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LB Balloons

For Connor’s family,
heads held high, keeping their dignity
in the face of attempts to shitestorm it away from them.

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


13.59  Jury returns and of returns to the stand .

14.00  Questions for from Fiona Paterson, counsel for .  Confirmation from she has been a consultant from 1999 and a psychiatrist since 1990.

14.01  FP asks LS about the review of all patients with a learning disability and epilepsy by a specialist epilepsy nurse following LB’s death.  Puts to LS that the review took place in Oct 2013 after the inspection?  LS: I hadn’t remembered that but I agree.
FP discusses staff difficulty with Rio FP: My understanding is there’s a free text box called summary is that correct?  LS: It is.
FP: We’ve heard JC Band 6 had to supervise 5 nurses at Band 5 underneath him?  LS: I’d say 5 is an acceptable number of people to supervise.
FP presents Verita findings that weren’t presented to LS to her and she agrees them.  LS confirms that there were difficulties between the community team and the STATT team.

14.09  The Royal College of Psychiatrists approves two ways of working w ppl w LD and epilepsy; LS attempts to explain ways of working.  LS: Ppl w epilepsy shd see a neurologist; there’s complexity around treatment of ppl w LD who have epilepsy, epilepsy is common in that group.  LS explains that STATT patients should have received specialist neurology support from John Radcliffe.

14.11  Jury question for LS: What supervision of the clinical team was undertaken?  LS: There’s management supervision about wellbeing and clinical supervision about clinical areas.
Jury question: In 18mths running up to taking over what work was done?  LS: There was a great deal of due diligence done by ahead of takeover; quality director spent a lot of time in STATT.  It included some estate issues in matron walk around and we did a mock inspection.  Deloittes and Contact Consulting and did reports during takeover period.
Jury: did any of those set any alarm bells ringing?  LS: Not around STATT.
Jury question: When did you close the unit?  LS: When the inspection happened essentially; it was finally closed in Dec 2013.
Jury: Was it under threat of closure? LS: We run a community based model in Hampshire… [long answer]… Were many more beds in Ridgeway services than we needed in Hampshire so always intention that wld be significant reduction in beds.
Jury question: Was there any automatic referral to epilepsy specialist nurse?  LS: No, I don’t think so, think it was informal, thru phonecall.
Jury question: how was Dr Adcock supposed to get involved with care plans and the unit?  LS: She saw LB in outpatient clinic appointments.  During LB’s admission she was available as a resource, I don’t think Dr Adcock wld have helped w care planning.  The epilepsy specialist nurse wld be the person.

14.18  LS is dismissed.

14.19  Up now: Professor Crawford, the Court appointed expert in epilepsy.  Prof Crawford confirms she’s a newly retired consultant neurologist.  Prof Crawford was a consultant neurologist since 1990 with special interest in seizure disorders and epilepsy.  [She] was a medical doctor, then did epilepsy research, then ran an epilepsy clinic for ppl w learning disabilities.

14.22  Coroner takes Prof Crawford to the three reports that she has compiled for the court.  Prof Crawford has had medical records at the point she wrote her report and has been handed further documents during this .  Prof Crawford has been present throughout .  Coroner will take Prof Crawford through her report.

14.25  Prof C: both the drugs LB was on could lower the seizure threshold; we’re wary of prescribing these drugs, poss adjust anti-epileptic meds.  Yes, there’s good evidence LB had a tonic clonic seizure in Jan 2013 when he was found by his brother, regardless of incontinence.  I felt a detailed description of each seizure type should have been collected from : history and precipitance.  A clear discussion should have taken place with about bathing too.  Obviously at the time of admission LB was an acute situation but within a week there shd have been a full risk assessment.

14.29  Prof C: I think the episode on 20/5 was a seizure; what I’ve heard reinforces what I thought.  2 big pieces of evidence: one is tongue bite, v characteristic and extremely suspicious; and ‘s email: [LB was] confused and drowsy.  Tongue biting plus confusion plus drowsiness means it’s highly likely this could be a seizure.  Sauce incident and repetitive actions and not responding: difficult to say whether seizures, usually over quite quickly.  I can’t tell if they were complex partial seizures but I was suspicious, that’s all I can say.

14.32  Prof C: With regards to risk assessments and bathing: they shd have been in place at the beginning, he shd have had someone outside listening.  He’d had a seizure 12 weeks before when he was admitted; bathing arrangements shd have been placed at that point.  20 May wasn’t recognised as seizure but bathing arrangements should have been in place anyway.  I’d have discussed whether his phenytoin medication should have been increased; Jan not a spontaneous seizure, it’s linked to dose.  If May was recognised as seizure I’d have discussed w putting up his dosage of phenytoin. Down side of increasing dose is side effects, phenytoin is a difficult drug to use, it accumulates, it’s not good .

14.36  Prof C: Simple answer: No, care and treatment LB received did not comply w national guidance about ppl with learning disability and epilepsy.  [] didn’t take a further history and didn’t do a proper risk assessment.  I wasn’t aware epilepsy toolkit hadn’t been rolled out at the time, I can not believe they followed local guidelines.   I don’t know what their local guidelines were because I was only sent 2012 toolkit that wasn’t available on STATT.

14.39  Prof C: 2 categories of failings in LB’s care relation to epilepsy: risk assessment particularly in relation to bathing; and a good history.    Epilepsy risk management, it has been filled in as a seizure risk management, what to do if to have a seizure.  The plan has been written for seizures, wld be included in epilepsy risk mgmt plan but seizures only part of it.  I think there was muddling between seizure risk management and epilepsy risk management.

14.41  Prof C: Obviously because LB was being treated with drugs that lower seizure threshold staff needed to be increasingly aware.  They don’t have a good description of what to look for for complex partial seizures because no-one took a good history.  0.5 mg is a low dose but we don’t know because everyone is different and it’s a well recognised risk to lower seizure thresholds.  When I read thru the notes, my feeling was staff filling in the forms knew very little about epilepsy and I think that’s come out.  Staff only had one hour e-learning training… a quarter of ppl with learning disability have epilepsy… they needed more knowledge.  York run a certificate and a diploma about epilepsy as e-learning, material is available, they should have known more.

14.47  Now asks Prof C questions.

14.48  PB: We’ve had the benefit of reading your report, have your conclusions been reinforced?  Prof C: Yes I’m afraid.
PB: Are things worse than when you looked at it on paper?  Prof C: Unfortunately yes, both nurses: only had two hours’ epilepsy training.  One in four people with a learning disability have epilepsy, it’s a bad failing, a serious failing.  PB: would you go as far as to say it’s a very serious failing staff had not been provided with training?  Prof C: Yes.

14.50  PB: LB’s admission was a crisis, reasonable couldn’t take a full history that night or talk to LB’s close family?  Prof C: Yes.  PB: If it couldn’t happen immediately, shd it have happened in the first 107 days?  Prof C: Yes.  As a doctor, wld clerk patients in within an hour or two.  This should have been documented properly when it was safe to do it.

14.52  PB: Shd a Consultant Psychiatrist know a patient w LD needs a full history of their epilepsy?  Prof C: Yes, they shd know it needs to be done.  PB: If Consultant Psychiatrist fails to do that is it their failing?  Prof C: Yes, they took Dr Johnson’s history but it only addresses some [aspects].  PB: Shd Dr Murphy have ensured a full history was taken?  Prof C: Yes, that was a serious failing.

14.55  PB: Shd Specialist Registrar, Dr Jayawant, know a pt w LD needs a full history of their epilepsy?  Prof C: Yes, she shd, a serious failing.

14.55  PB: Shd a Band 5 nurse have known a full history shd have been taken?  Prof C: They shd have known, but it’s a doctor’s responsibility.  PB: What about Band 6 or 7 [nurse]?  Prof C: They are not specifically epilepsy trained but shd have asked.

14.56  PB: So in your view the history failings are failings of the doctors?  Prof C: Yes, the history failings, yes.  PB asks Prof C if could conduct risk assessment without history?  Prof C: No, we rely on what happens before, during and after seizures.

14.57  PB: Bathing arrangements were basic nursing tho?  Prof C: Yes I agree, someone outside the door, door ajar.  Prof C: risk assessments in relation to daily risks I wld never normally do, a doctor is trained in diagnosis and management.  PB: Taking a history, producing risk assessment based on history and then decision on bathing as result of two?  Prof C: Yes, but the decision around bathing should have happened regardless of history, with recent seizures.

15.00  PB: Shd a Consultant Psychiatrist have ensured LB was watched in the bath?  Prof C: I’ve thought a lot about this and much like I’d have assumed this was happening, it’s basic nursing.  It was a very serious failing on part of Band 5 nurse not to ensure LB was watched while bathing.  Band 6 nurses shd have known, they looked at risk assessment, which was adequate for seizures not epilepsy. It was a very serious failing [that] Band 6 nurses did not ensure the Band 5 nurses they were supervising ensured LB was watched in bath.

15.03  PB: Events of 20/5 are neither here nor there?  Prof C: I’m afraid so, LB never shd have been left; shd have reinforced but shdn’t been left.  PB: In your opinion it was a seizure?  Shd the staff have treated it as tho it was a seizure?  Prof C: They were in a way, while conversely they’d written it wasn’t a seizure… we had ‘s email and the tongue bite.  They thought it wasn’t a seizure but they were half treating it as though it was, so they shd have reviewed bathing.  They should have reviewed the risk assessment if there was any hint of a seizure.

15.06  PB: Is the failing in any way exacerbated by the events of 20/5 and 3/6?  Prof C: It is, because there’s more evidence the epilepsy is active.  Bathing is different but if I’m observing someone for seizures and looking to see if surgery might help, we’d observe every hour.  Obs would be done according to their presentation, this is a nursing decision, I would rarely state as a doctor.

15.08  PB wants to talk to Prof C about risk of drowning in patients with epilepsy.  Prof C: the reason seizure in water is important because ppl drown and it’s preventable… you’re unconscious when having a seizure so… PB: The risk of drowning for ppl w epilepsy is higher than those without epilepsy? Prof C: Yes.  Prof C: Considerably higher risk of drowning for ppl with epilepsy; risk is much higher and should be foreseen in anyone with epilepsy.

15.11  PB: What about someone who’s had a seizure in last 12 wks?  Prof C: Very important because it’s active epilepsy, this is a recent seizure.  You can’t drive for a year after a first seizure, not allowed by the DVLA.  Band 5 nurse and more snr staff shd have known there was risk. PB: By time LB had been there 107 days everyone shd have known the risk?  Prof C: Yes, they should, particularly given 3 hr baths.

15.13  No more questions from for Prof Crawford; court breaks for 15 mins.


15.35  Alan Jenkins for Dr Murphy now asks Professor Crawford questions.

15.35  AJ: We know LB was receiving phenytoin?  Prof C: Yes, started in A&E and under the care of Dr Adcock.  AJ: We know Dr Rana increased the dosage and copied a letter to Dr Adcock?  Prof C: Yes, that’s right.  AJ: You told us Jan was probably a seizure?  Prof C: Yes it was a tonic-clonic seizure, likely linked to starting anti-depressant.  AJ: At time of his admission to STATT his behaviour was challenging and was discussion re starting risperidone?  Prof C: Yes, that’s right.  AJ: It’s apparent they knew the risk risperidone had of lowering seizure threshold?  Prof C: Yes, that’s right.  AJ: It was clearly known at start; is it right risperidone is only licensed medication for use in this situation?  Prof C: I wouldn’t know.  My colleagues would use it; with regards to dosage I think we often do start very low.  AJ: Is it apparent from documents within CTMs was a discussion re phenytoin levels, fluoxetine and risperidone?  Prof C: Yes.  Absolutely clear and thresholds for seizures is something I would expect any psychiatrists to know.  AJ: So you’ve no criticism of the prescribing?  Prof C: No criticism, we know the side effects and the risks.

15.43  AJ: You’re a neurologist not a psychiatrist, you don’t work on a unit like this.  Prof C: No, but I do a joint clinic with LD colleagues 6-wkly.  Half to 2/3 of my work is epilepsy and within the epilepsy work a large proportion have learning disabilities.  AJ: Do you feel appropriately placed to judge qualifications of psychiatrists?  Prof C: In what way?  AJ: In regards to their training.  Prof C: It was apparent Dr Murphy and Dr Jayawant knew a fair bit about epilepsy.

15.46  19/3 Dr Johnson history.  Prof C: It says epilepsy ‘usually well controlled’ which doesn’t mean ‘well controlled’.  I would call no seizure in 18 mths relatively well controlled, it’s not completely controlled and he had one seizure 12 wks before.

15.47  AJ: You’ve told us there shd have been nursing arrangements made in relation to bathing?  Prof C: Yes.  If 20 May had been recognised as a seizure it should have been reviewed but arrangements should have been already in place.

15.50  20/5 Rio note: Are we reading a report of the seizure?  Prof C: You can’t tell… I don’t think anyone knows when the tongue biting happened.   It’s not possible to ascertain when on that day the seizure took place.   It was most likely to be a seizure because of the combination of things but I can’t tell when it took place.  AJ: Lethargy fits in, in what sense?  Prof C: People feel tired after they’ve been worked up, I agree w that, but this looks like a seizure.
AJ: But the mother hadn’t seen many seizures, had she?
[Groans in court]
Prof C: You don’t need to see many seizures.
AJ: But staff were on full alert after this?  Prof C: Yes, I think so.  AJ: Is it also clear 2 days later an OT was trying to put together an epilepsy management plan?  AJ: For that to happen a full history would need to be taken? There’s repetition of the email from the mother, but you’d want a history?  Prof C: Yes.

15.56  OW asks Prof C questions.

15.57  OW: You said that bathing observation was not something as a doctor you’d really do?  Prof C: Not usually, that is nursing activity.

15.58  OW: If someone does something consciously that’s not consistent with a seizure?  Prof C: Some types you can be conscious.

15.58  Roddy James asks Prof C questions now. RJ: You’ve been clear what should have happened on day of admission: Band 5 supervised by Band 6 supervised by Band 7?  Prof C: I wld not expect Band 7 to be supervising risk assessments unless asked by B6.

16.02  RJ: You mentioned DVLA require you be seizure free for a year to drive.  Is that a gd example: after 12 mths risk assessment allows take risk?  Prof C: references New South Wales document that has strict bathing arrangements whch need to be in place for 2 yrs after seizure.  RJ: in this country 12 mths for driving, a sliding scale for risk?  Prof C: Yes, longer someone goes seizure free the more likely they’re [to remain] free.

16.04  RJ: Jan incident the only seizure for a long period of time?  Prof C: The only recognised seizure…. the only tonic clonic seizure.  I think Connor had a seizure on the 20 May as well, yes.

16.05  RJ: Decision was taken on 3/6 that it was not seizure.  Prof C: That’s right.  RJ: So someone after 3/6 wld believe not had seizure since Jan?  Prof C: That would be what they believed, yes.  RJ: That wld have been a wrong perception but it was perception at the time?

16.06  RJ: You said it’s usually suggested to ppl w epilepsy to have showers rather than baths?  Prof C: Yes, that’s right,  RJ: It was recorded that LB preferred baths?  Prof C: Yes, it was.  RJ: If ppl w epilepsy prefer baths the door is unlocked, a small amount of water is used and someone is in the house?   Prof C: Yes, that is the recommendation; but when we have someone in institutional care, we have a higher bar to use.  RJ: The risk of LB having a seizure was low?  Prof C: Low, but not absent.  A tonic clonic seizure is noisy, you hear movements but we’ve not gone in to seizure types.  RJ: So being [with]in few metres for example?  Prof C: Yes.

16.10  Adam Samuel for Jonny Cowee now asks Prof Crawford questions.

16.11  AJ: Anyone cld take Dr Johnson’s note as a starting point?  Prof C: It cld be taken as a starting point but it did need to be considered.  AS: Band 5 nurses had assessed 10 min obs, are you aware of that?  Prof C: I’m aware of that.  I feel from the beginning they need sight and sound observations… from the beginning, not every 10 or 15 mins.  I haven’t seen what [training] was used in the Trust at the time, its only since I’ve been here I’m aware it wasn’t implemented.  While these are not LD nurses with a specialist interest in epilepsy, I wld expect more knowledge when 1/5 ppl w LD have epilepsy.  It was clear that they were working at a lower level than was anticipated in their field… and lack of training was very relevant.
AS: A mental health nurse with no specialist training in epilepsy or LD wldn’t necessarily know risk you’re aware of?  Prof C: No, but they’re working in a learning disability unit.  They should have had training. There was a suggestion that training was not available locally but in-depth e-learning is available.

16.18  AS: 3/6 meeting a doctor looks at whether there has been a seizure, is that usual?  Prof C: Yes.  AS: reduction of obs due to absence of seizure, which we now accept to be wrong?  You said doctors do diagnosis and treatment?  Prof C: Yes that’s right.  AS: So a nurse wldn’t be expected to query doctors diagnosis and treatment?  Prof C: No.  I’ve heard observations were psychiatric checks and this was a mistake with regards to epilepsy.  AS: There are references in the care plan in relation to reduction of obs being specifically related to epilepsy risk.  Prof C: There is and there was evidence that this was a mistake.  AS: If it’s not correct these were interpreted as being purely related to psychiatric matters, nurses cld think was related to epilepsy?  Prof C: epilepsy observations were at same time and said patient was not having a seizure.

16.23  Michael Walsh for Kieran Dullaghan asks Prof C questions.

16.23  MW: Your evidence was every Band 5 or 6 nurse ought to have known about supervising bathing and done something about it?  Prof C: Yes.  And if they’d spoken to the family , they’d have known that this was their practice.  MW: Wld you have expected supervising nurses to have known this was practice and expect Band 6 to correct it?  Prof C: Yes.  MW: There is not one document that deals with clinical supervision of Band 5 nurses?  Prof C: Not one.

16.26  MW: Do you consider the 20/5 seizure activity or 3/6 meetings are akin to watershed moments?  Prof C: The answer is yes.  The issue of bathing had nothing written about it at that point.  MW: Everyone in the CTM had chance to discuss it?  Prof C: Yes and they obviously considered night-time seizures.

16.27  MW: Rather than everything being down to Band 5 nurses at start & everyone follows suit, were there a no. of opportunities to catch mistakes?  Prof C: Yes there were.  MW: So there were opportunities for any Band 5 or 6 nurse supervising bathing to know was a problem?  Prof C: Yes.  I couldn’t tell from reading reviews but I’ve heard a lot about how CTMs work since being here.  MW: Does that colour yr opinion about how the decision making process panned out  Prof C: It does in a way, there was no clear leadership.  I work in a big multidisciplinary team, we have our own areas… people take the leads in their areas but clearly people weren’t taking responsibility for their areas.  Normally you can work collegially and respect professional expertise between people.  It [MDT working] can produce difficulties, it can work well, it depends on the team.
MW: Was it working well here?  Prof C: No.

16.33  MW: Wld you expect nurses to act contrary to decisions made on the 3/6 CTM?  Prof C: I wouldn’t expect ppl to be acting contrary, no.

16.33  Michael Fortune for Winnie Betsva now asks Prof C questions.

16.34  MF: When WB asked to change observations was that the moment for a full review of observations?  Prof C: Yes I think it was.  MF: We heard was the opportunity for care plans and risk assessments be reviewed; so decisions were for meeting as a whole?  Prof C: Yes.  3/6 meeting would have been an opportunity to review, yes.

16.36  OW requests a further question.  Prof C: We don’t look at risk management, if doctors were aware what bathing was set at, was time to review.

16.37  Fiona Paterson for now asks Prof Crawford questions.

16.37  FP: You said you agreed managing someone in the bath with epilepsy was basic nursing care?  Prof C: Yes.  FP: Ensuring someone was outside the door when he was bathing was basic nursing care?  Prof C: Absolutely.  FP: Sadly people with learning disabilities can have a number of physical problems, not as common as epilepsy.  Prof C: Yes, that’s right.  FP: You’d expect a member of staff to seek help if they were unfamiliar?  Prof C: Yes and information is readily available.  FP: Anyone looking after someone with epilepsy shd be able to find out?  Prof C: Yes, epilepsy societies have very good leaflets re risks.

16.39  No jury questions for Professor Crawford, she is dismissed.

16.40  Coroner explains that was last witness, when jury return tomorrow he will sum up and give them detailed directions about their task.  Jury dismissed, asked to return tomorrow for 10am. We’ll be back then.