, would you like me to get the police to fetch the container or...

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Yeah, I want to know if it's open.

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Because if it's not open, fine.

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But if it's open, you're going to have to treat her as a cyanide case.

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It's the first time the coroner's team in west London

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has had to deal with a suspected poisoning like this.

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We had a phone call from someone who lived at the house

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to say that a pot of potassium cyanide

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had been found in her bedroom.

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They immediately stopped the postmortem examination

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because there's a real risk with certain chemicals

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that gasses might be given off, and that this could be very dangerous

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to the pathologist and the mortuary staff.

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If there is cyanide inside her, this young lady's body ought to go

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to a very special unit at St Thomas' Hospital

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where they deal with chemical deaths and that kind of thing.

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The family have booked a funeral in three days,

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so we really are racing against time on this one.

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Until a full postmortem examination can be carried out

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to establish how she died, the coroner will retain Jessica's body.

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Alison Thompson has been the coroner

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for the 1.5 million people of west London

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for the past 12 years.

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I've got a strange-shaped patch.

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I would say about 40 miles, top to bottom.

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We've got prisons, detention centres, motorways,

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big hospitals, main railway lines, airports,

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so lots of scope for people dying, I suppose, and certainly enough

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to keep us busy with just over 4,000 reported deaths a year.

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You can still get some violent crime here.

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We had an excellent Detective Chief Superintendent who used to,

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in the good old days,

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drop in for coffee and doughnuts early in the morning

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and tell me about the latest murders.

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He was great fun.

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And he said, actually,

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there's quite a lot of domestic stuff around here,

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domestic murder, and I always remember he gave me advice that,

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if you ever, by any chance, do kill your partner -

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without meaning to, of course - the best thing you can do

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is to actually ring and say you've done it as soon as you can.

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Once you start prevaricating, you've had it.

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To be fair, I'm simply not at the sharp end,

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so I don't have the difficult things to do, and I'm very thankful that

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there are other people in the system doing the difficult and dirty tasks.

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That role falls to her Coroner's Officers.

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They are, essentially, investigators of that death,

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from start to finish.

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We have at the moment ten Coroner's Officers working for us

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and I feel very fortunate to have them all.

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They are my eyes and ears.

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You need a strong stomach.

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Having to go and deal with bodies,

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sometimes bodies not in a very good condition,

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I think it's a difficult job.

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It's Monday morning,

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often the busiest day of the week for Alison's team.

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The badly decomposed body of a man has been found at a flat.

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At the scene one, of the Coroner's Officers is gathering evidence

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to help determine when he died.

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Morning, it's John Mitchell from the Coroner's Office here at Fulham.

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One of your patients, unfortunately he's passed away,

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and I need to get some medical history.

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Yes, at home. No, it's fine, thank you.

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At the court in Fulham, Coroner's Officer John Mitchell

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is trying to piece together details of Fred's life.

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It looks like he'd been there for some time.

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There are plenty of clues in Fred's fridge,

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where the food is nearly three months old.

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And he's got no other history apart from the blood pressure?

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Thank you very much. Thanks for your time. Goodbye.

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Well, he hasn't been seen at the GP since 2007.

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He's an unknown quantity as far as the doctor goes.

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Looks very much as if he probably has been there since late November.

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The police broke in, noticed the bad smell, found him,

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informed the on-call Coroner's Officer last night

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who took the details

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and organised him being bought into our mortuary in Fulham.

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There's no next of kin.

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He is 69 years of age.

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We'll organise a postmortem for him tomorrow.

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It's five o'clock the following morning at Fulham Public Mortuary.

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Manager Dave Colvin and deputy manager Lenny Browse are preparing

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for the morning's postmortem examinations.

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Visceral bag for containing the internal organs

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when they have been dissected.

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Shroud - no-one goes out naked.

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Always go out with a shroud.

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Let's see. Block, which goes under the shoulders,

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or under the head.

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Just preset everything, have it ready.

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Like anything else, the secret is in the preparation.

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Fred is one of four routine examinations to be carried out today

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by Dr Olaf Biedrzycki,

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who followed his father into forensic pathology.

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I do really enjoy coming to work, which I think I'm very privileged.

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I'm a very morning person anyway and it's a quite morning-suited job,

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so when the alarm goes at five, I do genuinely think,

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"Great, I wonder what we'll have today."

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There appears to be a beard and moustache on the face.

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The ears are not obviously pierced.

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Fingernails are 2-3mm.

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I really enjoy doing postmortems.

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And I quite enjoy the Coroner's Court side of it.

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I just enjoy doing the practical side of things.

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Parchmented abrasion to the back of the right hip measuring some 6cm

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and parchmented black abrasions to the front of each knee,

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measuring six on the left and five on the right.

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'It can be quite exciting.'

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When you're looking through bowel at lots of poo,

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all the glamour fades away very quickly.

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Having lain undiscovered for two months,

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Fred's body may present Dr Biedrzycki

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with a unique set of problems.

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When their body is decomposed, you're just trying to make sure that

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nothing horrendously untoward has happened,

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because the cause of death is probably going to be unascertained.

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When you do do a very decomposed body,

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even when you're wearing two and three pairs of gloves,

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you still have part of that smell on you for a while afterwards.

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It's very hard to get rid of.

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The eyes are partially destroyed by the decomposition process,

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but appear brown.

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I've even done a case where the body was very mummified, very desiccated,

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lots of decomposition-related holes in the body and, actually,

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when we opened up the chest there was a dead mouse within the chest.

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That's not unusual.

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The examination moves on to Fred's internal organs.

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You can just see part of the liver which,

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instead of being a lovely mahogany brown colour,

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is a very pale yellow colour.

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So this, to me, already says that this man

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is suffering from cirrhosis of the liver.

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Now, lots of causes for that but, unfortunately, in this country,

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by far the most common cause is drinking alcohol to excess.

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At Fred's flat, there was plenty of evidence of sustained alcohol use.

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So I've just started the internal examination,

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I've had a couple of helpful findings.

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I've opened the stomach,

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there's a lot of black, altered blood in there.

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It's all looking very good for a significant gastric bleed

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due to cirrhosis of the liver.

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Unusually in cases of severe decomposition,

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establishing a cause of death is looking possible.

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Fred will remain in the mortuary team's care

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while the search for his next of kin continues.

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Deep freeze at minus 20...

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..can hold a body for...

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..indefinitely.

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The longest I think we've ever held onto an individual

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was about two years.

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Over 600 inquests a year are held at West London Coroner's Court.

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These cases are the formal record of how, when and where people died.

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She was aged only 28

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and she had been found in a state of collapse at her home.

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A note found near to her

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suggested that she'd taken an overdose of medication.

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Today, Alison is hearing the inquest of a young woman

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who appears to have taken her own life.

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More than one in seven of our verdicts in west London

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is one of suicidal self-harm,

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and it has been as high as one in five.

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Hello, ma'am.

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Thanks very much for doing all this extra work on it.

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It's really very helpful. And we've got the original note now,

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-found by her dog-walker...

-Yes.

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..saying, "Do not resuscitate."

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Now she has Petra's suicide note, the coroner will able to decide

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not only how she died, but whether she meant to take her own life.

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Petra was the second-youngest of Peter's four daughters.

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She died just before Christmas.

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She was a lovely little, friendly girl, very sharp.

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Several people wrote to us at the time of her death.

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They said she brought joy into a room.

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And she did. She was that sort of girl.

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Very, very much loved.

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By all of us.

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At the age of 13, she contracted anorexia,

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which is a form of depression.

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Finally, at the end of last year,

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she'd had enough of trying to get better.

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She'd managed to get, through the Internet,

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some pretty nasty antidepressants,

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to the tune of 300.

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One morning my wife was rung up, to be told that

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she'd been found in her bedroom, on the floor, totally unconscious.

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She was in the Charing Cross resuscitation unit,

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absolutely fantastic doctors who did all they could.

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Unfortunately, one could tell she was braindead

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and one would have had to make a decision then

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whether to cut it off or not.

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Thank goodness she died, actually, from heart failure.

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But...not easy.

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It's interesting looking at the poisons information

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that the hospital were able to get, because it shows that this other drug

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is very difficult to deal with in overdose.

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So, really, from the outset, I think she was in difficulty

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and I think she was obviously an intelligent woman who knew that would be the case.

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I mean, she's giving clear instructions to people here, isn't she?

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-Is Tomasina the...

-Tomasina's the dog?

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To even sort of say, whoever takes the dog gets some money

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to look after the dog for insurance and stuff.

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Even mentioning the dog being due for a haircut.

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I mean, down to the nth degree of detail here.

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And giving money to whoever's going to look after the dog,

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and giving the PIN number for her bank account even.

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-That's the thing, isn't it, that really makes it so convincing.

-Shows it's final.

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I think it leaves us with a clear intention,

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and circumstances suggesting that she intended the outcome to be fatal.

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But, obviously, I'll look at all the evidence.

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John's going to take me into open court now, so I'm afraid

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the rules require me to respectfully ask you to leave.

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The coroner will make her final verdict on the death alone.

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Petra's family have chosen not to attend the hearing.

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I did determine that she had intended to take her life,

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and so I recorded a verdict.

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We don't tend to use the word "suicide".

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We actually write down, "The deceased took their own life."

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John now has to pass on the coroner's decision

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to Petra's family.

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We've just come out of court, having held the inquest.

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The coroner felt she had no option

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but to arrive at a verdict that Petra took her own life.

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For Petra's family, the conclusion of the coroner's investigation

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might do more than simply mark the end of this tragedy.

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I do feel there could be some benefit at the end of it,

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if there is such a word.

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And no child or... I call her a child - she's 28 -

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is able to just have available the access to taking her own life

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in this manner.

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If you want to buy any prescription drug through the Internet,

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you can do so.

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It's not legal in the European Union,

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but you can do it

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from outside anywhere.

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I will consider whether or not there is anybody I could report it to.

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I think the difficulty is regulating overseas sites.

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But it might be worth me contacting the regulatory body in this country.

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I think it's probably one of the most important features

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of what we do, actually, is prevention of other fatalities.

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It's something tangible.

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Another day is coming to an end at Uxbridge Mortuary.

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Technicians Cheryl and Cassie are tending the deceased

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and preparing the mortuary for tomorrow's cases.

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My other half, he thinks it's brilliant

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that we do this type of thing.

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He thinks it's really good. He certainly couldn't do it.

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My son's got more of an idea now about what I do,

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but my daughter thinks I send people to heaven!

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Sometimes you do get quite involved, say if it's a suicide,

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and you start feeling sorry and you really shouldn't, maybe, do that.

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You should just get on and do the job.

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You're aware that there's a family,

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that their parents are going to bury their child,

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and that's awful,

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even from a young child, to a teenager, 20s.

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And that's horrible, because life dictates

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that a parent shouldn't bury their child.

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It's meant to be the other way round.

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Coroner's Officer Diane Whiting has travelled to Fulham

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to brief the coroner on Jessica's unique case.

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-Diane, come in.

-Ma'am.

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We've got a young lady of 27 years of age,

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living with her boyfriend, who was found dead in bed, with notes left,

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and a tub of potassium cyanide was found in the room.

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Although I have to say that wasn't found until later,

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after her body had been moved over to us at Uxbridge.

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None of us realised what the dangers were.

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They're dangerous, suicides, in a sense.

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-You never...

-Fully know.

-..fully know what someone has got.

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So you just got to treat every body exactly the same

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and take precautions.

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We had one young lady who swallowed razor blades.

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I mean, that could be really dangerous if you're not aware.

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I think with the Internet, you're hearing of more and more cases

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where people are getting stuff online

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and mixing up concoctions and gassing themselves.

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And, of course, anyone else that then goes into that environment,

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be it the scene where the suicide's been committed,

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or the body itself, is at risk.

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The situation is at the moment that we were advised to move her up

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to one of the London hospitals for a postmortem examination

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Guy's and St Thomas', I think.

0:20:420:20:44

They had a detector which would have detected cyanide gases

0:20:440:20:48

had they been present, and there weren't any.

0:20:480:20:52

The chemical probes used to detect cyanide gas

0:20:520:20:55

at the specially-arranged postmortem failed to reveal

0:20:550:20:58

whether Jessica had taken the poison.

0:20:580:21:01

But, at the scene, a spoon and glass were also recovered.

0:21:010:21:07

The glass had traces of potassium cyanide on it.

0:21:070:21:11

The coroner wants to know if Jessica herself

0:21:110:21:15

left any information about what she'd taken.

0:21:150:21:18

Did the note give us any clues?

0:21:180:21:20

Did she say anything in the note?

0:21:200:21:21

No, they were, basically, sorry to family members.

0:21:210:21:27

They weren't indicative of what was in her mind.

0:21:270:21:30

Do you know what the note on the door said?

0:21:300:21:32

Don't come in, call the police.

0:21:320:21:34

Because otherwise her partner would have come in.

0:21:340:21:36

-Did the police look at her computer?

-She had used her computer

0:21:360:21:41

to research the use of potassium cyanide.

0:21:410:21:44

So we still haven't got a final cause of death yet.

0:21:440:21:48

We are still awaiting toxicology.

0:21:480:21:51

They're doing quite extensive tests.

0:21:510:21:54

Lovely, and I'll be in touch with you about that.

0:21:540:21:56

We'll speak again in three weeks.

0:21:560:21:58

-Yeah, thanks, Diane.

-Thanks. Bye-bye.

-Bye.

0:21:580:22:01

Jessica's blood samples may hold the key to how she died.

0:22:010:22:06

But, because cyanide cases are so rare,

0:22:060:22:09

the tests must take place in France.

0:22:090:22:12

It'll add another six weeks to the coroner's investigation

0:22:130:22:17

and keep Jessica's family waiting.

0:22:170:22:20

Yes, hello, it's John Mitchell from the Coroner's Office at Fulham.

0:22:230:22:28

Yes, plastic bag over his head.

0:22:280:22:30

How many witnesses do you have?

0:22:310:22:33

At Fulham coroner's office, things are proving more straightforward

0:22:330:22:37

in the case of Fred, who died alone.

0:22:370:22:40

Morning, John. Good news.

0:22:400:22:43

He's not as decomposed as we thought

0:22:430:22:46

and, actually, I managed to get a cause of death on him.

0:22:460:22:49

He's got cirrhosis of the liver

0:22:490:22:50

and a significant bleed in his bowel due to a oesophageal varices.

0:22:500:22:54

So we won't need an inquest in this case. I'm sure you'll be pleased.

0:22:540:22:57

-Brilliant news, Olaf. Super.

-Excellent.

-Thanks very much.

0:22:570:23:01

-Nice when it happens like that, occasionally.

-Exactly.

0:23:010:23:04

As Fred died of natural causes, his case won't need an inquest.

0:23:040:23:09

Establishing how he died has been surprisingly easily.

0:23:090:23:13

But locating friends and family has proved impossible.

0:23:130:23:17

I've been here five years. I think I've only had two people

0:23:170:23:21

who we've never been able to put a name on.

0:23:210:23:23

But we've had plenty of people who we've had to sort of

0:23:230:23:26

put in the hands of the local authority

0:23:260:23:29

because they've got no next of kin.

0:23:290:23:31

Can you give me a cause of death?

0:23:310:23:34

'Nine million people in London,

0:23:340:23:36

'but it can be a very lonely place if you've got no friends or family,'

0:23:360:23:40

and you're sort of, you know, you're getting on a little bit,

0:23:400:23:43

and you're holed up in your little flat with your cat,

0:23:430:23:45

and you never go out, your neighbours get your shopping,

0:23:450:23:48

and things like that, that's all too common.

0:23:480:23:51

They were walking, living, talking, breathing.

0:23:530:23:56

To us now, you know, with the most of respect, they are just shells.

0:23:560:24:01

But you still got to treat them as though they're one of your own.

0:24:010:24:04

Even if that person does not have so much as one single living soul

0:24:040:24:10

to shed a tear for them,

0:24:100:24:12

here they will be treated well.

0:24:120:24:15

So having respect for everyone, no matter what colour,

0:24:150:24:19

no matter what gender,

0:24:190:24:21

no matter what they've done in their lives, we never judge.

0:24:210:24:25

So, basically, you do the best you can, when you can.

0:24:250:24:31

Hello, it's Neil Sherry at the funeral directors.

0:24:310:24:35

I'm just ringing up about the funeral arrangements for Frederick

0:24:350:24:39

from the London Borough of Hammersmith and Fulham.

0:24:390:24:42

Right, excellent. We'll come along later on today to collect him.

0:24:420:24:47

The council have an obligation to arrange a funeral

0:24:470:24:49

if no-one else will take responsibility.

0:24:490:24:52

It's a statutory duty of every local authority.

0:24:520:24:55

It does happen quite a lot.

0:24:570:25:00

We probably do 150 local authority funerals a year

0:25:000:25:07

and out of that, I would say maybe 15-20%, there's no-one there.

0:25:070:25:13

We don't necessarily know anything about the person,

0:25:130:25:16

so we can't celebrate their life.

0:25:160:25:20

At least there is the vicar and us there for their funeral service.

0:25:200:25:24

It's the end of the day at her court in Fulham,

0:25:310:25:34

and Alison Thompson has some good news in Petra's case.

0:25:340:25:38

I'm always surprised at how many families say to us after a death,

0:25:380:25:42

you know, we just would love something good to come out of this.

0:25:420:25:46

We'd like lessons to be learned.

0:25:460:25:48

Petra took her own life by exploiting a loophole

0:25:480:25:52

to buy antidepressants on the Internet without a prescription.

0:25:520:25:57

I wrote with good effect, I think,

0:25:570:26:00

to the Medicines and Healthcare products Regulatory Agency.

0:26:000:26:05

They're monitoring the Internet for websites operating in the UK,

0:26:050:26:08

they're making test purchases from the Internet

0:26:080:26:11

so they can monitor more effectively,

0:26:110:26:13

and they say that, really, they've got two jobs.

0:26:130:26:16

One is enforcement to prevent the sale from illegal websites,

0:26:160:26:20

but also education.

0:26:200:26:22

It's not bringing anybody back, but it does help families to know

0:26:220:26:26

that it's been taken seriously and that some good may come of it.

0:26:260:26:31

Four months after her death,

0:26:360:26:38

and the mystery of Jessica's suspected cyanide case

0:26:380:26:41

is still unfolding.

0:26:410:26:43

At Uxbridge Coroner's Office, pathologist Dr Ashley Fegan-Earl

0:26:430:26:47

has finally received the toxicology results.

0:26:470:26:52

We've got the reports from France

0:26:520:26:54

that has showed the presence of cyanide.

0:26:540:26:58

So I think that's quite interesting

0:26:580:26:59

that the chemical probes were negative,

0:26:590:27:01

and yet in the blood, which is obviously the most sensitive

0:27:010:27:05

and the most important area, it's positive.

0:27:050:27:07

So your cause of death is cyanide toxicity or something like that?

0:27:070:27:11

We will go for 1a, cyanide intoxication.

0:27:110:27:13

Hello, there, it's Diane Whiting from the Coroner's Office.

0:27:130:27:18

Diane now has to pass the news to Jessica's family.

0:27:180:27:22

We have confirmed cyanide intoxication.

0:27:220:27:27

I know from what I've heard, you know,

0:27:270:27:29

that your daughter was a very kind and caring person,

0:27:290:27:33

and the likelihood is that she may have looked at the levels

0:27:330:27:37

and made sure that she took a level

0:27:370:27:39

that wasn't going to be injurious to people around her.

0:27:390:27:43

This does mean now that we can go to inquest.

0:27:430:27:47

Well, we appreciate hearing that news.

0:27:470:27:50

I suspected all along, so it's not a surprise to us.

0:27:500:27:54

Yeah, OK.

0:27:540:27:56

Thanks so much, Diane. We appreciate the information you've given us.

0:27:560:28:00

You're very welcome.

0:28:000:28:02

And please feel free to call me any time

0:28:020:28:04

if there's any other way in which I can help you,

0:28:040:28:07

or if there's anything else you need to know. Bye.

0:28:070:28:10

Well, Mum and Dad are now...

0:28:120:28:16

you know, they, they have the answer,

0:28:160:28:21

which...they, they knew they were going to get, I think, anyway.

0:28:210:28:27

But they did say it had been a long time waiting, which of course it is,

0:28:270:28:32

but we had to go through quite a long process to be sure.

0:28:320:28:38

There were times when we weren't sure and now we are,

0:28:380:28:41

and now they are,

0:28:410:28:43

and...we can start wrapping things up.

0:28:430:28:48

The coroner finally has Jessica's medical cause of death,

0:28:500:28:54

but her case file may provide clues about her background,

0:28:540:28:58

which could help to determine her state of mind when she died.

0:28:580:29:02

In the time I've been in west London,

0:29:020:29:04

I haven't come across a cyanide poisoning case before.

0:29:040:29:07

Sometimes, as part of an inquiry into the death,

0:29:070:29:11

we learn an awful lot about the person.

0:29:110:29:14

I notice from looking at the file and at the photographs,

0:29:150:29:19

that this lady created a very nice home environment,

0:29:190:29:22

the flowers and artwork in the apartment.

0:29:220:29:25

And I gather she was also a very keen photographer.

0:29:250:29:29

It's apparent that she had a close, loving relationship,

0:29:310:29:35

which, again, sometimes makes one think,

0:29:350:29:38

well, if that was such an important part of their lives,

0:29:380:29:42

it's difficult to understand how they can necessarily do this.

0:29:420:29:45

But, of course, I'm not naive enough to think that the two can't go together.

0:29:450:29:51

All of that background is really very important to us

0:29:510:29:54

in concluding how she died.

0:29:540:29:57

It's the morning of Fred's funeral.

0:30:060:30:09

He died alone and his body lay undiscovered for two months.

0:30:110:30:14

Without family or friends, it's been left to the local authority

0:30:180:30:21

and undertakers to arrange the service.

0:30:210:30:24

But the pews at Mortlake Crematorium are not entirely empty.

0:30:300:30:34

Fred's neighbour, Novlette, who lived upstairs,

0:30:360:30:40

and her mother are here to pay their respects.

0:30:400:30:43

We've come to say farewell to...

0:30:430:30:49

..you called him Fred, your neighbour?

0:30:490:30:52

To trust him to God.

0:30:520:30:55

Let's do so by starting with a prayer.

0:30:550:30:57

The thing is, I didn't really know him that well.

0:30:590:31:03

We was neighbours, so he lived downstairs from me,

0:31:030:31:06

so I'd see him in passing, really.

0:31:060:31:10

Once I hadn't seen him for maybe about a week or so,

0:31:100:31:13

so I rang the doorbell, and when he opened the door he said,

0:31:130:31:17

"Oh, no, don't worry about me, dear. I'm fine."

0:31:170:31:20

You told me how he used to pick up your mail in the morning so,

0:31:200:31:25

although he has no relatives, he has people that knew him.

0:31:250:31:30

Once in a while, I would hear that he's on the phone,

0:31:300:31:33

so I always used to think, "Oh, that's nice, he's speaking to his family."

0:31:330:31:37

But it was actually probably just,

0:31:370:31:39

you know, somebody from the electricity company.

0:31:390:31:41

Now we say goodbye.

0:31:410:31:44

It was over the Christmas period,

0:31:440:31:46

so I'd noticed his post was sort of piling up.

0:31:460:31:50

Every day I would ring the doorbell, just at different times,

0:31:500:31:54

just to see if he had come home, but he wasn't answering the door.

0:31:540:32:00

One evening I came home, and there was just this horrendous smell,

0:32:000:32:04

you know, the worst smell I've ever experienced in my life.

0:32:040:32:07

You know, I just knew something wasn't right there.

0:32:070:32:11

I even felt really guilty because, you know,

0:32:140:32:18

I was here in my front room, you know, just living life,

0:32:180:32:22

just going about my daily business, really and, you know,

0:32:220:32:25

having friends and family round, and things like that.

0:32:250:32:29

And all the time he was just down there, it's just horrible to think.

0:32:290:32:33

It's just not right.

0:32:330:32:35

To me, it was a beautiful send-off.

0:32:380:32:41

I don't know much about him personally,

0:32:410:32:44

but I could only imagine he could be happy with that.

0:32:440:32:49

And I feel as though his dignity,

0:32:490:32:52

that, you know, that was actually...

0:32:520:32:55

..regained if anything, you know.

0:32:570:32:59

Thursday, 14th July.

0:33:080:33:10

The West London Coroner's five-month investigation

0:33:110:33:15

into the sudden death of Jessica is reaching its conclusion.

0:33:150:33:19

Today, the inquest is being heard in court.

0:33:190:33:22

It's a legal process steeped in history.

0:33:220:33:26

Things have changed gradually over the last 800 years.

0:33:260:33:29

For example, we now can't hear inquests in public houses,

0:33:290:33:33

which is rather a shame.

0:33:330:33:34

We don't go through the whole palaver of,

0:33:340:33:37

"Oyez, oyez, all those people

0:33:370:33:38

"having anything to do with the sitting of the Coroner's Court,

0:33:380:33:42

"draw nigh and give your attendance, God save the Queen."

0:33:420:33:45

We don't do that any more.

0:33:450:33:47

When I come in, I set up the court.

0:33:470:33:50

I make sure the sound equipment's working.

0:33:500:33:53

The coroner has summoned six witnesses to testify...

0:33:530:33:57

We've asked everyone to come for 9.45am.

0:33:570:34:00

..including police and chemical specialists,

0:34:000:34:02

along with pathologist Ashley Fegan-Earl.

0:34:020:34:04

-Hello, Ashley.

-Hi, John. How are you?

-Good, thanks.

0:34:040:34:07

They have to promise to tell the truth

0:34:070:34:09

or swear on a holy book to tell the truth.

0:34:090:34:11

We have the Koran, a Bible of course,

0:34:110:34:15

an Old Testament for people of the Jewish faith.

0:34:150:34:17

The Sikhs have a special holy book

0:34:170:34:19

which is always kept wrapped in a cloth so that we don't touch it.

0:34:190:34:23

You know, it's only for believers.

0:34:230:34:25

We're ready to go. OK, that's absolutely fine.

0:34:250:34:27

Please rise for Her Majesty's Coroner.

0:34:270:34:31

Under English law, cameras are banned from filming in open court.

0:34:310:34:35

What follows is taken from the court's own transcripts.

0:34:350:34:40

The purpose of the hearing is to determine and record

0:34:430:34:46

when, where and how this young lady died.

0:34:460:34:50

Though the images are representative, the words are real.

0:34:500:34:53

I swear by Almighty God, the evidence I shall give shall be

0:34:530:34:56

the truth, the whole truth and nothing but the truth.

0:34:560:34:59

Do sit down.

0:34:590:35:01

The key to establishing if Jessica's death was an intentional act

0:35:010:35:05

lies in understanding her state of mind.

0:35:050:35:08

Her partner, who found her, is here to testify.

0:35:080:35:12

I do apologise, because I know this is something of a sad reminder

0:35:140:35:18

of all the events in February,

0:35:180:35:19

but your evidence is very important to us.

0:35:190:35:22

Obviously, you knew her well and you saw something of the illness.

0:35:240:35:28

A lot of effort was required to remain

0:35:280:35:32

at what normal people would consider...

0:35:320:35:34

An equilibrium?

0:35:340:35:36

Yeah, it was, it was difficult for her.

0:35:360:35:39

And that morning I was concerned at her level of calmness,

0:35:390:35:43

because that was unusual.

0:35:430:35:45

Did you have any contact with her during the day?

0:35:450:35:48

Yeah, she was texting me up to about 2 or 3pm.

0:35:480:35:52

The night before she said, "Keep in touch tomorrow."

0:35:560:36:01

As I walked through the door of the flat,

0:36:010:36:06

on the door there was a note, something along the lines of,

0:36:060:36:09

"Don't come in, just call the police," or something.

0:36:090:36:13

And I ignored that, and...

0:36:130:36:17

I think, greatly to your credit,

0:36:170:36:18

you made attempts, didn't you, to resuscitate her.

0:36:180:36:21

Yeah.

0:36:210:36:22

And at this point it's a bit of a haze.

0:36:250:36:28

Um, it-it just remains for me

0:36:280:36:30

to formally record a medical cause of death,

0:36:300:36:33

a brief narrative and a formal verdict.

0:36:330:36:35

She had battled valiantly for many, many years

0:36:390:36:42

with this devastating illness.

0:36:420:36:44

So I'm going to formally record a verdict that she took her own life.

0:36:480:36:53

It's not for me too presume but people are left thinking,

0:36:560:36:59

"Well, was there anything we could have done to prevent it?"

0:36:590:37:02

And I think the answer is no.

0:37:020:37:04

In a case like this, it wasn't an impulsive gesture.

0:37:040:37:07

She'd lived with a degree of unhappiness for a long, long time.

0:37:070:37:11

And she was tired. And I think she made it clear.

0:37:110:37:15

But she nicely made it clear also in her notes that she loved them all

0:37:150:37:19

and that they must not grieve for her

0:37:190:37:21

or think that they could have done any more.

0:37:210:37:24

And she was at pains to point that out.

0:37:240:37:27

Hello. My name is David.

0:37:270:37:30

I'm Jess's younger brother and I'm speaking on behalf of all of her siblings.

0:37:300:37:33

Big sisters are truly one of a kind, and Jess was no exception.

0:37:330:37:38

Good morning. I'm Pat, also known as Aunt Weedy.

0:37:390:37:43

Jess was a stubborn little Munchkin

0:37:430:37:46

and she had no problems standing, hands on hip,

0:37:460:37:48

looking up at her dad.

0:37:480:37:50

It didn't faze her a bit that he was five feet taller

0:37:500:37:53

and well over 200 pounds heavier.

0:37:530:37:57

I will forever cherish my memory of Jessica sitting in my office

0:37:570:38:01

right over there, saying,

0:38:010:38:03

"Bridget, um, no-one likes boring."

0:38:030:38:08

You claimed that you were no role model, but we all looked up to you.

0:38:100:38:13

You taught us the definition of perseverance

0:38:130:38:16

as you confronted adversity time and time again,

0:38:160:38:19

and showed us the meaning of courage.

0:38:190:38:22

I think this is very useful for families to know

0:38:240:38:27

that we've pursued things

0:38:270:38:30

and that we may be making things safer for other people.

0:38:300:38:33

"I was hoping that be writing to you, I may be able to highlight

0:38:350:38:38

"the dangers and try to prevent future fatalities."

0:38:380:38:42

I'm writing a general letter

0:38:450:38:47

to all distributors of cyanide-based products in the UK.

0:38:470:38:51

I would hope that they will look at it and make more stringent checks

0:38:510:38:55

about the people who are asking for it.

0:38:550:38:58

I should have taken my father's advice.

0:39:000:39:03

He said that I should never learn to type,

0:39:030:39:05

otherwise I might find myself working as a secretary

0:39:050:39:08

and he wanted to encourage me to do science or engineering of some sort, or medicine.

0:39:080:39:13

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0:39:200:39:23

But he hadn't foreseen the word processor

0:39:310:39:34

and how we'd be required to type anyway,

0:39:340:39:37

but I'm still a two-finger typist!

0:39:370:39:40

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