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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.


14.18  Jury returns and questioning of continues.  No further questions of from other Interested Persons so now Paul Bowen, her own counsel, questions her.

14.20  PB asks about her professional role; explains she works for and her initial research was linked to LB’s autism.

14.21  PB asks about her family; describes their family make up and introduces LB’s relationship to Richard, Rosie, Tom, Will and Owen.  PB to SR: You were a very close family, weren’t you?  : Yes.

14.22  PB: From an early age you knew something wasn’t quite right with Connor?  SR: Not ‘wasn’t right’, he was different.  PB: I remember Tom saying he wasn’t very good at football?  SR: No, no, he wasn’t very sporty.

14.24  SR describes how LB was diagnosed with Klinefelter’s syndrome, autism and later epilepsy; he had enough labels and didn’t want any more.  Connor loved buses and Eddie Stobart; had an encyclopaedic knowledge of buses and a collection of die cast models ‘.

14.25  SR: It was v apparent there wasn’t going to be a lot of support when LB became an adult and I was determined he’d work because he cld work.  SR describes some of her future plans for LB that would have involved a mobile shredding business.  PB: You knew he was unlikely to live independently?  SR: Yeh, he wanted a girlfriend, he wanted a job… we thought about this endlessly.

14.27  PB asks SR to explain Trax.  SR: ‘It’s where young ppl who are struggling, like young ex offenders, go to train to become a mechanic’.  Connor absolutely loved it there SR also describes LB’s time at the farm working with animals.  SR: Most ppl have to get up and go to school, it’s just what you have to do.  When he was in the unit they’d ask him, he’d say no and he’d stay watching DVDs.  LB loved the and one of his teachers had arranged a tour around their garages, it was arranged for the morning he died.

14.30  PB asks about LB’s epilepsy.  SR describes the first time when A&E consultant thought he’d had a seizure due to a tongue bite.  SR describes watching the film ‘Up’, LB would get very involved in films and got very distressed, in a trance, when the Grandad was in trouble.  SR took LB to neurologists who told her LB needed to learn to manage his anxiety.  Couple weeks later, he had tonic clonic seizure at school.

14.33  SR describes LB’s seizures in A&E and hospital; consultant was concerned he was clenching his mouth.  SR describes a lot of grimaces & tics.  SR describes pulling hair and other bodily movements all of which developed after LB was diagnosed with epilepsy.  SR: A&E consultant mentioned could be complex partial seizures.   Saw 1 full tonic clonic, 2 at school, 1 more in Jan 2013.  Quite few examples of absence seizures, suddenly look away, be rigid.  In an absence seizure he’d look right through you, prob last 10 to 20 seconds, it was quite quick.

14.36  PB asks about repetitious behaviour.  SR describes occasions when LB was getting in and out of the bath, you’d ask him what he was doing but he wouldn’t reply.

14.37  PB: there’s some confusion about a Dec fit?  SR: That’s my fault, I thought it was Dec but it was Jan; I did correct it with Dr Rana.

14.39  PB shows the jury the Jan 2013 ambulance record.  Reference to incontinence, what do you know of that incident?  SR: Tom said something up with LB; he’d fallen out of bed, was lying on his side, wasn’t conscious but came round by time ambulance arrived.

14.40  PB asks SR about the new teaching assistant who arrived at school who LB thought had previously bullied him.  SR: Was a series of events of LB acting aggressively and ended with LB punching his teaching assistant in the face.  PB: The teaching assistant was known as Big Sue?  SR: Yes she’s not small and he gave her quite a slug, it was a serious incident.

14.42  SR: GP prescribed him fluoxetine after Christmas and referred him to psychiatry at start of Jan, got seen at end of Jan.  PB shows court letter from community psychiatrist to LB’s GP with suggestion fluoxetine is increased.  Letter 28/2 to GP discharging LB from her care.

14.45  PB: Was LB back to his usual self?  SR:  No, for a short while, but it was still quite tense. PB: Do you recall saying he was reasonably well?  SR: No I recalled an event when he was quite threatening with a spanner the week before.   I told Dr Rana about that incident, it was awful.

14.47  PB asks SR about reference to Dr Crapshite on her blog.  SR: I’d emailed to ask what we should do in a crisis; called on 15/3 in crisis.  Person at end crisis line said had to call for out of hours GP, eventually another psychiatrist said cldn’t prescribe bcos Dr R’s patient.  When I wrote about this we were in crisis, we couldn’t manage his behaviour, he hit someone and hurt them; he’d be into criminal justice.  SR: So yeh I described her as Dr Crapshite.  PB: There’s no time you named her as Dr Rana?  SR: No, not at all, it was anonymous.

14.50  SR describing the days before admission into STATT; a friend of hers told her about it, not Dr Rana.  SR understood it to be a team of learning disability experts who’d observe him, assess him and come up with a treatment plan for him.  PB: Dr Johnson spent two hours in SR’s kitchen collecting information, spoke to LB for ten mins first.  Gathered quite good history?  SR: Yes.  Dr J said we shd take LB about 8pm so he cld be clerked in, we’d not been to the unit before even tho’ we’d been on the Slade site.  SR: We knocked on the door, JH opened door and said weren’t expecting him; by this point LB recognised he wasn’t going to hospital like JR.   We had to pick Tom up from his grandparents, we left Connor there, as you’ve seen he was restrained and then everything since happened.

14.53  SR describes how kind Jess Constable was, she gave her two phone numbers and she was very accessible.  SR: I don’t know if any of you have taken your children into provision like that but it’s absolutely frightening.

14.55  PB: It’s been put to you that you were difficult to get on with. In the early days you got on with Mr Dullaghan.  SR: I thought so, he worked hard to engage with Connor and got him a map of Ireland.  PB: Then he went on leave and couldn’t develop that?  SR: There were two student nurses, Kim and Cheryl, they were excellent… and Oli Cousins was great with Connor.  There were good staff there.  PB: Your overall view of the unit, that changed?  SR: I got frustrated, I think the ppl who were hands on w LB were doing what they should.  However there just didn’t seem to be any proper assessment… I was very worried they hadn’t treated Connor…. he was very anxious.

14.58  PB: How often did you meet Dr Murphy [psychiatrist] SR: I only met VM at the CTMs, there was no relationship of any sort.  I’m surprised by the vitriol she’s [VM] described this wk.  PB: Did you discuss medication?  SR: LB was very sensitive to new medication.

14.59  PB: When you put Connor in the STATT unit on the 19 March did you have any reason to think it wasn’t safe for him?  SR: We knew it wasn’t an ideal place, he wasn’t treated as part of a family… but we never thought it was unsafe.  PB: Did anyone from STATT ever ask you in detail about LB’s experience of seizures?  SR: No.  PB: Or steps to keep him safe bathing?  SR: No.

15.01  PB mentions tongue bite incident, asks SR if she made note about it. SR: Yes I wrote a blog about it, jury taken to .
SR blog 21/5: ‘The thought of him having a seizure, in a locked unit, unnoticed, has generated a new level of distress I can’t describe’.
PB: Describe to the jury the tongue bite?  SR: It was bitten and swollen and it’s recorded in the notes he did complain about it for days.  SR describes how LB was asleep when she turned up, ‘he wasn’t himself’, he went to get a drink and didn’t come back, set alarm bells ringing.  PB asks SR about significance of LB being lethargic SR: ‘Linked to seizures, it was almost a restorative process, sleep through it’.  LB went to his Dad’s every week but he [Dad] didn’t get involved with intricacies of his care or all meetings that come with a disabled child.

15.07  PB asks SR about 3/6 observation change.  SR: I’ve heard so much about observations this week, my brain is a mush.   I had no idea there was any discussion about whether he had had a seizure or not… I thought they were looking after him w monitor etc.  PB takes SR to note of 3/6 CTM sent to her: 7 bullet points.  PB: Anything that rings alarm bells there?  SR: No.  PB takes SR to full note of 3/6 CTM details reduction obs as result decision 20/5 was not seizure.  SR: I had no idea they were doubting it.  PB takes jury to email from SR to Verita 8/2/14; clearly indicates it was first time she was aware that two sets of notes were in existence.  SR: I had no idea 20/5 was in dispute, I assumed ‘no evidence of seizure activity’ meant since.

15.13  PB: Did you know LB wld be left in bath for 15 min intervals w the door closed?  SR: No, we didn’t know until this week the door was closed.  PB: What wld you have done?  SR: We would have objected to it and told them they couldn’t leave him.  Dignity this week has become a bit of a cover.

15.15  PB: Just to clear up one thing, there’s been some suggestion in Mr Jenkins’ questioning that family didn’t want LB home.  SR: We wanted him home.

15.16  Questions for finished and Rich Huggins, LB’s step-father takes the stand.  RH confirms that the statement is his and is true. ‘I’d lived with Connor for almost all of his life’.

15.18  RH: I felt the unit was inadequate from a very early stage. I felt the unit building and environment itself were bleak.  I remember a number of times when at end of our visit LB wld have to go search for a staff member to let us out as the door was locked.  RH: I expressed my concerns to on a number of occasions and felt we shd raise them with the unit manager.   was reluctant to do this as she was concerned that this might have a detrimental impact on LB’s experience in the unit.   I felt many staff were obstructive in respect of us visiting Connor.

15.21  No questions for Rich from any counsel; so Paul Bowen takes Rich through his statement and asks him to convey the impact of his experience.   PB: You said you felt set her expectations too low.  Cld you expand on staff you found unhelpful?  RH: On admission, when we managed to get an answer to front door, attitude of those who greeted us was ‘what are you doing here?’  It was difficult for me to understand why they’d think we’d want to be in that position; later Jess Constable was very kind.

15.25  RH: I remember occasion I took LB’s grandmother with me, she’d brought some bus magazines, for that entire 45min period no one engaged w us.  I felt like we were an inconvenience and they’d rather we hadn’t been there.  On front door of STATT was a set of printed visiting times, which were led to believe were open visiting times.  We rang to check OK to visit.  We were told we had to do this partly to seek permission from nursing staff and partly to seek permission from LB.  Staff mediated that discussion; again I wasn’t unduly concerned. On one occasion I rang in advance, rang bell for half hour; we could hear nursing staff, could hear the bell ringing, eventually we had to stick our heads in at a window to get let in.

15.29  RH: Night before LB died, RH spoke LB was keen to tell me about Trax, passed phone back to nurse – she said LB doesn’t want to talk any more.  I explained I’d asked him to pass it back so I cld explain I was coming over.  Nurse said he didn’t want me [Rich] to visit, but I heard him say ‘Yes’ and I went around anyway, and a good job I did too, because I was the last person from the family to see him alive, for 30 mins.

15.31  RH: At no point did we think our son would die in a national health service specialist unit .  PB: Did you assume professionals would do their jobs properly?  RH: Yes, I’m a great fan of the , they were specialists.

15.33  RH: Where folks were kind to Connor we appreciate that and we appreciate some of the openness that has been shown this week.

15.34  Rich Huggins is dismissed.  Discussion about rest of the afternoon and how it will be spent.

15.34  Break here until 4pm when we may hear more evidence or jury may be dismissed for the day.


16.07  Jury have been dismissed for the day, legal submissions now and the jury will return at 10am tomorrow.