Repeated concerns were raised that the Leyton home of Joan Turnell and her daughter Tracey was emitting “horrendous smells” and causing a fly infestation, East London Coroner’s Court was told.
Joan, then 77, was regularly observed with faeces on her clothes and shoes, which she would trail through Whitehouse Mews, worrying the building’s caretaker.
“The caretaker was rather conscientious and seems doggedly and persistently to have escalated concerns,” said senior east London coroner Graeme Irvine.
But those concerns went unheeded until it was too late. In November 2023, Joan was found pushing daughter Tracey’s dead body around Walthamstow High Street in a wheelchair.
“At the risk of descending into hyperbole, the death referral in relation to Tracey Jane Turnell is horrifying,” said Mr Irvine. “It is a truly, truly appalling case…. a horrific case.”
An inquest last week heard Waltham Forest Council failed to properly react to a string of referrals, including one shortly before Tracey’s estimated date of death.
Mr Irvine said there had been “significant missed opportunities” to “safeguard this obviously vulnerable young woman”.
John Binding, the council’s strategic safeguarding lead, agreed.
He testified that in 2013/4, the council encountered Joan and Tracey over a housing issue – but there was a lack of “professional curiosity” over their wider situation, including that Tracey was “demonstrably vulnerable”.
She was wheelchair-bound with a curvature of the spine, deformed arms and a knee complaint. A social worker also noted that Joan seemed to speak on Tracey’s behalf.
In hindsight, said Mr Binding, staff should have investigated whether the relationship was “perhaps coercive in nature”.
“We didn’t do that and that was an absolute missed opportunity,” he testified. “I don’t think we remotely refute that.”
In August 2022, a gas contractor raised concerns with Joan’s housing association about the state of her home.
That was the month before Joan later estimated Tracey had died – although Mr Irvine said he could not place too much weight on Joan’s estimate, given her mental state.
The housing association, whose staff could not enter the flat without consent, made a referral to the council.
“What happened after that referral to the local authority is effectively nothing,” said Mr Irvine.
“That was not a good response,” agreed Mr Binding, adding that a proper investigation “may well have led us to the court of protection”.
“The response in that situation, from us, was not sufficient,” Mr Binding repeated.
The housing association made another referral to the council in February 2023.
“Again, no clear curiosity seems to be evident,” said Mr Irvine. “Members of staff chose not to make independent enquiries or to make meaningful attempts to substantiate the concerns… instead, once again, the matter was closed off.”
“That wasn’t good enough,” Mr Binding accepted.
Joan was found wheeling daughter Tracey’s body around this shopping centre (Image: FTI Consulting) In October 2023, said Mr Irvine, the now “exasperated” housing association raised “significant concerns” about the caretaker’s latest “troubling” report, that Joan was filling bin bags with “human faecal matter”, which was “rotting”.
The council logged the referral as non-urgent and there was “no meaningful response” before “the grisly discovery” of Tracey’s remains, said Mr Irvine.
Mr Binding said there had since been systemic improvements, but the coroner replied: “Unless I’m getting something wrong, this wasn’t a case of the rules being wrong in 2022 and 2023. It was a problem that the staff weren’t following the rules.”
“I don’t think staff did follow what would be expected,” Mr Binding agreed.
“I very much appreciate that we live in a generation of looking at systemic factors, but sometimes there needs to be personal responsibility,” said Mr Irvine. “Has anybody been reprimanded? Has anybody been referred to their regulator, Social Work England?”
“Erm, no, that’s not happened – but I’m aware there’s been a series of individual, kind of, conversations,” said Mr Binding.
“I sit as a coroner and hear, on a day-to-day basis, about reflection, changes of procedure, changes of process – but unless and until somebody actually feels the flames at their feet about the consequences of their actions or inactions, not a great deal changes,” said Mr Irvine.
Mr Binding responded: “I’m very conscious of this having had a profound effect on adult social care. As you say, I think the circumstances are quite traumatic and I think people most definitely reflected upon it.”
“If people are habitually and regularly, it seems, dropping the ball in relation to their adult safeguarding duties – a vitally important role – surely there comes a time where people have to be brought to account for that,” said Mr Irvine. “Do you see?”
“I do see, absolutely,” said Mr Binding.
The coroner gave the council 28 days to consider and respond to his comments, before he decided whether to issue a prevention of future deaths report.
He said he would also write to NHS England over his concern Tracey had been “purged” by her GP in a 2015 “list-cleansing exercise”, following a period of non-contact.
“It must have been obvious to any reasonable GP that Miss Turnell was a very vulnerable woman,” he said. “She is not somebody who should have been removed from a GP’s list, in my opinion.”
Mr Irvine said the “shocking and heart-rending” case reminded him of the ending of murder mystery play An Inspector Calls.
“The responsibility for her death is everybody’s,” he explained. “Everybody is guilty. Various members of the cast have interacted with this person and all of them played a contributory effect on the death.
“At the risk of sounding overly dramatic, this is a death in which I reflected on that because it seems to me there were multi-factorial issues on various aspects of society that meant if something different had been done earlier, this tragic set of circumstances may have been avoided.”