The Gemini Project – Gaia Pope Inquest Statement

On Friday 15th July 2022, the 12 week long inquest into the death of Gaia Pope-Sutherland concluded in Bournemouth. A jury found that on the balance of probabilities Gaia passed away between 15:59 on 7th November 2017 and 10:00 on 8th November 2017 as a result of multiple factors.

Gaia was a beloved daughter, sister and friend. She is described by her family as “bright, brave, kind, creative and fiercely loyal to those she loved. She was funny and insightful, passionate and principled.” She was also a survivor of child sexual abuse who was let down by the police and mental health system. Like countless others, she was denied access to justice and appropriate support and the impact of this was devastating.

On 7th November 2017 Gaia disappeared in Swanage, Dorset. Her body was found where the family had repeatedly told police to search, between Dancing Ledge and Anvil Point eleven days later. She was 19 years old. Nearly five years after her death and following three closed-door reports, two from the IOPC and one from Dorset Healthcare Trust the inquest into her death began on 25^th April 2022 in Bournemouth. Her inquest is one of the longest in British History.

Gaia died as a direct result of the trauma of sexual violence. The process of reporting the sexual violence she had survived to the police was re-traumatising and the police’s decision to take No Further Action (NFA) following an inadequate police investigation further undermined Gaia’s health and wellbeing. Police told Gaia not to pursue a Victim’s Right to Review (VRR) a right she had, to have the NFA decision reviewed; misinforming her that the defense barrister could attack her and her mental health in court. The rape combined with the denial of justice and absence of trauma-informed holistic support from health professionals proved fatal.

The pervasive culture of misogyny, that exists both in the NHS and Police, systematically disbelieves women and girls when they speak out about their abuse. Survivors being disbelieved and not receiving the justice and specialist support they deserve has a profound impact on their recovery. This was apparent for Gaia who often wondered “Why does no one believe me? What is it about me?”.

Throughout the inquest Dorset Police and Dorset Healthcare Trust admitted to more than 50 missed opportunities (a list of just some of these failings can be found beneath this statement). Justice for Gaia is about holding the state accountable for their failings and demanding that what happened to Gaia does not happen again. Gaia’s preventable death is one of the human costs of decades of underfunding of services as a result of Tory austerity which lays the foundations for many of the Police and NHS failures. 

Gaia was failed in every way imaginable by the services who should and could have helped her both in life and in death. Her case starkly shows the devastating impacts that our fragmented and underfunded public services have on a person and ultimately their health, independence, safety, and ability to live.

It shows how inadequate these services have become and encapsulates so much of what is wrong with these often outdated, ill-informed systems, illustrated by the 50+ missed opportunities that the inquest identified. The list of failures feels endless and the anguish insurmountable.

As well as underfunding, the institutional contempt and discrimination that is prevalent across public services is in part what lead to the denial of sufficient support and care. NHS services and Dorset Police denied Gaia the support she desperately needed and deserved. This denial coupled with the trauma of sexual violence proved fatal.

It is clear that these institutions must enact immediate change. If we are to honour Gaia’s memory, we must fight to see changes to policing, the criminal justice system, and the welfare state. These sentiments are easily spoken by those of us who care and easily ignored by those who should listen, but if their apologies are to mean anything they must take action. Any more apathy is complicity in each failure, missed opportunity, and preventable death.

It should not be overlooked that the only reason a human right’s inquest under Article 2 of the ECHR was granted was because of the fight of Gaia’s family behind closed doors. The cruelty they have been subjected to behind those doors, throughout their fight and throughout the inquest is unjust and inhumane. 

Despite the welcome preventable death reports from the coroner, poignant central questions around police failure contributing to Gaia’s death were not allowed to be considered by the jury. This was additional silencing, additional withdrawal of scrutiny, and another opportunity for police to not acknowledge accountability. It was said there was ‘insufficient evidence’, despite the jury having heard 8 weeks of police evidence which made up two thirds of the inquest. It is because of this blatant act to protect police from further scrutiny that the fight for justice for Gaia will continue. True justice is accountability and full certainty that what happened to Gaia will not happen again to anyone else. 

We hope that anyone reading this joins us in demanding tangible action and that our work contributes to material change that ensures this can never happen again. Any changes must guarantee that no one is at risk of falling through the cracks, so that no one feels the way Gaia was made to feel. This government must pledge to fully fund our public services so that every person has their basic needs met. There are so many wonderful lights in our society at risk of being shut out if we choose to continue in vain. We must protect them all in whichever ways we can.

We send our unconditional love and support to Gaia’s family. It has been an enormous privilege to stand with them throughout this process. We will continue to stand by their sides in solidarity and rage, fighting for justice for Gaia and justice for all of us. – Lucy and Verity Nevitt, Co-founders of The Gemini Project.

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Failings:

Police’s fatal failures:

• Gaia was subject to grooming, coercive control and childhood sexual abuse by a known child sex offender already under investigation by Dorset Police

• Dorset Police NFA’d (No Further Action) the case after a short investigation and discouraged Gaia from submitting a VRR (Victim’s Right to Review). 

• Dorset Police take no action following harassment and witness intimidation by the perpetrator. 

• Gaia reports being sent indecent images of male genitalia from a stranger to police. She is due to meet with them to make a formal statement on the day she goes missing. Gaia and her Aunt Talia spend most of the day attempting to get details of which officer they are due to meet at Wareham and at what time. There is no record of the initial report and police cannot find who is due to meet with Gaia. 

• The Officer taking the initial call from Talia Pope following Gaia’s disappearance had no training in handling missing persons cases or responding to 101 calls.

• Police did not flag Gaia as ‘high risk’ from the outset despite her fitting the criteria. This meant that the appropriate level of resourcing (including POLSA) was not available to Gaia when it should have been and caused significant delay to essential action. 

• Gaia was eventually upgraded to high risk at 01:30am the following day after initially being reported missing. This delay meant the case was not immediately assessed by a force incident commander.

• Police took until 18:18 on 07/11/2017 to log Gaia as a missing person and go through appropriate questions with a family member. This is despite her Aunt Talia Pope phoning at 15:47 to report Gaia as missing. By that time Talia had phoned police 5 times and Gaia’s Mother had also phoned police.

• Multiple officers did not document completed searches or enquiries even after Gaia was upgraded to high risk.

• The acting sergeant at Wareham Police Station failed to take action in reviewing Gaia’s case and did not task officers with information gathering or searching. He was subject to disciplinary proceedings as a result and issued with a final written warning for his misconduct in the case. He has since retired from the force.

• Officers on the ground were not informed of a missing person within appropriate time frames and so an initial daylight search opportunity was missed.

• The National Police Air Service (NPAS) did not further investigate the thermal spots/heat signal detected the night Gaia went missing. They stated they believed that it was from a rock that was always in that location and assumed it was heat from the sun bouncing off of the rock and did not review any other possible explanations for the heat source. Gaia’s body was found nearby 11 days later. The heat signal was never investigated by NPAS.

• Police did not complete a MISPER (Missing Person) Booklet with Gaia’s family members, many officers assumed it had already been done. 

• Multiple members of Gaia’s family had told Police to search Dancing Ledge on multiple occasions at the very beginning of the search. Gaia’s body was found at Dancing Ledge 11 days after Gaia was reported missing.

• Police did not complete a missing person initial report with Gaia’s family members, many officers assumed it had already been done. This meant Police initially lacked vital information about Gaia including places of significance as well as her epilepsy and PTSD. The search strategy was instead based on generic data as opposed to specific data of women in Gaia’s age group.

• Police lacked communication within the force, handovers between shifts were not done, logs were corrupted and duplicated which made information difficult to ascertain and caused confusion to officers who struggled to track actions and determine what was still outstanding.

• There was delay with making a public appeal

• Police did not task Dorset Search and Rescue (DorSAR) to assist with the search until the early hours of 8th November, many hours after Gaia had been reported missing. They were also not called upon throughout the search despite being available.

• Police did not utilise volunteers to assist with CCTV searches and missed the opportunity to identify Gaia’s direction of travel.

• Police did not engage with volunteers, community searchers and other search agencies.

• Police refused to engage with the press

• Police originally refused to allow Gaia’s family to identify Gaia’s clothing that was found near a costal path.

• It took Police 2 days to conduct a thorough search in the area Gaia’s clothing was found. Gaia’s body was found near to where the clothing was found the day that search was conducted.

• Police later interfered with logs with PC David Taylor admitting to altering their contents following Gaia’s death. This only came to light mid-inquest.

• Police began to turn their sights on a murder investigation despite flimsy evidence, this meant focus was taken away from the search for Gaia. However the inquest scope does not cover the particular set of failures associated with that [batshit] line of police enquiry.

• Police were far more concerned with their own image and what they appeared to be doing than the actual search for Gaia.

NHS failures and negligence:

• No communication between the epilepsy and mental health teams

• Missed opportunities to refer Gaia on for further specialist mental health support

• Instead of listening to Gaia and taking a trauma informed approach, mental health professionals within Dorset Healthcare pathologised her and wrote off her experience of rape as ‘delusional’, a ‘hoax’ or a ‘fabricated illness’. One professional at St Ann’s Hospital even referred to Gaia’s rapist, a man who had groomed, drugged and rape Gaia while she was a child, as her boyfriend. 

• No holistic approach was taken

• Mis-diagnoses meant PTSD was left untreated

• Repeated failure to follow up or act on onward referrals

• St Ann’s (Dr. Kannan) failed to contact the neurology team or Professor Walker at UCLH

• Gaia being discharged from St Ann’s and community MH despite still being in crisis

• Gaia being discharged with no safeguarding referral or onward care plan and her GP not being informed of the hospitalisation or discharge (Dr.Kannan)

• Gaia experiencing sexual harassment as an in-patient at St. Ann’s with no safeguarding review

• CAMHS were supposed to consider Gaia for EIS (Early Intervention Service) however EIS never heard anything from the Dr who made the initial referral so closed Gaia’s case.

• EEG not undertaken in Feb 2017 following potential post ictal psychosis

• UCLH not carrying out a neuropsychological evaluation in July 2017

Other IP (interested person) missed opportunities/ failures/ negligence:

• Social services did not conduct a proper assessment for Gaia under the Care Act. The assessment was conducted late and rushed through with the majority left blank by the social worker.

• Ambulance trust non-compliant call on day of Gaia’s disappearance – clinician used leading questions and closed the call with ‘no response’ despite Gaia’s mental health history. Missed opportunity for a face-to-face assessment.

Other factors:

• The traumatising process of applying for PIP (Personal Independence Payments) and undergoing a PIP assessment with the DWP (Department for Work and Pensions).

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Change we wish to see:

• RASSO (Rape and Serious Sexual Offences) units in all Police forces across England and Wales.
• SOIT (Sexual Offences Investigative Techniques) Officers to undergo an annual training course to ensure they are up-to-date with legislation and guidance.
• All Police in England and Wales to undergo mandatory training in responding to initial reports of sexual violence. This must include modules on understanding sexual trauma and combatting myths surrounding sexual abuse. Police must understand how to communicate with survivors effectively, why victim-blaming is so damaging and the importance of thoroughly investigating crime in a timely manner.
• Police and Crime Commissioners to allocate further funding to ISVA services, to ensure all survivors receive specialist support whilst they are engaged with the Criminal Justice System. 
• Increased responsibility for Police and Crime Commissioners monitoring and delivery of services and for their accountability if they fail to provide appropriate levels of care.
• Home Office to (at the very least) double their current VAWG (Violence Against Women and Girls) funding streams.
• Counseling notes to be protected from Police and CPS requests.
• For organisations that support survivors to review their current trans inclusion policies to ensure that survivors can access specialist support services regardless of their gender identity.
• For organisations who employ ISVA’s and IDVA’s to increase pay and review benefits packages in order to retain current staff. 
• To make it illegal for perpetrators to use non-disclosure agreements or injunctions against their victims. Victims should be able to speak out about their experiences and should not be forced into silence by their abuser.
• Fully funded, trauma-informed NHS counseling services.
• A fully funded, fully staffed public National Health Service with effective internal communication across teams to ensure joined-up care. 
• NHS to make EMDR (Eye Movement and Desensitisation and Reporcessing) therapy available to survivors of sexual violence.
• Survivors’ voices heard through regular public consultations.
• Mandatory consent education in all primary and secondary schools, including education on what constitutes both domestic and sexual abuse.
• Juries to be educated and informed on trauma responses so that they do not perpetuate societal myths about sexual violence and for all prosecutors, defense teams and judge’s to undergo mandatory training if representing/ judging a sexual violence case.
• Reform the use of language by media when reporting on cases of sexual violence.