7 July 2022

Before HM Assistant Coroner Karin Welsh
Teesside Magistrates Court
4 – 7 July 2022

Tina Robson was 35 years old when she was found dead in Bridge House Mission in Stockton on Tees on 26 July 2020. The coroner at the inquest into her death has today concluded that Tina died of misadventure and said she had no concerns about the housing-related support offered by Bridge House Mission or the decision to offer Tina accommodation there.

Tina’s family have now criticised an ineffective investigation of Tina’s death by Cleveland police, which led to a dearth of information to inform the inquest. However, they welcome the misadventure finding and acknowledgement of the impact of Tina’s trauma. They now call for action to support women suffering lifelong trauma and associated mental ill health and addictions.

The Dying Homeless Project found that there was a significant increase in deaths of homeless people in 2020, many of which took place in temporary or emergency accommodation. These deaths often receive little public scrutiny or thorough investigation.

BACKGROUND

Tina was considered a vulnerable adult and was subject to a safeguarding enquiry (under Section 42 of the Care Act 2014) and a Police Public Protection Order. The charity run housing at Bridge House Mission is funded by Stockton Borough Council as short-term accommodation for people in need of housing related support, primarily individuals with ‘complex needs’.

Tina was from Sunderland and lived in Stockton. Her family describe her as a clever, creative and artistic person, who was unique and stylish. Tina faced significant childhood trauma and struggled with mental ill health and associated drug and alcohol addictions since. Tina’s mother Sue fought for years to find appropriate support. Tina’s son, who was looked after by Sue, was 11 years old when she died. The family's video pen portrait, shown to the inquest, is available here.

Despite Tina’s engagement with public services, the coroner refused to engage Article 2 of the Human Rights Act. As such, Tina’s family were denied legal aid for the inquest but successfully crowdfunded over £5,000 for representation. The council were represented at public expense. INQUEST continues to campaign for legal aid for inquests, to end this unfair and unjust situation.

EVIDENCE AND CONCLUSIONS

The inquest heard that Tina had long-standing complex needs arising from childhood abuse and a history of involvement with housing, social care and local health services. On 17 July 2020, Tina had had to leave a semi-independent tenancy due to violence and targeting from people in the local community. It was the first time Tina had lived on her own.

Tina was subsequently offered accommodation at Bridge House Mission after her mother Sue had paid for hotel accommodation over the weekend at her own expense. On 22 July 2020, Tina met with social workers from the Adult Safeguarding and Early Intervention Team at the house. During the meeting, Tina disclosed historic abuse and became so distressed that she had to leave the room.

The social workers had no further contact with Tina and nobody at Bridge House Mission was made aware of the disclosure or plan for monitoring that they were supposed to oversee. On 26 July 2020, Tina went out in the morning and returned to the housing at around midday.

On returning to her room, Tina appeared to be intoxicated. However, she was not seen again by staff until around 5pm when they were alerted to her death by residents, who had been going in and out of Tina’s room throughout the afternoon.

The coroner concluded that there was no evidence of third party involvement in Tina’s death and that statutory and voluntary sector services worked appropriately and proportionately in everything they did. The coroner was satisfied that the decision to place Tina at Bridge House Mission was appropriate, and that there was no requirement for staff to carry out welfare checks.

The coroner concluded that Tina died as a result of misadventure, when considering the reasons for her substance use and the totality of the evidence.

Sue Robson, Tina’s mother, said: “We arrived at Teesside Coroner’s Court on Monday seeking answers about how and why Tina died. We leave here today no clearer about her actual cause of death. The pathologist’s conclusion, although based on the balance of probabilities, was more due to there being no other identifiable cause of death.

We are left deeply disturbed by what we believe was an ineffective investigation into the circumstances surrounding Tina’s death by Cleveland Police which left a dearth of any useful information. That said, we are relieved with the Coroner’s conclusion of misadventure as opposed to drug-related death, which was advocated for by the lawyers for Bridge House Mission.

From what we have heard over the last few days, we are certain that Bridge House Mission was not a safe or suitable housing placement for Tina, nor for other women suffering lifelong trauma and associated poor mental health and addictions.

We are much reassured and encouraged that the work towards Tina’s inquest has influenced Ison Harrison, Garden Court North, INQUEST, Museum of Homelessness, Shelter and Greater Manchester Law Centre produce a straightforward, short guide for families of loved ones who have died in ‘supported’ homeless accommodation. In order to shine a light upon these needless and preventable deaths, we need more people to be supported legally and otherwise to endure the process that our family has just been through.

We feel that the coroner’s conclusion of misadventure and the reasons given for that, is at least some recognition that Tina’s dependence on drugs and alcohol was as a result of her historic and ongoing trauma.”

Gemma Vine of Ison Harrison solicitors, who represent the family, said: “Tina’s inquest has highlighted the need for regulation in the housing-related supported accommodation sector beyond simple contract monitoring. There is a dire need for care, compassion and concern in these settings that sadly appeared to be lacking for Tina.

It has been particularly concerning to hear professional witnesses from both statutory and voluntary services refer to Tina as having made ‘lifestyle choices’ to use alcohol and substances, despite the overwhelming evidence of historic and continuing abuse.

Professionals repeatedly used the language of ‘capacity’ and ‘consent’ to justify care and support decisions made in relation to Tina, which appeared to demonstrate a lack of awareness of guidance such as that from Alcohol Change UK.

There is a continued need to dispel and challenge the myths around alcohol use and the ‘choice’ concept; that vulnerable people dependent on alcohol choose to live their lives in the way they do and unless they consent to intervention there is nothing services can do.”

Jodie Anderson, Senior Caseworker at INQUEST, said: “Tina’s death is yet another example of the ways in which public services fail to support women dealing with significant trauma. For Tina this contributed to her mental ill health and addictions from a young age. Throughout her life she did not get the specialist care and support she needed to overcome this.

In her final hours Tina was not supported by staff. As such, she became one of hundreds of people to die whilst in accommodation for homeless people. The number of deaths of homeless adults continues to increase. This is yet another reminder that urgent and long term action is needed across public services to prevent yet more deaths in these circumstances.”

ENDS

NOTES TO EDITORS
For further information and interview requests please contact Lucy McKay on [email protected]

The family CrowdJustice page is available here. You can follow the family’s Facebook Campaign #TruthJusticeTina here and Twitter campaign here.

Tina’s family are represented by INQUEST Lawyers Group members Gemma Vine of Ison Harrison solicitors and Ciara Bartlam of Garden Court North Chambers. They are supported by INQUEST caseworker Jodie Anderson. Other Interested persons represented are Bridge House Mission and Stockton Borough Council.

Legal aid for inquests:
INQUEST, bereaved families and lawyers, are campaigning for automatic non means tested legal aid funding for bereaved families for specialist legal representation immediately following a state related death, to cover preparation and representation at the inquest and other legal processes. This should be funding equivalent to that enjoyed by state bodies/public authorities and corporate bodies represented. Learn more.

Dying Homeless:
The Museum of Homelessness runs the Dying Homeless Project which tracks and collates the deaths of people sleeping rough as well as those placed in emergency accommodation and other insecure settings. They also host the Dying Homeless memorial, detailing the people behind the statistics.