Isaac Mansfield inquest: Mystery remains over who gave boy cocaine

His death was attributed to natural causes until a “sharp-eyed” GP spotted metabolites of cocaine in a urine sample which was later corroborated by a blood sample. 

By the time Met Police and coroner’s court investigations had begun, Isaac's body had already been cremated – a police investigation failed to find evidence strong enough to criminally convict anybody. 

Senior coroner Graeme Irvine presided over Isaac’s inquest on Monday and Tuesday (September 1 and 2), where he said he faced the “invidious position” of carrying out “what is ostensibly a surrogate criminal investigation” into who exposed Isaac to the cocaine.   

East London Coroner's Court heard Isaac's parents, Faith Mansfield and Jordan Montlake, were divorced - they shared custody but Isaac was living with his dad in the period before his death. 

Ms Mansfield was eliminated from inquiries as cocaine has a short half-life and she had not seen him for a number of days. 

Mr Montlake, school staff and carers were all called to give evidence under oath at Isaac’s inquest and each said they had no idea how he encountered cocaine. 

At the end of the inquest Mr Irvine said he was convinced carers or school staff did not administer the cocaine. 

He indicated several factors that made him suspicious of Mr Montlake – including his resistance to his son being taken to hospital and inaccuracies during his conversations with 999 call handlers and paramedics.

But Mr Irvine said: “All those things make me suspicious, but suspicion is not something I can rely on in a coroner’s inquest."

Recording a narrative verdict, Mr Irvine said: “Isaac’s death was caused by renal failure brought about rhabdomyolysis caused by the combined effect of mitochondrial cytopathy and cocaine. 

“It has not been possible to determine how, when or in what manner the cocaine was ingested. 

“Isaac’s disability allows me to exclude the possibility that the substance was taken voluntarily.” 

Isaac and his mum Faith (Image: Supplied) During the inquest paramedics and a school nurse gave evidence Mr Montlake had tried to prevent Isaac from being taken to hospital after he fell ill at school. 

Mr Irvine, questioning Mr Montlake, said: “The evidence we heard yesterday was that your reluctance for Isaac to go to hospital was unusual to such an extent it triggered safeguarding concerns. 

“It also triggered a concern in my reading of it, because on any interpretations at this point the signs exhibited by Isaac were very serious issues.

"He had a high temperature of over 40C, a high respiratory rate, a high heart rate, he was pale, he had poor diffusion and vomiting. 

“One interpretation of your reluctance to allow Isaac to go to hospital was that you were aware there was a problem with Isaac you did not want to be discovered. 

“When you called the 999 service to interrupt what was going to happen, that your very ill son was going to hospital, were you concerned that it could be discovered that he had cocaine in his system?” 

Mr Montlake answered: “No sir, absolutely not.” 

Mr Montlake explained that he believed Isaac may have just been struggling with the summer heat and that hospitalisation would make his condition worse as it had on previous occasions – the court heard unfamiliar faces and sights distressed Isaac and could cause seizures. 

Mr Irvine asked if Mr Montlake is a drug user and if at any time there was cocaine present at his and Isaac’s home in Stratford.

Mr Montlake answered no to both questions. 

“Can you give any explanation of how cocaine came to be in Isaac’s blood and urine samples?” Mr Irvine asked. 

“No sir,” Mr Montlake said. 

School nurse Funmilola Jackson and carers Philomena Adu-Boahen and Edith Adachukwu were all asked the same question under oath – each answered no. 

Among the concerns raised by Isaac’s mum pre-inquest were that Isaac was cremated just three days after his death.

Mr Irvine asked Mr Montlake why this was. 

“I didn’t want him laying on a slab somewhere. I just wanted to take my son home,” he answered. 

Ms Mansfield was not asked to give evidence but Mr Irvine did read a background statement from her. 

She described her son as a “pure soul” who was “kind, patient and friendly with everyone who met him". 

Isaac had an undiagnosed metabolic condition which impacted his cognitive function and motor skills.  

Whilst he was non-verbal his mum said Isaac had fantastic ways of communicating and “would always babble along to his favourite songs and stories". 

She said: “He was so easy to love. His smiles always lifted those around him and his long eyelashes stunned and caused jealousy in all. 

“He suffered tremendously in his life but managed to bounce back with giggles and grins.

"He is loved and missed by everyone who had the pleasure to know him.” 

Det Sgt Jasmine Abbey told the court that unfortunately there was no evidence of how Isaac ingested the cocaine and who was responsible. 

Asked by Ms Mansfield if she felt the Met Police had taken the investigation seriously, Det Sgt Abbey said: “I can absolutely assure you this case has been taken seriously. 

“It’s been in my life for two years. I really want to tell you and your wider family what happened to your child. Unfortunately we’ve not been able to, that’s the way some cases go.” 

Det Sgt Abbey added that, short of someone confessing to giving Isaac cocaine, there was no way to identify how it happened. 

Paediatric pathologist Dr Andreas Marnerides told the court that Isaac’s immediate cause of death was renal (kidney) failure caused by rhabdomyolysis – a condition resulting from the rapid breakdown of muscle.  

Dr Marnerides said that both cocaine ingestion and Isaac’s metabolic condition can be causative factors of rhabdomyolysis.  

As Isaac was cremated prior to the discovery that he had ingested cocaine, no post-mortem was ever carried out so significant evidence was missing which could have assisted pathologists in identifying which of the two had caused Isaac’s death.  

But when pushed for an answer on the likely cause of death, Dr Marnerides answered 1a) renal failure, 1b) rhabdomyolysis, 1c) metabolic disease and cocaine ingestion – Mr Irvine later adopted this as the official cause of death. 

Dr Thomas Bycroft, a representative of Imperial College Healthcare NHS Trust, also gave evidence at the inquest.  

He said the trust has implemented changes to ensure toxicology tests for seriously ill children are completed as a priority. 

Whilst discovering the cocaine earlier would not have changed the treatment Isaac received, it would have assisted the safeguarding and police investigations, the court heard. 

Mr Irvine said: “It seems to me the serious incident report undertaken in relation to Isaac’s death was comprehensive and it seems to me that meaningful change has arisen out of this tragedy.”