Flaws in the disability benefits system were “the predominant factor and the only acute factor” that led to a young disabled mother taking her own life, a coroner has concluded.
Gordon Clow, assistant coroner for Nottingham and Nottinghamshire, yesterday highlighted 28 separate “problems” with the administration of the personal independence payment (PIP) system that helped cause the death of 27-year-old Philippa Day, from Nottingham.
It took more than two hours for the coroner to read out his conclusions and findings, after a nine-day inquest* that uncovered multiple failings by both DWP and its private sector contractor Capita in the 11 months that led up to Philippa’s death in October 2019.
Clow ended by telling DWP and Capita that he had decided to issue them with prevention of future deaths (PFD) reports, which will force them to consider how to make changes to the PIP system to prevent further deaths of claimants.
DWP will now need to examine the mental health training given to its call handlers and its poor record-keeping, while Capita will have to examine the process for changing where and how assessments are carried out and ensure that letters issued about this process “are accurate and [do] not create unnecessary distress”.
He dismissed suggestions made by DWP and Capita during the inquest that only a few individual errors had been made in dealing with Philippa’s claim, and concluded instead that there were significant, systemic flaws.
The coroner said that Philippa (pictured) had been eligible for PIP throughout the 11 months at the enhanced rates for both mobility and daily living, that DWP could have obtained all the information it needed to ensure she received those benefits, and that she should not have been told she would have to attend a face-to-face assessment.
Among the 28 “problems” he highlighted were the repeated failures to record on her file that she needed additional support with her claim; and the mistaken decision to remove her benefits after DWP concluded wrongly she had no “good cause” for failing to return a claim form.
He also pointed to the failure to respond to the mental distress she displayed in a call to a DWP telephone agent; the refusal to allow Philippa a home assessment; and the “institutional reluctance” to accept evidence from professionals such as her community psychiatric nurse (CPN) over the telephone.
The 28th, and final, problem was Capita’s failure to accept, despite a phone call from her CPN on the day before she was found unconscious – and repeated earlier warnings – that “requiring a face-to-face assessment at a clinic placed Philippa’s safety at risk”.
The coroner concluded that there were “deficiencies in the system’s ability to process PIP claims without causing unnecessary distress to claimants”, including problems with training for call handlers and Capita disability assessors, DWP’s record-keeping, guidance on additional support for claimants, and inaccurate DWP correspondence.
He also said there was an “institutional working assumption at the DWP that documents which are not on the claimant’s file are missing because the claimant failed to send them in”.
Clow also pointed to flaws in Capita’s initial review and change of assessment processes.
Philippa’s unconscious body had been found by her sister and father on 8 August 2019, just days after she had been told she would need to attend an assessment centre for a face-to-face appointment to decide her PIP claim.
They found her lying on her bed at her home in Nottingham. On the pillow next to her was the letter from Capita telling her she would have to attend the appointment at the assessment centre in Nottingham.
She was taken to hospital but later died after more than two months in a coma.
The coroner did not reach a verdict of suicide, concluding instead that he could “not be satisfied that it was more likely than not that Philippa intended her death”, even though she was responsible for taking her own life.
But he did say he was “satisfied on balance of probabilities that Philippa intended to harm herself and to put her life in danger” by her actions on 7 or 8 August 2019, which led to her death.
He concluded that there were many factors that led to her decision to put her life in danger.
But he said that “the combined impact of successive destabilising incidents caused by the problems in the handling of her benefits claim was… the predominant factor, and the only acute factor” which led to that decision.
Philippa had been diagnosed with type one diabetes when she was 18 months old, and was later diagnosed with emotionally unstable personality disorder, anxiety, depression and agoraphobia.
She lived a “chaotic” life characterised by repeated self-harm, suicidal ideation and drug and alcohol misuse, as well as repeated inpatient admissions to mental health units, but the inquest heard she received constant, dedicated and close support from her family and mental health professionals.
She had been claiming disability living allowance (DLA) for her diabetes since she was 16 but had started a new claim for PIP in November 2018, hoping to secure further support for needs related to her mental health.
Her PIP application form appears to have been lost by DWP, the inquest heard, after she posted it in January 2019, and her DLA was stopped that month because she had failed to return it.
Disability News Service (DNS) reported last week how a secret DWP investigation into her death found that, because of its errors, Philippa’s total benefits had fallen from £229 a week to just £73 per week for four-and-a-half months, while Social Fund loan repayments of £12.43 per week were deducted from the £73, leaving her with little over £60 a week to live on.
The inquest had heard how Philippa had experienced months of distress due to DWP’s decisions to remove her disability benefits when it lost her claim form, and then to confirm that decision, as well as the length of time it took to reinstate her benefits, and deal with a new claim.
DWP errors had caused her severe financial hardship, said the coroner, and resulted in her taking out payday loans she could not pay back.
Both DWP and Capita had been told of her history of significant mental distress and mental health inpatient admissions, that she was agoraphobic, and that she would be unable to cope with attending the assessment centre.
Philippa’s sister, Imogen, said last night that the family wanted “continued and systemic change”.
She said they believed that the treatment of her sister (known to her family as Pip) by DWP “had a direct impact on her mental state and in the end is the reason for her death.
“She was in despair because of the depths to which she had sunk, she could see no way out of the debt and the poverty in which she was living.
“Pip’s poor mental health meant she was not able to handle the battle with the DWP for the reinstatement of her benefits.
“The stress of the conflict with the DWP made her even more ill.
“Support from her community psychiatric nurse and from her family kept her going. But the constant cold and unsympathetic wall of resistance that she met at Capita and the DWP was more than she could endure.
“The refusal of a home assessment by Capita was just too much for Pip to cope with. We believe she just couldn’t take any more.”
She said she was “really happy” with the coroner’s conclusions, and she praised his “very full and thorough investigation”.
Merry Varney, a partner with solicitors Leigh Day, who represented the family at the inquest, said the coroner’s decision to issue PFD reports was “hugely significant”, as DWP and Capita would be required to respond to them, while their responses would be published.
She told DNS that the example set by the coroner and his “willingness” to investigate the role of DWP “should be very powerful messages for other coroners”.
She added: “I hope that Pip’s family and everything they have done helps other families who may have been in that position feel that they can come forward and that there may be a way to help them and for them to achieve justice”.
In a statement, Capita apologised to Philippa’s family “for the mistakes made in processing her claim and the additional stress which was caused to Philippa”.
A spokesperson said: “We have strengthened our processes over the last 18 months and are committed to continuously working to deliver a high-quality, empathetic service for every claimant.
“In partnership with the DWP, we will act upon the coroner’s findings and make further improvements to our processes.”
DWP offered its “sincere condolences” to the family, and said it would “carefully consider the coroner’s findings”.
DNS asked if it would apologise to the family for its failings, but DWP had not responded by noon today.
*Disability News Service attended nearly every session of the online inquest
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