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LB Balloons
For Connor’s family.
You’re diamond.  We see you shine.

and for George Julian, who is spreading the light
by live-tweeting, on the @LBInquest timeline,
everything you can read below.

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10.00  We’re delayed starting on Day 5 due to an in camera (private) hearing with the barristers and the Coroner.

***

10.58  Jury returns, coroner apologises for keeping them waiting and we’re back to Jonny Cowee .

10.59  Paul Bowen to JC: Verita concluded that the STATT lacked leadership from JC and no one individual managed and oversaw the care of LB.  JC: It’s true that we operated a collegiate approach, it’s not for me to comment whether it was a fair criticism or if it’s appropriate.

11.01  PB asks JC about interview where he states when LB was in the bath a special arrangement was in place that the door should be kept ajar and 15 min obs should take place?  JC: I must have been mistaken that it was in the care plan because we’ve all seen the care plan.  PB asks JC if the door should have been ajar?  JC: It would have been preferable.  PB puts to JC Verita concluding: ‘Staff shd have increased their vigilance of LB after his seizure and this was a missed opportunity’.  JC: We didn’t fail to consider them, we didn’t deem them necessary.

11.07  PB to JC: The family had material disclosed to them this morning.  PB: Were you aware in 2006 there was another death on STATT from a patient dying in the bath?  JC: I was aware.

11.10  Michael Walsh for Kieran D asks JC now: You consider the care plan balanced dignity and safety?  JC: Yes, based on info available at time.

11.11 MW asking JC about confusion surrounding named nurse pairings.  JC: There would sometimes be disagreements within the pairings about the balance of responsibilities.  JC: One thing we were clear about was that two ppl would carry shared responsibility and expectation was ppl wld communicate about shared pt.

11.13  MW to JC: You mentioned a lot of pressure on the unit, were you just dealing with STATT or John Sharich House too.  JC: Effectively we ended up with 1.5 Band 6 on each unit.  MW: This affected the Band 5 nurses as well? JC: Absolutely.. this is why it changed so I delivered supervision on an ad hoc basis.  JC: I discussed matters w Band 5 staff as they arose. It wasn’t protected time.  MW: That was what you were supposed to do?  Up to an hour?

11.15  MW suggests to JC that hour dedicated clinical supervision, should have occurred w Band 5s.  MW highlights that two named nurses but separate supervision meant JC would have little oversight of patients when split between two nurses.

11.15 MW to JC: Due to pressures of time you weren’t able to have more than one clinical supervision w Kieran D in 18mths?  JC: I have to say that I didn’t find that Kieran was very keen on formal supervision which was why I had more ad hoc supervision.  MC puts it to JC that KD only had one supervision in 18mths.  JC: I’d have to consult notes, perhaps my recording of supervision didn’t happen.  JC says he discussed it with his manager, Ben Morris. MW says to JC formal supervision shd have looked at care plans w staff for hour?  JC agrees.  ‘I took time on a frequent basis to follow what the Band 5 nurses were doing and discuss it with them’.

11.21  JC explaining how note taking was linked to care plan.  MW difficulties w Rio meant Band 5 nurses struggled where to put risk assessment.  JC: It wasn’t just that they struggled with where to put it… we were told the general risk assessment was a comprehensive list;  JC: The risk assessment was just a tick box thing really.

11.24  JC: there were two care plans, one about epilepsy and one about bathing, ideally they wld have been a cross reference MW: RiO wasn’t ideal.  JC: I’m not sure I’d blame RiO for that.  MW: Do you recall discussing LB’s care plans with Band 5 nurses?  JC: Yes frequent conversations in the office.

11.26  MW takes JC to 3/6 CTM record where collegiate decision was taken to change LB’s observations.  Wld you’ve expected nursing input to decision?  JC was chairing.  MW: do you recall there was sufficient time for ppl to input into meeting if they required it?  JC: That’s my job as chair.  MW: Wld you expect Band 5 nurses to simply implement decision from CTM or discuss it?  JC: Implication there, and doesn’t differ from my memory, that was the decision made after discussion at that meeting.

11.29  Alan Jenkins for Dr Murphy now questions JC.

11.30  AJ: you said yesterday the psychiatrist had role to do with prescribing and Mental Health Act.  JC: Yes and legal accountability.  JC: psychiatrists were involved in all discussions and decisions around patients, nurses.  AJ asks, Were nurses also involved?  ‘Yes’.  JC: Each different profession approaches a different dimension of care, looks at it with a different lens.  AJ: Was there any one person where the buck stops?  JC: for some issues.

11.32  JC joined STATT in 2005 and previous to Dr Murphy the doctor had a different personality and style.  JC: ‘Wouldn’t say power and mgt structure changed but personality plays a part’.

11.33  JC describing why he wasn’t happy with the Verita investigation; ‘didn’t expect his interview to be open to such scrutiny’.  JC: It was quite a lengthy, adversarial interrogation… thought it was about learning lessons but it wasn’t how it was used in the V report.

11.37  Did you say: said up until Verita report was commissioned the Trust had said everything that cld be done had been done?  JC confirms yes, Verita was commissioned under pressure from LB’s family (which he feels was an acceptable request).  JC considers that completely changed their position after Verita was published.  JC says that even though Verita was supposedly independent it was paid for by .  JC feels that his transcript was used very selectively by Verita and misrepresented him.

11.41  AJ takes JC to tongue biting incident and JC says he has concerns about the amount of weight (not) given to ‘s concerns.  AJ takes JC to a statement where he said that the risk assessment they conducted was appropriate.  AJ asks if that remains his view.  JC requests time to read the contextual paragraph….

11.45  JC: I don’t retract that particular statement, no.  AJ takes JC to a later extract of same statement where it says that JC believed 15min obs in bathing was acceptable.

11.46  AJ asks JC was LB on the STATT longer than other patients might be? JC: no, we would see three months as a rather typical time period.  JC: Of course he wasn’t discharged but we were getting towards his discharge.

11.47  AJ asks JC was it fair to say was anxious about him coming home.  JC: behaviour only makes sense within a context so it’s difficult to see behaviours in an inpatient setting that might happen as outpatient.

11.48  AJ takes JC to notes of a CPA meeting on 10/6 that LB’s parents attended and he attended for the last 15mins.  Records: In theory members of the Inpatient Team could offer support to LB as an outpatient.  10/6 Mum said that she was confused that LB was admitted to STATT for assessment and treatment, but where is the assessment and treatment?  10/6 record: He’s in a transition stage and is slightly younger than our usual patients.  10/6 record: Working with school is unusual too and LB has been here longer than our usual patients.  JC disagrees LB had been there longer.

11.54  AJ discussing record states ‘LB is much calmer when unchallenged’.  JC agrees, says ‘Connor was much like me, I’m calmer when unchallenged’.  JC points out its not simply case of being engaged/challenged or not, that there should have been opportunities that engaged and excited LB.  JC describes the ‘rich enclave’ that was LB and two other patients socialising in the evening.

11.58  10/6 record said, ‘From what she’s hearing LB shd in fact be an outpatient’…..but she feels only a minute proportion of LB’s time is spent engaging in actual activities…. doesn’t want him to come home at this point as there is no support or activities in place.   JC confirms that of course wanted LB home, she didn’t want him to stay in STATT, ‘She wanted something better for him’.

12.01  AJ: Did you see the part of blog where she described a doctor as crapshite?  JC: not particularly.   JC: I remember it being a very good and thorough account of the frustrations of being a parent trying to deal with health services.   JC: To my mind people had an irrational fear of the blog.   JC: We as professionals have a duty towards our patients and our families… you know the customer is always right.   JC: It’s my view that as professionals we have a duty to adapt our communication… Dr Ryan is under no such burden.

12.05  AJ suggests to JC that one of the psychiatrists refused to work with   JC: I’ve learnt that since and it’s absurd.

12.06  Adam Samuel, JC’s counsel now takes him through his questions.

12.07  AS: how well controlled would you say LB’s epilepsy was?  JC: It appeared very well controlled.  AS takes JC to care plans where it indicates LB was on 10 min obs on the unit and 15 min in the bath.  AS: Is it your understanding that the 10 min obs were linked to LB’s epilepsy?  JC: Yes, it’s explicit.   AS: Are you telling the court the 15 min obs were unnecessary when 10 min obs were happening? JC: Yes.

12.12  AS takes JC to Rio record made by Dr Murphy on 20/5 that she prescribed Bonjela for LB’s bitten tongue.  JC confirms Yes.   JC: Also confirms emailed about incident indicating she thought LB had had a seizure (in records).  JC confirms he was on 10 days leave at the time this took place.

12.17  AS takes JC to note of 3/6 meeting where decision made to reduce LB’s obs (the first day he returned from leave).   AS asks JC where the information that ‘No evidence of seizure activity’ had come from? JC: From reading the notes and talking to colleagues.  AS: Did you inform the impression that other people had discussed the tongue bite? JC: I can’t recall but it was still being discussed.  3/6 notes indicate Dr Jayawant did not consider LB’s tongue bite was consistent with seizure activity.  3/6 notes record Dr Murphy agreed to reduce obs, when WB requested.

12.22  JC: It would have been desirable if something specific had been put into the care plan to say 15 min bath obs were linked to epilepsy.  AS to JC:  You’ve given this a lot of thought since, can you explain why you weren’t perturbed by the 15 min obs KD and WB had taken?  JC: In a very busy unit you have to think about what is reliably done… I wld expect 15 min check was an auditory or visual check on him.  JC: Closer than 15 min wld mean you’d have be there all time however it wld have made it difficult for LB to have the lengthy baths he wanted.

12.26  Jury questions: Were you aware of KD’s concerns that Cheryl S was spending too much time with LB? JC: I don’t recall there being.  JC: I thought Cheryl (student nurse) was brilliant actually, I think it’s great that she was spending time with patients.

12.27  JC confirms to follow up jury question that he wasn’t involved in supervising Cheryl.  JC is released and jury dismissed for lunch.

12.28  We’ll be back in an hour at 13:30.

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