London: Jacintha Saldanha sent two last, desperate emails of apology and regret to her nursing colleagues before taking her own life after falling for an Australian radio hoax.
Her immediate boss, King Edward VII hospital's matron Caroline Cassells, wiped away tears as she told an inquest that she regretted not answering that email sooner.
Thursday was the first day of the long-awaited coronial inquest into 46-year-old Ms Saldanha's death.
Court 10 at London's gothic stone-and wood paneled Royal Courts of Justice heard that Ms Saldanha was a diligent, popular and highly professional nurse with a streak of perfectionism, who was overcome with guilt after the hoaxers tricked her into breaking hospital protocol.
At 5.25am on Tuesday 4 December 2012 she was in charge of the hospital's night shift – and of dealing with incoming phone calls – when she took a call from 2Day FM radio hosts Michael Christian and Mel Greig, who were impersonating the Queen and Prince Charles.
She immediately summoned another nurse, who revealed details about the treatment of the Duchess of Cambridge, who was at the hospital suffering from severe morning sickness.
The exchange was broadcast in the evening in Australia – about 10am London time.
In a statement Rhys Holleran, CEO of Southern Cross Media, said his staff made four calls to the hospital in the half hour following the prank, seeking consent to broadcast the exchange.
However, those calls were short – all less than a minute – and the hoax call was eventually broadcast without the consent of the nurses or the hospital.
Fiona Barton QC, representing the hospital, said the calls may have "further compounded" the stress Ms Saldanha was under.
She added it was "perhaps strange" that the radio station did not follow up its attempt to get consent to broadcast the material during working hours, rather than before 6am in London.
"Southern Cross accepts complete responsibility for broadcasting the segment," Mr Holleran said. "It does not apportion blame to any of its employees (and) deeply regrets (the broadcast)."
The company had reviewed its policies and decided not to make prank calls to emergency services or hospitals, and not to broadcast prank calls without consent.
The nurse who revealed details about Kate Middleton's condition gave evidence anonymously at the inquest.
She said Ms Saldanha had recently had a conflict with a colleague at the hospital which was "always on her mind". She was a hard working and resourceful nurse whom "I respected and admired."
She said Ms Saldanha summoned her to the phone and told her it was the Queen.
"Initially it seemed plausible," she said. "Time sort of stood still. I was alarmed but stunned."
But her suspicions grew when Christian intervened talking about corgis. "This didn't seem appropriate," the nurse said. "I replaced the handset and looked directly at Jacintha and said 'there was something wrong with the phone call, it wasn't right'."
Most VIP patients are contacted by mobile phone, she said.
They quickly established from the Duchess' guards that it had been a hoax.
However, they were unaware it was a radio station, and Ms Saldanha seemed calm about it.
But soon the hospital discovered the exchange had been broadcast, and the matron sent a message to the nurses warning them not to watch the news the next day.
Late the next day the nurse received an email from Ms Saldanha apologising for transferring the call.
"At that moment in time with [Greig's impersonation of the Queen's] voice I couldn't even think of anything else," Ms Saldanha wrote. "It's all my fault and I feel very bad for getting you involved… I am very upset I don't know what to do…. I accept the fault is mine, I should have checked. I can only say sorry."
The nurse sent a supportive text message in reply.
But the next morning on December 6 Ms Saldanha sent another email to the nurse, and the matron and deputy matron, saying "I feel very sorry for breaching security, I am ready for any punishment."
The nurse said she had not been blamed by the hospital over the event, "they supported me and reassured me," she said.
Ms Cassells told the inquest that hospital policy would have been to take a message and offer to call back.
She said Ms Saldanha was "obviously upset" but not overly agitated immediately after the hoax.
"I felt (the nurses) were victims of a nasty hoax call at a ridiculous hour of the day," she said.
Ms Saldanha "had this attitude she would just … draw a line and move on," she said. "She was a coper, she was someone who coped. A nurse has to cope under pressure. In a way she thrived on it."
When she received the email from Ms Saldanha on Thursday morning she was too busy to immediately reply. Later in the afternoon she sent a reply arranging an 'informal meeting' the next week.
"I do regret not answering that email [sooner]," Ms Cassells said.
Ms Saldanha's husband, accountant Benedict Barboza, attended the court with their children, son Junal, 18 and daughter Lisha, 16.
Mr Barboza gave a short statement, wiping the tears from his eyes as he described his "beloved and caring wife … a loving mother and one of the best nurses".
She was ambitious and successful, and received many thankyou messages from patients, he said.
She was always eager to help the needy and care for the elderly.
"She was a great lady and we are very proud of her," he said.
The family lived in Bristol, and when she was on duty in London they would talk by phone at least once a day.
But she never revealed details of the hospital's famous patients, only telling him "it is none of your business".
When he spoke to her after the hoax call she seemed normal, however she did not respond to any calls, texts or emails the next day.
On Friday, December 7 he called a colleague of hers at the hospital, who went up to her room.
Ms Saldanha was found hanged in her hospital accommodation. There was also evidence she had tried to cut her wrists.
The colleague said she had spoken to Ms Saldanha after the hoax call and "Jacintha told me she was very upset and she felt it was her fault".
Mr Barboza said her death came as a complete surprise – she had never suffered psychiatric problems or depression and had never before attempted self-harm.
"She was a happy lady around the house, a normal, bubbly lady," he said.
Ms Greig attended the court hearing and was represented in court.
She tweeted beforehand "I made a commitment to the Saldanha family that I would answer any questions they have, on or off the stand, I'm here to uphold that promise."
In court her lawyer Gerwin Samuel repeated her offer to give evidence, including as to Ms Saldanha's demeanour during their brief phone conversation.
However, the coroner declined the offer, saying it would not help the court and "may fuel speculation".
"I understand she may feel unfairly blamed and in this she has my sympathy," coroner Dr Fiona Wilxcox said. "This inquiry is not charged with apportionment of blame. From the evidence I understand there is no causation as a matter of law between the hoax and any subsequent action on the part of Ms Saldanha."
Dr Wilcox opened the hearing saying her job was to establish "how, when and where" the death came about.
"No-one is on trial," she said, at one point reining in the counsel present to remind them it was a fact-finding process not an adversarial one.
The inquest is expected to finish on Friday.
* Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14 or Suicide Call Back Service 1300 659 467.
