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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.


 14.28  Jury returns from lunch. First witness we will hear from is Charlotte Sweeney, an Occupational Therapist on @Southern_NHSFT STATT unit.  Coroner checks Charlotte Sweeney’s statement is her own and contents are true and correct [CSw in tweets to differentiate from Cheryl S].  CSw has been an occupational therapist since 2009, worked for between Jan 2013 and June 2014.

14.32  CSw asked if it is correct that she was at STATT on the morning LB died? It is. She wanted check they knew where they were taking LB on trip.  CSw ‘OTs help ppl manage independently with activities… part of job to get people to engage in activities amenable to them’.

14.36  CSw cant remember exactly what time she was at the STATT, imagines it was after 08:30. She usually started work at 08:15 and checked emails.  Coroner ask CSw did she see LB that morning? ‘No I didn’t, I didn’t need to that day’.  ‘I remember being in the office and talking to Maxine’.  CSw: ‘I don’t remember who else was in the office at that time, perhaps KD if he was the nurse in charge but I can’t say for sure’.  ‘I don’t remember how long I was there for but there was an OT training day so I imagine it wasn’t too long’: CSw.

14.38  Coroner checks that CSw had left by the time LB was discovered.  ‘Yes’.

14.39  CSw ‘As far as I can recall, I was not asked to contribute to any general epilepsy risk assessment or care planning…or any of the admission paperwork at time of LB’s admission to STATT by the multi-disciplinary team or at weekly clinical team mtgs’: CSw.

14.43  CSw: ‘At LB’s CPA on 10/6 his family requested he had more activities planned in his week’.  CSw: ‘My recollection of LB was quite a quiet person, initially spending lot of time by himself’.

14.44  CSw ‘I had not completed specific epilepsy training with (this was not mandatory training)..and was not aware of any epilepsy pathways, policies or procedures’: CSw OT.  Catherine (CSw’s line mgr) provided close supervision and advice re what needed to be completed from OT point of view in terms of epilepsy mgmt.

14.47  CSw describing her interactions with and asking around LB’s seizures.  CSw spoke to on 22/5 and recorded on Rio that she explained LB had tonic/clonic seizures in past and possible absence seizures.  CSw’s {notes} say that was unsure about night time seizures but CSw thought a night time alert system/monitor wld be beneficial.  ‘Specifically in relation to bathing I do not recall ever telling me she wld supervise LB in the bath at home’ CSw.

14.50  Coroner asks CSw, was she familiar with an epilepsy management plan? CSw says she was new to and had never seen one.  Coroner says he understands some documents are OT and some are nursing; CSw never seen one for an OT to complete .

14.52  Paul Bowen asks CSw about the assessment process, who would have asked you to contribute?  ‘Not sure, don’t know if there was any’.

14.54  Rio record 22/5 12:24 made by CSw of conversation w sharing concerns re tongue biting incident.  CSw and her line mgr liaised w Winnie Betsva regarding LB’s pattern of seizures, WB is to complete an epilepsy risk assessment.  Entry 28/5 11:54: CSw liaised w speciality OT re alarm system for LB. Specialist OT recommended sensor – meet 30/5 to discuss further.

14.57  PB asks CSw ‘so you’re still actively seeking an epilepsy monitor at this stage?’ CSw confirms ‘Yes’.

14.58  30/5 record: further discussion w specialist OT, trialling w another pt, will let CSw know how successful was. CSw contacted Epilepsy Society.  28/5: CTM says no signs of seizure activity, discussion about seizures, CSw was present: ‘Yes’.

15.01  Next CTM 3/6: at this mtg was decided to drop obs. ‘No sign of seizure activity’, discussion re tongue bite incident, WB asks to reduce level of obs.  PB asks, Do you recall either of those conversations? ‘No’ Wld you have been asked yr opinion re seizure?’  CSw ‘Can’t imagine wld have been asked because I wasn’t there at time to observe symptoms or him around that time’.  CSw: Can’t remember being asked; wouldn’t feel had expertise to input into decision about observation reduction at CTM.  CSw ‘Think we’d discuss as team what we’d seen, have feeling it wld have been Dr Murphy as the psychiatrist who wld have made the decision’.

15.05  AJ asks CSw if informal conversations about patients happened outside of CTM? CSw confirms, yes there would.  AJ states ‘You don’t wait for CTM to raise issue would you?’ CSw confirms that no, you wouldn’t wait.  AJ asks if people would offer a view in CTM, it’s not as if people were frightened to say anything?  CSw hesitates, says,  ‘I can’t speak for everyone but I think you could speak up’.

15.08  CSw completed OT Screening Tool on 20/3 [now shown to jury] says ? Care Manager.  ‘This was draft, likely to mean, Does he have a care manager?’.

15.12  OT screening tool shown, is there a risk of deterioration due to lack of engagement in occupation?  Yes, daily baths for 3 hrs approx.  AJ queries whether that relates to risk of deterioration or to staffing ratio? <<< Unclear from these handwritten notes but suspects former.

15.15  AJ shows CSw an OT Initial Assessment form.  CSw: ‘Screening tool is completed first, this is completed next’.  Bathing: Independent; ‘daily, long time, relaxation.  LB prefers bath over shower, may need prompting to wash’.  CSw says typed version exists.

15.18  Move typed version; no independent code incl. CSw doesn’t know why ‘ reports LB uses baths for relaxation increased to daily’.  AJ asks CSw if her understanding was that LB was independent in the bath?  It was.

15.20  AJ asks CSw if she found easy to communicate with? CSw says she recalls her returning her calls.  AJ asks CSw if she found it harder to develop rapport w [reported in statement].  CSw said took longer but can’t really recall.

15.22  RJ, counsel for Ben Morris, asks CSw if she spoke to LB’s teacher and in initial assessment?  CSw: ‘Yes, and to Connor as well’.

15.24  Does initial assessment say ‘Klinefelter syndrome with well controlled epilepsy’?  RJ asks where info came from? CSw can’t say for certain…’probably Rio or from the initial screening tool’: CSw.

15.26  AS, counsel for JC, asks CSw questions about multidisciplinary team: CSw’s line mgr asks WB to conduct an epilepsy management plan?  ‘Yes’.   22/5 12:24: CSw entry on Rio in relation to contacting STATT about potential epilepsy ‘OT and senior OT liaised w WB’.

15.28  21/5 note 12:13 WB tries to call . Note on 22/5 ends:
.                                         PLAN: Await epilepsy management plan.

15.30  Two CTMs later 3/6: ‘CSw can’t recall receiving plan by this time’.  CSw asked, Can she recall any discussion of plan at this mtg? – can’t.  AS asks CSw if it was a common view from 3/6 onwards that LB hadn’t had a seizure?  CSw can’t recall.  Nothing in the minutes.

15.34  MW, counsel for KD: You were aware of observations?  ‘Yes’.  Were you aware of the bath checks?  ‘I must have been, I must have read the care plan’.  MW returns to fact that 3 hr baths were a consideration when looking at personal activities of daily living.  CSw confirms it was.  CSw: I think it’s important to know that I didn’t have any understanding of epilepsy, I didn’t have any training.  CSw: From a physical point of view I had no concerns.  I assess from a functional point of view.

15.37  CSw: Discussed LB with her line manager who was aware he had epilepsy; she provided input re sensors etc and attended the CTMs as well.  CSw: I don’t think we’d have had an in-depth conversation re bathing… if concerns at CTM, am sure she’d have said something.  AS asks CSw if her line manager had ever raised epilepsy and bathing in her supervisions; she did not.

15.40  OW, counsel for Giri Jayawant, asks CSw relevance of epilepsy assessment and her role.  CSw: I wld look from a functional point of view whether someone cld physically access the bath, whether they require grab rails etc.  OW: So you would assess risk of someone getting in the bath, but not when they were in it?  CSw: focus on overcoming barriers from getting into the bath; ‘we didn’t have epilepsy pathways at the time’.

15.42  FP for now asks CSw about bathing responsibility; she says her focus was on physical, eg movement, strength, coordination.  Fiona Paterson for asks CSw whether she’d consider bathing part of personal care; CSw replies yes.  CSw says role is ‘trying to establish what help someone needs’. FP directs jury to record in OT screening tool and comments for bathing.

15.44  Purpose of screening: gather information about how LB was dealing w daily living before entering STATT – what he did, what help was required.  FP asks what independent in relation to bathing means?  CSw confirms she thought LB was independent given his function of getting in/out bath.

15.48  Jury question to CSw: Did Connor get the epilepsy monitoring equipment?  CSw: long answer about it being trialled before purchase but no.  CSw: ‘We didn’t have any epilepsy monitoring equipment in STATT,  the equipment we had wasn’t very good’.

16.05  Sorry, forgot to let you all know that CSw was dismissed and the jury have left. Back in the morning at 09:30.