Episode 3 Death Unexplained

Today is relatively unusual. Mostly with train cases, you have a very clear deliberate act.

West London.

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

with over 4,000 cases a year.

He gets almost sucked into the train.

Today, Coroner Alison Thompson is about to enter court,

to resolve the mystery of a young man who was hit by a train.

Hanging around on a platform, plucking up courage,

is quite consistent. We see that a lot.

It's the culmination of a nine-month investigation by the Coroner's team.

It happens so quickly. You can already see the train coming.

In court, Alison must establish the facts.

Who was the deceased?

When, where and how did he die?

When life's end is unexplained,

the answer falls to Her Majesty's Coroner.

Court rise.

March 2011.

British Transport Police pass the case of the young Polish man

to the Coroner's Office.

Coroner's Officer, Shirley Stewart,

is trying to retrace the man's final fatal steps with PC Steve Tucker.

This is the CCTV taken from the station

and it shows the deceased getting off the train

and arriving at Hangar Lane Station.

Have we established where he's been before he gets here?

Yeah, he'd been drinking after work in the Park Royal area.

By all accounts, he's not a big drinker.

He doesn't drink, he's not a boozer.

What he appears to do, for whatever reason,

he gets off the train here, one stop too early.

You'll see him just taking a seat now.

He gets off that train, and he sits down.

And he just stays there for 35 minutes.

His head goes back

and he basically settles down for a nice little sleep.

See, it's a classic pose really.

It's running fast, we see people going about their business.

People going up to him.

You see members of the public going up to him.

What can you do? He's asleep.

Watch in a minute, and you'll see, he starts to wake up.

There, you see, he starts to get up, and the trouble he has getting up.

He's got no balance, and when he does get to his feet,

he doesn't stay there long.

Oh dear.

Straight down onto the platform.

Seeing that the man is in trouble, two bystanders try to help.

They've been interviewed by PC Tucker.

They can tell he smells of drink, he's not with it.

And then, up to the end there,

you can quite clearly see in that shot there,

he's stood right in front of those barriers.

Those barriers, they're those swing gates that open.

They say, "don't go beyond this point, high voltage,

"trespassers will be prosecuted, staff only."

Ignoring the warnings, the man walks straight through the gates...

and onto the tracks.

The two bystanders implore him to come back.

He doesn't listen.

It happens so quickly. You can see the train coming.

There we go.

Now, we've got no footage of the impact. None at all, there's no cameras covering it.

But his final moments were seen by the two bystanders,

who are clearly distraught.

He's fallen to the floor

and dragged up against the platform, he impacts the platform.

The Coroner needs to establish why the young man

ignored the warnings and walked through the gates.

She'll need to decide if he meant to take his own life,

or whether it was a tragic accident.

Clearly, I accept you could interpret the fact

that somebody is on railway tracks

and isn't coming back when encouraged to do so

by members of the public, as possibly an act of self-harm.

It's the start of a new week at Fulham Coroner's Office.

Coroner's Office, can I help you?

John Mitchell, Coroner's Office.

With a high volume of deaths to deal with from the weekend,

it's often the busiest time.

First of all, may I pass on my condolences.

And don't hesitate to call if you want to know anything.

Because of the amyl nitrate that was found with him,

we have to do a postmortem.

Forensic Pathologist Dr Olaf Biedrzycki

is performing his third postmortem examination of the day.

Our next is Michael Downey, 3782011.

The body is that of a white male,

medium build with no hypostatise

and no significant signs of decomposition.

Now, this poor gentleman

may have a condition called asbestosis.

Each year, the West London Coroner investigates some 30 cases of industrially related deaths.

One of the biggest killers is asbestos.

As a plasterer in the '60s and '70s,

Michael may have been exposed to the toxic building material.

Just opened up the trachea and the right main bronchus,

and as I'm squeezing, I can see pus within the airways.

This is what we call bronchial pneumonia.

And it's a direct consequence of his diseased lungs.

But Michael's pneumonia does not confirm asbestosis.

So, Doctor Biedrzycki is cutting small lung samples

to send for specialist analysis.

They'll look for fibres invisible to the naked eye.

We're just going to take five pieces of lung tissue

to look for the asbestos bodies, and to quantify how many there are.

Dr Biedrzycki's conclusions are not only important for the Coroner,

they'll help Michael's family to determine whether his job contributed to his death.

I think the family are deserving of knowing more about it

and nationally, we need to know more about it.

It's on the increase and it's expected to peak around 2020.

During the 1950s and '60s,

it was in widespread use as an insulating material,

an industry where people were not aware

of the horrible consequences of it.

With the examination complete,

deputy mortuary manager Lenny Browse can prepare Michael to be returned to his family.

Even after 20 years in the job, Lenny still wonders

about the personalities of the people in his care.

When someone dies, and is required to have an examination,

you still get remembered as a human being.

'Human beings are more than a physical form.

'Your voice, the way you turn in your sleep.

'Once was toddling away, short trousers,

'school cap and blazer.'

What made them laugh? What were they allergic to?

Did they like dancing?

I assumed that when he died, he'd just got, you know, old and tired.

When I heard his body had gone to the Coroner's Office,

I was surprised and I thought, what's that about?

Michael lived in West London with his family.

He leaves two daughters and three grandchildren,

daughter Mandy and granddaughter Bonnie have fond memories of him.

'He used to laugh so much, he used to bring tears to his eyes,

'and it made everybody else laugh, didn't it?

'Yeah, he had an infectious laugh.'

Christmas, obviously Christmas day, I don't know where you was actually.

That's a quite a nice one of Dad, isn't it?

'He was a good dad. He was a good dad, I loved him,'

I was very close to him

and he was good to Bonnie, used to babysit for Bonnie.

Shall I tell them about the time we went to the pub?

I hadn't seen him for a couple of months.

We walked in the pub to see him,

and he turned round to my dad.

I'd lost quite a lot of weight and he turned round to my dad

and he went, "Oh Mark, she's got that disease,

"she's got that anaraxia, she's got that anaraxia."

I was like, "Granddad, it's called anorexia, and no, I haven't got it."

He had lots of friends, he used to like going to the pub

and have his pints of Guinness, which was his favourite tipple.

-Guinness was his favourite tipple.

-And a bit of brandy.

If the asbestos contributed towards his death, that's very sad,

because I know he worked very hard, obviously he worked hard for us,

for his family, and actually he was putting himself at high risk.

February 2011.

A devastating earthquake in New Zealand.

The country's Prime Minister calls it "the darkest day".

Christchurch, the country's second city,

is hit by a powerful earthquake.

'There's obvious concern for British citizens.

'Can you give us any news? Is it still too early to say?'

The city is popular with British backpackers

and home to many ex-pats.

Yes, it's John, from Fulham.

Coroner's emailed me to say we may have up to six victims coming back from New Zealand.

Alison is one of Britain's leading disaster specialists,

with experience from 9/11,

the Bali bombing and the Boxing Day Tsunami.

We need to be able to react very quickly in West London,

because we have Heathrow in our patch.

There are commonly repatriations from mass fatalities

and we have to be ready to respond to anything that we're given.

We need to know what flight they're on,

the time they're arriving at the mortuary,

and be sitting in court and opening the inquest.

With the tsunami, we would maybe have five or six a day.

We built out a whole extension, right out here, to the street

and just had to expand the site to accommodate all the victims.

It is imperative the victims are correctly identified.

Therefore the part we play in that here is important.

We have had coffins come back with the wrong people in them

and we've put that right, and also if you make one mistake

in the identification process it throws out the whole thing.

There's a team gone out with a view to making sure that all of the identification is correct.

Alison will work closely with the British team in New Zealand.

Commander Nick Bracken of the Metropolitan Police

is already on the scene.

Hello, Richard. Nick Bracken. Are you at the mortuary?

Cmdr Bracken is leading the British operation.

He's Alison's eyes and ears on the ground

and has worked closely with her on previous disasters.

Bodies have been burnt in this scenario.

There are the kind of crush and damage injuries

that present the problems in identification,

and where mistakes can be made.

The team is working at a military base several miles out of the city.

If there are British dead, they'll be identified here.

I think anyone has real sympathy to anybody who's lost a loved one

and they will always work as hard as they can to get loved ones recovered.

It is very, very difficult and that wait must be absolutely agonising for the families.

And there is every likelihood, given the number of British people that do live and work here

and of course the high level of British tourists who come to this beautiful city.

Press reports suggest that up to 10 Britons may be missing.

One of those is 41-year-old Phil Coppeard,

whose parents Barbara and Barry live in Suffolk.

-I think you put the radio on at 6:30.

-Put the radio on at 6:30.

-And heard...

-And heard that there'd been an earthquake in Christchurch.

And obviously then we were immediately trying to contact Philip

and there was no answer to his phone.

He was extremely loyal and...

-..caring.

-Very caring. Fairly strong willed.

Very strong willed!

As they say in this part of the country,

he was a good little old boy.

THEY CHUCKLE

After a career in the City, Phil and his wife Suzanne,

who was from New Zealand, decided to settle in Christchurch.

They actually married in England four years ago,

but we flew out immediately and had a church blessing in Christchurch.

And they had bought a house in New Zealand anyway, and they decided

about two years ago that they would change their lifestyle completely.

They weren't materialistic. The money... They weren't after all that,

they just wanted a simpler, easier lifestyle.

Phil and his wife had been living in Christchurch for just six months.

He had recently started a degree course.

On the day of the earthquake, he left home to catch a bus to university,

but was not seen after that.

His wife Suzanne was interviewed by local radio.

When did you last see Phil?

He left home some time between 12:15 and 12:30.

He was still, you know, working out bus timetables and how long it would take to get to university,

so he wanted to make sure that he was on time.

The bus that took Phil to university was a number 702.

A bus of that number was crushed by a building

that collapsed in the earthquake.

My husband is not the usual university student age, he's 41.

The phone for a long time after the quake was ringing and ringing and then going to voicemail.

I'm just struggling to get information, and we just really want Phil to come back.

He'd phoned us about an hour or two before he got on the bus,

he was going off for his second day at university,

told us all about what had happened on the first day.

We didn't know if he was still on the bus under the rubble,

we didn't know if he was alive or not at that time,

and didn't know if he was badly injured in a hospital somewhere, so...

With hundreds still missing,

this city is bracing itself for even further loss.

On the other side of the world in London, the Coroner's team

are still waiting for news of British victims.

Progress is being made in the case of the young Polish man

hit by an underground train.

In Uxbridge, forensic pathologist Dr Ashley Fegan-Earl

has completed his postmortem report.

The cause of death is unlike the majority of railway fatalities.

It is a bit of a more unusual one.

As I understand it, it's managed to pinion him between the tracks,

as it were, and the...something called the shoe of the train.

What it's actually done as a consequence is pinioned his chest,

preventing any of the normal movements of breathing, resulting in this traumatic asphyxia.

We can see that from the petechial haemorrhages that are present in his eyes.

The postmortem has revealed that the man's liver was undamaged,

corroborating accounts that he was not a regular drinker.

There's certainly no changes in his liver that would suggest that.

The exact effects of drink on any one individual are obviously going to

depend on how used to drinking they are.

Toxicology results from St George's, University of London,

reveal that the man had alcohol concentrations

five times higher than the legal drink-drive limit.

They have been passed to Coroner's Officer Shirley Stewart.

The alcohol has been absorbed into the bloodstream so the concentration

in the urine is higher than in the blood, which indicates to us

that this is someone who's been drinking over a several-hour period.

I do know that he was self-employed here in the UK

working as a carpenter, and that he was a very reliable worker.

And he'd been at work the day before he died.

And whilst he was at work he was saying that he felt quite unwell

and wasn't sure whether or not he was going to go in the next day.

Life in Poland prior to coming to the UK, we have very little,

other than the fact that he was a happily married man, with a two-year old son.

There was no evidence at postmortem that he was suffering any natural disease or illness

that has either caused or contributed to his death, so it's really very tragic.

The Coroner has yet to decide

if the young man's death was accidental or deliberate.

But, for mortuary technicians like Cassie,

the latter is all too familiar.

We went through a patch here of a lot of Polish...young Polish gentlemen hanging themselves,

I presume...coming over to start a new life, and earn money,

and it obviously didn't work out for a lot of them and we went through a stage of having a huge number.

Probably...why would there be more men?

I guess there's more financial pressure on men -

you know, to run a family, to run a home.

Not that I'm being sexist,

but I would say there's probably more pressure on a gentleman.

I just find it very sad. I find it sad for the family.

There are now over half a million Polish people living in the UK

and West London is a major hub for the community.

When deaths occur, they're dealt with by Monika Panasiuk of the Polish Embassy...

Monika.

..who liaises between the Coroner's Office and bereaved families.

Sometimes people, they have never heard even such a word, coroner,

because in Polish there is no such a word, coroner.

They're asking, "Coroner, Coroner? What is it, who is it?"

Also I can tell you one thing, that in Poland there is a tradition

that the...person who died is buried very quickly.

Even after one, two days after death.

Hello?

Shirley. Shirley's on the line.

Hello, Monika, it's Shirley from the Coroner's Office.

Shirley is preparing for the court inquest into the young man's death.

His wife lives in Poland and has been asked if she wants to attend.

-And she told us that she's not going to be come.

-'So she's not going to be attending. OK.'

-No.

'There's probably also the matter of money, and the matter of organising the family life,

'so that's why she's not coming.'

However, her friend, or their friend, is going to attend.

The Coroner often likes to have somebody that can actually

tell us who that person was in life,

and what their dreams and aspirations were.

And, you know, just what their life expectations

and who they were as a person,

and I also think it's always very nice to have that on record as well.

The reasons people are taking their own life,

it's probably the expectation.

Or different reality, if they met here.

Also they feel lonely.

They have troubles and they have no-one to talk about this.

Because someone appeared to be a satisfied, reliable person

who seems to have settled in the UK, it may be that at inquest

somebody will turn round to say, "Well, actually, that's not the case."

Probably it was suicide. Well, we'll see what the Coroner says.

So we will see.

Dr Olaf Biedrzycki is at the pathology lab at Queen Mary, University of London.

He's here to continue the investigation into how former plasterer Michael Downey died.

Michael's lung tissue has been prepared for detailed forensic examination.

Dr Biedrzycki takes each section of the sample

to count the number of asbestos fibres.

They are quite hard to find,

and to fulfil a diagnosis of asbestosis,

we need to find at least two asbestos bodies per centimetre squared of the tissue.

The problem we have is that we haven't got enough asbestos bodies

to substantiate the diagnosis.

After weeks of extensive testing, there's insufficient evidence

to determine whether Michael's exposure to asbestos caused his death.

Six months after he died, Michael's case is at its conclusion.

There is a danger that if we didn't get involved,

these deaths would be lost under the title of chronic respiratory disease,

chronic lung disease, whatever, but we are able to bring them

out of that general category into a category of their own,

labelled as industrial disease, and therefore we're able to predict

that we're going to hit a peak in 2020

and we need to be preparing for treating those patients over the next 10 years

and giving them the best quality of life that we can.

For my Granddad, who in baptism was given the pledge of eternal life,

that he now may be admitted to the company of the saints.

This is a copy of a letter that was sent to my Auntie Maureen.

"I'm very sorry to hear about Mick. He was larger than life and very funny.

"He was fun to drink with, God love him.

"There are so many people who act like we live in an artificial world.

"When I think back as a kid, I remember...

"I remember the local characters that made the difference.

"To me they were the colours, the bright colours to a dull, boring canvas.

"Michael was a bright colour."

And that's from America. From my dad's first cousin.

Two Britons are known to have died in the earthquake that struck the city of Christchurch in New Zealand.

In total, 102 people are known to have died,

although more than 200 are still missing,

but hopes of finding more survivors are already fading.

Nearly two weeks after the earthquake,

missing Briton Phil Coppeard has still not been identified.

The grim task being undertaken at a military base is painstaking forensic work.

It's an agonising wait for anxious families.

Until the identification process was followed through

right to the end, we couldn't say a word to anybody.

We couldn't say Phil was dead because we didn't know for certain.

And that was the most horrible time.

For the postmortem examinations,

a temporary mortuary has been organised in an army hangar.

Complete bodies and unidentified remains are stored in refrigerated containers.

Because of the nature of the disaster,

much of the identification work falls to forensic experts.

Dr Chris Briggs is an Australian forensic anthropologist.

It's very important to measure the diameters of certain bones

and that will provide information in relation to the age,

the sex and the ethnicity of the people who've died here.

Many of the victims were very badly burnt.

And it's very easy for those remains to become mixed up with adjacent remains

and also with building material, so at times it's very difficult

to distinguish human from non-human from building material.

Most mass fatality incidents, of the four questions we answer - "Who, when, where, how?" -

"who" is the most important.

The other part of the identification process is obtaining antemortem information.

Toothbrushes, hairbrushes,

anything that might contain DNA or fingerprints from the missing person, is obtained from their home.

People will always be critical of the length of time it takes to do

the identification work, and I think we have to stress from an early stage

that it really has to take time, it can't be rushed, it's really important that we get it right.

Personal items such as keys and watches are taken from the remains.

Medical and dental records are trawled through,

all with the aim of providing a match with the postmortem evidence.

They took DNA from the house, and then

they asked for dental records, but he'd got absolutely perfect teeth.

He'd never had - although he hadn't been very meticulous about cleaning his teeth -

he had had no fillings as a child,

no treatment at all, but he had no outstanding identification marks.

He had no tattoos or anything.

It was extremely frustrating, but there was nothing we could do.

As so many nationalities are involved, the coroner's process for identifying British victims

is now going to have to take place in New Zealand.

In a corner of the army building, a small room transformed into a temporary Coroner's Court

houses the most important part of the process.

Coroner Sue Johnson presides over the hearings in which postmortem and antemortem information are matched.

Do you swear that the evidence you are about to give

-will be the truth, the whole truth and nothing but the truth?

-Yes, I do.

-Thank you.

The evidence I have received consists of fingerprint comparison,

property comparison and some circumstantial evidence.

What happens in here, if that evidence is sufficient to establish

the identity of that body, then we can then say,

"This body that's only had a number has now got a name."

And that's a very...poignant moment.

In this way, the earthquake victim given the number DVI 15720

was proved to be Phil Coppeard.

When they asked about identification and we said he'd had one ear pierced

and we couldn't remember... you can see it in that photo.

It was his left ear. THEY CHUCKLE

Two weeks after the earthquake,

Barbara and Barry were given confirmation of Phil's death by his wife Suzanne.

Mm.

She had promised that she would phone us. I made her promise that she would phone us.

And so...she phoned us

and told us that it was confirmed that Phil was dead.

The fallen building that crushed the bus Phil was on

had been badly damaged after a smaller earthquake the previous year.

The traffic passing the building was not restricted that morning.

At the Coroner's inquest in New Zealand

it was revealed that he died of multiple injuries.

I was just glad to know that he was...

if you like, in a perverse sort of way, that he was safe.

You know, that he was...

I presume, you would have known that they treated people, I'm sure, with dignity

and that...he was...safe.

Not safe and alive, but safe.

Phil's family decided that he should rest in New Zealand,

the country he had wanted to make his home.

He was one of 20 British citizens

who died as a result of the Christchurch earthquake.

None were repatriated to the UK.

We have to remain involved where we've got British nationals killed overseas.

I don't think we could have predicted any of the incidents that we've dealt with

but they always have to be adapted to the particular circumstances

of the disaster you're dealing with, and no two of them are ever the same.

It's a safeguard. It's a safeguard that hopefully exists

whether you die here or overseas.

And then it's an entitlement for the family to know exactly what happened,

and I hope that that is reassuring to them,

that we're able to do that for them.

The date of the court hearing into the death of the young Polish man has now been set.

PC Steve Tucker from the British Transport Police has been called as a witness.

Five months after he handed the case to the Coroner's Office,

he's revisiting the scene of the incident.

This is the...end of the platform.

Leads to the tracks beyond.

This is where it happened.

Two types of signs here, signs that tell you it's dangerous and signs that tell you it's illegal.

We have no idea why he would go through these gates and down there.

'This is Hangar Lane.

'Please mind the gap between the train and the platform.'

And the loss is...is terrible.

His wife's a widow, his child's not got a father,

and...all in the blink of an eye.

It's September 2011, nine months after the young man's death.

Today, the court inquest will finally establish

whether it was a deliberate act or a terrible accident.

I think there's always that edge before you go into court.

I've got the Polish Embassy to liaise with the family, because obviously I don't speak Polish.

No. You barely speak English!

Here you're doing all the hard work.

You're taking the witness through their evidence, you need to have read it.

The young man's family will not be attending from Poland.

But the two key witnesses, who saw how he died, are here.

You've got to assess how long a witness is going to take, it's got to look slick.

You finish one witness, you're on to the next.

This is the court room itself.

Now, the Coroner comes through the door at the side there.

Do they need a break, is somebody looking tired?

And I need to establish if you're going to swear on the Bible or if you'd prefer to affirm?

I get a fair amount of adrenaline going, maybe that helps you do the job properly.

Court rise.

The inquest this afternoon concerns the death of Mr Marcin...

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

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

And the purpose of the hearing is to determine and record how this young man died.

Though the images are representative,

the words are real.

Now, I'm going to hear from two eyewitnesses, Mr Cristou and Mr Humphries, who I assume are here.

I swear by Almighty God that the evidence I shall give...

-I, David Humphries, do solemnly...

-And nothing but the truth.

As Pete and I were standing talking, waiting for the train to arrive,

we heard some sort of impact noise behind us.

It was certainly loud enough to catch our attention from a few yards away.

Pete and I went over to him and asked him if he was OK.

He wasn't aggressive towards us in any way

but he wasn't interested very much in our help.

We tried to give him his phone and bag back but he didn't take any notice of that.

He didn't have any interest in getting those back from us.

-He didn't seem interested in getting his possessions back?

-No.

We saw him walking down towards the very end of the platform,

through the barrier.

We were calling to him to come back, and don't be stupid.

Pete and I went through the gate and followed him down.

-So you followed him as well?

-Yeah, yeah.

He kind of turned around to us,

the force of the train kind of span him round.

Some part of the train seemed to catch his clothing, dragged him,

I don't know, for about five yards or so, released him, then another part grabbed him again.

It was pretty horrible.

Obviously at that moment the panic set in,

and I felt a bit sick as well

and I seem to remember one person distastefully taking pictures.

I don't know if he was drunk or he was just having a bit of a wander, I've no idea why.

Perhaps if he was drunk, he may have thought

that we weren't trying to help him, that conversely, we were trying to cause him harm.

That's kind of what I thought might have happened.

Essentially that concludes all the evidence.

Obviously I do need to consider at least the possibility of suicide,

but remind myself that I have to be satisfied to a very high standard of proof indeed.

I mean, there was simply insufficient evidence to support any finding of suicide.

This is in all probability a sad accident.

Our formal verdict will be one of accidental death.

Just... Yeah, just a guy being in the wrong place at the wrong time.

I think he was unwell, very intoxicated

and just disorientated and confused.

Thanks, Steve.

Sad that he wasn't accustomed to it, and what a shock for the family.

You'd like to think it would put their minds at rest in terms of

any suggestion that it may not have been an accident.

Some people say, so what is the point of a Coroner's inquest?

It says that in the fast-moving world we live in

that we can still find the time, even now, to sit down in a room,

every single time someone dies in circumstances other than natural causes, to talk about it.

And it puts an importance on it, for the family, because it says,

this death was important, because this person's life was important.

Another day of...

of sadness. SHE LAUGHS

Alison, if you hadn't have been a Coroner, what would you be doing?

I would have wanted to be an actress and a dancer.

That was my basic ambition when I was a youngster. It hasn't changed...

..I've just never done it.

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