Call for coroner to resign over Teesside inquest delays
It's been almost 10 years since Margo Wright lost her daughter Mandi.
She collapsed and died at her home in Middlesbrough - aged just 32.
There was no obvious explanation for the death of a young mother in apparently perfect health.
For that reason an inquest had to be held.
But that just added to Margo Wright's agony. It took 14 months for it to take place.Few answers
She said: "It's month after month after month of not knowing. You start asking yourself were there drugs involved, has someone hurt her?"
End Quote Margo Wright Bereaved mother
It's awful the pain you go through not knowing and wanting answers - and if it was one of his children, would he let it go 14 months? I don't think so”
In the end, there were few solid answers. It was put down to Sudden Adult Death Syndrome - a catch-all description for unexplained deaths.
But Margo was angry that the Teesside coroner Michael Sheffield had taken so long to complete the investigation.
And she was not alone. At the time, bereaved families were waiting up to two years for inquests in Teesside.
MPs called on Michael Sheffield to resign and forced an investigation by the Lord Chancellor's office.
Mr Sheffield kept his job but was severely reprimanded.
But 10 years on, MPs are again concerned about delays to inquests in Teesside.New investigation
The average waiting time from death to inquest has gone from 33 weeks in 2009, to 43 weeks last year.
That compares to a national average waiting time of 27 weeks in England. And in the neighbouring district of Hartlepool, the coroner takes just 20 weeks.
Stockton North MP Alex Cunningham says the Lord Chancellor should begin a new investigation.
He said: "My concern is for the families of loved ones. They've lost relatives and they're very keen for the inquest to be completed.
"Something has to be done. It's no good Mr Sheffield making excuses. He should really pull his finger out and make something happen or consider his position."
Margo Wright goes even further. She says he should have been sacked 10 years ago, and certainly should be now.
She points to his age. He's now 81.Wanting answers
She said: "He should have left when he was known as a good person but now he's got all these people waiting again trying to find out why their loved ones died.
"It's awful the pain you go through not knowing and wanting answers. And if it was one of his children, would he let it go 14 months? I don't think so."
End Quote Helen Shaw Co-director, Inquest
It's a postcode lottery at the moment - you can have a waiting time of 10 months in this particular jurisdiction and a similar death could be heard in the area next door much, much earlier”
And what of Mr Sheffield? I encountered him while filming outside his office in Middlesbrough.
He said he didn't have time to do an interview and couldn't because he is an officer of the court.
But when I asked him whether he would resign, he said: "Why should I?", and he urged the MPs to check their facts.
His office has told the local newspaper that a withdrawal of police resources has caused delays - something Cleveland Police has rejected.
But many people will be surprised that he is still allowed to hold the post well after the state pension age.
But there is no mandatory retirement age for coroners, and only the Lord Chancellor's office can dismiss one.Unacceptable delays
Some campaigners though say it's time to reform the whole system.
The charity Inquest helps families through the process. But it says waiting times are unacceptable in many parts of the country.
Helen Shaw, its co-director, said: "It's a postcode lottery at the moment. You can have a waiting time of 10 months in this particular jurisdiction and a similar death could be heard in the area next door much, much earlier.
"What really needs to happen is an improved service across the board."
The charity and some MPs and peers are also concerned about government plans to abolish the office of chief coroner - a post introduced two years ago to try and reform the system and cut waiting times.
They fear the plight of families will only get worse if the job is scrapped.
And the scars left behind by delays can last a long time too. Margo Wright is still angry at the way her family was treated.
And she believes an inquest process that is supposed to offer explanations and comfort, just added to her grief and pain.