The death of ten-year-old Isaac Mansfield, from Stratford, was attributed to natural causes until his GP, reviewing the records, spotted a hospital urine test had been positive for a metabolite of the Class A drug.
But by the time police and senior east London coroner Graeme Irvine began investigating, Isaac’s body had already been cremated.
A Metropolitan Police investigation failed to find evidence strong enough to criminally convict anybody.
“What that effectively leaves me in the invidious position of having to do is to hold what is ostensibly a surrogate criminal investigation,” Mr Irvine told East London Coroner’s Court yesterday (June 12).
“It seems to me that it’s very unfortunate that I’m left in this position.”
An inquest has a far lower burden of proof than criminal proceedings, allowing a coroner to make findings on “the balance of probabilities”.
Mr Irvine added that an inquest would now have to try to determine who had exposed an “incredibly vulnerable” child to the substance.
Although Isaac died at St Mary’s Hospital in Paddington, Mr Irvine said that he was “more likely” to have ingested cocaine in east London, where he lived and went to school, than in west London.
He added that he would have to look at everybody who had unsupervised access to Isaac in the 36 hours before his death, including his father, carers and staff at the John F Kennedy Special School.
Isaac, of Mirabelle Gardens, was rushed into Newham Hospital on September 6, 2023, after falling ill at school.
He was then transferred to St Mary’s paediatric intensive care unit.
The cause of the ten-year-old’s death on September 10, 2023, was originally given as organ failure, believed to be caused by an underlying metabolic disorder for which Isaac had received ongoing treatment.
But Isaac’s GP later spotted that a toxicological result from a urine sample taken at St Mary’s Hospital was positive for a metabolite of cocaine.
Mr Irvine said he was confident this could not have been a “false positive”, as blood samples taken at Newham Hospital and St Mary’s returned the same result.
The court had previously heard that a specialist paediatric pathologist has indicated that “on the balance of probabilities, it is more likely than it is not that cocaine set into motion a series of issues that led to Isaac’s death”.
Issac’s father, Jordan Montlake, attended court yesterday. At a previous hearing, Mr Irvine expressed his “disappointment” that he had not been present.
But the coroner confirmed that Mr Montlake did not know the hearing was taking place and was outside of the country at the time, adding that he “makes no criticism of him”.
He asked that Isaac’s father prepare a statement within the next 28 days, setting out biographical details relating to Isaac’s life and a chronology of events leading up to his death.
Mr Irvine added that he also wanted to know what concerns “if any” Mr Montlake had about Isaac’s death, including if there was a line of investigation he should pursue.
The coroner had also said at a previous hearing that “one of Isaac’s relatives occupies a senior position within the paediatric ICU at St Mary’s”, where Isaac was treated.
“It seems to me entirely feasible that questions could be put to witnesses within the body of the inquest about that familial relationship and whether or not that had any impact on treatment decisions or disclosure decisions,” he explained at the time.
But yesterday he clarified that he had since determined that this person is a “distant relative” who “was not intimately involved in Isaac’s care”.
“It was entirely proper for a child such as Isaac to have been transferred to St Mary’s, one of the limited paediatric intensive care units in London, given the general circumstances of his health that was diagnosed at Newham University Hospital,” he added.
He said that this “allays any concerns” about “undue influence in relation to that process”.
Carer Edith Adachukwu was told that she would likely have to come to court to answer questions about what she remembers about the events immediately before Isaac became unwell.
The court heard that care agency Care Avenue would also be asked to “facilitate the identification of any other carers who may have had access to Isaac at this material time”.
JFK School was told that staff, including school nurses from East London Foundation Trust, might be required to give evidence.
However, the coroner said that he did not want to put any staff through the process of appearing at the inquest “if the prospect of them having administered cocaine to Isaac are fanciful”.
Mr Irvine added that the Metropolitan Police would continue be involved in the inquest, “so that they’re intimately acquainted with the evidence as it develops”.
“I don’t suggest that there is any causal relationship between the Metropolitan Police Service and the death,” he said .
A date for the inquest is yet to be confirmed.
