The first inquest into Poppi Worthington’s sudden and unusual death was so short that when the coroner concluded, everyone in court gave each other the same look: was that it?
The hearing, at Barrow town hall on 21 October 2014, lasted just seven minutes.
By that point, almost two years had gone by since the 13-month-old had died at her chaotic and overcrowded home nearby, and yet the circumstances remained shrouded in mystery.
Delivering his minimalist conclusions, the Cumbrian coroner, Ian Smith, did not address how a healthy baby who had just taken her first steps suddenly stopped breathing in her father’s bed. He called no evidence as to how she was discovered, whether any attempts were made to revive her nor whether any public agencies were at fault.
No mention was made of the fact that at the time of the inquest both of Poppi’s parents were on bail in connection with her death and that her father, Paul Worthington, was suspected of sexually assaulting her. Neither parent was ever charged.
No one from the police was called to court to explain why key evidence, including the nappy Poppi wore the night she died, had been thrown away. Or why intimate swabs were only taken from Worthington many hours after her death, long after a member of hospital staff had warned detectives that they suspected the baby had been abused because she was bleeding from the anus.
The coroner, attempting not to breach a reporting restriction imposed in the family court, did not reveal that an X-ray had shown Poppi’s leg was broken when she died. Her death was recorded as “unascertained”.
Inquests are usually open to the public but no one was present that day. Only those with intimate knowledge of the case would have known it was even happening: Poppi’s name, highly unusually, was not on the court list.
It took another three years and sustained media pressure before Poppi was given a full, public inquest after a high court judge ruled the original was “irregular”.
On Monday, David Roberts, senior coroner for Cumbria, finally gave his verdict as to how Poppi had died.
After hearing three weeks of evidence at Kendal town hall, Roberts ruled that Poppi had been sexually abused by Worthington after he took her out of her cot and put her into his bed. It was this “unsafe” sleeping environment which caused the toddler to suffocate, he ruled.
Roberts is not the first senior member of the judiciary to accuse Poppi’s father of abusing her. In 2016 a family court judge ruled that on the balance of probabilities, Worthing probably assaulted Poppi shortly before she died.
Yet Worthington is unlikely to be put on trial. In November 2016 the Crown Prosecution Service (CPS) said he would not be charged because there was “no realistic prospect” of his conviction due to insufficient evidence.
No new evidence emerged during the second inquest and Worthington was careful not to incriminate himself when called to give testimony. He cut an arrogant figure, refusing to answer 252 questions as he exercised his legal right to remain silent and for his silence not to count against him.
Saying nothing was probably sound legal advice from his high-profile lawyer, Leslie Thomas, QC, who is also representing the families of the Grenfell Tower victims. But it made a mockery of the inquest process. How could it be that the only person present when Poppi began to die was allowed to dodge all questions as to what actually happened that night?
It may seem absurd that a man accused by a senior coroner and judge has never been tried for the crime and probably never will be. The blame for that lies with Cumbria constabulary, whose investigation was criticised by the Independent Police Complaints Commission (IPCC) as “unstructured and disorganised”. Gillian Irving, QC, acting for Poppi’s mother, called it “a farrago of failures”.
It took the force eight months to arrest Worthington, long after crucial evidence that could have incriminated – or exonerated – him was lost. Officers allowed the nappy she was wearing to be thrown away when she died and there was a 10-hour delay in taking swabs from Worthington’s penis.
The IPCC also criticised senior officers for dismissing warnings from a Home Office pathologist, Dr Alison Armour, who carried out Poppi’s postmortem. She warned detectives early on that she thought the baby had been abused, but was accused of jumping to conclusions.
Two senior officers who could have been found guilty of gross misconduct retired before action could be taken.
It was Armour’s evidence that led Mr Justice Peter Jackson in the family court to conclude that Poppi had been abused.
At the second inquest, Armour said she was sure Poppi’s anus had been penetrated by “a penis or penis-shaped object”. But her evidence was contested by one of the UK’s top pathologists.
Dr Nat Cary – who carried out postmortems into the poisoned Russian spy Alexander Litvinenko and the newspaper seller Ian Tomlinson, who was hit by a police officer during G20 protests in 2009 – said he saw “no clear-cut evidence” of trauma suggestive of abuse.
He said there was “no explanation” for a fracture to Poppi’s leg, which was not diagnosed in life. But he stressed that the break was to the thinner leg bone, the fibula, which is not weight-bearing and would still have allowed the toddler to walk, albeit in some “discomfort”, and so may not have been noticed by her parents.
Rounding up the second inquest, Roberts said a conclusion of unlawful killing was not available to him as he was not satisfied beyond reasonable doubt that Poppi died from an act of murder or manslaughter. Although satisfied that she was penetrated before her death, he concluded she did not die immediately afterwards and that penetration did not cause her death.
