Coroner call after violinist death
A coroner has criticised mental health services for "failing" to provide proper care to a concert violinist who died just a week after giving evidence against her predatory former choirmaster.
And he demanded that new rules are put in place to ensure that vulnerable witnesses are given better support when they face often traumatic trials.
Mother-of-four Frances Andrade was "extremely traumatised" after testifying about abuse she suffered as a teenager at the hands of ex-Chetham's School of Music choirmaster Michael Brewer and his wife Kay.
She took a fatal overdose at her home in Guildford, Surrey, days later on January 24 2013.
She did not live to see her abuser jailed for six years for five counts of indecent assault two months later.
Delivering his verdict at Woking Coroner's Court, coroner Richard Travers said he could not be sure she intended to kill herself and ruled out a verdict of suicide.
But he said he would be writing three reports - two to the Director of Public Prosecutions and one to the local health service to call for changes in the wake of the inquest.
Brewer preyed on the young violin virtuoso at the prestigious Manchester school, forcing her to perform sex acts on him in his office and camper van.
His ex-wife later joined in the abuse and was jailed for 21 months for one count of indecent assault.
Mrs Andrade had confided in her husband Levine, 59, but chose not to tell police. In 2011 she told a friend, who later contacted officers.
As police investigated the case, she became increasingly down, withdrawn and depressed and repeatedly took overdoses, the inquest heard.
But despite this, failures among health professionals meant she was accidentally "amber-zoned" in records kept by a mental health team, whereas she had been assessed as the top "red" priority.
As 2012 drew to a close and the date of her abuser's trial got nearer, her mental health deteriorated and she "changed significantly" and her overdoses became more frequent.
Mr Travers said Mrs Andrade told doctors "the overdoses had been triggered by anxiety that came from the court case.
"Her reason to overdose was not to kill herself but was a way to cope with the court case."
But the coroner hit out at the support received by the talented musician. Health professionals repeatedly failed to appreciate the risk she posed to herself, he said.
He said: "I can't help but think there was a real failure to appreciate the urgency of the situation and a failure to act upon it in an appropriate manner.
"What is clear is she found giving evidence extremely traumatic."
She had to endure a tense cross-examination by defence lawyers during her abuser's court case in January last year.
And during the trial, on January 23, the judge in Brewer's case ordered the jury to deliver a number of not-guilty verdicts because of principles of law.
At 8am the next day Mr Andrade found his wife, known as Fran, dead at their home.
He earlier told the inquest she had sunk into "incredible despair" and "felt the defence barrister seemed to be attacking her personally".
The coroner said a failure to explain to the violinist why the not-guilty verdicts had been ordered was wrong.
He said: "Such matters, if left unexplained, could have a devastating effect on a complainant, who might well take it to be a reflection of the evidence that they have given."
Mr Travers said failures in Mrs Andrade's medical care at the end of 2012 meant she was not allocated a care co-ordinator quickly enough, and when she eventually was he was off sick.
And he said there were serious shortcomings in communication between her mental health worker and GP.
He said the lack of urgency surrounding her care was "quite extraordinary", adding: "There was a real failure to provide Fran with the care that some two months before it was recognised that she needed."
The coroner said he would write to the Director of Public Prosecutions (DPP) to call for alleged victims in trials to be given an explanation when jurors are ordered to give not-guilty verdicts.
He also wants the DPP to ensure that advice about the psychiatric counselling available to vulnerable victims is clarified.
And he will write a third report to Surrey and Borders NHS Trust, calling for greater safeguards to ensure that prescribed medication belonging to family members of people who have overdosed on it is better protected.
Speaking after the inquest, Mr Andrade said he hoped his wife's tragic death would ensure that other victims do not have to go through the same ordeal she did.
He said: "I think that all the services involved really looked at what went wrong and they have all tightened up their measures. And hopefully for the next lot of victims something will have changed for the better."
Asked if he wished his wife had never had to go to court, he said: "I can't say that because, for one reason, she needed to for her own peace of mind."
He said she "maybe" his wife "could have got more (care)", adding: "I think that was shown today in the inquiries of the coroner's final decision."
The verdict follows a damning serious case review by Surrey Safeguarding Adults Board in April which found Mrs Andrade's death ''could and should'' have been prevented.
It concluded she was let down by mental health services who failed to recognise she was vulnerable as she made repeated suicide bids and faced her abuser in court.
Brewer, who went on to direct the World Youth Choir, was stripped of his OBE for services to music after being jailed for the assaults when Mrs Andrade was aged just 14 and 15.
Adam Pemberton, assistant chief executive at Victim Support, called for an urgent inquiry into how the criminal justice system treats victims of crime who have mental health issues.
He said: "It is appalling that Frances Andrade did not get the help she needed to cope with the trauma of the sexual abuse she suffered as a teenager.
"It's critical that vulnerable victims and witnesses get the right support and information about the progress of their cases. Without this we fear more cases will end in tragedy.
"We believe there is an urgent need for an inquiry into how the criminal justice system treats victims of crime who have mental health issues, matching recent efforts to help the people who commit those crimes who have mental health needs."