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LB Balloons

For Connor’s family,
all doing him proud
one long, hard day after another.

and for George Julian, whose fingers must be worn to near the bone
from live-tweeting, on the @LBInquest timeline,
everything you can read below.

***

10.01  Jury returns. We’re back with Dr Giri Jayawant, Associate Specialist Psychiatrist in Learning Disability giving evidence.

10.02  No questions from Fiona Paterson, counsel for for Dr Jayawant.

10.02  Adam Samuel for Jonny Cowee now asks Dr Jayawant questions.

10.03  3/6 CTM notes shared.  AS: You did the referral for EEG and you and Dr Murphy were leading the investigation into LB’s epilepsy?  GJ: I wouldn’t say we were leading the investigation altho Dr Murphy was the responsible clinician…we’d have relied on colleagues to collect the evidence.  AS: So you were leading the investigation into epilepsy…There’s Dr Murphy’s note on Rio, nursing records… is it right you & Dr Murphy were leading assessment of what that meant clinically?  GJ: I wouldn’t say we were leading on anything…. I certainly wrote the referral letter and I did go thru the notes so I had more info.  The OT had spoken to and JC had spoken to the nurses so there were many ppl sharing information.  We didn’t change the management plan after 3/6.

10.06  AS: nothing changed in the management of epilepsy, that’s your evidence for the jury?  GJ: All the things carried on, the epilepsy monitor, keeping LB under strict observations.  AS refers to note of 3/6 where Dr M reduces obs.  AS: No evidence of seizures we’ve heard a few times from discussion, you do accept general observations were reduced?  GJ: Yes, the general obs we talk about are obs in communal areas.  We’d also had information that LB was more in communal areas after being moved downstairs…

10.10  AS checks that reducing obs were related to epilepsy.  GJ: Epilepsy was definitely something I had in my mind during this meeting.  AS: Your evidence is that there wasn’t a connection between epilepsy risk and reducing observations?  GJ: If it was just the risk of epilepsy we were talking about, the 10 or 20 min observations don’t make sense clinically; the observations we talk about take into account all risk factors.  AS: It appears there was no mechanism for managing risk if it’s not related to observations?  GJ doesn’t understand the questions, AS [puts qs] again.  GJ: Someone signs on the log every ten mins but you’re vigilant all the time.

10.13  AS: If 10min obs reducing to an hour wasn’t to do with epilepsy, how was epilepsy risk managed?  GJ: The nursing staff were very experienced.  Staff would report back anything not in keeping with general behaviour… anything which was distressing LB wld be recorded.  We wouldn’t have specific obs for epilepsy, for autism, for risk of harm to others, it would be taken together.

10.15  AS: We’ve looked at the records numerous times and you saying ‘this doesn’t appear to be consistent with a seizure’. GJ: Yes.  AS: If it’s not consistent with a seizure you’re excluding a seizure?  GJ: Not exactly, if someone remembers biting their tongue and pain it’s unlikely to be consistent with seizure activity.  However mum, sorry Dr Ryan, was concerned and was 1% chance it cld be, we didn’t dismiss concerns at all.  AS: Even if you’re saying emphasis is slightly different to what is recorded on the notes, a person receiving notes cld only go on these?  Someone would see this and see the evidence isn’t consistent, from a doctor, that a seizure didn’t take place?  GJ: In my mind there was no doubt that LB had epilepsy; whether a seizure took place or not was the conversation taking place at CTM.  AS clarifies his question related to how other staff would take that record to indicate LB hadn’t had a seizure.  GJ: I can’t speak for how someone would interpret what was written down, that’s the best I could explain it.

10.21  AS takes GJ to note where Dr M takes lead around epilepsy.  GJ: Yes Dr Murphy was the lead clinician, I don’t think anyone is doubting that.  AS takes GJ to 1/7 meeting note GJ: I don’t think I was present at this meeting from the beginning so I can’t comment on what was discussed.  AS: The records appear to suggest that you and Dr Murphy were taking the lead on LB’s epilepsy here as you were a month before?  GJ: I’ve explained before, the way the unit worked there was not a lead… we were a multidisciplinary team, Dr Murphy was lead clinician.

10.24  AS: Dr Murphy rang the neurologist Dr Adcock about this?  GJ: Yes, Dr Rana and Dr Murphy did.  AS: So both the psychiatrists were dealing with epilepsy risk there? GJ: Yes that’s the way it would go, Dr Rana in the community.

10.26  AS takes GJ to admission assessment of seizures, nurse has written LB suffers from epilepsy and needs observing every 10 mins…so that clearly links observations with epilepsy?  GJ: Yes.  AS later record stating ‘his observations have been reduced because LB has not suffered any seizures’.  GJ: Yes, we’re getting confused.  This care plan is linked to seizures but not the psychiatric plan.  AS: The jury will form their view.

10.29  AS: Someone looking at those documents wld take a different view from what you’re expressing here today, wouldn’t they?  GJ: I and Dr Murphy have worked a long time with the team and I would hope our observations were clear…I don’t think any of the nurses were less vigilant no matter whether 10 min obs or hourly obs.

10.30  MW for Kieran Dullaghan asks GJ to confirm at no stage did she see LB’s care plan [she said she only saw it when it came to court].  GJ: I wasn’t using care plans, if it came to CTMs I would input in, I wasn’t using RiO in July 2013, there was no expectation in 2013.  MW: What changed?  GJ: We had a session from a RiO guru in roughly Nov/Dec 2013 and now I use RiO differently.  I do look at care plans more frequently but it wld not be true to say I look at every patient’s care plan; I don’t look at every one [now].  MW: Until you had training you found RiO difficult?  GJ: I still find RiO difficult… the whole concept is difficult.  I much prefer writing to typing for example, I’m still learning about RiO, as a team we are using RiO more effectively and efficiently.  MW: When you had paper it was much easier to sign off notes?  GJ: Yes and you can’t sign off anything on RiO.  MW: You mention w paper care plans it was easier but w RiO there was nowhere to do that?  GJ: As far as I’m aware there isn’t, I cld be wrong.  MW: So in 2013 you weren’t aware and you’re not aware now?  GJ: No.

10.37  MW: Did you have difficulties with putting in info and finding it? GJ: Yes, it’s easier to enter than to find…the information has to be collected and put into different boxes, it’s a complex process.  MW: We’ve heard of a RiO update in 4/13 did that help?  GJ: Not really, I had difficulties with the update.  MW: Was it ever mentioned that there’s difficulty with RiO?  GJ: There was a RiO champion in each team so we fed our views forward…the RiO was fixed but the one we are using now seems more user centred, it was inflexible in 2013…our patient care had to fit into RiO somehow and the fit was not always easy.  Nov 2014 perhaps, gosh no July 2015, we went live with new RiO, I remember because I was on holiday, came back and it had all changed, some of us were struggling more than others but all of us were trying to do our best.

10.42  Oliver Williamson, Dr Jayawant’s own counsel now asks her questions.

10.43  OW takes GJ to clerking-in record from the SHO who covered the unit.  GJ: That SHO didn’t have access to RiO, they’d do a paper note.

10.44  OW takes GJ to her first contact with LB: 20/3 15:12 note, where she feels he needs to stay in the unit for a period of assessment.  OW: Did you see any evidence of a complex partial seizure at this time? GJ: No, it was just Connor, he was saying he felt sad.   At this stage I had to decide whether it was safe for LB to go home, it was about harm to himself and others [72hr holding power].  GJ describes how Section 2 under MHA works; OW confirms that wasn’t a contact she had with Connor.  GJ: No, no.

10.47  OW: First CTM was on 2/4; any idea why it’s so late after he was admitted?  GJ: No, unless there was something else going on. I don’t know why.  OW: 2/4 Note GJ to ring mum and fill in the front of the drug chart – were you present?  There’s no record of who attended meeting.  GJ: I can not remember if I was at the meeting. The notes show phonecall between GJ and on 3/4.  3/4 note of call from GJ to : ‘I also explained Dr M will be back next week’.  GJ: Yes [she was covering while VM was on leave].  OW reads record to GJ that suggest focus on behaviour and mood.  GJ: yes, if risk of harm to others cld be contained sufficiently there was …nothing stopping Connor returning to school or the activities he had in place before arriving in the unit.  OW: You were in the meeting as a doctor, listening to nursing staff, did you have any reason to doubt the accuracy of what they reported?  GJ: No reason to doubt.

10.54  OW: How many patients were you involved with?  GJ: I wld say 20-25.  OW: You would rely on what nursing staff told you?  GJ: Yes, if poss JC or BM wld come to CTMs and be main channel to bring nursing views.  13/5 CTM, GJ and Dr Murphy present: ‘continue risperidone and fluoxetine. Review if needed’.  GJ: We had no concerns about LB’s mental state.  OW: Had you seen any evidence he was suffering from epileptic seizures however they might present?  GJ: No.  CTM 20/5 record: ‘No change to medication, risperidone is taking the edge off his anxiety’.  GJ was not present but confirms this was the case.

10.58  21/5 email.  OW: Did you know risperidone cld reduce seizure threshold?  GJ: Yes.  28/5 CTM note: No discussion of tongue bite incident, but seizures discussed?  GJ: Yes.  OW: You were aware of the epilepsy?  GJ: Yes.   Epilepsy doesn’t stop ppl doing anything, I had it at the back of my mind, wanted to encourage LB to do something meaningful w his day.

11.02  31/5 letter to neurophysiology: ‘LB has had more seizures recently which is out of character according to his mum’.  OW: You considered what his Mum said was evidence of more seizures?  GJ: Yes… that was the presumption I was working on.

11.04  OW takes GJ to Dr Johnson’s pre-admission assessment; that info was on RiO?  GJ: Yes.  PB: The witness did just say this was a starting point.  OW: I’m not disagreeing with that.  OW: As far as you were aware was LB able to describe his seizures?  GJ: No… and that wld be unfair to ask anyone w epilepsy to describe.  It’s best to ask anyone who has witnessed a seizure, or his closest..  OW: What about the neurologist?  GJ: Yes.  PB objects.  OW: implication wasn’t that information came from the neurologist, just that she could have been useful.

11.08  OW: You requested an EEG as result of email from Dr Murphy?  GJ: Yes and as result of email from mum.  OW: That email is in the RiO notes?  GJ: Yes.  OW taking GJ through RiO notes to check contents.  3/6 CTM: ‘Dr Jayawant explained that this doesn’t appear consistent with a seizure’ [remembering biting and the pain].  OW: Did you have any reason to doubt what Dr Murphy said or Mr Cowee said?  GJ: No, not at all.  Re. 3/6, OW: Was any question raised in relation to LB’s bathing at that meeting?  GJ: No.

11.18  10/6 CPA meeting, OW: Were you present at the CPA?  GJ: No.  17/6 CTM meeting: GJ confirms she wasn’t present.

11.21  OW takes GJ to 999 call.  GJ: When I arrived, I parked my car, I saw staff running, there was some panic, the landlines were not working.

11.23  GJ: Between 20/5 and 3/6 weren’t any fresh concerns about seizures …I must say I am not an expert in the management of epilepsy.  OW asks GJ if LB’s behaviour before entering unit cld be described as complex partial seizure?  GJ: It’s very unlikely if there was no trend.  Most of Connor’s behaviour, in my mind, that we saw on the unit, could be explained by his diagnosis of autism.  We’re focused on the problems Connor had but he had a lovely life.  He was a lovely young man, he was a great character.

11.27  Adam Samuel queries the suggestion nursing information didn’t make it to the 3/6 CTM.  PB confirms we don’t accept it did.

11.28  Jury questions to GJ: When LB was admitted were observations about his behaviour, epilepsy or both?  GJ: Those obs were about behaviour.
Jury: When obs were reduced was that about behaviour, epilepsy or both?  GJ: Those were related to behaviour…
Jury asks about LB’s epilepsy obs in the care plan at 10mins – so where was that from?  GJ: I don’t know.
Jury question: Can I ask about Dr Adcock’s role, you said y’day she last saw LB in Nov 2011 but today she was actively managing LB’s epilepsy?  GJ: Usually you’d see someone once a year, I don’t know what happened w Nov 2012… understand Dr Rana spoke to Dr Adcock.   Understand Dr Murphy spoke to Dr Adcock.  PB: There is no note of this conversation anywhere.
Jury question: Was there a history of dealing with epileptics on the unit?  GJ: We had other patients admitted to STATT w epilepsy.  We saw a whole range of patients with epilepsy.  Jury: With observations?  GJ: generally speaking ppl wld observe and be vigilant and be aware.   Jury: With bathing too?  GJ: Yes, generally speaking.

11.39  Final comment, Dr Jayawant: I have the utmost respect for Dr Ryan and Connor’s family… I am really sorry for what has happened.  We as professionals are finding this whole inquest very difficult and I can’t imagine what it’s like for .

11.41  Jury dismissed for a 20min break, we’ll be back after with giving evidence .

***

12.14  Jury returns, next up Dr Ryan Connor’s mother giving evidence .  Coroner takes through her statement, reading some parts to the jury.

12.16  SR: Once LB was admitted we visited him almost every day. From the start of Connor’s admission, the conditions were never very good.  Initially I tried to focus on the positives of the STATT unit… there were some staff whom I found to be kind.

12.18  SR: CTMs were held approximately once a week on Monday. I tried to attend altho’ it wasn’t always possible with work.  CTM discussions would generally last about 10 mins… no other parents of other patients were ever present.  I attended CTMs as I wanted to be involved in Connor’s care and obtain information about what progress he was making.  There were 6 actions supposed to happen after meeting 20/5, by time of LB’s death, 6 wks later, only one of these actions was completed.  They didn’t revisit actions from the previous meeting, instead adding more action points (or same action points) each week.  This exemplified Connor’s experience on the STATT unit.

12.23  SR statement describes LB’s medication and fact that ‘on one occasion they ran out of it [phenytoin] and had to contact us for more’.  When Connor was admitted no one sat down with us to find out about him.  Overall I felt the unit saw me as troublesome because of the fact that I wanted to be involved in Connor’s care .  Weeks were passing and Connor was just existing on the unit. It was hard to see what was being achieved for him whilst he was there.

12.26  SR now reading sections of statement describing LB’s epilepsy.  SR: LB always bathed downstairs with the door open with one of us talking to him and listening, so had some privacy but so we could hear him.  I would never have thought of leaving LB alone in the bathroom for any period of time without being within hearing distance and close by.  There was no focus on LB’s epilepsy until I noticed his seizure in May. I then gave staff more info about his typical seizure activity…and I assumed they were acting on this information.   Connor was very resistant to the idea he had epilepsy and was also very ‘suggestible’.  I thought they were taking action in relation to LB’s seizures in obtaining appropriate equipment, moving downstairs and monitoring.  I assumed they were supervising LB in the bath and were in and out like we were, & given staffing levels I thought there was little risk.  Re 1/7 CTM: I understand they dismissed my concerns which is surprising as there’s a record in notes from previous day recording him tired.

12.34  Alan Jenkins for Dr Murphy now questions .  AJ: Can you confirm Dr M didn’t see LB until after CTM?  SR: I believe so.

12.35  Alan Jenkins questioning about her plans for LB when he came out of the unit; would he have got funding for college placement?  SR: LB clearly wasn’t happy at school, they tried to pick n mix what he did like… when he was admitted to the unit was a shift for future.  When he was admitted to the unit there was a change in the way he [was] asked, so he said he wouldn’t go to school…. social care wld need…to decide whether there was funding for college placement.
AJ suggests that the family didn’t want Connor home.
SR: Can I say LB was a school boy when he was admitted to that unit from a loving family… he wanted to come home and we wanted him home.

12.38  AJ asks about risperidone and pulls up records 8/4 CTM meeting.  AJ: Do you agree increase of risperidone was discussed in the meeting?  SR: I’m not a medication expert so I’d probably have just agreed.  AJ: Is it right Dr M explained cld be used to treat LB’s anxiety?  SR: Yes.  AJ: Did you have the chance to ask any questions? SR: Possibly, but it wasn’t an environment in which that happened.
AJ: Did you agree to it?  SR: She was a psychiatrist so if she said needed to increase his medication I’d have agreed .  AJ: Do you think you were given paperwork about risperidone?  SR: Possibly, I don’t really remember.
AJ: Can I suggest you’ve forgotten a discussion about interaction of drugs?  SR: No, there was no discussion about interaction of drugs.

12.42  29/4 CTM, AJ: Connor’s father was present, did you discuss things with him?  SR: Not really, no.  AJ: Do you accept drugs were discussed in CTMs?  SR: Yes.  AJ: Wld you have discussed that CTM and changes in medication with Connor’s father?  SR: No.
Note from next CTM, AJ: Do you remember these drugs being discussed in CTM?  SR: CTMs for Connor would last about 8 mins.  It could have just been a sentence.  AJ: Cld you ask questions?  SR: It wasn’t a very conducive environment for asking questions.  AJ: Did you seek a meeting with Dr Murphy?  SR: I wouldn’t have known where she was.  AJ: Did you call her up?  SR: I didn’t have a number.  Taking Connor into STATT was a very frightening experience… Presenting it like this is in a very bare way.  CTM notes, AJ: Did you have a chance to ask about medication if you wanted to?  SR: Yes.

12.48  22/5 RiO note from Charlotte Sweeney OT.  AJ: Do you remember the call?  SR: Yes.  AJ: Was there difficulty getting across your understanding of LB’s epilepsy?  SR: She asked me questions about LB’s epilepsy and I replied.  I think there is a difference between what would have been said and what was translated into notes.  AJ: Charlotte Sweeney said you didn’t offer information.  SR: She asked questions and I offered information; she was the expert.

12.51  AJ: Did you have difficulty developing a rapport?  SR: Tbh I was surprised to see sections in statements about my comms.  AJ suggests Cheryl was scared of .  PB jumps up to point out that Cheryl had clarified this in her testimony.  AJ suggests was ‘slagging staff off’ in her blog.  SR confirms no-one was named, was anonymous, she wasn’t aware staff reading.  SR explains to the jury that the day after LB died prepared a briefing about her blog and risk given what she’d identified.

12.53  Roddy James for Ben Morris now asking questions.

12.54  RJ: Bathing was a soothing mechanism for Connor?  SR: Yes… the very long baths were a new intervention over the previous few months. It was only when he became seriously distressed that this became relevant; previously he’d just have a 20 min bath.

12.56  RJ: I preface this is not a criticism but want to make sure what you say about it, do you accept Dr J admission and call w OT you… didn’t mention the need to observe Connor in the bath.  SR: Yes, but can I add it didn’t occur I’d need to raise with specialist staff.  This was a unit that cost £3.5k a week to keep Connor in it…It was a bit like asking a school teacher who took one of our kids on a school trip not to let them loose on a motorway.

12.58  RJ: In respect of the 20th tongue bite you raised it in three ways?  SR: Yes [in person, by phone and by email].  RJ asks SR about occasion when LB punched himself in face SR: He was quite agitated, he was fixated on finding Dappy from NDubz in London.  On motorway on way home he started punching himself and he had the worst nose bleed and he was absent, it was awful.  [At] the CPA meeting the next day, I’m almost certain I asked if the nosebleed could have been a seizure.  RJ queries that wasn’t recorded in the RiO notes.  SR: It’s a hugely frightening experience and didn’t bring that up at time returned him.  You reflect overnight and I brought it up the next day.

13.02  1/7 CPA meeting SR had emailed administrator to express her concerns that LB was apathetic and tired [she couldn’t attend].  RJ: The email: you raise the point he’s apathetic and unresponsive; you didn’t mention seizures.   1/7 record of discussion: At this meeting. LB’s mood [was] discussed but no-one discussed seizures.  RJ: Do you accept the email was raised?  SR: Yes it was raised, but I don’t think you can say that; they came to a conclusion that isn’t consistent with what’s recorded elsewhere.  The records from the days before LB died indicated he was tired, had red eyes, they don’t match up to the CTM and no-one checked them.

13.06  RJ: This was one of the CTMs were you raised an issue?  SR: It was the only occasion where I raised an issue.  RJ says SR was sent minutes of the CTMs.  SR: No, I was sent an abbreviated set of notes.  RJ: You were sent them by an administrator?  SR: Yes.  RJ: 28/5: Quick mtg, you were sent bullet point notes.  SR: We did not find out there were full sets of minutes ([which] we didn’t receive) until 2/15.  PB interjects with fact it’s first time this has been raised; he [RJ] has not shown him [PB] any emails w full notes sent to Dr Ryan.

13.10  RJ: It appears w respect to 28/5 and 3/6 you received an abbreviated version of the minutes?  SR: Yes, I did.  RJ: You mentioned yr frustration and impression of lack of progress being made and one example you gave was the action points from 20/5 CTM.  RJ: You said only one action point had been dealt with. I want to look at this as an example. (Pulls up 20/5 note).  RJ: We can see the 6 actions you referred to.  SR: Yes.  RJ: You said only one of these actions was completed.  SR: Yes.  RJ: By way of example I want to look at the third bullet, was this one uncompleted?  SR: We never heard about it.  RJ: Do you remember the emails being served just before the inquest?  PB interjects to point out emails were received day before the inquest.

13.15  RJ takes us to email that shows an email from Carol Clarke to Connections.  Email record shows email saying will be discussed after review [scheduled for April and postponed]… says wld be hard to get ££ for college.  Emails show discussion between staff and STATT unit staff .  RJ fully accept you’ve only v recently had emails, certainly after you wrote your statement, but in fact was one action point followed thru.  SR: Yes, I fully accept that.

13.20  RJ: You said you hadn’t phoned Dr Murphy.  SR: I never said I wanted to phone her.  It’s only after Connor’s death and we get all these records we realised the true state of Connor’s care and the lack of leadership.  I assumed that Dr Jayawant and Dr Murphy were two psychiatrists doing their job.
RJ: You didn’t raise concerns with Ben Morris, Unit Manager did you?  SR: No, I raised them with Mr Cowee.

13.22 Jury out for lunch, return at 2.15pm is under oath so can’t discuss her evidence.

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