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LB Balloons

For the lovely , Rich, family and friends,
who are demonstrating a warmth & capacity for joy
in circumstances beyond grim,

and for George Julian,
who has discovered depths of exhaustion she never imagined, 
but is still live-tweeting, on the @LBInquest timeline, the information you can read below.


14.12  Jury returns and Coroner apologises to them for the delay due to legal and procedural issues this morning.  Coroner will give jury directions of law and will sum up evidence that they have heard.

14.21  Coroner directs the jury that their findings must be based solely on evidence heard in court.

14.22  You have heard all the evidence in this case. The evidence includes the evidence of witnesses from the witness box…statements of witnesses that were read, and other documentary evidence.

14.23  Jury has to answer four questions: who was the deceased and where, when and how did Connor come to his death.  You are required to enter the immediate cause of death 1a with underlying condition under 1b.  In answering the questions you may use judgmental words such as ‘inadequate’, ‘improper’ or ‘insufficient’, and terms such as ‘defect’, ‘failure’, ‘serious failure’, ‘very serious failure’ or ‘gross failure’, but you must avoid using words…Sorry, failed tweet, can use above but not ‘negligently’, ‘carelessly’, ‘recklessly’ or ‘in breach of their duty of care’.

14.26  It is not in dispute, you may record as follows: “Connor Sparrowhawk died by drowning following an epileptic seizure while in the bath”.  You may add words ‘contributed to by neglect’ if you are satisfied, on the balance of probabilities, that there was a very serious failure

14.27  In addition you are asked to provide a short narrative setting out contributory factors to Connor’s death.  Jury will be asked to answer a series of questions:

Qu 1 Was there a failure in the systems in place?

Q2 Was there any error or omission in Connor’s care at any time after his admission to the STATT on 19 March 2013?

14.29  Considerations for Qu1 – whether staff received adequate training in assessment, care and risk management of epilepsy in patients like LB.  Whether staff were provided adequate guidance in assessment, care and risk management of epilepsy in patients w learning disability like LB.

14.31  Considerations Qu2: focus on proper observations, obtaining adequate history, risk assessment, communication with LB’s family…communication between staff at STATT and failures in record keeping.

14.32  Coroner will now sum up the evidence that has gone before the jury; warnings are made about hearsay and disputed evidence.

14.33 Who Connor was is not in dispute; was a pathology report [requested by the jury and provided].

14.34  Was a statement from Lenka Mullerova who couldn’t be located to come to the inquest and be cross-examined; Coroner re-reads her statement.

14.36  Coroner re-reads paramedic Daniel Chilvers’ statement to the jury.

14.38  Coroner now re-reads the statement of Phil Hormbrey, the Emergency Department Consultant.

14.39  Coroner re-reads some of Joanna Ciapala’s statement, she’s a psychologist who facilitated the ‘Let’s talk about feelings’ group on STATT.

14.46  Coroner reads through sections from statements of witnesses who gave evidence in person.

14.49  We’re having twitter problems, Coroner is recapping what we’ve already heard so we won’t tweet more of summing up.

14.57  Twitter failure earlier, this is instruction given to the jury about what sorts of words they can use in Section 4.


15.40  Coroner finishes recalling the evidence that has been shared; written directions will be given to the jury shortly, alongside jury bundle.

15.41  Coroner: It’s important you consider the documents alongside the oral evidence you’ve heard.  Also take into account these events were two years ago and memories can fade.

15.41  Jury warned not to look things up on the internet.

15.42  Coroner asks the jury to attempt to make a unanimous decision, if not they’ll return to court for more direction.  Jury asked to appoint a foreperson or chairperson, no additional responsibility but will be spokesperson in court.  Jury told to take as much time as they need; may return today but no need. Deliberate until 5 pm today and return tomorrow if needed.

15.45  Jury leave court; we’ll tweet any further legal discussions on and return here with a determination when available.