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LB Balloons

For Connor’s family,
with awed admiration
for KBO and Keeping Your Zen On.

and for the indefatigable George Julian,
industriously live-tweeting, on the @LBInquest timeline,
everything you can read below.

***

 10.31  Jury return for Week 2 of Valerie Murphy joins the court by video link from Ireland where she now works.

10.32  Barristers each have to move in turn to speak to a microphone .

10.33  Roddy James for Ben Morris: Your evidence on Friday was that it was difficult to identify leadership on the team?  VM: Yes I’d agree w that.  RJ: That decision was made by more senior management at ?  VM: No we didn’t have a say in it and it wasn’t our choice, no.  VM: It was very clear to us that wanted it this way… I felt that it was more significantly in place under .  VM: Under Ridgeway it was more possible to have a conversation about such things, wasn’t the case with .

10.35  RJ: As responsible clinician under the Mental Health Act it was clear leadership from you?  VM: There are certain things you can do under the mental health act and certain things you can’t do.  VM: Treatment of a psychiatric illness is allowed under the Mental Health Act but you can not force someone to treat a physical illness.

10.37  RJ questions VM further about her role as responsible clinician.  VM: I wld expect that was my role as part of the multidisciplinary team.  VM: We would keep an eye out on the other areas of a team.  RJ quotes VM responses to Verita 1.  RJ quotes ‘discussions and arguments at CTMs about what the care plan was to be’ not in relation to LB’s care.  VM: I wouldn’t say arguments.  VM: There would be debates and discussion on the team and I would encourage that to happen.

10.39  RJ confirms that LB was under the care of the Mental Health Act when he was first admitted and the first care plans were put in place.  VM: Unclear on timings, would have to check that.  RJ asks VM was she aware of Dr Johnson’s pre-admission assessment?  VM: I was aware when Dr J was conducting it because I was on duty.  RJ: Did you familiarise yourself with that assessment?  VM: Yes, of course.  RJ: What was your view of his epilepsy?  VM: It was as what Dr Johnson said… had a discussion w Dr Rana, that was my understanding of LB’s epilepsy.

10.41  RJ: initial care plan had 10 min observations, no view taken at CTM that was insufficient.  VM: For all aspects of care I’d have said 10mins was appropriate.

10.42  RJ asking VM about the sequence of events in relation to tongue bite incident.  RJ: You became aware and went to see him?  VM: That’s right.  RJ: You said at that point you must have been satisfied it wasn’t seizure activity? At the point you made your entry in the RiO notes?   VM: Yes it would have been, I’m very careful about my words, I don’t write long passages.  In hindsight now, I shd have documented more clearly.   VM: I shd have noted he acquired this by accident and that was a failing in my note taking.  VM: I would never take anything in isolation, I’d take on board what people around me were saying.

10.44  RJ: The following morning when you had email forwarded, what was your view?  VM: Difficult for me to remember exactly what.  VM: I must have been pretty sure that it was not a seizure however I was still listening to what was said & I took it on board.  VM: LB at the time was informal [patient] and changes you make to someone’s care has to be balanced.  Have to have a good reason to do them.  VM: All the changes we made were minimally intrusive.  You wouldn’t know yourself if you were sleeping on a bed sensor.  VM: This is more important if someone is informal.

10.47  RJ to VM to 3/6 ‘whatever the rights or wrongs of that decision, a decision was reached that 20/5 incident had not been a seizure’.  VM: That is correct.  RJ lists who was in attendance. It’s not possible to show the document to the court because the screen is in use for video.

10.48  RJ: As a result of the 3/6 decision his obs were reduced from 10 min to hourly.  VM: As I described on Friday it appears there was a communication error in that decision making.  RJ reads the record of that meeting to the court ‘as no evidence of seizures it was agreed by VM to reduce to general obs’.  VM: As I described on Friday it appears there was a communication error in that decision making.  VM: As I described on Fri there were three ppl involved in putting that note together: VM, Winnie B and the note taker.  Somewhere between my hearing, Winnie mentioning obs and the person taking notes ‘it was confused’.

10.51  RJ asks VM to confirm observations were part of the care plan VM: I suppose so… but there are two separate things between obs and checks.  RJ: You didnt think that reducing observations was to do with epilepsy?  VM can’t hear; repeated three times.  RJ: You don’t remember reducing observations to be related to seizures?  VM: Yes, that’s correct.

10.52  RJ:  As far as epilepsy was concerned you said in your Verita interview ‘you did not have a concern’ and his epilepsy was not a concern.  VM: My understanding was that he did not have a seizure while he was on the ward.

10.54  RJ asks VM about the CPA meeting in June.  VM: It takes a bigger picture of what’s happening, what’s happened and where we’re trying to go.  RJ: There are 2 items on a standard CPA mtg agenda 1) look at current care plans 2) risk assessments to be looked at?  VM: Yes, I think so.  RJ: By 10/6 the epilepsy care plan had been amended from 10 min checks to hourly.. were the care plans reviewed at that meeting?  VM: I can’t remember what was seen or discussed at that meeting, but I remember it as quite chaotic.. I’m sorry, I can’t be absolutely sure.  I can’t be sure whether the care plans or risk assessments were reviewed but I don’t think they were.

10.58  Up now: Adam Samuel for Jonny Cowee, questions to Dr Valerie Murphy, Consultant Psychiatrist.

10.58  AS: As I understand it your view is that risk assessments and care plans is very much a Band 5 nursing job?  VM: Yes.  AS: You would be able to review them on RiO at any time though?  VM: Yes, that is correct.  AS: You concluded by 3/6 that LB had not suffered from a seizure on 20/5?  VM: Yes, as discussed with my colleagues.

11.01  AS: From 20 May there are two strands of information in relation to the bite mark on LB’s tongue… he bit because was angry, or as seizure; two different potential causes and subsequent to yr discussion w LB, an email from is forwarded to VM and Dr Jayawant?  VM: Yes it was forwarded to Ben [unit mgr] who forwarded [to the two psychiatrists].  AS: Jess Constable said had discussed email?  VM: Yes.  AS: You said on Fri there would be many and frequent discussions that weren’t recorded in the notes?  VM: Yes, that wld be correct.  AS: You had already formed the view before the meeting on 3/6 that it was not a seizure?  VM: Yes.  AS: Lists who she’s likely to discussed with.  VM: Confirms.  AS: The decision is already made before JC has chance to have a say on it.  VM: As you pointed out Jonny was on leave at the time… there could have been discussion but yes, we had already come to that conclusion.

11.05  AS asks who those minutes wld be sent to?  VM: Wouldn’t know.  AS: Do minutes of CTM meetings find themselves in patient’s medical records?  VM: Yes, they would.  AS: Would members of the team have a duty to ensure those records were accurate as medical professionals?  VM: It depends, we were struggling w RiO, the Chair would read and confirm them.  AS: …and they wld be sent out potentially?

11.07  AS: Do you recognise the conversation between you and WB where you said was no evidence of seizure activity?  VM: Yes, there was no evidence.  AS reads from the iterations of the care plan in relation to epilepsy and medication.  VM: I don’t know, it was quite a long time ago.

11.09  AS: Care plan obs were related to epilepsy and on 4/6, day following CTM, expresses reduction in obs to be directly related to epilepsy risk.  The significance of that is when initially written observations are related to epilepsy, when altered it’s related to epilepsy.  In view of that are you prepared to concede that the reduction in observation was linked to epilepsy?  VM: NO, because I did not write.  VM: I did not write the first or later care plan or the minutes of the CTM.  VM: Maybe I wasn’t terribly clear, quite possible because CTMs can be quite busy.  VM: My decision to decrease those observations was observation, psychiatric observation.  AS: If anyone saw minutes they wld think you reduced those obs.  VM: Its not straight forward, I’d expect ppl to know about psychiatric obs.  VM: Was it my understanding he didn’t have a seizure, yes, that’s separate to obs.  AS: Well, according to you.

11.16  AS puts quote to VM from Verita 1 ‘Were you aware his obs level was 15mins for bathing’?  VM: No, I wasn’t aware but I wouldn’t expect to be.  AS: If you weren’t aware of 15min checks you took a view they were appropriate?  VM: Yes I think they probably were.  AS: Why were those reasonable?  VM: This was a man who was informal, to increase observations when taking a bath, need a very good reason to invade his personal space.  VM: I think that decision was the right one.

11.19  AS asks VM about the conversation she had with JC after the CPA meeting, where she called ‘toxic’.  VM said to Verita that the meeting was ‘chaotic’ and ‘threw her off her stride’.  AS suggests she was upset about the meeting.  VM: I remember I was very frustrated w Carol Clarke [care manager ]; there was a lot of frustration.  AS: Are you aware that Dr Rana [community psychiatrist] had refused to work w ?  VM: I found out when I went to Dr Rana to discuss LB’s discharge… she cut me short and said she wasn’t to be LB’s psychiatrist any more.  VM: She told me she found very aggressive and didn’t like what was said on the blog.  AS: I want to make it clear that I and Mr Cowee do not agree w this assessment of but wish to consider this was the context.  AS asks VM if frustrated after the CPA meeting, in an unguarded moment, she said those things to Mr Cowee?  VM: I wasn’t a close friend of Mr Cowee and I absolutely did not, I did not say those things.

11.26  AS asks VM if she’d considered input.  AS: By the meeting of 3/6 we know in fact that suspects a seizure may have occurred.  VM: We know that was her view, yes.  AS: We’re at the point of suspicion by then [of a seizure]?  VM: Well no, we take the information available to us.  We make a call on it and my understanding was that is what we did.

11.27  AS finishes.

11.28  Michael Walsh for Kieran D up next.  MW: In your Verita interview you cover a number of matters, in particular care plans.    VM: ‘Any care plans, questions or any risks that anyone is worried about, they are always discussed at CTM’ [quote from V transcript].  VM: Yes, anyone on the team would be able to raise it.  We had a limited amount of time and very very complex patients.  Any questions about care plans or risks would be discussed at CTMs.  MW: Was there an agenda for CTMs?   VM: There was a looser agenda than wld have been for CPA, I can’t remember exactly what was on the agenda, we’d discuss patient by patient.  MW: The dose of risperidone LB had was unable to lower the seizure threshold.  VM: Yes… there is a risk but it’s dose related.  The usual dose is 3-6mg but I only prescribed 0.5mg… the smaller the dose the better.

11.32  Malcolm Fortune for Winnie B up now, asking questions of Dr Valerie Murphy, STATT psychiatrist.  MF: Can I take you back to your appointment as a consultant, in Oct 2011; you took up your position in early Jan 2012, is that correct?  VM: That’s correct.  MF: You were a replacement for a former psychiatrist?  VM: Yes, that’s correct.  I took over at STATT and John Sharich House and the plan was eventually I’d build my workload on Evenlode.  MF: You were appointed 0.6; did you have some protected time for your continuing professional development?  VM: Yes, theoretically.

11.35  MF: With regards to caseload, when LB was a patient, how many patients were you responsible for?  VM: I would say roughly about 15.  MF: In addition to your 3 days a week were you on call at any time?  VM: Yes I was regularly on call.  MF: Did you have a private practice?  VM: No I did not.  MF: On your appointment did you use paper notes alone?  VM: Yes, I believe so.  MF asks when computers were introduced?  VM says that period was hazy.  MF: When it was just paper were individual patient files brought to CTMs so risk assessments and care plans could be reviewed?  VM: Yes that’s my memory of them.  MF: Who wld sign off paper notes as being reviewed at CTMs  VM: I certainly signed them…and I think other members, I can’t be sure.  MF: What message wld it send to someone picking up that file, looking at your signature?  VM: Well, that I agreed with the plan.

11.38  MF asks when RiO was introduced?  VM can’t recall when.  MF: Do you accept a more sophisticated version of RiO was introduced under in April 2013?  VM: It was constantly changing.  It made it quite difficult to work with.   MF: Do you accept what was on RiO wld be available to every member of the team?  VM: Yes it wld have been.

11.40  MF: We have heard the approach to LB’s care described as collegiate.  Prof C has referred to meritocratic.  VM: My understanding was that it was multidisciplinary and everyone had input.  MF: Although the Coroner will direct the jury to refer to evidence… some units like STATT were doctor led.  VM: It was a flattened hierarchy.  It was not a doctor led service, no.

11.42  MF: The take over didn’t happen over night did it?  VM: No?  MF: Did you have any discussion with the medical director during the takeover?  VM: No, my views were not sought or wanted.

11.43  MF turns to LB’s admission; he was admitted to do with his challenging behaviour and not his epilepsy.  VM: When someone with epilepsy is presenting with challenging behaviour, physical causes must be ruled out.  My understanding was that the community team had ruled out that connection.

11.45  MF takes VM to a discussion around the Mental Health Act and sectioning.  MF has to repeat his question three times.  MF: A nurse has the power to hold someone for 6hrs pending an assessment by a doctor?  VM: Yes.  MF: To be detained, must be two doctors (approved by the State) to assess, concur and agree to a section?  VM: Usually they will give their decision to an AMHP, usually a social worker, and they will apply for the section.  MF: Stands for 28 days?  VM: Yes, if it’s a Section 2.  MF: I’ve already confirmed that it was.

11.48  MF: Two guiding principles 1) how do we treat the presenting complaint and 2) how do we prepare for discharge. Do you agree?  VM: Yes, I do.  MF: The first CTM should have looked at the sectioning process, care plan and risk assessment.  VM: If appropriate to do so, I wasn’t there.  MF: You should review throughout the 28 days, do you agree?  VM: Yes.  MF: And if was not previously available should take on board care plan and risk assessments, do you agree?  VM: You’re describing an ideal scenario… MF: I’m talking about your professional duty as a responsible clinician Dr Murphy.  Wld you not consider it appropriate to consider a care plan or risk assessment to inform you as to how LB was managing?  VM: I would normally and I’d ask the nurses for one because they were very good… It depends what care plan you’re talking about.  There are ideal scenarios and there are reality…. I wldn’t just rely on paperwork, I’d rely on input of other multidisciplinary teams.

11.52  MF: Epilepsy is an illness for which there is no cure?  VM: Yes.  MF: So even if well controlled there is always a risk of seizure?  VM: Yes.  MF: Wld you agree good medical practice wld require you to obtain as much detail about previous fits, even if suspected, from all sources?  VM: Again you have to bear in mind what is ideal and what is reality.  VM: I was satisfied we had what we needed…. I was satisfied I had what I needed.  MF: For jury, the information wld agree what sort of seizure, what happens before or after, that’s the sort of information you might welcome?  VM: Well yes, I suppose it is.

11.55  MF: A well known risk in epilepsy is bathing, is that correct?  VM: Yes, it is.  MF: Showering is preferable?  VM: Preferable if you don’t take into account the individual’s preference.  MF: LB was known to like long baths and as such were considered therapeutically beneficial to him?  VM: Yes.  MF: A potential issue for the jury to consider is whether the team got the balance correct [dignity and ensure safety].  MF: Do you consider in collegiate approach, got that balance right?  VM: He was an informal pt, I think we did get that balance right.   MF: From 9/4 you prescribed risperidone 0.5mg VM: Yes that’s correct.  MF: That lowers the seizure threshold does it not?  VM: Yes.

11.59  MF: The discharge of LB from the section is not the end of your clinical responsibility is it Dr Murphy?  VM: No, it’s not.  MF: We’ve heard about a seizure pre-admission in Jan 13 and four other incidents, 2/5 sauce incident at tea, do you recall reading that [lorazepam prescribed]?  VM: I recall reading that.  MF: 20/5 we have the tongue biting incident and your note to say it was by accident.  Following EEG recommended, LB moved downstairs.  MF: On 16/6 was bloody nose incident and on 20/6 the incontinence issue.  Do you remember that? VM: Yes.

12.02  MF: Do you accept concerns about LB’s condition needed to be heard and investigated?  VM: I mean we did take it into account.  MF: Did you sit down w and say why you were satisfied these were not incidents involving seizures?  VM: No I didn’t sit down on a one-to-one basis with MF: Why not? VM: It wasn’t the normal way we operated, wld be at CTMs.  VM: Other families would email me or phone me.  I never had a problem doing that but interactions with wld take place at CTM.  MF: Did you feel for whatever reason you could not meet to discuss with her face to face her son’s condition?

12.05  Problems with video link, pause.

12.06  VM: No there wasn’t any reason but I didn’t see a reason to break with the way I normally operated with family members.

12.06  MF: The notes at CTMs were usually taken by a secretary?  VM: Yes.  MF: Did you consider them important?  VM: Yes.  MF: Was it your job to check they were accurate? VM: If I was the Chair.  MF: Even if not the chair given they were medical records?  VM: well you have to remember it was very collegiate, but I agree I would read them.

12.08  MF takes VM to notes of CTM on 3/6.  You’d have access any time you were on premises?  VM: That’s correct, yes.  MF: Did you in fact read the notes to prepare for the CPA meeting on 10/6?  VM: I probably would have, I can’t be sure.  MF: LB had been on 10 min obs prior to 3/6, do you agree?  VM: I’m a bit fuzzy about that, the night time obs were not 10 mins, I’m not sure.  MF confirms there were 10min obs at night.  VM: I’ll take your word for it, I don’t remember.  MF: You were clear observations were for psychiatric reasons?  VM: Yes.  MF: There seems to be a confusion that bath-time observations were checks?  They are in fact observations, aren’t they?  VM: Well, ummm.  MF asks VM why she draws distinction between obs and checks.  VM: they are two separate things and I don’t think anyone has disagreed w that.

12.12  MF: What went thru your mind when you agreed to reduce obs from 10min to hourly?  VM: I think psychiatric obs, there was absolutely no risk to himself or to others, we had no good reason to check on him every 10 mins.  MF: In reducing obs to hourly were you preparing LB for discharge?  VM: That was always the aim for all patients on STATT.  MF: In reducing the obs, were you reducing the burden on the staff? VM: That wld never feature in why I made such a decision.

12.14  MF: At CPA on 10/6 did you explain to why you’d reduced the level of observations to hourly?  VM: I don’t remember if it came up.  MF: At that stage had any member of staff informed why observations had been reduced?  VM: I don’t remember.  LB’s father had been present on 3/6.  MF: Mere fact LB’s father was present does not indicate that he understood the significance.  Had you seen any note in RiO that anyone had informed of the change?  VM: I didn’t see any formal note, no.  MF: Do you consider on 3/6 you shd have taken on board the risk assessments or care plans in place?  VM: From psychiatrics, we had.

12.17  MF: You heard Nurse B admit she had failed LB and his family; is there any failure in your care you wish to admit?  VM: It was an act of tragedy, ppl go in to medicine to help ppl. In hindsight we cld have made some different decisions but with the, with the information we had at the time we made the right decision.  MF: Dr Murphy I asked you, not we.  VM: I made the decision, with others, with the information we had at the time.  So no, I don’t consider that there was a failure of mine.

12.20  Coroner suggests break for lunch. VM says she’d like to catch up with her team so it’s not ideal. Jury dismissed, back in an hour.

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