Thread by @GeorgeJulian

I attended Laura Booth's 8th pre-inquest review meeting on Monday. PIR was remote, Coroner was in court at Sheffield Town Hall, everyone else online.

Laura died in October 2016, aged 21. Her parents, Ken and Patricia talked to @JayneMcCubbinTV here

https://twitter.com/BBCBreakfast/status/964070878555398145

1/25+

'We went in the hospital with our daughter for an eye operation, and we came out with a death certificate' Patricia told @JayneMcCubbinTV

An inquest was opened, 16mths after Laura died, after the BBC contacted the Coroner's Office to share their concerns.

2/

Laura liked jigsaws, colouring and doing craft activity, the only time she'd willingly wear her glasses. Laura liked watching TV, CBeebies, Mr Tumble and loved handbags and purses, bowling and being read to.

Laura's parents provided her with support 24/7, even in hospital.

3/

Laura's parents have many concerns and questions about the care Laura received on her final admission to hospital, and the transition from the children to adult hospital system. It's now 4.5 years since she died.

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Laura's parents are represented by David Evison of @ACSLLP and Mark Lomas of @3PBChambers, @SheffieldHosp and @SheffChildrens are represented by Diane Hallatt of @DACBeachcroft and Paul Spencer of @serjeantsinn. Assistant Coroner Abigail Combes conducted the 8th PIR on Monday

5/

This PIR was a relatively short one to address what the Coroner described as:

'matters that need tying up before the inquest... finalise scope bearing in mind this is an Article 2 inquest at this point in time, and finalise the witness list, albeit not running order'

6/

Coroner had distributed her thoughts in advance of PIR. She'd not seen family's written legal submissions sent week before.

Mr Lomas: 'We agree with the temporal scope of the inquest, admission from 25 September and invite you to consider a number of issues in timeframe'

7/

Mr Lomas highlighted three main areas of concern for the family:

* consequences on admission of pre-operative assessment on 14 September and low potassium levels detected then

* affects of her transition from child to adult services upon the care during admission

8/

* care during admission in the context of Laura's complex medical condition and her lack of capacity

The family agreed with Coroner's focus on decision making in context of mental capacity for the reasons she set out...

9/

'but also we say the likelihood is if Best Interests process was followed, the matter may not have gone to the Court of Protection... but the process would have had other benefits in any event' - Mr Lomas

Coroner invited Mr Spencer to respond...

10/

'In respect of admission and pre-admission assessment the Trust accept it was a missed opportunity but do invite you to consider how far you're going to be assisted by consideration around issues of potassium because one can only speculate about potassium issues' Mr Spencer

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'Against that background, the Trust have admitted a missed opportunity, we question whether it is necessary to consider'

Mr Spencer the continued to lay out why the Trust felt the three issues raised by the family were not relevant

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'Transition... this was Laura's 3rd admission to the adult service, she had transitioned over a 3 year period, the matter is also dealt with in the IRR* and madam we do seek to raise...

[*not sure, independent review commissioned by NHS England I'm guessing]

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'...and seek your reflection on whether that's an issue that needs to be explored given the 3yr transition period and Laura had been in adult services on three occasions, we say it is not necessary for you to explore that issue'

Mr Spencer continued....

14/

'In relation to Best Interests we saw your thoughts on that, understand why they're of interest to the court, again Madam we query whether consideration of the BI decision would assist you in matters you're considering'

Mr Spencer provided further explanations....

15/

Before concluding:

'Madam, we recognise that's a matter you reflected on but we seek to put that in front of you, we're struggling at the moment, with the greatest respect, to understand how that would assist the court to consider these issues in the round'

16/

The Coroner gave Mr Lomas the opportunity to reply, he simply highlighted that there was obvious disagreement between parties and offered to elaborate if the Coroner felt it would assist her.

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Coroner responded including: I've been through the paperwork on a number of occasions now. I'm mindful this is an Article 2 inquest at this stage, I fully anticipate there may be submissions on Article 2 as we go through proceedings and funnel the evidence

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Coroner explained she'd reviewed the paperwork on several occasions including when instructing Mr Patel, the court expert. She continued:

'I will consider admission and pre-operative assessment'

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'I acknowledge the point the Trust make, that they've already acknowledged some issues with that pre-operative assessment but at this stage, on the basis of what I've got, it is something that warrants exploration in the inquest'

The Coroner continued...

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'I do agree with the Trust that the issue of transition for Laura is not something I would view as being in scope with this inquest, the transition period had taken place and Laura was in receipt of adult services'

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She expanded 'That's not to belittle the process Mr an Mrs Booth had been through with Laura and the difficulties that presented, or belittle the hospital's attempts for someone with Laura's complexity'

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Coroner concluded: 'I am content decision making will be in scope, Laura's lack of capacity means Best Interest decisions are within scope for this inquest. I will include the decision making process, including BI for Laura's treatment within those date constraints'

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Mr Lomas sought clarification in relation to transition 'Laura's parents have raised on a number of occasions their concerns over transition which include the availability, for instance, of records from Laura's hospital admissions, suitability of equipment on adult wards...'

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'the knowledge base going forward from clinicians who treated Laura in @SheffChildrens. I understand your decision on scope in that the transition process was completed, but will you consider in scope the effect of those issues? It's not just process, it's the consequences'

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The Coroner explained further: 'inevitably to some extent the treatment she received on the adult ward will be in scope, however, I don't believe for the purposes of the inquest before me, the decisions made in the children's hospital and handover to adult hospital are'

26/

'The transition process itself is not in scope. Questions and issues to be raised about availability of equipment in adult hospital I'd expect in scope for anyone who had this particular need e.g. a particularly petite adult who has never had any children's treatment'

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Scope agreed, Coroner moved to discussion of expert witness: 'Dr Patel has been instructed in the case, has received letter of instruction and paperwork to commence that'

Coroner will distribute final letter of instruction to all parties by start next week.

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Next up discussion about whether a second expert, an intensivist, was required:

'Having reviewed evidence once again, and taken my view on scope, I don't think I would be assisted by an intensivist expert in this case and won't be instructing them'.

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'I am content for treating clinicians to be asked about treatment options considered and available to Laura throughout her admission' Coroner

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Mr Lomas interjected: 'Madam, forgive my interrupting, your email did invite submission on expert evidence and the written submissions from the family submitted last week did deal with that, we did request you re-consider'

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Mr Lomas summarised his written submission:

'Eye lash surgery would have been a day admission, but Laura progressed to more serious ill health over 22 days until her death. Although nutrition is central to her care and subject to the expert you are instructing....'

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'That shouldn't be seen in exception to her declining health during her admission'

Family's view is Laura's immune position, hospital or community acquired infections, sepsis, abnormal potassium and albumin, other bio markers and reported fluid overload were all relevant

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Mr Lomas referenced Prof Green's report that includes the phrase 'endeavoured to put together a coherent case' and argued that reflected the complexity of Laura's presentation and illness

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'It is the submission of the parents in light of those background factors that the court would be assisted by an expert to match the nutritional status, and provide a full picture to the court, particularly of the inter relationship between those issues'

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Coroner: 'in order to do your submissions justice and ensure Mr and Mrs Booth understand I've given full consideration to the submissions made I'll ask my Coroner's Officer to send those today and I will circulate a decision by the end of the day on the intensivist'

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Mr Spencer had not made written submissions but responded that himself and Ms Hallatt would prepare 'a short submission and ensure you have them by the end of the day'

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I have heard that since the PIR concluded the Coroner decided she was satisfied that the witnesses listed to give evidence could address the issue of the complexity of Laura's presentation and she has decided not to instruct a further expert

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The discussion then moved on to witnesses. The Coroner was content for the evidence of Ms Curry and Matron Clohessy to be read onto the record, unless those representing the family had questions they wish to put to them.

Mr Lomas confirmed they did. They will be called.

39/

Discussion then had about further witnesses, Susan Moorhouse who has since retired. Trust suggested her statement was compiled from case notes and could be read under Rule 23

'I'm not sure how much further her submission could be taken'

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Mr Lomas invited to respond by the Coroner

'Madam, I don't wish to sound difficult over this, we've reviewed this statement and 3 others and tried to be proportionate. We've not asked for the others to attend'

She will be called

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Then discussion moved to Professor Sam Ahmedzai
@Samhja, the Coroner said:

'The only other witness who provided a statement was Prof Ahmedzai who provided a statement of what he saw when he visited Laura, and went beyond that'

42/

'I'm content for Prof A to give evidence of what he saw when he visited Laura, I will give a clear warning... he is not an expert for the purposes of this inquest, he's not to give me clinical evidence or pass any comment on Trust policy or procedures or internal workings'

43/

Coroner continued: 'I am not sitting with a jury on this occasion, I can instruct myself to disregard anything not relevant to the inquest. I will direct myself to do that'.

Coroner will indicate what aspects of Prof A's statement she were disregarding so parties are clear

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Parties will have opportunity to make submissions in due course: 'if you think i've missed something that is prejudicial or might be considered in relation to this evidence'

Prof A approached court directly, Coroner is not expecting Mr Lomas to give instructions to him.

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Discussion then about timing; Laura's inquest will be held between 12 and 26 April 2021. Coroner doesn't anticipate sitting on all days, anticipates period of consideration for submissions, and for her to read and reflect once she's heard all the evidence.

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Inquest will be held at Sheffield Town Hall.

'We are going to support witnesses where they wish to give evidence remotely, we'll support them to do so' Coroner requests her officer is made aware to ensure video links are distributed to witnesses

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Plan is for a running order of witnesses to be circulated by 24/3

Discussion that preference was for all Trust witnesses to give evidence remotely, Mr and Mrs Booth would like to give their evidence remotely too and follow the inquest online

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When discussing timetabling a discussion was held about the evidence of Prof Egner, Trust suggested his evidence could be read under Rule 23:

'he has retired from the Trust and I believe his evidence is relatively uncontroversial'

49/

Mr Lomas points out family requested at last PIR that he be called as a live witness.

Coroner wanted have 'another look' and make a decision later.

Since heard she's agreed he will be called as a live witness. Her Coroner's Officer will assist the Trust to find him.

50/

8th and final pre-inquest review hearing into death of Laura Booth was concluded and the inquest adjourned until 12 April 2021 at 10am.

I'll finish this thread with a picture of an 8yr old Laura, she didn't like waiting, soon the wait will finally be over

#OpenJustice

/51

Sorry, haven't had a coffee yet today.

Laura was 8months old in that pic, not 8 years old.

With thanks to @LauraBo87351752 for letting me know.

/END