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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.

***

13.47  Jury returns and Coroner clarifies with them Rule 22, in relation to witnesses giving evidence and electing not to answer.  It is the right of a person to decline to answer and neither Coroner / jury is entitled to draw any inference from them exercising the right.

13.48  First up is Dr Valerie Murphy, who was a Consultant Psychiatrist at STATT.  Asks VM to confirm it is her signature on her statement – it is.  VM confirms that she’s a Consultant Psychiatrist and is a specialist in learning disabilities; she has been a Consultant since Jan 2012.  VM was employed by as a Consultant Psychiatrist from Jan 2012 to June 2014.  VM worked 3 days a week and covered STATT, John Sharich House and relief work in a unit in Middlemoor.

13.54  Coroner asks VM what the purpose of STATT was.  VM: It was supposed to be a short term assessment and treatment unit.  VM: Generally the people who came into STATT were very unwell.  Coroner asks how long patients stayed.  VM: It varied, between a week and over a year depending on the circumstances.  Coroner reads her statement to VM.  Describes concerns about LB’s behaviour raised by and the school nurse at LB’s school.

13.59  Hearing that LB was anxious and agitated on admission and LB was detained under the Mental Health Act.  VM statement: From 16/4 LB was discharged from MHA and remained as an informal patient on STATT.  VM statement: We were aware on LB’s admission that he had epilepsy and experienced multiple types of seizures incl tonic clonic and absences.  VM statement: STATT were aware that there had been an apparent seizure that seemed to coincide with the introduction of new medication.  VM statement: While on the unit there were two instances that were explored as potential seizures.  VM statement: Both were ruled out therefore there was no evidence of seizure activity during LB’s admission.

14.05  VM statement: Carole Clarke at was contacted to explore potential discharge.  VM statement: clearly expressed that she wanted LB to return home when he was discharged.

14.08  Paul Bowen will now ask Dr Murphy about decision making, leadership of STATT, CQC visit, families experience, LB’s care, care planning.  PB will also ask about the tongue bite incident, squash incident, medication and observations during bath.

14.09  VM: documentation of decision making was made at CTM, were multiple discussions and putting that information together wld take place at CTM.  PB: Were decisions around LB’s clinical care be made by you?  VM: LB had multiple interventions by different disciplines.

14.11  PB: Asks who made decisions around his epilepsy?  VM: Different disciplines have different area of expertise; up to them to flag up epilepsy.  PB: Decisions around LB’s epilepsy drugs were made by Dr Adcock?  VM: Not necessarily, I was approached by community psychiatrist.  VM: …and I wasn’t entirely clear about the types of seizures or epilepsy, sometimes I would increase or decrease medication.  PB clarifies that VM could make changes but a big change wld be made w his neurologist? VM: Yes, I’d always work with specialists.

14.14  Debate around whether STATT was a secure unit, PB points out it was locked.  VM says this debatable; PB says prob not relevant to debate it.  VM: From a psychiatric point of view we talk about levels of observation. We wld think about levels in terms of risks, psychiatric risks.  VM: Generally if someone is admitted, if you don’t know them you’d suggest a high level of obs because you don’t know what you’re dealing with.  VM confirms observations levels.  L1: Hourly, L2: 10-15 mins, L3: In sight, L4: In arm’s length.

14.17  PB confirms w VM that a decision to increase obs cld be made by nursing team but decreased by multi disciplinary team?  VM: I believe that would be good practice but there was no set in stone around how observations were decreased, cld discuss w another nurse.  PB quotes observation policy to VM; check with VM that psychiatrist has ultimate responsibility?  VM: It’s a difficult one.  Discussion around psychiatric risk.  PB quotes statement to VM where she says when asked who makes decisions around observations, ‘Normally it’s me’.  VM confirms.

14.21  VM: It would be good practice for decisions around bathing observations to be made at multi-disciplinary CTM.  PB asks VM where buck stops. VM: Things aren’t black and white… no individual was in overall charge and everyone tried to be in charge.  VM: Things seem to be more in control (in STATT) at that time (as a trainee) but things changed dramatically and at times it was chaotic.

14.24  PB: Verita conclude that there was a lack of clinical leadership on STATT.  PB to VM: Unit lacked clinical leadership in particular from Valerie Murphy and Jonny Cowee. Do you agree or disagree with that finding?  VM: I echo sentiments of JC this morning, I thought this was about learning… it was apparent to me Verita had already made up their mind.  VM: I had members of staff in tears in my office after (Verita) interviews, it was not helpful, it was not constructive.  VM: I fed back a number of comments on the report, none of which I saw included in the report, it appears it was based on incomplete records.  VM: Overall I found this investigation and conclusions very unhelpful, don’t feel it was accurate or took on board the complexities.  VM: We went from being a happy and contented workforce to one of fear.

14.29  PB now reads conclusions of the inspection to Valerie Murphy and asks her to agree or disagree with them.  VM: These are very general.  PB: Yes, but it’s a scoring system and the unit failed.  VM: I suppose it’s important to consider that document in its entirety; prescribing was good.  PB: You’re correct, I’m just talking about what is relevant to the death of a young man on this unit.

14.32  PB refs statement that incl [was] only 8mths after LB’s death she found out she was only given abbreviated minutes of CTM meetings.  Not the complete records as had understood them to be.  VM: I don’t know why that decision was made.

14.34  PB puts to VM about visits and how family felt they could only visit if LB gave his permission.  Do you feel that was appropriate?  VM: You know really I’d be devastated if anyone felt they couldn’t visit their own son on the unit and I’m sorry if that was the case.  VM: It wasn’t unusual, but I would hate to think anyone was ever stopped.

14.36  PB: You heard JC’s evidence y’day where he told us ‘there’d be an irrational reluctance on members of the team to engage with ‘.  VM: The social media that was kept did cause heightened anxiety for colleagues on STATT and in the community.  VM: Colleagues in the community were nervous that they would be spoken about on the blog… and that extended to the STATT.

14.38  PB puts to VM that statement was that CTMs only lasted 10 mins per patient and no other parents or families attended.  VM: Didn’t think it was necessary to invite anyone.  PB: found VM uninterested in LB and arrogant in meeting.  VM: I’m sorry if I came across like that… there was a lot happening.  VM: At times I probably came across as a bit distracted and focused.  VM describes how hard it was to work .  VM: I remember sitting in the CTM and made everyone aware it was potential for risperidone to reduce the threshold for seizures.  VM: I recall I did say it.

14.41  PB: felt no-one took responsibility for LB’s care.   VM: Its difficult when you don’t see what goes on behind the scenes.  VM: It can be hard to see how much goes on.  VM: I found it difficult to form a relationship or rapport w … some people are more vocal than others in CTMs…VM: to be honest CTMs with LB’s father flowed more easily; I dont know whether that’s down to personalities or something else.

14.44 PB: You’ll recall when the CPA mtg took place asked for two members of to accompany her and support her and help plan.  VM: I do recall that meeting very well… it was difficult, there was a lot going on at the time.  VM: I was probably quite aware of the fact that a lot of what we were doing with LB could have been done in a community setting.  VM: I was not convinced he should have been an inpatient.

14.46 VM describes how it was ‘impossible’ to engage Carole Clarke the care manager with LB’s care planning.  PB recalls JC evidence ‘The most offensive invective against ‘.  VM: Says it is not true PB: So he’s lying? VM: It’s not true.  The notes record that Carole Clarke attended the CPA meeting, VM says she did not.  VM: We didn’t have the best of relationship [her with ] but I’d never let anything like that interfere with my care of a patient.

14.50  PB describes the key types of epilepsy to VM.  VM doesn’t recall being told LB had complex partial seizures on admission from Dr Johnson.  VM: I don’t think that he had complex partial seizures PB: I’m going to suggest that he did [describes them].  PB: Dr Johnson recalls LB getting in and out of the bath repeatedly, is that the sort of thing one sees in complex partial seizures?  VM: Hard to speculate but that could have been the case.  PB puts to VM that 1 in 5 people with learning disabilities have epilepsy VM: I couldn’t say exactly.  PB: Would you agree a good medical history of a patient with epilepsy would be required VM: Yes.  PB: Would you agree that history should include a description of seizure types, triggers and how patient presents after a seizure VM: Yes.  VM confirms ppl with epilepsy are at higher risk of early death AND people with learning disabilities are at a higher risk of early death.

14.57  Court shown paperwork from Dr Johnson who conducted an assessment of LB immediately before he was admitted to STATT.  Dr Johnson’s assessment highlights unusual behaviour and symptoms that have appeared in recent times before LB’s admission.  History taken in a relatively short time with LB’s family before his crisis admission.  PB: Do we see anywhere in LB’s clinical notes from STATT this history being developed and explored further? VM: No, we don’t, no.

15.00  Court shown Individual Epilepsy Profile developed by since LB’s death.  PB asks whether the areas in this tool had been explored [not the tool used] by VM during LB’s time on the STATT?  PB: Did you collect the information [3 most recent EEGs] VM: No, because Dr Rana had already told me.  VM: I would say that all of these things [on the tool] were relevant I would expect people to already know these things.  PB: Did anyone know whether these things had been triggers in Connor’s case in any of his seizures? VM: No.  PB: Was this information [description of seizures] ever captured in Connor’s case?  VM: I didn’t come across it, no.  PB: Was this [description of behaviours relating to seizures] ever captured in Connor’s case?  VM: No.

15.06  Court breaks for 10mins.

***

15.22  Court returns; Paul Bowen asks further questions of Dr Valerie Murphy, Consultant Psychiatrist at STATT.

15.23  PB: Verita concludes an epilepsy profile should have been compiled when LB entered the unit. You accept a profile was not completed?  ‘Yes’.  PB care plans and risk assessments are usually nurse led?  VM: Yes.  PB: The quality of the care plans and risk assessment would depend on the medical information supplied to them?  VM: Yes.  PB: Should care plans have been signed off by the multi-disciplinary team?  VM: It’s a difficult one, it was hard when RiO was introduced.  VM: Not all care plans were brought to the CTM, if there was an issue or concern someone was unhappy with it was brought to CTM.  VM: We were very busy, things were quite chaotic, it was very pressured.  VM: I had to trust that the nurses would work like that and raise any concerns.

15.27  PB takes VM to Rio notes of care plan; did that care plan ever come to the CTM?  VM: Not that I remember but it was a long time ago.  PB puts Verita conclusions about no epilepsy plan, no risk assessment and didn’t capture family information.  VM: I’m sorry to hear that.  Prof Crawford: If a better description of seizures had been obtained from staff might have been able to identify LB’s seizures.  VM agrees.

15.31  PB tells VM he’ll ask her about LB’s tongue bite incident. In April LB was started on risperidone.  VM: Yes, that’s right.  PB: It’s likely that Jan 2013 seizure had been as a result of the introduction of new medication, fluoxetine.  VM: It’s complicated.  PB: Can we both agree that both drugs can reduce seizure threshold?  VM: Yes.  PB: You note this in the notes so you’re obviously aware of the risks at that time?  VM: Yes.

15.33  PB: If LB had a seizure on the 20/5 15min bath observations… VM: …If it was a proven seizure, no it would not have been appropriate.  PB: If the risk is very serious it doesn’t need to be that likely before you take steps to avoid it?  VM: Yes, yes you’re right.  PB: …and the severity of the risk couldn’t be higher than someone with epilepsy having a seizure in the bath?  VM: Yes.

15.36  Rio note 20/5 14:15: LB had presented anxious in mood that morning, LB gritted his teeth, clenched his fists…20/5: LB has since been de-escalated in mood and has presented as very lethargic and has been in bed since 11 am.  PB: Was this indication of a complex partial seizure?  VM: Are you saying that it is?  It could be.  PB: the record i’ve just shown you is consistent with LB having a seizure?  VM: Well yes, it could be.

15.49  Incident in morning, then CTM, 3pm met LB in sitting room, still in his PJs.  VM: I can’t remember if I saw him first or did.  Both and VM saw LB that afternoon and saw his tongue.  How did you know it was an accident?  VM: I must have been fairly sure to put it in notes PB: You must been reasonably confident it might be a seizure; you took steps as result.  VM: I must have been reasonably confident it was not a seizure to record it was an accident in his notes.

15.45  VM: I was aware the family were concerned about seizure activity and I wanted them to be reassured that we were listening to them.   VM: There’s perfect practice and then there’s reality of a 0.6 consultant covering three wards.  PB: It’s fair to say you didn’t know he suffered from complex partial seizures did you?  VM: No, I don’t recall.

15.46   PB reads record where shared concerns, LB says he doesn’t know how he hurt his tongue.  Joanne Hook said she didn’t talk to Dr Murphy on that day.  VM ‘I do recall speaking to her that day’.  PB: Some times we remember things that we want to remember don’t we?  VM: That’s a fact.  VM: I made a judgement call that day with all the information I had but I’m always thinking bigger picture.

15.47  PB: Did you at any time write down a description of bite mark?  VM: I didn’t, no.  PB: Should you have?  VM:  It wld have been good practice.  PB: Would you now?  VM: That depends.

15.50  Coroner asks VM to describe the bite mark.

15.51  PB asks if she was aware thought was definite signs of a seizure VM:  Doesn’t recall it was definite.  RiO record indicates was.  Court shown 31/5 letter from Dr Jayawant requesting EEG.  Says ‘Connor has had more seizures recently’.  VM: Can I just add, that wasn’t consensus on the ward.

15.56  Note 3/6 meeting: There been no sign of seizure activity.  PB: I’m assuming no-one was looking at complex partial seizures if you didn’t know?  VM: What I’d say to that is that when someone has epilepsy you have to consider lots of types.  Discussion around notes and who saw LB’s tongue first.  VM: Well I wouldn’t randomly check a patient’s notes, so I must have been told.  3/6 note: LB remembers the biting and the pain.  VM: Well you have to understand we record discussions at those meetings.  PB: You had seen LB yourself and you suspected LB had had a seizure.  VM: No I didn’t.  VM: I must have had a good reason to write it was an accident.  PB: Either that or you’re choosing what you want to remember.

16.00  PB: AS put to Jess C a nurse was the best person to know what LB meant. She answered an incredulous no and looked directly at .  PB: Who is the best person to know what LB means when he says something? VM: I cant answer that question, I think its too broad.  PB: You’ve never said in any of your statements you decided on 20/5 it definitely wasn’t a seizure.  VM: I’m careful of use of language, that’s important as a doctor and as the type of person I am.  VM: I could write longer notes but that’s never been my style.

16.03  PB: had seen LB that day and was the best person to know he’d had a seizure.  VM: I suppose so.  PB points out that Prof Crawford also concluded it was likely LB had had a seizure.  VM: With the greatest respect Prof Crawford wasn’t there. [Professor Crawford is the court appointed expert in epilepsy].  PB points out that VM wasn’t there either.

16.05  VM discussing 3/6 minutes.  ‘Maybe it wasn’t documented accurately because the lady who did the minutes wasn’t medically trained’.   PB: Let me be clear you’re saying you did not authorise the reduction in observations? VM: I did, but psychiatric observations.  VM: Maybe this is part of the problem when you have a team made up of different professionals.  VM: Different professionals have different priorities and different ways of thinking. When someone says Level 2 I think psychiatric.

16.09  3/6 PB: You did not have an epilepsy monitor, the EEG had not been obtained, the blood results had not been obtained.  VM thinks bloods were.  The records show that they were not, neither set of blood tests returned until mid June (meeting was 3/6).

16.10  PB moves onto the assessment of LB’s capacity.  VM: That was an error, I wrote that wrong.  This was a mental capacity assessment by a consultant psychiatrist.

16.12  CTM notes 1/7 ‘after further investigation no-one was able to shed any light on the apparent episode of incontinence’.  1/7 Dr Murphy was initially concerned that this might have been the result of a seizure, but there is no evidence to suggest this.  1/7 Dr Murphy was chairing this meeting and ‘doesn’t know what that’s about’.  PB If you haven’t excluded incontinence do you need to continue on the basis it may have been a seizure?  VM: Yes.

16.14  VM: I don’t remember having any conversations around bathing observations.

16.15  Paul Bowen has no further questions for Dr Valerie Murphy.  Dr Murphy won’t be back physically but will give evidence by video conference next week.

16.20  End Week 1 of LB’s inquest .  We will return 10 am Monday.

Read more about LB

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