, , ,

LB Balloons
Love and light to Dr. Sara Ryan and all Connor’s family,
because NONE of this should have had to happen,

and kudos to George Julian for doing the in-person support,
especially for live-tweeting, on the @LBInquest timeline,
everything you can read below.


9.42  Jury returns and we’re onto Day 4 of .

9.43  Briefly hear from Charlotte Sweeney today, then Winnie Betsva and Jessica Constable.

9.45  Paul Bowen says to Charlotte Sweeney he’s no more questions for her and makes it clear Verita 1 report found CSw’s work w LB very positive.  Charlotte Sweeney is dismissed.

9.47  Winnie Betsva, Staff Nurse at STATT and one of LB’s two named nurses is called and sworn in.  In this case no witness statement but is a transcript so WB isn’t asked to confirm that it’s true; will be addressed on issues by counsel.

09.48  WB trained as a learning disability nurse in 2005 and started working at STATT in 2006.  At that time STATT was run by Ridgeway Partnership and after that took it over.

09.49  24/3 (5 days after LB’s admission) WB found out she was one of LB’s named nurses, first day she worked since LB was admitted.

09.51  Coroner asks WB about her training from 2006 onwards.  WB says, ‘Used to do e-learning training or if someone on ward with epilepsy…then someone from community team gave an hour session on epilepsy’.  What year?  WB: ‘I can’t remember but about 2011’.  WB did an hour e-learning training about different types of epilepsy seizures; Coroner asks, ‘When was that, was it before LB’s death?’.  WB: ‘Can’t remember’.

09.52  Coroner asks her how she got on with the Rio system?  WB: ‘It was new to us, we were still in a learning phase’.  Started using Rio in about 2012.  Coroner asks, Did the learning phase extend into 2013?  WB confirms it did.

09.54  Coroner asks WB if she herself had experience of other patients on STATT w epilepsy?  WB: ‘Yes, it was before, 6 mths before LB’s admission’.  Coroner asks WB to describe that patient’s epilepsy.  WB says they had seizures about once a day.

09.56  WB wants to say something to before Paul Bowen questions her. ‘I’m so sorry that I failed Connor and your family’.

09.57  Paul Bowen starts w WB: ‘We have your records and you did epilepsy training in 2013 after LB’s death and prior to that in 2008’.  WB confirms.

09.58  PB checking w WB what her role as named nurse was.  Shared role w KD?  ‘Yes’.  And there was a risk assessment element and care planning element?  WB: ‘Remembers on 24 March, she did a late shift and KD gave her handover and he’d started a care plan’.  WB confirms shared care planning w KD.  PB asks WB, Were there any challenges with sharing care planning? WB: ‘Yes, it was very confusing’.  It was the first time they’d shared.

10.01  PB asks WB about shift patterns. Ridgeway were 7 hr shift; a couple hours handover with next shift.  Used to have one hour to do handover.  Shift patterns changed around 2012 [when took over]; moved to 14 hr shifts with a 15 min handover.  WB confirms this was case.

10.03  STATT 7 bedded unit but most of time LB was there was only 5 pts; ‘must have a band 5 nurse on every shift, if we were lucky we’d have 2’.  ‘We would struggle to get staff on shift.  Wld care for patients, do paperwork, clean the toilet, cook for patients and shop for patients’.  PB: Is it true that you used to have more staff and at time of handover you had fewer staff available?  WB confirms ‘Yes’.

10.05  WB: ‘Used to have clinical team meetings on a Monday… used to have a chair rota’.  Rotated chair, one week cld be doctor, one nurse, one OT.  PB asks who was in charge? WB: ‘My understanding all professionals were in charge, they’d put their heads together’.  PB asks who was the senior nurse on STATT. WB confirms was Ben Morris, unit manager, band 7 nurse responsible for nursing care.  WB confirms that Dr Murphy was the responsible clinician, the STATT psychiatrist.  WB says she attended one clinical team meeting during time LB was at unit.

10.08  WB confirms Jonny Cowee [Band 6] was her manager and was responsible for her supervision, he was responsible for supervision of 5 nurses.  WB indicates that supervision was difficult when LB was on the unit, used to be two Band 6 nurses, not then.

10.09  WB confirms that ‘Anyone can have epilepsy but for ppl with learning disabilities it’s very common and people with autism’.  PB asks WB if she knows 1 in 200 ppl have epilepsy? ‘No’; are over 40 types seizures?  ‘No’; and 30 different syndromes?  ‘No’.  PB asks WB if she knew about tonic clonic seizures?  WB: ‘Yes, I looked it up on the internet’ when LB was admitted.  PB asks WB if she knows the proportion of ppl w learning disabilities who have epilepsy?  No, don’t know.  Agrees 1 in 5 when told.  PB asks WB if she knows about SUDEP, she has heard about it.

10.13  PB asks WB about epilepsy care plans and risk assessments – lists required elements, WB agrees all should be included in a care plan.  Do you agree a lot of this information should come from the ppl who know the patient best, ie the family?  ‘Yes’.

10.15  PB asks WB if she knew about the NICE Epilepsy Guidelines; she does now but didn’t then.  WB agrees that all elements recommended by the guidelines should have been addressed and considered inc bathing risk assessment.

10.17  PB asks WB about the Epilepsy Map and Toolkit produced by since LB’s death; aware of it but wasn’t there at time.  WB ‘I take full responsibility for failing on Connor’s epilepsy risk management and care plan’ .

10.19  PB asks WB what she knew about LB’s epilepsy and she confirms what she’d written ‘LB has well managed epilepsy’.  Did you know at time of admission that LB had seizure in Jan 2013?  WB: I didn’t know.  PB suggests therefore couldn’t have known it was brought on by change in medication, introduction of an anti depressant?  ‘No, I didn’t know’.

10.22  PB says to WB that he will ask her the same question that KD refused to answer on legal advice.  PB: Did you carry out a risk assessment in relation to LB’s bathing arrangements in so far as they related to his epilepsy needs?  WB: No.

10.25  PB puts findings of V1 [first Verita report] to WB and she agrees with them all in turn and accepts them all.


10.28  Put to WB that on day LB died the bathroom door was closed and locked; legal counsel disagree was said.  Coroner queries.  PB points out it was Maxine Hemmings’s evidence, jury nodding.  Another counsel says, ‘She said she used a key, we don’t know she unlocked it’.

10.30  We move on to discussion around observation plans.  Observation record shows LB on ten minute observations during the day and night.  WB confirms she was mistaken thinking it was half hourly.  Note of meeting 22/5 says WB to complete Epilepsy Management Plan.  WB says she didn’t know what one was, contacted epilepsy specialist nurse.  WB: ‘I take full responsibility for this failing… I forgot to produce one’ [Epilepsy Management Plan].

10.36  Record of clinical team meeting 3/6: ‘There has been no sign of seizure activity’.  3/6 record: WB asks if we cld reduce LB’s observations which are currently at Level 2, this was because of the possibility of seizures…but as there has been no evidence of seizures it was agreed by Dr Murphy to reduce this.

10.38  WB accepts now that it should have been treated as though LB had had a seizure.  WB accepts if it had been treated as a seizure his bathing care plan would have had to change.

10.41  PB moves on to asking WB about the squash spilling incident that there was confusion about (whether it was squash or urine).  WB was on nights and doesn’t recall the incident.  PB moves on to LB’s bathing.

10.43  WB: ‘Was told to do epilepsy care plan, which she did and Mr Dullaghan said he was going to complete the bathing care plan’.  PB asks WB if she recalls any instruction, note or conversation where she was told when LB was in the bath the door should be open?  ‘No’.  PB asks WB: Any conversation, observation, note to say should stay in earshot?  ‘No’.  Any to say bath water level should be shallow?  ‘No’.

10.46  PB puts each of these statements to WB and asks if she agrees, she accepts them all.


10.48  AJ for Dr Murphy asks WB if she remembers LB was admitted to the unit with challenging behaviour?  ‘Yes’.  Under the Mental Health Act?  ‘Yes’.  AJ: Observations were reduced; bath time observations were completely separate, they were nothing to do with psychiatry?  WB [pause] Yes.

10.50  Roddy James for Ben Morris questions WB now: on nursing side you’re supervised by Band 6 Mr Cowee, above him is Band 7 Mr Morris?  WB agrees.  STATT had its own manager (Band 7) and that was the model?  WB confirms. Over 18mths prior to LB’s death that position had changed?  WB: Yes.  Manager of STATT had gone and Ben Morris (Band 6 at time) had stepped up to cover position.  STATT lost full time manager and just 2 x Band 6.  RJ: Mr Morris became Band 7 manager for two units, previously two managers; vacant Band 6 position left empty?  WB: confirms.  RJ asks if the Band 6 role was to be filled (another manager).  WB says she knew Band 7 wasn’t to be filled.  RJ corrects and asks re Band 6.  WB confirms she is unaware that the Band 6 post was ever advertised.  Confirms that there was less time available for formal supervision.

10.55  RJ talks WB through shift pattern changes: two hour window of double staffing often used for supervision, formal conversations and training.  WB confirms that those opportunities were lost when shift pattern changes and staff raised concerns and reported to management.  RJ: As result even though continued to be supervised by Mr Cowee Band 6 opportunity to formally discuss reduced?  WB confirms.  WB ‘If we were lucky to work on the same shift’ would have chance to discuss things.  RJ asks WB if she was aware she had route to go (to her supervisor) if she had concerns?  WB agrees.

 10.58  RJ confirms w WB that she said she was not aware of NICE guidelines at time she constructed epilepsy care plan; Yes.  Asks WB did she note on the system that this was highlighted in NICE guidelines; she confirms Yes, had Googled the NICE guidelines.

 11.01  RJ asks WB about system before Rio; she confirms paper care plan wld be taken to CTM and physically signed off before Rio: ‘Yes’.  RJ: Rio system didn’t have chance to sign off at CTM, didn’t allow for it?  WB: ‘No, but the CTM had a projector and cld view the care plan’.  RJ suggests that understanding was that CTMs would view and accept care plans, or make changes.  WB confirms yes.

 11.06  RJ asks WB what happened with Epilepsy Care Plan?  WB contacted Jackie (epilepsy specialist) ‘went on leave and forgot to follow it up’.  RJ asks WB if she handed responsibility to anyone else?  WB doesn’t think she did.

11.07  RJ: Who made the 3/6 decision that it wasn’t a seizure?  WB: ‘It was discussed at a CTM, I can’t say who made that decision’.  RJ: Did you accept and act on the decision that was made at the CTM?  WB: Yes.  RJ: From 3/6 onwards were you acting as though it was not a seizure?  WB: Yes.  RJ: Following on from that did you assess, re-assess LB’s needs in light of observations being reduced to an hour?  WB: Updated after decided not seizure.  RJ: 15min bath obs remained in place?  WB: Yes.

11.10  MW for Kieran Dullaghan now; thanks WB for what she said at the start of her evidence ‘was very brave of you’.

11.11  MW asks WB if CTMs had nursing input; WB if they were available. WB only attended one during LB’s admission.  MW asks WB for the reasons nurses might not attend CTM, she replies, ‘If on nights, on annual leave, or the only nurse in charge on ward’.

11.14  Break here until 11:30


11.43  Return with MW asking WB about risk assessment documents.  Did you find there was any difficulty using the risk assessment documents in Rio?  WB: It was a new document in Rio, and yes, I had some difficulty.  MW: We’ve already heard there was no box, nowhere for physical health on risk assessment documents?  WB: Yes.

11.45  MW: There are 3 documents in Rio that deal with risk in one way or another: risk assessment, risk summary and risk overview.  Court directed to risk overview, 4 page document.  MW: do you recognise inputting information into this document?  WB: I can’t remember.  MW: progress notes on 15/3 repeats, word for word, information from other documents; was generated automatically, was never filled out?  WB: Yes.

11.46  No questions for WB from Fiona Paterson for or from her own brief Michael Fortune.

11.47  Jury question: Was it the first time you wrote a care plan for someone with epilepsy when you wrote one for Connor?  WB: Not my first time.  WB says did one previously, about 2007.  Jury ask did you look at the NICE Guidelines then? WB: No, I can’t remember.  Jury ask, When you first wrote a care plan did they go to a CTM for signing off?  WB: Was opportunity to be reviewed during CTMs.  WB wasn’t there so can’t help further.

11.50  Jury ask, ‘When someone is admitted to STATT is there a time limit to when the assessment must be done?’   WB: Used to be a five day limit.  Coroner asks whether was case at time LB was admitted.  WB: Yes, around five days the care plan is written.

11.52  Jury clarify: WB was asked to compile care plan on Day 5, even though that was the first day she had worked since LB was on the unit?  ‘Yes’.  Jury ask was epilepsy included in that five day assessment?  WB can’t remember.  Jury ask, As part of their training, do they get alerted to change in guidelines?  WB can’t remember.  Coroner asks, Did WB have ongoing training plan?  WB says was online record.  No standard number of hours had to spend.

11.55  Jury ask whether patients with epilepsy were common on STATT?  WB says, ‘Yes, quite common, patients come and go’.  WB: STATT was short term, patients would come for a week, a month, three months, up to 18 months.

11.58  Jury try to ask a question around drug changes.  Coroner advises that is a question for a clinician.

11.58  Jury ask about unit environment.  WB: No, it was a very challenging unit to work at, we weren’t quite coping.  Coroner asks for more information.  WB explains some patients had very challenging behaviour.

12.00  Jury member asks if any time of day that it was harder to work on the unit?  WB says No, it was very unpredictable.

Jury ask WB if she was aware that Risperidone lowered the threshold for seizures?  WB says she wasn’t aware.

12.04   Court adjourned for lunch, back in an hour.