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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.


 13.29  Jury return and we’re back to Fiona P counsel for . She has no questions for Dr Murphy.

13.30  Alan Jenkins, counsel for Dr Murphy now asks her questions.

13.31  AJ: You told us you were unhappy with the way the Verita investigation took place and you were also unhappy with things that were overlooked.  The report suggested that there hadn’t been a medical assessment but we’ve seen Dr J report. What was your concern about the Verita team?  VM: I had two concerns, they appeared to have difficulty w understanding the way the unit worked…and it seemed as they were being deliberately picky, for want of a better word, about what they’d consider as evidence.

13.34  AJ: Had they suggested there was no contact w Dr Adcock? VM: Yes and I wrote to them to correct this but it wasn’t incl in the final report.  AJ: Did the report talk about staff not knowing LB had seizure 18 mths before admission?  VM: Yes it did & I’m not sure where info came from.  I’m not sure where they got that idea and they didn’t seem to accept what I was telling them.

13.35  AJ: Is there anything else you wanted to raise in your evidence before the jury?  VM: No, I don’t think so.  I wld like to say this has been absolutely devastating for everybody and I think about it every day, it was tragic beyond words.  At the end of the day a young man lost his life and I’m sorry about that.

13.36  Jury question to Dr M: What did Connor understand about his epilepsy?  VM: It’s difficult to know… he was aware he had epilepsy but it was hard to know what he understood in terms of risks.  In answer to your question it’s hard to know how much and what detail LB understood about his epilepsy.

13.38  Jury question: Was it discussed with LB about how he might communicate with staff when he thought he’d had a seizure?  VM: LB had spoken language… he had a good relationship w some staff so they cld communicate with him well in terms of figuring his needs.  There was a certain amount of communication with staff.

13.39  Jury question: Did you consider any methods other than medication to help LB control his anxiety?  VM: the ideal approach is to use behavioural and psychological methods…but it’s not always possible.  Sometimes pts dont have the space in their mind to deal with these matters so we use medication to bring down anxiety to work with behavioural methods.

13.42  Jury question: You’ve described a chaotic environment at STATT.  Can you explain why you think it was chaotic?  VM: It’s a difficult and complex question…. there was a pressure to fill beds so we had a lot of difficult out of county patients, there was a lot of focus on paperwork, were taking over and ppl were worried for their jobs.   Some changes were communicated well, some not so well from Southampton .  There was a lot of stress for nursing staff, it was chaotic.

13.44  Jury question: How long did you spend with Connor?  VM: I didn’t spend a lot of time with Connor.  That wouldn’t have been hugely unusual [not spending time with patients] <<<< In response to jury question to Dr Murphy, STATT psychiatrist.

13.46 Coroner question: you’ve said a number of times that LB didn’t have seizures on STATT.  You weren’t incl 4 July were you?  VM: No, you’re right.

13.47  Dr Valerie Murphy dismissed.

13.47  Ben Morris is called and sworn in.  Ben Morris was the STATT Unit Manager during Connor’s time on the unit.  Ben Morris was a Band 7 nurse manager, worked across STATT and John Sharich House and incl the management of the OT team.

13.49  Coroner asks BM how many patients were at John Sharich House – 8 beds.

13.50  Ben Morris’ job title was Senior Clinical Nurse on STATT and JSH.  He initially started working there in 2002.  BM: My role was around functions of HR, staffing, finance, training and other such tasks.  Job was split 2.5 days at STATT, 2.5 days at JSH.  Had an office in both places, Mon wld be STATT, Tue at JSH and then no specific location for rest of week.

13.53  Paul Bowen now asks questions of Ben Morris, Band 7 manager.  PB: Did you have any additional training when you moved up from Band 6 to Band 7 role?  BM: No specific training on that, no.  PB: Did you have any specific training around epilepsy or epilepsy risk management?  BM: No specific training on that, no.  PB reads his interview transcript to BM: ‘LB had one seizure in 18 mths’.  PB: Was it your understanding that he’d had one in 18 mths?  BM: Yes I knew he’d had a seizure in Jan 2013; not one 18 mths ago but one in the last 18 mths.

13.56  PB: Did families have a role in care planning?  BM: Were asked about things… but we weren’t very good as a service in involving families.  BM: In the culture of this service [involving families] no.. the culture and system we had set up made it difficult for families to do that.

13.58  PB: You’ve heard others refer to flattened hierarchy of the service, have you reflected on what Verita said about leadership within service?  BM: Yes.  PB reads Verita conclusions re failure of leadership: ‘Is that a conclusion you think is a fair one?’  BM: Yes.  PB: We’ve heard about some of the failures when took over… who wld you raise concerns with?  BM: In general clinical issues, my service manager… one of problems when took over was you didn’t know who anyone was.  It was difficult to get clarity around how things should work .

14.02  PB: Are you aware of any epilepsy risk assessment form that had to be completed?  BM: No I haven’t seen the epilepsy pathway [at that stage].  PB: Did the RiO risk summary include epilepsy as well?  BM: It wasn’t written in LB’s risk summary.. it should have been documented in there.

14.03  PB asks BM if he thought the CQC criticisms were fair?  BM: There were many, overall I think it was reasonably fair.  PB: Care and treatment was not planned in way to ensure safety and welfare… is that a fair criticism?  BM: Yes.  PB: Risk assessment and recording was not effective… is that a fair criticism?  BM: Yes.  PB: The buildings in which STATT was housed were not clean?  BM: The cleaner had quit two weeks before CQC arrived.  I was on holiday when the cleaner quit and there was no mechanism for anyone to recognise the cleaner had gone.   The cleaner was agency staff managed by estates department.  PB: So you hadn’t handed over to anyone while you were on holiday?  BM: No.

14.08  PB: Do you accept that you were Jonny Cowee’s boss and he ended up getting it in the neck from Verita?  BM: Yes, I was and I do.  PB: You didn’t have a lot of involvement on day to day basis with LB’s care?  BM: No.  PB: wrote to you and you forwarded it to the psychiatrists (Jayawant/Murphy)?  BM: Yes.

14.09  PB: We’ve since heard confusion whether was a tongue or lip bite, is it right that wrote the following morning to clarify?  BM: Yes.  PB: Did you forward that to members of staff?  BM: No, I don’t recall that.  PB: Should you have done?  BM: Yes, I should.

14.11  Questions for Ben Morris from Adam Samuel, for Jonny Cowee.

14.11  AS: Did JC raise with you concerns about managing Band 5 nurses?  BM: Yes, we had conversations about the challenges, yes.  AS: Did you feel you could help him?  BM: Some of the time.  AS: What were the issues?  BM: Staffing… there was an issue about only having one Band 6 member of staff…when I became Band 7 we recruited to Band 6 but recruitment was put on hold by before we could put through paperwork.  There were half as many managers in the unit as there had been previously .  AS: When JC was away would there have been cover for the Band 6?  BM: No, there wouldn’t have been .

14.15  AS: Do you recall Mr Cowee asking to get further training for atypical epilepsy presentation?  BM: I don’t recall that specific conversation, but we had a number of conversations about training and staff development; we were restricted in what time we had available.  We had ‘Learning beyond registration’ training at a local university, unfortunately those didn’t start until Sept 2013.  AS: Did JC come to you and have conversations about training and how could get the unit better?  BM: Yes, we had numerous conversations.

14.19 Questions for Ben Morris from Fiona Paterson for .  BM: I’ve been a learning disability nurse for about 11 years [read from transcript].  FP: Wld you agree the proportion of ppl w LD who have epilepsy have a higher instance of epilepsy?  BM: Yes.  FP: You’re aware of the NICE Guidelines and that as a registered nurse you must follow them?  BM: Yes.  FP: As a Band 6 nurse you had experience of supervising Band 5 staff and care planning?  BM: Yes.  FP: You were promoted to Band 7 before took over Ridgeway. Is that correct?  BM: Yes.  FP: Staffing structures took place before acquired Ridgeway?  BM: I don’t recall.  FP: Changes in shift patterns and moving to electronic records happened before took over?  BM: Yes.

14.23  Roddy James, counsel for Ben Morris now asks him questions.  RJ: We’ve already seen the emails that you forwarded and that OTs became involved?  BM: Yes.  RJ: You were asked about a second email from clarifying LB bit his tongue not lip?  BM: Yes.  RJ: No dispute that exchange happened?  BM: No, none.  RJ: Was there any doubt from the medical records that it was his tongue?  BM: No.  RJ: Was that email correcting it forwarded?  BM: I can’t recall.  RJ: From unit perspective did ppl doubt it was his tongue?  BM:  No.  RJ: Can you recall, was it relayed to nursing staff?  BM: I don’t recall but I would have spoken to the nursing staff.  RJ: We’ve seen the record on Rio to say the unit were informed orally by about her concerns?  As well as email.  BM: Yes.  RJ: Within the limits of which you were working did you do what you should have?  BM: I did my best.

14.30  No jury questions for Ben Morris. He’s dismissed. Short break for 15 mins here.


15.00  Jury returns and we hear the second 999 recording from 4 July 2013.  999 call Dr Jayawant for LB ‘had seizure’. C. 1 min in, operator: Would 4 hrs be appropriate?  Then becomes clear requires emergency response.

15.06  Dr Jayawant, Associate Specialist Psychiatrist in Learning Disability is sworn in.  Coroner checks that the statement is that of Dr Giri Jayawant – it is.  Coroner asks how long she has been a psychiatrist GJ: I finished training in 1999, been working w ppl with learning disabilities since 2002.  Coroner reads GJ’s statement incl info that EEG referral was result of ‘s concerns re seizures.

15.13  GJ: Worked as supporting doctor [psychiatrists] across 4 units, worked w two part time consultant psychiatrists.  Part of my role is to provide continuity of care for patients.

15.15  PB puts Verita conclusions to GJ, is that a conclusion you agree with?  GJ: I accept it, I don’t agree with it.  GJ: In my opinion they [Dr Murphy and Jonny Cowee] were doing the best they could.

15.17  PB asks GJ if she accepts CQC conclusions.  GJ: We failed to provide whatever they were looking for.  PB: It goes further than not meeting the standard on the day; puts each CQC conclusion to GJ: This wasn’t a slight criticism, you failed on things.  GJ: I think it’s only fair we try and improve our services.  They didn’t actually fail us.  PB: This wasn’t could do better, they did issue warning notices.  GJ: Yes, I agree with that.   PB: Did not have effective system in place to identify and manage risk.  GJ: Again I accept the findings.  PB: CQC weren’t just looking at LB.  GJ: That’s correct yes, they were, all patients.

15.20  PB: You saw LB on the day after he was admitted; at the time what did you understand to be the symptoms of his epilepsy?  GJ: I quickly read thru Dr J’s note, from that I knew LB was a young lad w minor learning disability, autism and Klinefelter’s and epilepsy.  PB shows to the court Dr Johnson’s pre-admission assessment, after a couple of hours at LB’s home before his crisis admission.  GJ: I understood he had tonic clonic seizures and absences, now know complex partial seizures.  I knew the EEG had been conducted in the community.  PB: Did you see the EEG?  GJ: No, I didn’t.  GJ: On 20/3 I didn’t have much information about epilepsy.  PB: You know Dr J’s and there is information out there that will tell you more.

15.26  PB: You were here for Dr Murphy’s evidence, she claimed she didn’t know he suffered from complex partial seizures.  GJ: I don’t remember a specific conversation with Dr Murphy about complex partial seizures.  After 20 May I did a detailed look thru notes.   I didn’t know he had complex partial but I suspected he might and was reported by Mum, who knew him much better than us.

15.28  PB describes possible behaviours related to complex partial seizures.  GJ agrees with all of them.  PB takes court to Dr Johnson’s assessment references: muttering, head banging, chopped up words, getting in and out of bath numerous times.  PB: There were other behaviours that you’d know if you’d spent any time at all with LB; he had a grimace.  GJ: Yes, he’d do that.  PB: Prof Crawford suggests some of LB’s seizures cld have been mistaken for his learning disability.  GJ: I agree that’s a possibility.

15.30  GJ: I couldn’t decipher anything that was a repeated pattern [linked to seizures].  PB: At what point?  GJ: When I went back thru the notes….At the point of making a neurophysiology referral.  PB: What sort of information wld you seek to obtain to properly manage his care?  You’d expect to get a full history?  GJ: Yes.  PB: Incl description of each and every seizure, triggers and how presents after?  GJ: Yes to all.  PB: You’d agree Dr Johnson’s assessment is a very good starting point but it isn’t a full history?  GJ: Yes, yes, I agree.

15.34  PB takes the court to the RiO print out of initial entry; no reference to seizure in Jan 2013 or proper history?  GJ: Yes, I agree.  PB: We’ve heard RiO is first point of call.  GJ: I’m not sure that’s exactly true, I was not using care plans in RiO as much as we do now.  GJ says she’d have looked at progress notes, clinical documents but rightly or wrongly didn’t use care plans at time.   GJ: The first time I saw this care plan was in the bundle to court.

15.37  PB: We don’t see anywhere a history that looks at LB’s seizures do we?  GJ: No, we don’t, it’s not in the progress notes.  PB: Dr Jayawant. it doesn’t matter where you look, it isn’t in there.  GJ: No.  GJ goes on to explain where she’d expect to see information but says she did not call and ask her, no.  PB: You accept that you didn’t collect all the information needed to compile an epilepsy management plan?  GJ: I wasn’t trying to put together an epilepsy management plan; I was going through notes before contacting neuro department.

15.43  Note from Dr Murphy to GJ saying, ‘You will remember we discussed getting an EEG at the big meeting’.  31/5 letter from Dr Jayawant to neuro.  PB: What’s the point of getting an EEG at this point?  GJ: To be very blunt, nothing.  It wouldn’t have told us if tongue bite was seizure.   I wasn’t expecting it to tell us anything, but it might have uncovered something…‘s concerns were enough evidence for me to treat it as a seizure, it might have established something.

15.46  PB: Email 21/5 and letter is 31/5.  Why did it take 10 days to make the referral? GJ: I wasn’t at STATT every day of the week…I couldn’t access my emails out of the building, I went through the notes, it was done at the first opportunity…It cld be that it was a complex partial seizure.

15.49  PB takes GJ to note 25/5 ‘At 4am LB suddenly got up and started getting dressed…’  31/5 letter, GJ: ‘Connor has had more seizures recently which is out of character according to his mum’.  Refers to Jan 13 & poss May seizure.  GJ: I don’t think we can ever rule out someone has had a seizure in someone with epilepsy.  GJ: Absence seizures can come on and go in matter of seconds… complex partial can take longer and be lethargic.  PB: It’s important to know how individuals respond, isn’t it?  Did you know LB wld be v lethargic post seizure?  GJ: Yes, it is; most ppl are.  20/5 RiO LB ‘has presented very lethargic and has been in bed since 11am’ GJ: I wouldn’t say it’s inconsistent w a seizure, or consistent.

15.53  PB: I believe it’s your evidence you analysed the notes before you ordered the EEG?  GJ: Yes, whatever we had at the time, much less than now.  PB asks about getting history.  GJ: It wld have been impossible to get information from LB, it would have to come from the family.  PB: Presumably you did that and asked his family for this information?  GJ: I didn’t, I already said I didn’t.  PB asks GJ if she agrees w Verita conclusion that they failed to complete a full history.  GJ: Yes at his admission it wasn’t the right time.

15.56  PB: You looked for evidence of seizure activity in May, so that wld have been the time to develop a proper history?  GJ: Sure, in hindsight that is something I could have done, Dr Murphy was taking the lead as a clinician, OTs were assessing, so I assumed other ppl were.   I wasn’t taking the lead in managing Connor’s care; I wasn’t the lead clinician.

15.58  RiO note: ‘There has been no sign of seizure activity.  Jonny has spoken to the staff around at the time of the suspected seizure’.  GJ: RiO notes and what Jonny was reporting and Charlotte [OT] had spoken to so not just depending on what nurses said.  PB: Is that a failure of the notes then?  GJ: Possibly, it’s very difficult to capture multidisciplinary discussion.  PB: The information recorded in the notes, feeds into discussion ‘Dr Jayawant explained this doesn’t appear consistent w a seizure’.  PB: Is that an accurate account?  GJ: Yes, I think so.  PB: Are you saying that LB, in a bad mood, remembered biting and pain was not consistent with a seizure?  GJ: Yes.   PB: Did you speak to Connor yourself?  GJ: No.  PB: Did you speak to the nurses yourself?  GJ: No.

16.04  PB refers back to RiO notes; Dr Murphy doesn’t mention why; 21/5 nursing note: when asked ‘LB says he does not know how he bit his tongue’.  GJ: For me, if was concerned, I would treat it as a seizure.  GJ: If someone bit their tongue and remembers the pain that is not consistent with a seizure.  PB: There is no consistent account on RiO.  GJ: We didn’t dismiss the possibility of a seizure outright, well I didn’t, I gave a lot of weight to what said.

16.06  PB: You ordered an EEG, did you have outcome before 3/6?  GJ: No.  PB: An epilepsy monitor was ordered, had that been used before 3/6?  GJ: No.  PB: A blood test was ordered?  GJ: Yes as result of 3/6.  PB: So, an EEG, epilepsy monitor, blood tests had not been obtained at time you decided was no seizure.  GJ: By 3/6 I was 99% certain it was not a seizure. Before then my opinion was different because I didn’t have enough information.  PB: What was the new information?  GJ: He had been observed every 10 mins in the previous two weeks and I had no reason to doubt them.

16.09  PB: Three independent means [blood tests, EEG, epilepsy monitor] but you didn’t have any of those on 3/6 did you?  GJ: No, but…. EEG wouldn’t change management plan; phenytoin blood tests wld not have changed management in any way; bed monitors give false positives.  Bed monitors would add a little bit of information but it would not have been the decision maker;  we were doing all of them but I don’t think they would have added anything or changed the management plan that flowed thru from there.

16.13  PB: You decided on Connor’s information?  GJ:  I take your point that one word answer, ‘angry’, was open to interpretation.

16.14  PB: Were you aware of the strength of feeling had [that] it was signs of a seizure? GJ: I was aware, she’d spoken, called and emailed.  PB: Were you aware that was certain? How had you ascertained that?  GJ: The fact she had emailed.  PB: Did you speak to her yourself?  GJ: I didn’t, I hadn’t.  I worked across 4 units; it was an assumption that the team would…

16.16  PB: You’re aware that Prof Crawford felt that LB had had a complex partial seizure?  GJ: Yes, I am, I agree.  PB: Are you also aware that Prof C thought the phenytoin shd have been increased?  GJ: I’m not sure I agree, we’d have watched and waited.   One seizure is not enough to make clinical decisions on, we would watch and wait.

16.18  PB: If LB had a seizure, would it have been appropriate to only have a 15 min observation, with a door closed?  GJ: My opinion is that anyone with epilepsy should be supported in a bath one-to-one at all times.  PB: Were you asked at any time about LB’s bathing?  GJ: No I wasn’t and I would have said 15 min obs were inappropriate.

16.20  PB moves onto GJ’s 999 call. Retrospective note on RiO added afternoon of 4/7.  Started phone call in car park, someone said the landline wasn’t working in STATT.  PB: Did they tell you what was happening?   GJ: I knew it was desperately urgent but I didn’t know what was happening.  PB: How did you know it was a seizure?  GJ: I didn’t, it was speculation given Connor’s history.

16.22  Alan Jenkins for Dr Murphy asks GJ questions. AJ: Did Verita understand STATT had been set up to deliberately not have clinical leadership?  GJ: No they did not, psychiatry used to be very hierarchical but there was a national push to be more holistic with multi-professional input.

16.25  AJ refers GJ to Dr Johnson’s pre-admission history: clear things come to a head at home.  AJ: Is it standard to put impression at end?  GJ: Yes some would say impression, others working diagnosis.  AJ: Note ‘epilepsy seems to have been explored and ruled out as cause’ where was this from?  GJ: I don’t know why Dr Johnson thought that.

16.30  AJ: Connor to be observed on level 2 obs at 10 min intervals, is that psychiatric observations?  GJ: Yes, I would think so.  AJ: Was it a common view that seizures were well managed?  GJ: Yes, aside from Jan 2013 seizure, that is well managed.  3 am night LB was admitted ‘He was restrained figure of 4’ LB was distressed, extremely stressful for someone w autism.   That itself [ATU admission] is enough to make someone behave in a manner they wouldn’t normally do.

16.35  21/3 6am RiO note: ‘LB slept until 01:45 when he got up asking to go home… returned to room, occasionally came to office to ask to go home’.  AJ: He was clearly disturbed?  GJ: He was anxious.

16.37  AJ: 20/5 note from Dr Murphy on RiO that she’d seen his tongue.   AJ: Staff to be extra vigilant – would you say ppl were?  GJ: Absolutely.  GJ: I would expect staff to be aware and vigilant not just of tonic clonic seizures but of any changes in behaviour.  AJ: 22/5 RiO note Winnie is to write epilepsy management plan – that was to be done by nursing staff?  GJ: I believe so.

16.41  Jury retires for the day.  Dr Jayawant will return and continue giving evidence tomorrow at 09:30.  We’ll be back then.