Catalogue of failings unearthed in Gaia Pope-Sutherland’s inquest

We stand in solidarity with Gaia’s family and recognise the immense courage of her loved ones in seeing through this very painful inquest. Through their struggles in seeking justice for Gaia, they fight for all women and girls who have been raped and sexually abused.

The inquest into Gaia’s death was one of the longest individual inquests in British history. It uncovered more than 50 missed opportunities in the care of Gaia and the search for her – including failings by Dorset Police, Dorset Council and Dorset Healthcare Trust. These are the failures of institutions that should have protected her.

Gaia was let down by the police when she reported her rape and the case was dropped; let down again when she tried to report an incident of sexual harassment; and let down once more when she went missing and ultimately lost her life.

Gaia was also let down by mental health services when they took no action after she experienced sexual harassment in hospital – and then again when they discharged her with no long-term support plan in place. Her family have also stated that the support she received whilst in the care of mental health services was often detrimental to her mental wellbeing.

Findings from the inquest

The inquest concluded today. The jury found that Gaia’s death was caused by hypothermia, and that she died between 15.59pm on 7 November 2017 and 10am the following day.

The organisation Inquest, who have been working with Gaia’s family, have shared the following conclusions from the jury.

The jury found:

• Gaia’s mental health and mental state on 7 November 2017 probably caused or contributed to her death.
• Gaia’s acute situational crisis and an epileptic seizure contributing to her psychosis possibly caused or contributed to Gaia’s death.
• Gaia not being referred to either the community mental health team or the crisis team when discharged from hospital on 22 October 2017 was a factor that possibly caused or contributed to her death.

The coroner did not allow the jury to decide on whether failings with the police search or calls caused or contributed to Gaia’s death, despite the critical evidence heard. However, there were admitted failings by Dorset Police, recorded in the record of inquest, including:

• Police should have treated Gaia as a missing person earlier.
• As soon as Gaia was reported missing she should have been graded as a high-risk missing person.
• Dorset Police’s response in the first 24-48 hours was disorganised and lacked clear strategy, leadership and focus. It was accepted that the response was deficient.

There were additional failings admitted by Dorset Healthcare University Trust (DHUFT), also recorded on the record of inquest, including:

• There were missed opportunities to refer Gaia for mental health support following her discharge from hospital on 22 October 2017 when she had been in mental health crisis.
• There was a missed opportunity following Gaia’s discharge from hospital on 22 October 2017 to communicate with the neurology/epilepsy team involved in Gaia’s care.

You can read the full statement from Inquest on their website.

Very significantly, the family succeeded in making the case for the coroner to write reports to a wide range of agencies, both regional and national, to prevent future deaths.

These include reports to the College of Policing on national training on epilepsy, Post Traumatic Stress and supporting those with sexual trauma; to Dorset Healthcare Trust across several issues, including policies on how staff deal with incidents of sexual harassment as well as communication with patients’ families and carers; and to the Secretary of State for Health and Social Care on resourcing and communication between epilepsy and mental health teams to improve holistic care.

The purpose of these reports are to prevent future deaths, but many are relevant to rape and sexual abuse survivors everywhere.

Gaia’s family said:

“Gaia was many things. A beloved daughter, sister and friend. Bright, brave, kind, creative and fiercely loyal to those she loved.  She was also a survivor of child sexual exploitation who was badly failed by the state.

We miss her every minute and there can be no justice for a loss like this but we know how proud Gaia would be of what we have achieved here, having argued successfully for the coroner’s unprecedented decision to issue numerous vital Prevention of Future Deaths reports that challenge the underpinnings of austerity and misogyny at a local and national level.

There has been a lot of talk about the complexity of Gaia’s needs but the truth is they were basic. She needed to be treated with kindness, respect and dignity. She needed professionals to take the time to listen to her and her family and each other. She needed trauma-informed support and advocacy as she pursued justice and tried to rebuild her life after rape. She needed to be protected and she needed to be heard.

This is not much to ask for and if she had received it we believe she would be alive today.” 

You can read the powerful statement from Gaia’s family in full here.

Jayne Butler, CEO of Rape Crisis England & Wales, says:

“The Rape Crisis movement has supported thousands of women and girls whose experiences have been similar to Gaia’s – those who have been failed by the system. It is imperative that police, mental health services and all agencies responsible for Gaia’s care accept their mistakes and take immediate action. It is key for all police forces and mental health services across the country to learn from this devastating case.

"With sexual violence and abuse so prevalent, it is certain that professionals within every aspect of health and justice will interact with victims and survivors. We therefore call for police officers at every level, and all statutory health practitioners, such as GPs, mental health nurses and counsellors, to have access to quality, in-depth and regular, mandatory sexual violence and abuse training. It is crucial that all disclosures of sexual violence and abuse are treated seriously and that those caring for victims and survivors are resourced and equipped to support them.

Finally, independent, trauma-informed and specialist sexual violence services such as those provided by Rape Crisis centres need long-term resourcing, so that women and girls like Gaia can access the service provision they desperately need and deserve.”