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LB Balloons
Sending supportive thoughts to Dr. Ryan and all Connor’s family,
because NONE of this should have had to happen,

and awe to George Julian for her amazing work
in live-tweeting everything you can read below
on the @LBInquest timeline.


10.07  We’re back in court. First up the Coroner will read a witness statement from Joanna Ciapala (Psychologist), then call witness.

10.08  Before that Coroner wants to very briefly mention that during the course of evidence witnesses may elect to not answer a question.  Coroner: A witness may refuse to answer a question the answer of which may potentially expose him or her to a criminal charge.

10.10  Statement read from Joanna Ciapala (24 Aug) joined in June 2008 as support worker in 2012 seconded as assistant psychologist…on STATT, facilitated psycho-social groups ‘Let’s talk about feelings’ and ‘Tea and chat’.  JC saw LB occasionally at groups she facilitated.   JC: During all our interactions Connor was calm and polite, clearly stating if he did not want to participate.  Coroner reads JC statement reference to 20/6 incident where Cheryl S stated LB wasn’t coming to a session because ‘he’d wet himself’.  Further discussion 24/6, where agreed incident needed clarification w Cheryl or Kieran D [was he incontinent or did he spill a drink?].

10.15  Cheryl Sindayen who was a student learning disability nurse on STATT now sworn in and will give evidence to jury.  CS confirms to Coroner that the statement is hers, that she’s read it today and the contents are true and correct.   Coroner asks, Is it correct you were on placement at STATT as part of training?  CS confirms yes.  CS confirms that she is training to be a learning disability nurse.  Cheryl confirms she was at STATT from March 2013 to end June 2013, a three month placement.  CS placement ended a week before LB’s death.

10.19  CS is qualified nurse from the Philippines, moved UK in 2011, qualified as LD nurse in UK in 2015, experience of working w ppl w epilepsy.  Training overseen by her university, worked under supervision of KD at STATT; her training was extended by month at end May 2013.

10.22 CS: During my placement at STATT at times I assisted LB with some of his personal care… would also attend some of the CTMs.

10.25  Coroner reads CS statement about events on 20/6 in relation to LB being wet.  LB’s bedroom was open, CS heard something drop in LB’s bedroom, immediately went to bedroom to see what happened.  LB was next to his bed and bedside table. On table a jug and cup (containing squash) were tipped on their side and liquid was spilling out.  CS asked LB what happened and he said he’d spilt his drink. LB wasn’t pleased about having to change his bedding but he was a teenage boy.

10.29  Coroner continues to read statement covering Connor’s epilepsy .  CS: ‘I felt that Connor should be checked on every 5 or 10 mins when he was in the bath because of his epilepsy’.  CS: ‘If the bathroom door was left just open I couldn’t see LB but I could hear him. I wld listen for splashing of the water’.  CS: Around the time my placement was extended KD told me that I did not have to stay with LB all the time he was in the bath.  CS: KD said, ‘Don’t worry, he’s ok’.  I understood that KD was trying to reassure me that I did not have sit in the bathroom w LB all the time…he was in bath but I still thought that I shd check on him.  I did not disagree with him as I was a student and KD had more experience.

10.34   Coroner continues inc passage about contacting STATT with concerns LB had had seizure. She was crying which was unusual.

10.35  Coroner now checking statement with CS.  Says when she got there liquid couldn’t still have been pouring out the jug?  CS says that squash was spilt out of the jug. Coroner checks was LB stood up or lying down – she says he was lying on the bed.  Coroner checks CS’s use of phrase ‘wet himself’ she apologises and says she knows now she should not use that phrase [she meant he was wet].

10.39  Paul Bowen now asking CS questions.  Asks her to explain to jury why would it have been relevant if it was urine, not squash.  CS explains to jury that if LB had been incontinent of urine that it would be an indication of seizure activity.

10.42  CS says to PB that she never left LB in the bath, she was always around and she wld not have allowed LB to bathe after a seizure.

10.43  Court now shown record of medical notes, where confusion indicated over whether LB had been incontinent or spilt squash.  Medical record 24/6: Dr Murphy raised that there was a note on Rio that LB was incontinent of urine, but was no note about the circumstances.  CS confirms she had clarified on the day 20/6 what had happened; 24/6 CTM notes inc action Jonny Cowee to ask CS and KD for more info.  CS left on 27/6, CTM notes from state 1/7 ‘no-one was able to shed any light on the apparent episode of incontinence’.

10.47  1/7 notes: Dr Murphy was initially concerned that this might have been the result of a seizure, but there is no evidence to suggest this.  PB asks CS if she’d have expected a note of her clarification conversation to have made it onto Rio; she would have.

10.48  PB confirms that it’s clear that CS gave LB the best of care; asks would she have let LB lock the door to the bathroom? ‘No’.  PB: Wld she have left LB for more than 10mins in the bath? ‘No’.

10.49  PB takes CS back to phonecall from in tears where she said she was concerned LB had had seizure. CS had initially forgotten to…tell colleagues and pulled car over on way home to call them. PB asks CS about incident and she confirms in her opinion LB had had a seizure.

10.52  AJ for Dr Murphy asks CS about incident she describes in her statement that shouted at a consultant; asks what she said.  CS doesn’t recall who but was saying that this is meant to be a short term assessment unit, what have you done for my son.  AJ asks CS if she was scared of [in statement] she says, ‘No, its my language, she is very intelligent, I was not scared of her’.

10.55  RJ counsel for Ben Morris, STATT Mgr, asking CS about instances when LB had asked CS to leave him in the bath and be on his own, CS confirms.  BM describes CS checking on LB if he wanted to be left alone as ‘knocking on the door or popping her head in’.  She confirms ‘Yes’.  RJ confirms that when CS phoned in to tell colleagues about phonecall, they were already aware as she’d emailed.

10.58  CS confirms she did discuss her belief that LB had a seizure on her return to work; she spoke to Joanna, who said she’d ‘dealt with it’.  RJ confirming that LB was on 10 min obs on 20/6 when tongue bite incident occurred; CS says yes.

11.00  AS for Jonny Cowee, Charge Nurse asks CS if she’s familiar with patient dignity; she is.  AS asks CS how long she would have left LB in the bath ‘5 to 10mins’.  You accept there is some risk in leaving him even for 5-10mins? ‘Yes’.  AS: ‘There’s a balance of risk and dignity’.   CS agrees, states she’d have always been in ear shot.

11.04  AS: CTM record [clinical team meeting] on 24/6, reference to action for Jonny Cowee to ask CS and KD for more info about LB’s incontinence.  AS listing who attends CTMs, nursing staff, OTs, psychologists and psychiatrists – CS confirms yes.

11.06  Coroner: Do you remember a nurse asking you for clarification about what happened after this meeting?  CS confirms several nurses had asked her about this incident Jonny Cowee and KD but not sure when.

11.07  AS shares record of STATT CTM on 3/6 where decision made to reduce observations from 10mins to an hour.  Winnie Betsva asks if cld reduce obs from Level 2 [10min]; this was because of possibility of seizures but no evidence of seizures.  CS was attending CTM and AS asks why she didn’t raise her concerns about LB having seizures when this decision discussed.  CS replies, ‘As a student, you are in the middle of all these professionals, you speak when asked’.

11.12  Record says ‘CS says he remembers that he bit his tongue as he was in a bad mood, so he remembers the biting and the pain…Dr Jayawant explained this doesn’t appear consistent with a seizure’.  CS can’t recall this meeting, it was a long time ago.  AS Clarification: In this instance in the records, CS is Connor Sparrowhawk not Cheryl Sindayen, she does not recall and did not say it.

11.15  Michael Walsh for Kieran Dullaghan now questioning CS; KD also clarified what happened with her? CS confirms.  MW suggests she should have made a note of the conversation on Rio; she confirms she should have.  MW suggests to CS that ‘she didn’t explain at the time that it was a spillage of lemon squash’.  CS rebuffs strongly and says she did.  MW says to CS, ‘You were happy with the mentoring KD gave you and he was thorough’.  She nods.

11.19  Paul Bowen interjects that MW making a series of assertions to CS won’t help the jury; he’s asked to be clearer by the Coroner.  MW to CS: ‘You know that as far as your competencies were concerned you were meant to raise concerns if you had them’, she confirms yes.  MW to CS: ‘Kieran simply had some concerns that CS wasn’t leaving herself enough time to enter things on Rio’.  CS: ‘I don’t remember’.  MW suggests KD told CS she didn’t spend enough time on paperwork; she doesn’t remember but recalls KD said she was too ‘hands on’ as a nurse.

11.23  MF for Winnie Betsva asks one question of CS, ‘Can you confirm a secretary was present to take notes at Clinical Team Meetings?’  CS confirms.

11.25  Fiona Paterson for asks CS to confirm she moved to UK in 2011, ‘Yes’ and she hadn’t much chance to practice English until 2012.  FP asks CS to confirm that LB’s bedroom was only a couple paces from the office.  ‘Yes’.

11.28  Coroner confirms with CS that the office door was usually open. ‘Yes when we’re not having meetings’.  ‘Office door usually open but would be shut if the staff were talking about patients’.

11.31  Question to CS from jury ‘During your placement time did LB have a seizure that was witnessed by a member of staff?  ‘No, I don’t think so’.  CS finishes and dismissed, court breaks for 15mins.


 12.15 Jury returns. Joanne Hook, Staff Nurse at STATT, sworn in to give evidence.  Coroner asks JH to check and confirm it is her statement, she has read it recently and it’s a true recollection. She does.

12.17  JH is registered Learning Disability Nurse, worked as Band 5 Staff Nurse at STATT from 2005-13 employed by Ridgeway then .  Coroner asks how many Band 5 nurses were employed on STATT . JH confirms ‘about five’.

12.18  JH was working the night shift the day before LB died; left at about 8am on 4 July.  JH: ‘Role as staff nurse required being named nurse to 1 or 2 allocated patients, responsible for care plans, risk assessments, nursing obs…whilst maintaining good channels of communications w the patient, their family (where appropriate) and wider multi-disciplinary team’.

12.21  JH’s contact w LB was limited as she was named nurse for another two service users and didn’t supervise any support workers allocated to LB.  JH’s statement recalls LB complaining to her on 20/5 that he had a sore tongue, he told her ‘he’d bitten it when he was angry’.  JH aware raised concerns to staff 20/5 that felt LB was more sleepy in presentation / bitten tongue cld be indication of seizure.

12.25  Coroner asks JH what action took place after tongue biting incident.   raised concerns, passed to unit manager (BM) and Dr Murphy.  LB was moved downstairs to a bedroom next door to the nursing office and level of observations at night increased to half hourly intervals.  Coroner to JH: What training done for epilepsy?  Medication and online session on epilepsy management: ‘reading with a quiz at the end’, hr long.

12.28  Paul Bowen asks JH to describe what she saw on LB’s tongue ‘a bite mark on the tongue, a tooth mark slightly bleeding’.  ‘I had a one word relationship with LB’.  PB asks JH what LB said?  ‘Sore’ and she asked what happened and he replied, ‘Angry’.  PB suggests that LB wld sometimes repeat back to you what you said; so if you said, ‘Were you angry?’ he might reply ‘Angry’.  JH confirms yes.  PB asks JH what first thought was when she saw LB’s tongue, she says, ‘He’d bitten it accidentally’.  PB asks, Did you consider a seizure?  ‘Yes’.  PB asks JH did LB say, ‘I bit my tongue because I was angry’? She says no, I asked ‘How did you hurt your tongue’; he said, ‘Angry’.

12.32  PB suggests to JH that LB could have meant that he was angry that he’d bitten his tongue? JH says yes.

12.34  20/5 3pm note on Rio made by Dr Murphy: met w LB in sitting room, showed her his tongue, bitten when angry.  20/5 later record: JH says ‘LB says he does not know how he hurt his tongue. Staff to be extra vigilant for evidence of seizure activity’.  PB suggests to JH she believed it could have been either a ‘meltdown’ or a seizure, she confirms ‘Yes’ and wrote doesn’t know how hurt it.

12.38  PB asks JH describe seizures: LB had tonic clonic seizures (shaking or rigid). PB asks JH to describe absence or complex partial seizures.  JH can’t remember what a complex partial seizure looks like, describes absence seizures as ‘day dreaming, someone looking through you’.

12.39  PB asks JH cld have recognised difference between some of behaviours associated w LB’s learning disability and seizure activity.  JH: ‘I’d have liked to have thought as a nursing team we’d have known the difference…. but yes’.  PB asks JH to confirm to jury that was chance LB could have had a seizure in between 10min obs and ppl wouldn’t have known ‘Yes’.

12.40  PB asks JH, Was she part of any discussion took place between staff about whether LB had had a seizure? JH replies, ‘No’.  PB puts to JH increasing observations from hourly to half hourly at night wouldn’t have made any difference if he was on 10 min obs.  ‘Yes’.

12.44  AS for Jonny Cowee questions to JH. Asks her to confirm she was not one of LB’s named nurses. She confirms.  AS asks JH ‘How confident were you that he was telling you he had bitten his tongue because he was angry? JH replies ‘100% certain’.  20/5 record 15:27 entry by Dr Murphy stated ‘he had bitten in accident’, confirms with JH that she had not seen Dr Murphy that day.  JH also confirms that conversation recorded by Dr Murphy took place before her conversation with LB (that eve) 20/5.

12.50  AS brief for Jonny Cowee asks JH if she spoke to him about what happened, she says she ‘Can’t remember’.  Is it possible?  ‘Very possible’.

12.52  Coroner asks JH to describe in more detail what she saw.  ‘On his left side, it was tiny, bit of peeled off skin, it was red… like a graze’.  Coroner asks JH, Was it at the front or back? She replies, ‘Sort of in the middle of the tongue’.

12.55  Witness said to AS, ‘100% confident LB bit his tongue at time, 100% confident was anger’; responded to PB, ‘Cld been anger, cld been seizure’.  PB seeks to clarify inconsistency. JH confirms she was 100% confident at time was anger, now considers could have been either.  JH recorded on Rio 19:42 20/5, ‘When asked LB says he does not know how he hurt his tongue’; recorded this from handover before she spoke LB.  JH says, ‘She was told that as part of handover’.

12.58  MW to JH: Were you aware that night-time observations were 10 mins before 20/5 and not half hourly? She can’t remember.

12.59  Fiona Paterson counsel for puts questions to JH now. Dr Murphy note says she prescribed Bonjela.  JH confirms the note does; FP asks to confirm 19:42 record was from handover.  Next day 21/5 19:31, JH on Rio: ‘Bonjela applied to sore tongue at 1600hrs’.  FP asks, Did she talk LB?  ‘That was the point he said he was angry’.

13.03  JH dismissed. Jury dismissed. Break for lunch, back in an hour.