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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.


 13.32  Jury is back, first witness to be called is Jessica Constable, who was a Band 5 learning disability nurse on STATT.  Coroner: You’ve come to this matter relatively late in the sense of being asked to give evidence, your statement is dated 27/9/15.  JC confirmed that statement is correct but at the time she wrote it she had no chance to look at documentation.

13.37  JC: The consultant was Dr Valerie Murphy tho’ I would say the doctor that we saw most frequently on the unit was Dr Giri Jayawant.

13.42  JC: I don’t recall the details of LB’s care plans or risk assessments. I do know we were all aware he had epilepsy…and it was in the admission documentation – JC.  JC: Regarding Connor having a seizure, with hindsight there was an incident one evening at dinner when Connor had to be restrained.  JC: I feel he may have had atypical seizure activity, I used wrong term, meant partial absence seizure.

13.44  PB asks JC where she would have got information about LB’s epilepsy?  JC confirms she spoke to .  [Some wifi issues here so apologies for slow/delayed/poor tweeting.]

13.45  23/5 09:42 record by JC ‘Bonjela administered.  LB reported he had bitten his tongue because he was angry on Monday’.  JC says she doesn’t recall seeing it but she would have seen it because she administered the Bonjela on it.  PB asks JC when LB told her about tongue biting incident: Did he say ‘I bit my tongue because I was angry’, or did he say ‘Angry’?  JC: Angry.  JC agrees that she interpreted that as being because he was angry but LB could have been telling her he was angry about it.

13.50  PB: Did Jonny Cowee ask you about what you’d written in those notes?  JC: I don’t recall.  PB takes the opportunity to thank JC for her kindness and support when LB was first admitted to the unit.

13.51  AJ for Dr Murphy shows JC record of CTM meeting on 8/4.  AJ asks JC confirm record of mtg; she does ‘Jess mentioned that this will need to be carefully care planned as he reacts quickly to drugs’.  Note said that was present and it said it was 18mths since his last seizure. AJ asks if this was accurate.  JC replies that this is what it says but the notes of CTM meetings were not always accurate.  AJ: Was it pretty standard to hand paperwork to relatives? JC: Yes, if they wanted it.  AJ: Wld you have carried out that task?  JC: I honestly can’t remember if I carried out that.

13.58  AJ asks JC if she noted on Rio what LB told her about biting his tongue; she did (we’ve seen it).  JC demonstrated the face he pulled and says he stuck out his tongue and gritted his teeth.  Discussion/showing of 20/5 Rio notes about the tongue bite incident.

14.06  Now medical records from incident on 2/5: this relates to occasion when JC thinks in hindsight LB may have had a complex partial seizure.  AJ asks ‘Are you telling us now that this could have been a seizure?’ JC: ‘it could have been altho she didn’t think it was at the time’.  Risk rating very low. AJ: Are you seriously telling us that could have been indicative of seizure activity? JC: I didn’t at the time.  Record: Physical intervention was used and LB was taken to bedroom in a figure of four [restraint].

14.10  AJ: Do you think you may have over interpreted this in light of what happened later? JC: Yes.  This is incident that occurred at dinner time, was thought to be challenging behaviour due to staff member commenting on LB using sauce.

14.12  RJ for BM showing hand written admissions form to JC, asked about something that wasn’t in her handwriting, can’t help.  RJ asks JC to confirm her entry on admission paperwork: How was patient supported if upset?  Hand-squeezing, bath, distraction?  ‘Yes’.

14.14  JC wasn’t LB’s named nurse but was on shift during his first few days on the STATT.  Confirms LB was anxious and upset during initial days.  RJ asks JC ‘is it right that having a bath was one of the triggers that settle LB down?’  JC: It’s possible.  Rio note 21/3 by JC: ‘LB has appeared far more settled this am, watching DVDs, playing w trucks, having a long bath and watching TV’.  JC confirms it was her entry.  RJ: You told the Coroner that the bathroom door would be closed if LB was in the bath?  ‘Yes’.

14.20  RJ asks JC if she remembers LB having a small nose bleed in the bath; she did and raised it w KD who entered on Rio and raised at CTM.  Note CTM 17/6 ‘JC reported LB had a nosebleed yday. He was in bath and when she asked him about it he said someone had punched him in face’…which JC thought unlikely as he was in bath. JC saw no other signs of trauma, when asked if he had done it himself he said maybe, maybe not.

14.23  AS asks JC if she recalls the changing in his observation schedule; ‘JC doesn’t recall anything about his observation schedule’.  JC: LB dictated how long he spent in the bath unless he was going somewhere.

14.25  AS comments to JC that she and JH had both described LB’s tongue bite in similar way.  AS to JC: What made you think he had bitten his tongue because he was angry? JC: It was a long time ago and I don’t recall.

14.28  AS ‘Would you suggest a nurse is in the best position to interpret what a patient with learning disabilities means in their communication?’  JC: In the best position, no. <<< This line of questioning is dropped.

14.29  3/6 CTM note ‘LB says he remembers that he bit his tongue as he was in a bad mood’.  AS asks can JC confirm she was asked about this incident?  JC can not remember; she confirms she’d expect everyone (except LB’s family) to have access to, and read the Rio notes before a CTM.

14.30  No questions from Mr Walsh, Mr Fortune or Ms Paterson.

14.30  Jury questions for JC: If a patient gets new medication how do staff know about it?  JC: Handover and goes on medication chart.  Jury asks JC if she produced Risperidone care plan?  Doesn’t recall.  Jury: how staff learn about new drugs?  They expected to look up online.  Jury asks JC if there was ever a discussion about the incident in the dining room with the sauce; some discussion of triggers.

14.34.  Jury retires for a 15min break.


15.00   Jury back, up next Jonny Cowee, Band 6 Charge Nurse on STATT.  JC confirms his role at STATT in July 2013 (Band 6 Charge Nurse).  Started at STATT in 2005.  JC is a registered mental health nurse.

15.01  JC: ‘As a Band 6 nurse one of my primary duties was supervising and overseeing work of Band 5 nurses and hierarchy of nurses beneath them’.  JC: At that time were five Band 5 nurses, previously there had been six.

15.03  JC qualified as a nurse in 1993; he wasn’t on duty on 4 July. Coroner asks if he received any training in epilepsy prior to LB’s death.  JC ‘I was attempting to get myself onto a taught course at the time because I felt it was overdue’.  JC: I had experience of working with people with epilepsy in different forms.

15.05  Paul Bowen tells JC he will ask questions about takeover, CQC inspection, communication with LB’s family, care planning, NICE guidelines.

15.06  JC: took over Ridgeway in late 2012.  ‘It was confusing for all concerned, including myself’.  JC agrees it’s fair to say that STATT was in a poor state with wallpaper peeling off the walls.  JC confirms changes in shift patterns and introduction of new policies .  Can I ask whether changes had had on staff morale JC: ‘I think it would be fair to say that but I cant speculate on other people’s feelings’.  PB asks how he found the takeover and changes and JC says: It made things very difficult.  JC asked about the lack of meaningful activities on the department: he confirms there were not enough.

15.12  PB: Did you feel the process of the transfer to had been well managed?   JC: I did not feel it was well managed.  JC describes vacancies frozen, ppl working double shift, and physical management drives of leading to standards dropping.

15.13  Had there been changes between LB’s death and the CQC inspection later that year?  JC: it did not help with morale.  CQC: Provider didnt have effective system in place to monitor care provided; to monitor risk; accurate & appropriate records not maintained.  JC: I entirely endorse the scathing judgement of services by the CQC, I’d been complaining about it internally for 3yrs.

15.16  PB: Who was ultimately responsible for nursing staff on STATT?  JC: That fell to Band 7, Ben Morris, within the framework available.  PB: Ultimate responsibility was Ben Morris, day to day running was you?  JC: We did it together.  JC: All disciplines co-existed and had their discussions in a consensus CTM.  PB: Is there anyone who can say had ultimate responsibility?  JC: Difficult to say.  PB: Who had ultimate responsibility for LB’s epilepsy when on the unit?  JC: There was no one person.

15.20  JC: I received a phonecall the weekend before LB was admitted from a senior nurse who said that…I needed to be aware that his mother had a blog on the internet in which she’d been critical of the Trust – JC.  JC: I responded that it was our duty to provide care without fear or favour.  JC reads from transcript where he said he thought it was a disgrace the way was treated and blocked out of LB’s admission.  JC explains that he was in a highly emotional state when giving these interviews but wouldn’t retract them.

15.25  JC reads: Valerie Murphy [psychiatrist] described as a toxic woman and said that LB should be discharged.  JC: I can only assume that because was assertive and didn’t always agree w professionals that made ppl defensive.  JC describes that Dr Murphy [psychiatrist] made these statements in the context of letting off steam but he was appalled.

15.26  JC makes it clear that this made things very difficult to work as a multi-disciplinary team.

15.27  Moving on to discuss visits: JC explains he wasn’t aware of any occasion when it was LB’s choice that his family shouldn’t visit…and that he wld have been appalled if staff had stopped them visiting; he is also sorry ppl misunderstood his request to call ahead – JC.

15.30  PB asks JC about assessment and treatment unit use and ppl’s length of stay.  JC felt it was inappropriate for LB to be on STATT but there was no appropriate care package available for him to leave.

15.31  JC: became aware from testimony of others who worked on STATT that they’d observed staff manipulating the way they asked LB questions to avoid having to take LB out on activities, e.g. they didn’t want to muck out stables on farm so they’d ask in way that he’d decline to go.

15.34  PB asks JC if he’s aware of new policies on epilepsy assessment and toolkit since LB’s death?  He is.  They’re excellent tools and are an aide memoire and I wished we’d had them – JC on new toolkit.  JC: I’m aware that in 2011-12 we had a priority to improve epilepsy care; I wish someone had taken this forward then.

15.36  JC: We all had, or we should have had, knowledge of the NICE Guidelines; I certainly did.  JC: we were told that his epilepsy wasn’t linked to his current problems.

15.39  19/3 assessment by community doctor Keith Johnson: when fluoxetine [antidepressant] started had a seizure, unwitnessed, brother found him coming round…prior to that no seizure for 18 mths.  No reference made in the care plan to the Jan 2013 seizure. Or to link to fluoxetine.  JC: Difficult to speculate what might have happened but one assumes we’d have had a more thorough assessment if we had had the toolkit.

15.44  PB asks JC how well did he know LB and how aware was he of his epilepsy?  JC: I was aware he had tonic clonic seizures.. I was aware there were absence seizures, I wasn’t aware he had complex partial seizures.  JC confirms a number of behaviours observed in LB could be down to complex partial seizures; not going to engage in speculation.  Agrees w PB some complex behaviours such as undressing and dressing, standing staring not getting in bath might be complex partial seizures.  JC says some people have been known to go to train stations and undress at night when having complex partial seizures.

15.49  PB reads JC a statement he made that said in early 2015: When seizures occurred they occurred at night.  JC explains this was because they’d ordered a sensor to use at night, his understanding was LB had seizures at night, may have been wrong.

15.51  PB shows JC an ambulance record from 05/01/13 call out to LB’s home after seizure that occurred in Jan; asks him to look at call time: 11:24.  PB: Putting aside 20 May, this was the last recorded incident of seizure activity.  JC confirms: ‘That was the received wisdom that I was working on’.

15.54  WB said this morning that there was no assessment in relation to LB’s bathing arrangements in so far as they related to his epilepsy needs.  WB apologised for this. PB then put series of findings to her that she agreed with, asks if he needs to read these to JC. He does in turn.


15.57  1: JC agrees 2: LB was medically assessed before coming but was not clerked in overnight.  3: was considered but not sufficiently extrapolated.  4: Yes.  5: All care plans can always be better, that one certainly cld have been.  6: My belief was there was a multidisciplinary assessment and Dr Murphy had consulted and wld have been unreasonable infringement of dignity.  7: That was an area where we fell down – Jonny Cowee responding to Verita findings.

16.01  Prof Crawford: ‘A detailed description of what sees when LB has seizures should have been recorded’.  JC agrees.


16.20  Return from break and PB asks JC about the tongue bite incident on 20/5, concerning as potentially evidence of a seizure.  JC directed to the medical notes about that incident ‘Jonny has spoken to the staff around at the time of the suspected seizure’.  Joanna Hook and Jess Constable have both given evidence about this incident and the jury must take their own judgement about that.  JC confirms he returned from 10 days’ leave, read notes on Rio to inform himself of developments and must have spoken to them.

16.25  JC confirms he said LB’s lip had been bitten, not his tongue in later interview; this was wrong.

16.28  AJ, counsel for the psychiatrist, says that he can’t ask questions of JC yet; he needs more time.

16.29  Roddy James for Ben Morris now asking JC questions.  JC confirms he was responsible for the day to day management of nurses.  RJ: You managed downwards and reported upwards to Mr Morris?  JC: Yes, that’s correct.  RJ highlights the consequences of take over for staffing levels.  RJ: is it right staffing and funding more generally had a direct impact on activities for patients?   JC: funding was always an issue, yes.  JC: Most people enjoy recreational activities during the evening, our patients never did <<< due to funding and staffing.  JC: Unless LB was to go out with members of his family.

16.33 RJ: Wld you agree the changeover of shift pattern had an impact on internal training?  JC: Lot of in-house mandatory and statutory training no longer offered frequently or locally, ppl were often required to go to Southampton.   JC: Previously JC had arranged training for long two hour handover that was well attended; couldn’t be done any more in 15 min handover.  JC: After took over previous training providers no longer available, had to do online training.

16.36  RJ: Two named nurses was something you’d originally proposed?  JC: Yes due to annual leave and nights you cld have an allocated nurse you’d not see for a month at time. Suggested but didn’t implement it.  JC: It was proposed during two CTMs [some months prior to LB’s admission] and agreed by CTM and introduced.

16.40  RJ asks about CTM JC: Everyone who attended CTMs had made a commitment that they’d fully familiarised themselves w Rio prior to attending.

16.41  RJ asks JC about STATT pts: epilepsy was much less frequently encountered in our patient group… than other learning disability services.

16.41  RJ asking JC re performance mgt: ‘I supervised the Band 5 nurses and was familiar with what they were doing’.  JC confirms if he felt something was going wrong w Band 5 nurses was his responsibility to address and ‘if I could not, to escalate to Band 7’.  RJ asks JC to confirm who was the responsible clinician; confirms was Dr Murphy but doesn’t absolve others of responsibility.  JC: Central work of CTM, particularly on admission to review care plans and particularly to take responsibility for patient safety.

16.46  JC: My understanding at the time was that care plans met minimum to keep him safe, mention of seizures, 10min obs and so on.  JC believed that psychiatrist, consultant neurologists were experts to whom he should accede.  JC: A ‘central part of my duties’ to familiarise myself w notes.  RJ: was bathing sufficiently addressed?  JC: I wld have raised if felt not.  RJ: So you saw notes following 20/5 CTM that said should be extra vigilant; 3/6 step down – what was view of meeting decision?  JC: Consensus of meeting that wasn’t sufficient evidence of seizure.  RJ: Was that fed back to nursing team?  Did they rely on it?  JC: There’s such a thing as a belt and braces approach, so we could decide it was not a seizure and be extra vigilant.

16.53  RJ asks JC who wld have decided to reduce observations, could nurses decide that?  JC: No, decision was of responsible clinician Dr Murphy.  JC: But it would have been a consensus decision.  JC confirms LB had ‘formal 15min checks’ when in bath. RJ: from 3/6 was 15min sufficient JC: Yes.. epilepsy was factored into assessment.  JC: ‘many of our patients had baths without any supervision’ so bath checks were linked to LB’s epilepsy.

16.58  RJ asks JC if he investigated spilt squash incident JC: miscommunication because two nurses, neither of which had English as first language.  CTM minutes say ‘no-one could shed any light on the incident’.  JC: I don’t believe those minutes are accurate.

16.59  RJ: Post 3/6 did anything happen that made you change your view of whether 15min checks was suitable balance between risk and and dignity?  JC: No, I would have acted if it had.

17.01  RJ: Mr Morris had specifically asked JC to pay attention to LB’s situation as he approached discharge…because was concern LB’s care might get lost in the maelstrom of some more… noisy and challenging people.

17.03  Jury dismissed, back tomorrow at 09:30