Case Summary: Adrian Pullman
Oct 24, 2020CASE SUMMARY
Adrian Pullman was 11 years old when he drowned in shallow water after being unsupervised for less than five minutes. The accident occurred on Sunday, 10 August 2003, at council-approved respite centre Little Farm in Southleigh, Devon and took place within hours of Mr Pullman dropping his son off at the centre. The centre was run by Mr Philip Crofts and his wife, Mrs Christine Shuttleworth-Crofts and provided vital respite for parents from their caring responsibilities. The centre was popular and valued by parents and children alike.
Adrian had learning difficulties, and his specific needs meant he required lifelong care and supervision during most activities. The respite centre had a swimming pool which was used regularly by visitors to the centre, supervised by Mr Croft and Mrs Shuttleworth-Croft. Adrian could not swim, and the centre was aware of this, Mr Pullman having taken Adrian to the centre before.
On 10 August, there were five children staying at the respite centre. Mr Crofts said he and his wife had been in the pool with the five children earlier that day to escape the 35-degree heat:
Adrian was in the water, jumping up and down, pretending to be diving like a dolphin. He was opening his mouth and drinking a lot of pool water, so Christine told him not to drink all the water.
We got the children out of the pool and started to prepare for a barbecue. Adrian was excited and initially followed me around. When I noticed he and another boy were gone, I went to look for him.
When I got to the pool, Adrian was in the shallow end (0.9m) of the pool with another boy who also had learning difficulties. The other boy jumped in the pool and started to push Adrian over to our side of the pool. At first, I thought he was doing his pretend dive impression which he had done earlier. As the other boy pushed Adrian in our direction, Adrian’s head bumped the wall on our side of the pool - not hard - but he still didn't lift his head out of the water. Within a few moments, I realised Adrian hadn't moved.
I can’t have left Adrian for any more than five minutes before going to look for him.
Mr Crofts and Mrs Shuttleworth-Crofts then called an ambulance and tried to resuscitate Adrian. Adrian was then airlifted to the Royal Devon and Exeter Hospital. On arrival at the hospital, Adrian was pronounced dead. Mrs Christine Shuttleworth-Crofts, who had 27 years of experience as a carer, said:
Adrian had been left alone for between three and five minutes. After we found Adrian’s body in the pool, the boy who he had been playing with said “we were having a race…have I done something wrong?”
I keep reliving the tragedy over and over in my head, asking if I had done things differently, would it have made any difference? I don't understand why he didn't stand up. He was not out of his depth and was a big strong lad.
Devon County Council is working with Devon and Cornwall Police to establish how the incident happened. An inquest into Adrian’s death was scheduled to take place in Exeter; however, it would not complete until 2012, nine years after the accident. Due to confusion on the part of the investigating authorities about who was the responsible authority and the standards which applied to a swimming pool at a respite centre, Mr Pullman waited almost nine years for the inquest into his son’s death to take place.
Inquest into the death of Adrian Pullman (Exeter County Hall, 13 February 2012)
The inquest took place at Exeter County Hall and was concluded on Monday, 13 February 2012, after a two-week hearing. Coroner Dr Elizabeth Earland heard evidence of how Adrian arrived at the respite centre at around 16:20. The owners of the respite centre were registered carers with Devon Social Services but also with Lifeways, an independent company licensed to provide respite care. Dr Earland heard that this had caused confusion over how many children were supposed to be staying at the respite centre on the day Adrian had arrived, resulting in four children being under the supervision of the two carers.
Pathologist Guyan Fernando concluded that Adrian died from drowning. He ruled out that Adrian had experienced a seizure prior to drowning, stating that whilst Adrian had experienced seizures five years before, there was no evidence of any seizure on the day he died.
Mr Richard Appleton, a consultant paediatric neurologist from Alder Hey Children's Hospital in Liverpool, said Adrian needed constant supervision from his carers. The inquest heard how encephalitis (a brain infection) might have explained why Adrian lost consciousness in the water. Dr Appleton did not take that view and concluded that his opinion was that Adrian drowned and encephalitis was not the cause of death.
The inquest heard how Mr and Mrs Crofts were unable to resuscitate Adrian due to a blockage in his airway caused by food and a swollen tongue. Despite attempts by the carers and paramedics to resuscitate Adrian, their efforts to open his airway came too late to save Adrian’s life. Adrian’s father, Roger, sat at the inquest wiping away his tears as he heard how the carers and paramedics fought but failed to save his son.
In a narrative verdict, the Corner for Greater Devon, Dr Elizabeth Earland, an experienced medical professional and solicitor herself, said:
I offer my most sincere condolences to Adrian's family. I recognise you have been required to wait a very, very long time for this matter to come to hearing at the inquest. This is because among other things it has been a complex inquiry and many people were asked to give their advice. Having taken that advice, we are finally here today.
I am satisfied that Adrian Pullman would not have died if he had not gained entry to a swimming pool. This was partly due to the poor communication between the services responsible for his care.
The conclusion of a post-mortem was that Adrian died by drowning, but I accept the evidence of the expert witness that a minor brain infection may have been a contributing factor.
Adding to the tragedy for Adrian’s family, it was confirmed in a speech in the House of Lords in November 2011, that Adrian Pullman’s father, Roger Pullman, was himself now dying of cancer whilst attending the inquest into his son’s death.
Dr Earland also criticised a lack of resources which led to the lengthy delay for the hearing to take place and called for a review of respite services. Since the conclusion of the inquest, no prosecutions are known to have been brought against the carers, and the respite centre has since closed. A council spokesman, following the conclusion of the inquest, said:
We would like to express again our sympathy to Adrian’s parents and family.
We welcome the coroner’s acknowledgement that there have been major improvements made in respite care provision since Adrian’s tragic death. The county council, with our partner organisation, will be responding to the coroner’s report in due course.
Adrian's father, Roger Pullman, said that he hoped things would change following the hearing:
It is very important to me that the inquest is concluded. Hopefully, it will mean I can put things behind me and move on with my life.
Adrian’s case led to changes in the law
Each year more than 30,000 inquests are held in England and Wales. Statistics from 2012, around the time Adrian’s inquest was concluded, show an average waiting time from the date the coroner’s office is notified of the death to the conclusion of the inquest of 26 weeks. A spokesperson for Inquest, a charity providing support for families bereaved by a death in custody, said:
Finding out how someone died is an essential part of the bereavement process. Unnecessary delays cause considerable distress to bereaved families, who often report feeling as though their lives have been put on hold until the inquest is over. Delays also hamper the role of the inquest in preventing further deaths, as failings are not identified and acted upon quickly. This undermines public confidence.
In 2009, Baroness Miller of Chilthorne Domer said in the House of Lords that the fact it had taken so long for Adrian Pullman's case to be heard was inhumane. The Ministry of Justice said:
We are committed to meaningful reform of the coroner system to ensure inquests are timely, efficient and effective, and bereaved families are provided with the information and support they need throughout this emotionally difficult process.
We are consulting with families and other groups about creating a Coroners' Charter, which would set out the standards that bereaved family members and others could expect to receive.
In 2011, Baroness Miller asked the Government in the House of Lords what responses they have received on the draft charter for the coroner service and whether they anticipated making any substantial changes before they publish the charter:
Lord McNally
My Lords, the Government has received 135 consultation responses, of which 16 were from organisations representing the bereaved. We are concurrently considering these responses, and we intend to publish our response to the consultation in December.
Baroness Miller
My Lords, the Minister will remember that the idea of the charter was that it would create a standard of service for bereaved people. He will be aware that the Government now propose a general charter for anyone coming into contact with the coroner service.
What does he say to the likes of the father of Adrian Pullman, now himself dying of cancer, who has waited eight years for an inquest into why his son was found dead in a swimming pool on a local authority care break?
Does the Minister recall that in 2009, when we debated the Coroners and Justice Act, the coroner’s office involved said, “We have a lot of cases, but this will be given a bit of priority because of the delay, but I cannot foresee it being heard before the end of the year”? It has still not been heard.
Can the Minister say what in the Government’s revised proposals would mean that a bereaved father no longer had to wait eight years for an inquest?
Lord McNally
Let us be clear that in a system such as this are sometimes unavoidable; for example, because of ongoing criminal or other investigations or, in some cases, because of the family’s wishes. We want to ensure as efficient a system as possible. As part of that, we believe that the measures in the Coroners and Justice Act 2009, which we are implementing will help to reduce delays. We will also publish a wider range of statistics about the coroner system than we presently collect, drawing on our experience of service personnel inquests, where the quarterly publication of statistics has helped to eliminate delays throughout England and Wales.
…My right honourable friend the Lord Chancellor has decided that the immediate appointment of a chief coroner is not justified in the present circumstances. After listening to the various representations, we left the title of chief coroner in Schedule 5 to the Bill when it returned from the other place, and that will allow this House, the other place and the outside organisations to judge whether we are still able to carry through the bulk of the 2009 Act without the chief coroner.
…The Coroners and Justice Act 2009 provides for the Lord Chancellor to issue statutory guidance about the way in which the system operates, specifically in relation to bereaved families. We plan to revise the charter when we implement the coroner provisions in the Act, and at that stage, we will give the revised charter the status of statutory guidance.
…We have made substantial changes to the implementation of the Coroners and Justice Act, so much so that I believe that I can stand up the claim that we are implementing the bulk of the 2009 Act. But our judgment is that a chief coroner is not needed in post at this moment. We have left it in the Bill so that a judgment can be made at a later stage.
However, Baroness Miller and other supporters would not have to wait long to convince the Government to utilise the power enacted by the Coroners and Justice Act 2009 to appoint a Chief Coroner to office. In 2012, HHJ Sir Peter Thornton QC was appointed as the first Chief Coroner of England and Wales, a senior circuit judge at the Central Criminal Court and previous Head of Doughty Street Chambers. Hope for improvement in the standards applying to inquests was given a much-needed lift.
The Office of the Chief Coroner (2012)
The inquest into Adrian's death was concluded in February 2012. Later that same year, in his new post as England's first Chief Coroner, Sir Peter Thornton QC introduced a new standards code that required all 96 coroners to complete inquests within six months of being informed of death unless there are good reasons not to do so. Acceptable delays include waiting for related criminal investigations or trials to be concluded.
The Chief Coroner has a number of roles, but the main responsibilities are to (Judiciary, 2015):
- Provide support, leadership and guidance for coroners in England and Wales.
- Set national standards for all coroners, including new inquest rules.
- Oversee the implementation of the new provisions of the Coroners and Justice Act 2009.
- Put in place suitable training arrangements for coroners and their staff.
- Approve coroner appointments.
- Keep a register of coroner investigations lasting more than 12 months and take steps to reduce unnecessary delays.
- Monitor investigations into the deaths of service personnel.
- Oversee transfers of cases between coroners and direct coroners to conduct investigations.
- Provide an annual report on the coroner system to the Lord Chancellor, to be laid before Parliament.
- Monitor the system where recommendations from inquests are reported to the appropriate authorities in order to prevent further deaths.
Whilst the scheme drew support and most agreed it reduced delays and raised standards, the widespread sale of courts and local authority budget cuts left the Coroner’s Service with a lack of resources. There was criticism of a lack of independent inspection to validate the numbers being reported by the Ministry of Justice and the ONS. Legal aid cuts had also undermined the sole family lifeline to seek judicial review in situations where they sought to overturn or correct an error of a Coroner.
It would not be long before problems with case backlogs began to re-occur again.
A deterioration in standards and a further review by the Justice Select Committee
Government rules state that inquests should normally be completed within six months of someone's death, but there are currently 1,508 which date back more than a year – and one case goes back to 2003. The Right Honourable Sir Robert (Bob) Neill, MP for Bromley and Chislehurst and Chair of the Justice Select Committee, said:
It is not fair on bereaved families who desperately need answers to how a loved one has died. This is simply not good enough, and the committee will want to look into this.
Two inquiries by the Commons Justice Select Committee are taking place to take evidence on the issue; (i) the impact of coronavirus on prison, probation, and the court system (CJSC, 3rd August 2020) and (ii) what changes are needed to the Coroner Service. Coroners are expected to operate locally across 85 authorities and rely on funding from local authorities for their court and office space. A review into the coroner service by the House of Commons Justice Committee began with two leading Coroners who claim sporadic resourcing is causing issues with the quality of service coroners' are able to provide and the length of the backlog.
André Rebello OBE, the senior coroner for Liverpool and Wirral, told the committee:
We have a postcode lottery because of the resourcing that different coroners have. Some areas have dedicated coroner’s courts; others struggle to book into any court they can. There is no funding for local authorities and police authorities to carry out more complex investigations or to pay for expert witnesses.
Dr Mike Osborn, chair of the Death Investigations Committee and president of the Royal College of Pathologists, told the committee:
You need a national coroner service. The Chief Coroner is hamstrung by the fact they have responsibility but no power over other coroners.
Deborah Coles, CEO of INQUEST, said most families endure inquests because of their preventative value. She told the committee:
They go through that process in the hope that they get the truth, their answers, and any acknowledgement of mistakes and failings. One of the really important things is their potential, preventative value. Knowing how someone died means we can identify faults and dangerous, harmful practices which could prevent people from dying or being injured in the future.
Impact of the coronavirus pandemic
In 2020, when coronavirus hit, the 30,000 coronial inquests which are held in England and Wales each year were put under strain by an additional 38,362 registered coronavirus deaths. Problems have been compounded by the shutdown of the Coroner’s Courts across the country between late March and mid-August. Many Coroners struggle to find and share court space to hold inquests following c.33% of the court estate has been sold since 2010.
Delays to the Magistrates Court cases almost doubled from 64,000 to 123,000 between March and June, while crown court cases rose from 45,300 to 47,600. The effect of deaths that occur in the workplace is that:
(a) Less cases are being heard by a jury which is the main system by which a family can receive reasons for the finding. The family does not get the same type of closure with a verdict.
(b) Indictment only or either-way offences are taking longer for the authorities to charge any accused and longer to reach closure of the trial. Until the trial is concluded, the inquest will typically be delayed.
Further work is likely to be needed to ensure the families of the deceased can have inquests heard and concluded in a timely manner. It is important the lessons of Adrian’s case lead to lasting improvements in the way coroner’s inquests are resourced and delivered.
References (16)
Note: I wish those affected all the best in their future. No part of this article purports to attribute blame. See our methodology page for further details of how these case summaries are constructed.
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CTJ (2020). Chief Coroner’s Guidance, Advice and Law Sheets (Courts and Tribunals Judiciary, 8th October). Available at https://www.judiciary.uk/related-offices-and-bodies/office-chief-coroner/guidance-law-sheets/coroners-guidance/ accessed on 8th October 2020.
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Morris, S. (2012). Boy, 11, drowned in respite centre pool after careers were distracted – inquest. (6th February, 18:11). Available at: https://www.theguardian.com/society/2012/feb/06/inquest-boy-drowned-in-swimming-pool accessed 8th October 2020.
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Citation: Jacklin, D. 2020. Case Summary: Adrian Pullman. Water Incident Research Hub, 24 October.
