On 2nd October 2006, Sandra Jean Allen, a frail and vulnerable mental health patient died whilst in the custody of the Highgate Mental Health Centre in North London. The circumstances of her death raise important questions for today's mental health sector as her complex needs were unable to be properly cared for, nurses were untrained in basic and advanced life-support, and a security guard was sleeping whilst she was choking, denying urgent ambulance access.

During her inpatient stay at the Centre under s.3 of the Mental Health Act 1983 she repeatedly suffered assaults from other patients, extremely high levels of tranquillising drug treatment and an environment of fear and force.

Whilst most deaths in custody - running at the rate of over 600 a year to April 2007 (see  http://www.preventingcustodydeaths.org.uk/) the investigation of Sandra's death shows the failures of the coronial system for holding the state to account.

Since her death, Sandra's family have been campaigning to have the circumstances of her death properly investigated. After her death the Coroner for Inner North London, Dr. Andrew Reid opened an inquest into her death. However, in the most discreditable of proceedings and with the most appalling of conduct, the Coroner refused to hear any of the family's evidence, being solely focussed on a restrictive medical cause of death.

In denying justice to the family of the deceased, the Coroner refused to call a jury to hear the relevant evidence in the case, and even said that the Human Rights Act did not apply to the proceedings. Indeed the Coroner refused to hear evidence against the hospital and mental health trust where Sandra died despite voluminous evidence showing institutional failings to protect her life.

On the first anniversary of Sandra's death, her family are issuing Judicial Review proceedings at the High Court to have Dr. Reid's proceedings quashed and a fresh inquest ordered. Mind, the mental health charity, have been supporting the family's calls for justice and the family's legal team believe that the case could be important in changing the way that deaths in mental hospitals are investigated in Britain.

Interested people are urged to visit the family's blog at  http://justice4sandra.blogspot.com and to sign up for email updates, or alternatively to email  steven.allen@gmail.com.