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LB Balloons

With raging sympathy to Dr. Ryan and all of Connor’s family
and with profound thanks to George Julian for live-tweeting,
on the @LBInquest timeline,
the admirably lucid summary of proceedings reproduced below.


08.30 We’ll start tweeting here once proceedings commence, 10am at earliest

10.00  We think we’re five mins off starting LB’s inquest. We will only tweet if the jury are in court, so may not start immediately

10.45  The Coroner is currently doing house-keeping and addressing issues raised in legal submissions received since last PIR

11.12 We’re still hearing legal arguments and discussions around where agreement lies before can start. No jury yet. Torturous process.

11.33  Still housekeeping. Any jurors who ‘follow twitter accts or blogs to be excluded’.

11.38 Any jurors who follow this acct or on twitter or Sara’s blog to be excluded .

11.43  Coroner’s Assistant has gone to collect the jury

11.47 Coroner introducing the inquest to the jury, checking weren’t employed by Ridgeway or social services.

11.48  Now checking none of the jury knew Connor, his mother , his stepfather Rich Huggins or father Andy Sparrowhawk

11.49  Checking whether the jury follow or <<< None of them do

11.50  There is a need for formal swearing in (happening now) and a formal intro (in a moment); each juror sworn in individually

11.51  I do solemnly, sincerely and truly declare and affirm that I will diligently enquire on behalf of our sovereign lady the Queen 1/2

11.52  2/2 … into the death of Connor Sparrowhawk and will give a true conclusion according to the evidence << Oath jurors made

11.53  Coroner makes clear jury inquests are very rare these days, make up about 1-2% of inquests.

11.54  Coroner introduces the legal representatives for each interested person to the jury

11.55 Coroner introduces process to answer 4 questions: who was the deceased (Connor Sparrowhawk), when, where and how did he come to his death.  Jury must complete a record of interest that will include the medical cause of death – Coroner will tell more towards end of .  Some evidence will be read out, some will be provided by witnesses in person.  Coroner will introduce witnesses and take them through their evidence, then legal teams can question them, then jury can ask questions.

11.57  Coroner gives warning to the jury given: not discuss with family and friends, don’t communicate with anyone about it…  …jury at is not to do its own investigation, look up information on the internet or social media sites. Any concerns talk Coroner.  Is likely to be publicity about this the jury are instructed to ignore it.

12.00  Coroner now giving jury a brief, neutral, overview of the case.

12.03 Coroner directs jury to a photo of Connor provides background to what known currently.   Connor was diagnosed w autism as a young child, was diagnosed with epilepsy some years later. His mother said was a quirky, fun young man.  Coroner outlines that there have been a number of reports into LB’s death. accept findings of Verita 1 report.  Coroner shares agree LB should have been subject to line of sight/sound observations while bathing.

 12.05 Also accept LB would have been in sight if appropriate risk assessment and care plans had been in place.

12.07  The issues that will address are detailed in and on attached pic

J4LB issues

Jury have a bundle of documents provided by the court including a list of witnesses they’ll hear from in writing or in person .  Jury bundle also inc identification statement, post mortem report, ambulance statements/records, ER statement and STATT floorplan.

12.11.  Jury introduced to record of inquest that they will need to complete at the end of Can see one in Annex A

12.14  Coroner now reading an opening statement of Lesley Thompson (Coroner’s Officer) and identification statement formally indentifying Connor

12.15  Coroner now turning to pathology evidence – standard for the Coroner to instruct these tests to be run and report to be written

12.17  No alcohol in LB’s blood; drugs inc fluoxetine (an anti depressant prescribed to LB) and phenytoin (anti convulsant prescribed to LB).  Question from LB’s counsel about why risperidone wasn’t found (was prescribed at time of death); pathologist believes dose too low to trace.  ‘Absence of risperidone does not indicate that LB had not taken medication’ Pathologist’s judgement, test not sensitive enough to pick up.  Pathologist report believes LB died due to 1a drowning due to 1b epilepsy associated with klinefelter syndrome (mosaic variant).

12.22  Pathologist, Dr Ben Phillips, now giving evidence .  Ben Phillips giving his major findings at post mortem inc markedly distended lungs and bite marks down either side of tongue.  Given changes of lungs drowning most likely cause of death as result of seizure (indicated by bite marks, empty bladder and small bruise).  Histology report supported post mortem findings, brain evidence similar to someone w epilepsy, no alternative cause from histology result.

12.28  1a immediate cause of death (drowning) in relation to 1b underlying factor (seizure linked to klinefelter syndrome mosaic variant).  Questions from Dr Murphy’s counsel asking whether bruise cld be caused by LB being pulled from bath <<< Dr Phillips says possibility.  Question whether empty bladder due to drowning rather than epilepsy; unlikely.  Last question from Dr M’s counsel whether bite marks cld be due to intubation; possibly on lips, definitely not on tongue.

12.33  Pathologist asked whether he could ascertain how long Connor had been in the bath unchecked/unfound; not possible.

12.34  Pathologist thanked and dismissed from . Coroner now reading statement from LB’s GP .  LB last sought advice from his GP for treatment of a verucca .

12.36  Now sworn in and is to read the start of her witness statement to introduce Connor to the jury .  Connor was 18 when he died, he was a quirky, loving, funny and loved off the planet by his family .


Connor’s favourite question was why although he stopped asking it once he reached 18 .

12.39  Jury hearing background of what happened that led to Connor’s admission to STATT from .  Hearing describe how she contacted Carol Clarke, Connor’s care manager at for support .

12.42  Hearing describe taking Connor to STATT unit on 19 March 2013, later he died .

12.44  Coroner now reading statement from Lenka Mullerova who was on duty on the day LB died. Statement not agreed but Lenka can not be traced.  Lenka’s statement is her account of what happened on 4 July 2013, the day Connor died.  Hearing there was a problem with the phones so she had to use her mobile to call an ambulance .

12.49  Coroner reads statement from Dan Chilvers, the paramedic solo responder called on day; ambulance crew on scene when he arrived .  History given to paramedic by staff on the day was that LB went for bath at 08:55 and was found at 09:15.  Paramedic’s statement to describes CPR attempts at STATT and on the way to John Radcliffe Hospital.  Ambulance records show call time 09:15, crew mobile at 09:16, arrived 09:19, left scene at 09:39 and arrived at John Radcliffe at 09:46.

12.55  Coroner now reading statement from Phil Hormbrey the Emergency Department Consultant about their resuscitation attempts on July 4 2013.  Resuscitation was stopped 23mins after Connor’s arrival in the department at what was estimated as 1hr20 after LB last seen alive.

12.58  Now adjourning for lunch for hour; evidence to be given after lunch from Maxine Hemmings and Kieran Dullaghan (both on duty on 4 July 2013).

13.00 FYI we’re tweeting what is said and won’t be tweeting unless the jury is sitting in court. So we’re stopping for lunch now .