15 July 2022

Before HM Senior Coroner Rachael Griffin and a jury
Bournemouth Coroner’s Court
26 April – 15 July 2022

Gaia Kima Pope-Sutherland, 19, was a rape survivor who had engaged with Dorset mental health services and police. She was reported missing on 7 November 2017 in Swanage, Dorset. Following a police investigation and a public search, her body was found 11 days later less than a mile from where she was last seen.

After twelve weeks, the inquest into her death has today concluded finding Gaia not being referred to either the community mental health team or the crisis team when discharged from hospital on 22 October 2017 [just weeks before she went missing] was a factor that possibly caused or contributed to her death. The conclusions also recorded a series of missed opportunities by Dorset Police and Dorset Healthcare University Trust.

The coroner will also be making multiple reports 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.

Gaia’s family describe her as a bright, brave, kind, creative and loving. The challenges she faced as a young woman living with epilepsy and as a survivor of sexual violence had inspired her to pursue a career in health and social care. Her family believe the inquest evidence has demonstrated the broader systemic failures in public services for survivors and women with mental ill health.


Gaia was 16 years old when she was raped and exploited by a (then) 22 year old man. Following this her mental health went into serious decline and epilepsy symptoms worsened. In December 2015 she disclosed the rape to family and mental health professionals, and it was reported to police. At this time she was admitted to hospital in her first serious mental health crisis.

The following year, in 2016 Gaia continued to access mental health support in the community. She also received further treatment for her worsening epilepsy. The inquest heard evidence that the NHS mental health and neurological professionals recognised the connection between her conditions, but the services were disconnected and did not communicate or collaborate.

In 2016 the man who Gaia accused of rape was charged and found guilty of unrelated sexual offences against children, but Gaia was informed there would be no further action in her case. In April 2017 he was sentenced to two years of imprisonment.

In late 2016 Gaia was discharged from community mental health services. No onward referral was made. Two months later, in February 2017, Gaia was admitted under section to a mental health ward, St Ann’s. Whilst there she was sexually harrased by another patient. She was discharged two days later and assessed as low risk, and no safeguarding referral or onward support was arranged.

In October 2017, Gaia was again in serious mental health crisis. After spending over 24 hours in hospital in extreme distress her mental health was eventually assessed. Despite her presentation, they found she was not suffering an acute mental disorder and was low risk. She was discharged home with no onward support.

On 2 November Gaia was sent sexually explicit images by a man on Facebook. She reported this to police and was due to attend the police station with family to discuss this on 7 November, but no time was given. She also made an appointment with her GP for 7 November at 5pm, to request a referral back to community mental health services.

On 7 November, Gaia’s family called police to try to confirm the appointment with police. The inquest heard recordings of calls in which the family and Gaia herself were dismissed by officers. Gaia was in extreme distress and she and her family tried to access support from both police and health services. That afternoon Gaia ran off and her family reported she was missing.

The inquest heard evidence of a range of delays and missed opportunities shortly after Gaia went missing, including delays in completing the missing persons report and grading the incident, and fundamental information not being recorded. On 16 November, members of the public found Gaia’s clothing. On 18 November her body was found, less than a mile from where she went missing and less than 300 metres from the clothes.

For more information on the circumstances and key issues see this media briefing.


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

In a narrative conclusion, 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.

In a joint statement, the family of Gaia Pope 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.

This is not just Gaia’s story. Public services nationally and locally in Dorset continue to fail survivors. That is why today we are launching a campaign for Dorset Police to invest in a Rape and Serious Sexual Offences Unit of officers who are trained to investigate properly and protect people like Gaia.

What we demand now is justice for those left behind. All the lives not yet lost, which are precious and worth fighting for. If it takes a lifetime, it will be a lifetime well spent because Gaia is worth that and so are all of you.”

Read the full version of the family statement, which was read outside court, here.

The family have today launched a campaign, including a petition calling for Dorset Police to step up for survivors and invest in a Rape & Serious Sexual Offences (Rasso) Unit.

Sarah Kellas, of Birnberg Peirce solicitors who represent the family, said: “Over 12 weeks, the family of Gaia Pope Sutherland have sat through a harrowing inquest which has confirmed what they have always known: the very institutions supposed to protect and support Gaia, a survivor of child sexual exploitation, failed to do so.

Gaia’s inquest has identified multiple missed opportunities by the mental health services and the police which, had they been acted on, could have made a real difference to Gaia’s story. As a survivor of rape, Gaia deserved to be listened to and supported by professionals involved, sadly, like for so many other survivors of sexual violence this was not the case. Real change is needed.

The jury’s findings albeit on the limited matters that were left to them, vindicate the family’s position. It is a matter of grave concern and disappointment however that 8 weeks of evidence relating to the litany of police failings in the crucial 24/48 hour window after Gaia went missing, as well as other matters, were not permitted to be considered by the jury. We disagree with this ruling, and remain of the view that the evidence speaks for itself.

We are, however, pleased that the Coroner has made a large number of powerful Prevention of Future Death reports at a national and local level, some of which, critically, deal with issues surrounding sexual trauma.

Gaia’s family will now continue in their campaign to make real and effective change for survivors of sexual violence.”

Deborah Coles, Director of INQUEST, says: “Gaia's death is part of a broader pattern of deaths of survivors of sexual violence, who are being systematically failed by public services. INQUEST has hundreds of cases involving the deaths of young women with experiences of abuse and associated trauma. They should have received quality specialist support but instead died preventable deaths.

There are so many clear issues arising from this inquest, which speak to systemic issues around the country. These include institutional misogyny in the criminal justice system, which consistently fails and further harms survivors. Alongside health and social services which are disconnected, ill resourced and ill equipped to offer holistic and specialist trauma informed support for women.

We welcome the coroner’s detailed plans for reports to prevent future deaths, which must be acted on urgently.

Gaia’s death and the damning evidence of this inquest must be a wake up call for public services in Dorset and nationally. Women and survivors need and deserve action, to prevent yet more deaths.”


For further information and interview requests please contact Lucy McKay on [email protected]. A selection of family photos of Gaia is available here.

INQUEST has been working with the family of Gaia Pope since January 2018. The family is represented by INQUEST Lawyers Group members Sarah Kellas, supported by Aneeka Shah and Josie Fathers of Birnberg Peirce Solicitors, and Caoilfhionn Gallagher QC, Sophy Miles, Stephanie Davin and Rosa Polaschek of Doughty Street Chambers. They are supported by INQUEST caseworker Jodie Anderson.

Other Interested persons represented are Dorset Police, the IOPC, National Police Air Service (NPAS), DORSAR, HM Coastguard, Dorset Healthcare University Trust (DHUFT), Poole Hospital NHS Foundation Trust, Dorset County Council.

Gaia’s family have led the campaign Justice for Gaia since her death. See their Facebook and Twitter. See previous press releases on the case here.

A more detailed briefing on the evidence and key issues, with a timeline of key events is available here.