What did happen to Rachel?

The story of Rachel Whitear's death has been used worldwide in the war against drugs. Yet the coroner at her inquest was 'certain' that she 'did not die from heroin'. So what is the truth? Jason Bennetto reveals a catalogue of official incompetence

The death of Rachel Whitear did not initially seem that unusual. The 21-year-old student died from an apparent drugs overdose in a rented room in the south-coast town of Exmouth in May 2000 - just another tragic entry, one would have assumed, in the long, dismal death toll of addiction in modern Britain.

What made the case remarkable - and led to its being reported all over the world - was the courageous decision by Rachel's mother and stepfather to allow the publication of the unexpurgated photographs of their dead daughter as she was found in her room. The pictures of her bloated body, bent double alongside a discarded heroin syringe, are among the best-known and most shocking anti-drug images of modern times. They show the young woman crouched on the floor in a foetal position. Her blackened arms and face are swollen and covered in purple and dark-pink veins. A used syringe lies inches from her body on a carpet stained with blood from a cut on her knee. Nearby are a neatly made single bed, a rucksack and a pile of clothes next to a small chest of draws with a television perched on top.

The Daily Mail called it one of the most shocking pictures that the paper had ever published. Secondary-school children throughout Britain were subsequently shown a video called Rachel's Story, made by the dead woman's family and friends as a warning of what can happen if you turn to drugs.

But was the case really as simple as the publicity implied? Devon and Cornwall Police treated the case as a routine overdose, and quickly concluded that there was nothing suspicious about it. No post mortem was ordered, and the dead woman's body was returned for burial before toxicology tests had been completed. But the seemingly straightforward case was turned upside down at the inquest when a Devon coroner stated that he was "certain" that she had not died of an overdose because the level of heroin in her blood was too low.

That was three years ago. Since then a new inquiry has been set up, which The Independent understands has uncovered disturbing evidence of police incompetence and of flaws in the coroner's system. Rachel's parents still believe that another explanation could be possible.

No one who knew Rachel when she was growing up in Ledbury, Herefordshire, could have imagined that she would become an addict. A bright and sociable teenager, she came from a stable and loving home, with a brother (now a policeman), a step-sister and stepbrother.

She excelled as a pianist, left school with 10 GCSEs and went on to Hereford Sixth-form College, where she gained two A-levels. Five of the six universities to which she applied offered her a place. But as the 19-year-old was choosing which offer to accept, she started going out with Luke Fitzgerald, then 24, who had been a heroin addict for three years. She started to take drugs with her new boyfriend, and soon became hooked on heroin.

Counselling helped her to kick the habit for a time, and at one point she was clean enough to decide to read psychology and sociology at Bath University. But after one term she gave in to heroin, dropped out of college, and in January 2000 moved to Exmouth with her boyfriend. She took a series of low-paid jobs and would sell anything to raise money for a fix.

She loved living near the beach and liked Exmouth, a slightly scruffy, unfashionable seaside town. In March that year she decided that her relationship with her boyfriend was over, but she told her mother that she wanted to stay by the sea in Exmouth. In May she secretly found new digs for herself in a rented room in a small, three-bedroom terrace house in Pound Street in the old part of town. On Tuesday 9 May she left her ex-boyfriend a note, telling him that she needed her own space "uninfluenced by anyone, to develop a new life in". As a farewell gesture, she suggested that they meet at the beach on the following afternoon. After leaving the goodbye message, she moved into her new home. Her body was discovered three days later by her landlord, Darren Tynan. The decomposition indicated that she probably died on the Wednesday.

At Rachel's inquest in December 2000, the Exeter and Greater Devon coroner, Richard van Oppen, was at a loss to provide a cause of her death, describing it as "unascertained" and recording an open verdict. He based his comments on toxicology results, which showed that there was 0.05 micrograms of the drug per millilitre of blood. Experts said that 0.15 micrograms was the level of dose needed to kill. Mr van Oppen, who has since retired, concluded at the inquest: "There is only one thing here today of which I am certain - Rachel did not die from heroin."

At this point her mother Pauline Holcroft, 53, an estate manager, and Rachel's stepfather Michael Holcroft, 55, a leisure-centre manager, became increasingly uncomfortable about how the case was being dealt with. Mrs Holcroft said: "Devon Police's handling of the case beggars belief. They released the body before the blood tests came back and didn't carry out a post mortem. If we had known things were not cut and dried, we would have been willing to delay the funeral."

She continued: "I had every reason to think that Rachel was well, which is part of my grave concern about it. It seemed that the relationship was over. She left him the day before she died. I had seen her 10 days before, and she was feeling very positive. It looks as if she moved into new accommodation on Tuesday. She had had a shower and washed her hair, and had been to the launderette.

"Rachel told me that she had arranged to meet him [Mr Fitzgerald] at Wednesday lunchtime. In the night before she died she told me that he came and made a scene. When he got back from finding a letter from her saying that she had left him and found someone else, he said that he was so upset that he injected himself with a whole £10 bag of heroin. I telephoned her on Thursday, but there was no answer. Her body was found on Friday, but everything looks like it was Wednesday she died."

The Holcrofts raised their concerns about the ex-boyfriend's role on the Wednesday with the police. In August, Mr Fitzgerald was arrested on suspicion of man- slaughter and questioned about the chain of events that resulted in his former lover's death, including contradictory statements that he gave to police. Having initially said he never saw her on Wednesday, the day she is thought to have died, he later admitted meeting her in the street during the morning and borrowing £20. But he denied having set foot in her new room. He was later released without charge after no evidence was found that he was involved in her death.

There remained, however, other aspects of the death that perplexed the family, including the whereabouts of a tin in which Rachel used to keep her rolling tobacco, and other personal items that were missing from her room. The family were surprised that the door to her 6ft-by-10ft room was open when the body was found. If she was injecting drugs on her own, she would surely have wanted some privacy. They also found it suspicious that the cap of the syringe had been replaced - a strange action for someone dying of an overdose - and that the tourniquet she used to help her find a vein when injecting was not in the room. But most of all, they were bewildered as to why a post mortem had not been carried out.

The family made a formal complaint about Devon and Cornwall Police, who referred the case to the Police Complaints Authority. In turn, the PCA brought in officers from the Wiltshire force to carry out an investigation, which was widened to look at the whole process rather than just the role of the police. Although the final PCA inquiry is not due to be completed until the end of the year, it is understood that the investigators have already made a series of disturbing findings. One of the principal conclusions will be that it was a major mistake not to have carried out a post mortem, which the investigators consider to be absolutely fundamental when dealing with a suspicious death of this kind. They believe it is extraordinary that there was not even an exterior examination of the body. This could have established whether there were signs of injuries that may have contributed to, or caused, the death. A more thorough examination could also have provided a clue as to whether Rachel died of asphyxiation - in heroin overdose cases, the drug can repress the body's system and the person can die because the body "forgets" to breath.

The family have offered to have Ms Whitear's body exhumed, but because of decomposition any clues left on the body will have been destroyed. The failure to order a post mortem was due to a series of errors, the inquiry has found. The coroner's office, which had to cope with a heavy workload at the time, did not order one, detectives discovered. It is the coroner's responsibility, but the police should have noticed and insisted that a post mortem was conducted, investigators will conclude.

The inquiry also believes that the coroner was mistaken to have stated that Rachel could not have died from an overdose. A leading toxicology expert has told the inquiry that although the young woman had a low amount of heroin in her blood, it was enough to kill her. Part of the explanation given is that while Ms Whitear had been a regular heroin user for two years and had developed a tolerance to the drug, she had not taken the narcotic the week before her death. An addict's tolerance rapidly declines if no drug is taken within about three days, according to the drugs specialist.

Furthermore, a re-examination of the death scene concluded that the dead woman's body was blocking the door, which suggests that no one could have got into or out of room. A forensic examination revealed no evidence that the ex-boyfriend had been in the room. On other issues, the inquiry team found that it is good practise to replace syringe caps. The inquiry has found no evidence to suggest Ms Whitear was unlawfully killed. But because of the lack of a post mortem, investigators are expected to say that it is not possible to rule out foul play completely.

Despite the exhaustive police inquiry, there also remains a number of unanswered questions. Ms Whitear had been drug free for a week, so why start taking heroin just as she appeared to have made a fresh start, with a new home and a new job working in a supermarket? She had even been talking about going back to university; friends describe her as being much brighter; and her counsellor, who saw her hours before she is thought to have died, said that his client was very positive-minded.

Even with all the controversy surrounding her daughter's death and question marks over whether she did die from an overdose, Mrs Holcroft still believes it was right to publish those shocking photographs. "I don't feel any regret," she explained. "Rachel was a heroin addict and we wanted to deter any young people who were thinking of going down that route." But she is angry with the police, who she believes have failed her family.

"If they had done their job properly and done a post mortem we would know what Rachel died of. I suspect they looked at the evidence in the room and saw a heroin user with a syringe in her hand, and all the trappings of drug abuse, and decided it was an open-and-shut case. I think the sudden death of a 21-year-old who had given up heroin and was looking forward to a fresh start should have sounded warning bells. Instead, they chose to ignore them."