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LB Balloons
With love and sympathy to Dr. Ryan and all of Connor’s family,
and thanks as ever to George Julian for live-tweeting,
on the @LBInquest timeline,
the admirably lucid summary of proceedings reproduced below.
***

14.40 Due to hear evidence from Maxine Hemmings, Health Care Support Worker at STATT; & Kieran Dullaghan, Staff Nurse and LB’s named nurse, this pm.

14.41 Before we hear from witnesses the jury will be played the audio recording of the 999 call made by Lenka Mullerova on 4 July 2013.

14.45  999 call operator asks how old the patient is, Lenka mishears and says ‘We don’t know how long he has been in the bath’ .  Lenka confirms that Connor was found under water in the bath and is not breathing and that they were using a defibrillator .

14.51  Now hearing from Maxine Hemmings, Health Care Support Worker at STATT working on the day Connor died .   Maxine Hemmings worked at STATT since Aug 2012, having previously worked at John Sharich House for .  Maxine was working with Lenka Mullerova, Kieran Dullaghan and Elizabeth G? on 4 July 2013 .  MH confirms she started work at 07:30 on 4 July.  She woke Connor and left him for 5 mins or so to get up and said she’d run a bath.  She ran bath, left Connor to get in and went to get socks from laundry room for him to wear that day and then went to make a cup of tea.  Had conversation in office with Kieran Dullaghan, he went to check Connor had got in bath, then OT arrived and they had conversation.

14.57 MH went to check on Connor after this conversation and found Connor submerged in the bath; called for Kieran Dullaghan.  Coroner reads more detail, asks Maxine if statement is correct <long pause> she says yes, Coroner observes she hesitated and asks again…if it is correct; Maxine H confirms that it is. Coroner now asking further questions of Maxine.

14.59  The Coroner asks whether the bathroom door was shut and whether it would normally be shut. MH confirms it was, and she would have shut door.  MH statement says the time was 09:15am, Coroner asks where she was when she checked time?  In office.  Who were you with?  MH can’t remember.

15.02  ‘Connor was in the bath and needed checking on, extra to that he had a trip planned and he usually liked to have baths, was little concerned once he was in the bath he wouldn’t want to get out, so MH made it clear to him that he had trip.  09:15 check to see he was OK and to make sure he knew he would have to get out soon’ (to go to Oxford Bus Company on day trip out).

15.03  MH says she went to get LB’s socks and when she came back he’d taken himself into the bathroom and shut the door.  MH didn’t see him then.  Coroner checks MH started running bath, went laundry room so last time she saw him he was in bedroom and he was in bathroom on her return.  Coroner asks MH at that stage whose responsibility would it be to check on Connor in the bath; she replies ‘mine’.   Coroner asks MH about observation schedule; she replies it’s been a while since she’s worked but describes 3 levels of observations: hourly, intermittent and constant.  MH says Connor would have been subject to intermittent obs (15min) in bath and hourly otherwise.

15.08  Coroner asks MH if she’d had any epilepsy training from She replies ‘no’ and explains there was an online record of training.  The online system logged training.  She’d received an email to do epilepsy training but she hadn’t been.

15.12  Coroner asks MH why Kieran checked on Connor: KD asked MH where Connor was; she said she was about go check on him but KD offered to do so.

15.13 Paul Bowen now asking Maxine questions. Lenka’s statement said she’d put Connor in the bath at 08:30 and checked him about 08:45.   MH says she ran the bath at about 08:30 and left Connor to get in the bath, she didn’t check him at 08:45.

15.15  Paul Bowen clarifying MH’s statement, comparing what she told the Police 2wks after LB’s death and in a later statement.   Later statement says that KD offered to check on Connor, but she said, Don’t worry, I’ll do it.  MH says must be an error in later transcript.   Paul Bowen reads from second statement that indicates there was no 9am check and that MH opened door with a key and found Connor submerged.  MH says there’s a bit missing from the second statement, it *should* say she checked on Connor <but it doesn’t>.

15.22 MH being asked about observations records, Paul Bowen takes her thru three sets of observations (start 3 June last day LB was on 10min obs).   LB was observed in the bath and a record was made of this; next record 4 June (day new obs levels are introduced), general obs every 60mins.

15.29  Interjection as paperwork is shared; not enough copies, so short break while photocopying done. Maxine Hemmings will return after break.

 15.56  Court has returned, paperwork shared, back to Maxine Hemmings’ evidence.

 15.57  Paul Bowen directs MH to document Observation Plan and Record of Observations; can see records made at hourly intervals night before LB died.  Paul Bowen asks MH to identify whose signature is on the chart at 8am and 9am (Lenka signed bathroom at 9am). Asks MH why Lenka wld have signed at 9am if Kieran had conducted the check; MH can’t answer because would be speculating.

16.00  Asked what normal procedure would be.  What is policy for making a record and who should record it? MH doesn’t recall. Paul suggests if you did observation you would record it?   Lenka’s evidence MH put LB in bath 08:30 MH thinks more like 08:45. MH police evidence says KD checked 9am, later transcript doesn’t mention.  Paul Bowen takes MH thru what transcript says again, says MH will check on LB but she knows KD went.  9am observation signed by Lenka not KD.  Lenka’s evidence statement says check was at 09:20, MH says she is confident was 09:15.  Paul Bowen asks MH when she became aware that LB’s observation requirements changed; she can’t recall.

 16.06  No questions from two legal teams, now one from Roddy James, counsel for Ben Morris, about observation record.  MH answers that if patient was on Level 2 (15 mins) or Level 3 observations (constant) then a rough timetable would be made at start of shift.  MH says ‘if she was doing hourly obs and was sure someone had done a check, she’d be happy to sign it; if she didn’t know that she’d check’.

16.10  Counsel for KD, Michael Walsh, checks whether Maxine H went with Kieran for the 9am check. She didn’t.

 16.12  Counsel for now questioning Maxine H. Asking MH to explain what the Oxford Bus Company tour (which LB was due to go on) was.  MH believes was a tour of the bus depot.   asking MH why she had stressed with LB that had to be a quick bath because of tour.  Counsel for checking when MH returned w socks that bathroom door was shut; after that MH went to kitchen to make a drink.

16.15  MH states she needed to do an online food shop so she got a cup of tea, got the menus/stock inventory and took to office to do food order.  MH intended to do a Tesco food order; having got tea and menus, went back to office, met Kieran outside office door, KD asked about LB.  MH said she’d go check LB in bath, Kieran D offered to do it, she left him to do it. Didn’t do food order because Lenka and EG were using PCs.  Counsel asking MH what intended to do, she intended to return to food order after she’d taken LB out. She was making list.

16.19  Then OT arrived on the unit and MH had a 2/3min conversation with her; was usual for MH to take LB out on trips .  Counsel for asks MH what happened after she finished talking to the OT.  MH says ‘she can’t remember exactly but the way she remembers it she went to check on Connor’,  prompted by the time/clock in the office.

16.22  Counsel for checks that Maxine Hemmings’ evidence is that she couldn’t find a pulse? It is. <MH visibly upset recalling it>.  Counsel now checking with MH that the minimum observation any patient on the STATT would have is hourly.  MH replies it is.   Counsel asks MH: ‘Can I check, were recordings made anywhere that 15min observations took place’?   She replies: No.  Lenka signed for LB’s hourly obs, she must have felt she was in close enough proximity to know LB mood .

 16.27  Counsel for ‘Can I just check whether recordings were made of 15 min observations?’  MH answers: No.  << 2nd time clarified >>.

16.28  Jury are dismissed for Day 1 and asked to return tomorrow.  Kieran Dullaghan’s evidence will be heard in the morning .

16.30  Jury has left so we’ll not tweet any more here today but will return in the morning.

 

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