Thread by @SammyInquest

Coroner calls Jonathan Deslandes

He affirms

JD: I'm Head of Wellbeing

C: You were involved with Sammy in that role

JD: yes

C: I'll ask you to read your statement but before you do, I'll ask you to explain introduction to Laleham Gap, what kind of school

JD: Laleham Gap special school for children with autism, speech and language difficulties and learning disabilities...

<he's fast, can't catch>

JD: focused on children with average or above average academically but have autism as well, support from primary through to secondary, more recently post 16

Approximately 210 ? children in school

C: So quite large school. Mum moved to try and get Sammy to attend your school, what's process for obtaining place?

JD: have to go thru local authority, we're a maintained school, part of a trust. Any children coming to the school have to go through process of local authority

C: So you cant just apply or you'd been inundated?

JD: yes, Kent County Council pay for the fees so they assess, working alongside us as well

C: So you're designated safeguarding lead for school and provided details in your statement if I can ask you to read from that

JD: Before I start reading, I'd like to say this review was compiled as part of review... Sammy brought so much to our school, we're reflecting on what we did as school but there was so much more to Sammy than this, and positive experiences in our school

C: thank you for that; sounds from his Mum he had positive experiences there

JD: covers more complex issues we had to deal with. Head of wellbeing and designated safeguarding lead...

JD: lead on safeguarding issues in school, arrange participation at CHIN meetings, develop and foster relationships with families and communicate with professionals.

JD: Did not support Sammy on day to day basis with his learning but often at times be closest member of senior leader team if support required.... built positive and trusting relationship with Sammy and his family

JD: Additional records such as chronology, incident reports, health records and CHIN records give further detail of my involvement

When state school within minutes it was me representing school in all but one of those meetings

JD: Sammy joined our school on 14/3/19 having spent some time out of school... Sammy was assessed as meeting our admission criteria, while complex needs including diagnosis of PWS, as school we were in strong position to support his range of needs

JD: Sammy benefit from universal support strategies to deal with his needs; small numbers in classroom, communication aids, OT on site; ability tailor needs with high levels of support when required

JD: Curriculum adapted where necessary to reduce anxiety and promote engagement... through his time with us were several health issues for which he received support; close liaison with his mum

JD: 9 May staff noted his growth hormone stopped and medication changed [lists]

9 May entry Sammy came in with savlon and plasters, explained had to stay in medical room. Rang mum and asked speak about it, Sammy became upset.

JD: 10 May 2019 healthcare file communications log entry mum came into school to update changes in medication

Sammy slept in learning support unit felt very tired, urinated while sleeping, staff took for shower and clean clothes.

Mum felt was due to change in medication

JD details other instances when Sammy had medical support at school

[Detail records and logs]

Sammy extremely anxious as he'd over eaten that morning and was worried wouldn't make it to toilet, very anxious... while talking Sammy urinated... cleaned himself up

JD recounts logs of toileting accidents and how staff supported Sammy

Mum is struggling with all washing as he's having so many accidents, asked staff remind Sammy to go to the toilet every hour

JD reads from notes of meeting where Sammy's medication discussed and strategies

6 Jan 2020 healthcare communication log record Sammy got upset because his bandage had got wet - he stood on needle over holiday; we put new bandage over existing one

Sammy in art, burn his finger on glue gun, blistered, Sammy refused burn gel or cold water and bit at it

Welfare form asking dressing change on his finger, explaining had cut it previous day on blade. Cut cleaned and rebandaged it.

20 Jan 2020 confirmed mum had taken Sammy to walk in clinic and cut dressed.

General summary around this area: Sammy loved being at Laleham Gap school, building positive and trusting relationships with many staff particularly in learning support unit.

JD: regular breaks and timetable adapted, important in reducing general anxiety as Sammy became more confident in school

Anxiety triggered by unpredictable issues; would often place demands on his mother to buy items...

JD reads: other children fond of him and no concerns about social interaction with his peer group.

Was able to play star role in our school play that made everyone proud

Music therapy in Jan 2019

JD: supporting Sammy's general anxiety was a challenge, when in positive frame of mind recalling incidents to reflect on can cause greater anxieties, I'll add to this Sammy didn't like to swell on negatives

JD: Sammy did well in school, the incidence of serious incidents was not high... major concern was severity of incidents when he became distressed... relevant action taken to keep him safe

JD: feel as school provided high level of support to Sammy and his mother... fact he was generally happy in school, felt he fitted in, was appropriately placed academically, positive relationships with peers and staff were all protective factors for his wellbeing

JD: next element of statement is relating to action and communication regarding risks and incidents in school

21 May 2019 Sammy was upset about situation with loom bands becoming more and more distressed; offered opportunity to talk about, refused

JD: went to remove seals around door... guided away... repeated on another office door.... becoming distressed, Mr D requested escort, dropped to floor, Sammy tried to bight Mr D until he eventually calmed and laid down on equipment

JD: I remained in the room and talked through with Sammy. Communicated to his mother and social worker in children in need meeting.

JD detailed Sammy putting led in his ear out of pencil, taken A&E, used suction tube remove objects

Debrief with Sammy agreement was formed about his pencil case use

JD: contract agreed, Sammy agreed not to put items in his body, would only put food and drink in my mouth, take care of school and other people's belongings, when worried will talk to adult about what will help me

JD describes high anxiety incident where Sammy was worried he'd lost sewing materials; updated plan for de-escalation

JD describes an episode at school... decision made to remove Sammy to beanbag room, describes Sammy being taken to room, support from 4 staff

Social workers informed during CHIN and concerns raised regarding safety

JD describes further incidents - well documented efforts to de-escalate, including discussing with Patricia AS and social workers afterwards

JD describes incident where Sammy put pin cushion in his mouth... swallowed needle...

JD reads: after Patricia joined myself and Mrs S at hospital, we picked up daughter from school so Patricia AS could stay with Sammy

JD reads from school records

JD: 8 Nov 2019 incident was shared and concerns raised in CHIN meeting, social worker agreed to liaise with health professionals for further engagement in CHIN meetings. Also raised concern I had to support incident yesterday because Mum had so little support.

JD: 11 Nov 2019 Sammy worked well for most of lesson then became almost trance like, bit his arm... arm was red with teeth marks, left class and returned to learning support

JD: In 12 Dec 2019 Sammy went to toilet, calm and not unsettled, when returned he said he'd swallowed a needle, then said wasn't sure if he swallowed it or not. Decided staff would take Sammy to A&E to be checked.

JD: Xray confirmed Sammy had swallowed needle... was agreed by all that Sammy should not be sewing or using needles in school; further support by way of direct payments had been agreed

JD: March 2020 Sammy said he had tooth ache, had paracetamol, started punching his face because he said he wanted to take his tooth out. Tried climb out window, became stuck, wouldn't let staff help him out.

JD called Patricia and text her regarding monitoring Sammy's breathing as this had been a restraint

These are general comments in relation to the incidents. Each serious incident followed through and communication with parent and social worker

JD: When incidents occurred where Sammy presented risk to himself... I do not believe Sammy while in highly anxious frame of mind understood the serious risk of harm this could do to himself... he was in extreme heightened state

JD: during incidents in school Sammy did not indicate plan to take his own life but clearly had very high level of risk which was raised with other professionals and his mother

JD: Vast majority of time Sammy was happy, rare occasions when he became distressed everything could instantly become a risk, such as paper, fabric, pencil.... managed with high level of support from learning support team

JD: minimising incidents by giving as much positive XX as possible

Communication with other professionals regarding concerns for Sammy's welfare; Sammy was CinN and receiving support from a number of professionals.

JD: While we could meet his needs, there were always risks, and these would be the same in other environments albeit he'd be at greater risk

To ensure social worker aware of risk when Sammy became distressed and impact on his mother, the primary carer, and wider family

JD: Expressed my professional opinion whatever support was put in place would not eradicate risks; his mother knew him better than anyone

CHIN had confirmed referral for care, education and treatment review had been made

JD lists CHIN meetings, he attended all except one, headteacher attended one given rising concerns

8 Nov 2019 raised concerns about Sammy's behaviour when he becomes distressed. Discussed impact on Sammy and challenge to Patricia in supporting this.

JD: Raised CAMHS and health professionals should be more involved to understand and address these risks [I think]

School raised considerable concerns... want more joined up approach between health and CAMHS

JD reads email he sent to social worker about further incident of Sammy swallowing needle - Patricia is really struggling given this, can you do anything to support?

JD says social worker assured had tried to contact health professionals, Dr Baker couldn't attend, others hadn't responded [I think]

JD: I raised my concerns about Sammy, not in relation to his mother's care of Sammy, but the challenges faced by her and others given the risks

JD: We've had to take Sammy to hospital on two occasions; other instances where he's tried to swallow materials

JD: concern about impact on Patricia and his siblings given the complexities of Sammy's needs. Previously agreed Patricia should contact police if behaviour or concerns of needs.

JD: in meeting Patricia stated that she would like more support, was agreed he was very happy in her care and loved school... asked Siobhan, social worker, in meeting if she'd discussed Sammy's needs with her line manager and that they were aware of serious risks.

JD reads: Was assured by Siobhan that they were aware.

If I was not assured concerns were understood, discussed and agreed at high level I'd have escalated further; I was assured they were...

JD: school reported Laleham was one of best places to meet Sammy's needs. In relation to his PWS his weight was well managed, he was doing well, felt residential care was not best for Sammy

JD reads: school reported they had concerns for Patricia and ability to recharge. Patricia encouraged to consider family group conference to see what support in networks.

Patricia said she worries for girls and impact on them

JD details further CHIN where doctors/medical professionals did not attend or send reports to meeting

2 March 2020 had discussion with John Hollands at NELFT regarding Sammy, discussed incidents at school

JD: John stated he was making contact to come to next CHIN meeting; he asked when meeting was, I emailed Siobhan to check and indicated CAMHS would try attend

JD reads from report: Family Group Conference coordinator identified, FGC not just to support Patricia with Sammy but also other children in case, for example, Patricia needed to attend hospital with Sammy

JD: While FGC are not for professionals Patricia asked if I'd attend given I knew Sammy well; I did, it became clear that no additional support was available... overwhelming feeling was social care needed to provide more support

JD: was concerned about support family would get if schools were to close; wasn't sure what impact would be but wanted to ensure support was being considered, 16 Mar 2020 emailed social worker to discuss

JD reads from his email: think it would be wise to consider asap what social care support can be provided to the family to meet Sammy's needs

JD spoke with CAMHS, reinforced Sammy's high needs

18 March received email from social worker Siobhan in return, apologies for not getting back sooner, been out office on visits, can you update me following your meeting with CAMHS.

JD regarding CHIN meeting, based on coronavirus we're not having face to face meetings... regarding holidays looking whether can increase support but will need service manager approval before anything is confirmed

JD: As society went into lockdown, March 2020, school in collaboration with parents decided what pupils could attend... Sammy was advised shield for 12 weeks, school shut for Easter holidays

JD: 16 April 20 after holidays JD called Patricia for update; few incidents, spoken to social worker who'd like Sammy to be back in school, explained while we're not against it, when he has letter for shielding, coming to school against advice would need agreement at CHIN

JD: PWS affects respiratory system... 17 April 2020, attended by Skype the CHIN meeting discussed behaviour at home and school; discussed Sammy coming into school, explained not against this, stopped due to shielding. Not happy make decision on our own.

JD: Sammy doesnt have capacity to make safe choices around social distancing in school.. agreed by all would not be safe to go against this [shielding] and other strategies discussed; sisters could go into school for respite as much as needed

JD: discussed risks of Sammy going out for exercise with 1-1 PA, safer than attending school... further requests will be made to XXX team.

JD agreed to do report by 24 April, made clear school position would be happy to have Sammy in school but needs be agreed by health and be multi agency decision

JD: I believe we communicated well with other professionals as documented... range of concerns that led to involvement and was assured they'd refer for a CETR

C: thank you very much, unfortunately we're out of time, so I'm afraid we're going to have to ask you to come back tomorrow for questions

That means you're under oath while you go home overnight; can't discuss case with anybody at all.

C: Avoid conversations with anyone tomorrow when you come in.

We're starting at 10:30 tomorrow. If you can be back then, apologies for that.

C: thank you very much, I'll see you tomorrow morning at 10:30

Court is adjourned.

C: thank you very much for coming back, apologies for delay, our IT isnt as good as it could have been this morning. You remain under oath from yday, few questions arising from the evidence you gave.

C: first, couple general questions, if you have pupil at school who consider does need extra support in their home environment, what steps are available to you as a school?

JD: <cant hear>

C summarises referral into social services and ask if follow up

JD: may be that family are supported, and in other cases we need to work together to support the family

C: You mentioned CETR process, was initiated but hadnt started already, who initiates that?

JD: It was suggested. Sammy was already open to social services as a Child in Need, he was already receiving input from CAMHS so there were a number of professionals already involved

JD: It was @NELFT that suggested they'd make a referral to the CETR process

C: would it usually be healthcare bodies that make that referral?

JD: more recent guidance looks at support given through CETR process, my understanding it can now be made by different professionals

C: As far as school was aware in regard to Sammy the relevant agencies were aware and it was up to them what action they took?

JD: in relation to Sammy we felt we could meet his needs at school, albeit there were risks, but we felt it was when Sammy wasn't in school that the support needed to be looked at

C: were you more concerned after it took more of you to manage his episodes? [paraphrase]

JD: yes as time went on it was a challenge, but you might have a month or so when he responded really well to support given, then they'd be an incident and it was how he was in that incident that caused the concern

C: was your concern that Sammy's mother was the only person available to manage that incident?

JD: that was a concern, and the impact on Sammy [missed]

C: were episodes escalating?

JD: I wouldn't say escalating in terms of behaviour and incidents, but I'd say the more times it happened the more concerned you'd get

C: you were concerned about his safety were you?

JD: when in that they high level of heightened state of anxiety, yes

C: you mention in report when dealing with incidents there was SLT support, whats that?

JD: senior leadership team

C: was that the action plan you had in place?

JD: that was yes, that was protocol followed for any concern regarding pupils that staff felt they had

C: so was senior leadership team involvement when needed; was there any way of anticipating episodes, anything that triggered episodes?

JD: it could be for any reason and it was very difficult to predict

C: so spontaneously something could occur...

JD: in my evidence I mentioned loom bands... he got upset about them on occasion, on another occasion upset regarding a tool he couldn't purchase. To most ppl these would be quite trivial matters resolve through communication and reassurance

JD: for Sammy he didn't understand that, the smallest disappointments could lead to, develop into the biggest incidents

C: all incidents you had you logged and reported to @kent_cc social worker and discuss at Children in Need meeting is that right?

JD: yes, by coincidence the most severe incidents took place very close to those meetings

C: At those meetings did you make it clear that you considered Sammy needed extra support at home?

JD: yes, yes

C: did you have a view on what extra support was required or is that outside your remit?

JD: very difficult to have view on that, we see Sammy in context of school, we dont go into family homes to support within the home...

JD: Patricia was my first point of contact, to assess that from school perspective was outside our remit

C: you recognised she may need further assistance, or Sammy might, at home, but you weren't in a position to say what that is because you saw him in school environment

C: we come to difficulties of pandemic and Sammy being in school or not during that time. We heard you give evidence of that, what's your view of what impact that would have on Sammy knowing him and how he was

JD: I was very concerned at start of pandemic, at that point none of us knew where it was heading. I know Sammy and family did struggle during holidays and long periods out of school. All children suffered during that period of time, so yes, it must have had an impact

C: without structure and benefit of school he'd have required more support outside of school, in whatever form that may have taken?

JD: yes

C: do you have any detailed recollection of the last children in need meeting in April you attended?

JD: it was done remote and I can recall some of the information in that meeting

C: do you recall concerns about him not being in school being raised at that stage

JD: yes

C: was there a discussion between professionals about what could assist Sammy during that time?

JD: I recall a conversation regarding direct payment allowance, hours built up could potentially be used

C: was there any discussion about how he'd been at home during that period?

JD: it had been challenging at home; he had settled for a period of time but it had been challenging, my understanding was some police involvement as well on at least one occasion

JD: Sammy was on list of vulnerable children to be kept in school...only thing that changed that was when shielding letter came through, I had direct discussion with Patricia and she'd taken advice from health professionals and it was very clear.

JD: To deviate away from what had been healths very clear instruction and health guidance, could not be taken in isolation by school, had to be multiagency decision, including health

AP: Good morning, I'm Angela Patrick and I ask questions on behalf of Sammy's family, I'll try not repeat questions Coroner has already asked or were in your statement yesterday. Few things to ask you about, mostly in relation to documents.

AP outlines what she'll ask about

AP: first up I dont know if you were in court yesterday and listening to Mrs AS evidence but she was very clear in her evidence that Sammy loved Laleham Gap and I've been asked by the family to reiterate that.

AP: I think you said in your evidence that Laleham Gap was the right placement for Sammy, is that right?

JD: That's right

AP: the family agree with that.

AP: Can I ask about Education, Health and Care Plan, EHCP... do you have in your file, I see you have a big lever arch file there

C: it might be easier to go through bundle

AP: if that's easier, if the learned Coroner's officer can assist and pull up what we're calling Bundle 3 that would be helpful

Final version from 14 March 2019

JD: I do have a copy of 14 March 2019

AP: i'll work with version I've got, everyone else is following electronically, I also have internal page numbers which might help with pages you have in front of you

AP: An EHCP is an Ed, Health and Care Plan is that right?

JD: that's right

AP: sets out in one document for any child their education, health and care needs, is that right?

JD: yes

AP: and provision of services from any agencies [I think]

JD: yes

AP: that is a document owned by the local authority isnt it?

JD: yes

AP: LA brings together school, such as yourself, and any health care professionals involved in care?

JD: yes

AP: they're reviewed regularly?

JD: annually

AP: and if any significant change in presentation of child can an EHCP be reviewed?

JD: yes

AP: EHCP says little about who child is and then their needs, isnt it?

JD: yes

AP: p20 cognition and learning at top, is that right

JD: yes

AP: fantastic... this is Sammy's cognitive needs... consistent with pupils with high functioning autism, that's the first statement isn't it?

JD: yes

AP: essentially says good cognitive ability, given appropriate support has potential to be successful in academic environment, in his strengths that's highlighted isnt it?

JD: yes

AP: with support he could function? is that right?

JD: yes

AP: there's no question he had some cognitive difficulties is there?

< AP reads difficulties from document and JD agrees >

Samuel does not like getting things wrong which contributes to frustration and anxiety when he feels pressured

JD: yes

AP: over page, Samuel requires a lot of extra processing time when presented with new task or following verbal instructions - requires broken down, repeated, visual cues

... panics easily when unsure of an answer

AP: so there were cognitive difficulties in Sammy's presentation?

JD: yes

AP: Sammy's anxiety linked not only to his autism and learning disabilities but was particular issue of concern to the school, is that fair?

JD: yes

AP: were you ever asked at any time by CAMHS to input into how severe Sammy's PWS, autism or learning disabilities were in terms of how it effected his life?

JD: no

AP: were you aware at any time of an educational psychologist being invited in to assess how severe his...

JD: there were conversations with @NELFT regarding his disabilities, in evidence made comments of conversations that took place in early stages...

JD: was communication there, in terms of formal information communicated in writing, reports, or to assist formal assessment I didn't do that, but in early stages of starting to work with @NELFT was some communication

AP: thank you Mr Deslandes that's very helpful; question was specifically about cognitive difficulties or how his disability impacted on his daily life

AP: I think you're saying may have been informal conversations but no opportunity for you to input into a formal assessment process?

JD: no

AP: mental health, is this part of EHCP that describes Sammy's needs when it comes to social, emotional and mental health [I think]

JD: yes

AP reads strengths and highlights how many are related to him not being anxious or stressed

Then discusses anxiety, challenging behaviour

AP: That's a fair reflection of what's recorded in EHCP is that right?

JD: yes

AP: learned Coroner asked in her questions what was known about Sammy's episodes, this is record in EHCP that Sammy was known to have behavioural episodes isn't it?

JD: yes

AP: and there were some triggers that could be learned and to some extent anticipated, is that fair?

JD: yes

AP: Section of EHCP deals with health... Prader Willi Syndrome, Autism, Challenging Behaviour is that right?

JD: yes

AP: Does an individual healthcare plan exist? No?

JD: no

AP: there's no record of Sammy having an individual healthcare plan is there?

JD: no

AP: then social care needs, Sammy as a child in need wasn't he?

JD: yes

AP: social care needs that require provision, none identified at this point; is that strictly accurate?

JD: at point meeting took place that would have been put in if social worker wasn't present

AP: but this is meant to be an accurate account and if Sammy was a Child in Need he had a Child in Need Plan which suggests there are provisions to be made to meet that need. Is that fair?

AP: Would you expect in an EHCP if child is open to social services, and there are steps being taken to meet their social care needs those would be recorded in an EHCP?

JD: yes

AP: and there's nothing in Sammy's EHCP about social care needs?

JD: that's correct

AP: 129 looking at provision and strategies to meet Sammy's special educational needs; up front makes clear needs education setting with strategies and coping skills for pupils with high functioning ASD and where he feels safe and has sense of belonging...

AP: ...staff skilled and experienced in working with children who are highly anxious

JD: yes

AP: fair reflection of provision you were able to make at Laleham Gap?

JD: yes

AP: not just ASD experience of staff, but also dealing with child who was highly anxious, that was particular requirement of Sammy's EHCP isnt it?

JD: yes

AP: due to his flight risk Sammy requires secure school environment... that was known is that right?

JD: yes

AP: thank you. After deciding that, the EHCP goes on to discuss particular provision needed for that child's need doesnt it?

JD: yes

AP: tools Sammy needs to get by, to be really blunt, not only in school but also in life, is that fair?

JD: yes

AP reads - support to understand... develop appropriate social interaction skills... another example given use of social stories to teach rules of social conduct, sustaining appropriate relationships, managing stress inducing situations

AP: These are recommendations of things need done to help Sammy live his life and give him tools to help him manage his emotions, and perhaps reduce likelihood of episode or better equip him to deal with episode, is that fair?

JD: yes

AP: then we have specific interventions to happen at Laleham Gap; social skills programme delivered daily, overseen by qualified teacher and members of staff at Laleham Gap

JD: yes

AP lists other strategies about memory, auditory processing, speech and language

AP: I dont want to hammer this home but next provision we have is on 133, couple pages over, provision in respect of social and emotional and mental health, dont want to read all out, others may come back to it but Samuel's emotional wellbeing will need to be monitored

AP reads: ..., need access to haven or calming area, stress reduction and relaxation techniques to be employed

This is EHCP saying the school will work with Sammy on daily basis for him to use these techniques, is that right?

JD: yes

AP: understand anger and resistance may not be due to non compliance but overwhelming state... <didnt catch>

AP: I'll pause there, that's a clear statement and indication there, a reminder to staff reason Sammy may be unable to control his emotions is connected to his disability, isnt it?

JD: yes

AP: everything in this EHCP, all assessments of Sammy's needs is designed to address Sammy's needs as a disabled child, is that fair Mr Deslandes?

JD: yes

AP: then reminder staff would be aware of Sammy's most common triggers and consequences wherever possible strategies to prevent emergences of escalating behaviour [I think]

Stress reduction and relaxation techniques taught to Sammy every day is that correct?

JD: yes

AP: Structured programme to address Sammy's self esteem is that there?

JD: yes

AP: emotional literacy [I think]

JD: yes

AP: was that provided at Laleham Gap?

JD: yes, a lot of staff trained to deliver universally to all children, and sometimes specifically, its embedded in everything we do

AP: exactly, you have professional staff working not only to keep Sammy safe in school if an episode happens, but to give him the tools that might better enable him to manage his emotions and reduce impact of an episode is that right?

JD: yes

AP: is likelihood any of this therapeutic support would be available to Sammy when outside school, whether on holiday, or during pandemic, unless alternative arrangements were made available?

JD: at time to large part that support was provided by family, by Patricia

AP: so unless family were doing it, no-one else was going to come in and give Sammy daily support and help him understand tools he'd need to live his life with emotional regulation?

JD: discussions with Patricia... he was such a unique individual, whoever was supporting Sammy needed to get to know Sammy and support him in context of his needs

AP: so in school your staff might be tasked to undertake these with him, outside of school its all Patricia?

JD: yes

AP: right, thank you

AP: moving onto episodes, there's a risk assessment prepared by school, coroner asked how you understood risks associated with Sammy's episodes. There's a risk assessment provided by school isnt there in bundle?

JD: yes

AP: formulated first in June, but reviewed later after more significant incidents happened on 22 Nov 2019

JD: yes

AP: this is tool, one of number you have in school, to help you understand Sammy's risks and help you meet them, is that fair?

JD: yes

AP: first page of risk assessment under challenging behaviour and physical aggression, Sammy in situation can not control eg demanding object from home or food, can display physical aggression towards himself and others.

AP: Statement Sammy also self harms in this situation, objects up his nose, in his ears, mouth. Any object around can become a potential risk...

AP: risk of injury to others and self harm - we have risk, low, medium and high and not one is selected, but we heard about risks in your evidence

JD: let me check whether its highlighted in my record

JD: in my record here, it's high, high risk

AP: and that fits with your evidence yesterday, I want to be clear we are not in any way criticising the school, just wanting to highlight the tools you had in place, how risky Sammy's behaviour was in episode, and how useful steps were in place in school.

AP: Want to understand the tools you were using, we are not criticising the schools

C: its helpful to have the original too and know that

AP: strategies in place, for example senior leadership team always aware of risk and onsite in case of emergencies?

JD: yes

AP reads another example: thats soft room or safe place away from other children in school?

JD: it is yes

AP discusses restraint... usually takes three members of staff to ensure Sammy's safety is paramount at all times, you said yesterday up to three members of staff, sometimes more?

JD: sometimes a number of professionals come to support, physically intervening two to three, other staff around to support if required

AP: definitely multiple members of staff if Sammy was in an episode, required on scene to keep Sammy safe?

JD: for physical intervention, yes

AP: all windows had restrictors...

JD: acknowledgement of risk for Sammy but universal to keep all children safe in our special school, but here to indicate was known risk

AP: Sammy had tried to get himself out of school window hadn't he?

JD: yes

AP: took a number of members of staff but you were able to keep him safe?

JD: yes

AP: So in school environment even with all those strategies in place the risk remained medium?

JD: yes, at least medium

AP: do you have Sammy's behaviour support plan there?

JD: yes

AP: we have triggers identified for staff to help anticipate how to keep Sammy safe, is that correct?

JD: yes

AP: proactive support strategies, a number of different activities, some of which we've heard about from family, zones of regulation to help manage emotions.

AP: Last bullet I want to focus on, all staff working with Sammy are to ensure they have a radio or walkie talkie on them at all times, is that correct?

JD: yes

AP: so if there's something risky happens you want them to call for help quickly?

JD: yes

AP: Sammy was 2:1 ratio for any out of school activity, is that right?

JD: that's correct

AP: it says Sammy currently does not take part in offsite activities due to frequent incidents and risk he may pose to himself and others when out in community, JD will assess this regularly

So even at 2:1 basis school wasn't happy with level of risk Sammy would pose in the community if partaking in off site activities?

JD: yes

AP: absolutely clear we're not criticising school, but looking at clear approaches taken to manage Sammy's risk.

AP: It's twofold 1) professionals supporting sSammy so he has tools or develops tools to understand his emotions to make episode less likely, is that fair?

JD: yes

AP: other techniques were all targeted on how to keep Sammy safe if an episode did happen?

JD: yes

AP: on those occasions would be multiple members of staff involved?

JD: yes

AP: Also safeguarding report prepared by school wasn't there?

JD: yes <checks date>

AP: 9 Nov 2020

JD: yes that report was undertaken by Deputy Head, my part of that was the evidence I submitted in my statement

AP: just want to highlight one section picked up in safeguarding report at A15 - incident stuck in window - when incidents occur that Sammy presented risk to himself

AP reads: I do not believe that Sammy in this highly anxious state of mind understood the harm he could do to himself... <reads>

Your view was Sammy was not aware of the implications of his actions?

JD: no, no

AP: you said was no indication at school that he wanted to take his own life, but you were aware he'd said to his mother and others he wanted to kill himself, aware from Children in Need meetings. You were aware of those statements being made?

JD: i can't recall that, however his behaviours were very risky to his life

AP: and he had very limited awareness of danger did he?

JD: no

AP: thats very risky in itself, does it have particular risk with child with autism or PWS where they might involve fixating on something, or having repetitive behaviours

JD: that level of fixation was very high risk, yes

AP: move onto different contact, your contact with social services before covid. Your concern arbout risk associated with Sammy's episodes out of school was raised by you, with children services and CAMHS on different occasions, is that fair?

JD: yes

AP: and raised before the pandemic?

JD: yes

AP: so while Sammy was accessing support in school.. you were still concerned was need for additional support when he was out of school?

JD: yes

AP: was application for direct payments, you were aware as result involvement in Children in Need process?

JD: yes

AP: this is assessment of family when direct payments were applied for.. one particular incident happened recently immediately before assessment, shared by setting... 21 May 2019, Sammy become extremely emotional, damaged school property and attempting bite staff...

AP: Mr Deslandes stated only able to address incident alone due to his own stature... wld need minimum of two staff members... asked whether concerns of mother managing episodes alone... thought of mother managing it alone would be very concerning given the challenging behaviour

AP: Mr D said Sammy was functioning at much lower level in emotions and cognitive functioning [I think]

That's consistent with safety plans used by school, multiple staff members needed when Sammy in episode

JD: yes

AP: that was what you were communicating with the local authority, is that right?

JD: yes

AP: your concern wasn't just that this mother couldn't cope, it was that anyone dealing with these episodes alone would struggle to keep Sammy safe, is that right?

JD: yes

AP: that was May 2019 after Sammy had joined Laleham Gap obviously

JD: yes

AP: separate issue dealt with yesterday would like to turn to, is about how recorded, or how you reflected on your contact with social services. In your witness statement...

AP: if I've got your evidence wrong please tell me I've got it wrong.

Was conversation, you precipitated it, about residential care.

JD: yes

AP: one of meetings, definitely discussed in December, maybe discussed in November

JD: yes

AP: you didnt feel residential care was in Sammy's best interests?

JD: Sammy had been out of school for a long time before he came to us, we were on a pathway to building a different life for Sammy.

JD: I talk about family being protective factor, the love there, the bond there, Sammy's reaction when it was [residential care] mentioned. Disappointment was a trigger, there could be no greater disappointment than being taken away from that love and care that was given.

AP: I appreciate that. In that discussion with professionals and Mrs AS you communicated view residential might not be in Sammy's best interests didnt you?

JD: My concern was about residential; Sammy's behaviour was linked to his unique needs. Moving Sammy to another environment wouldn't necessarily address problems, managing risk is difficult and moving Sammy's risk to another place would lead to greater difficulties...

JD: and even more people would need to get know Sammy

AP: did you feel Mrs AS and other professionals took your views on board?

JD: they weren't just my views... Patricia was supporting as much she could in family home, along with others as well

AP: Mrs AS had researched residential options herself hadn't she, and she told you that and told the LA that?

JD: yes

AP: Mrs AS said she would have been open to residential placement if it was in Sammy's best interest; was your impression she'd been open to that, whether short term or otherwise, if it was felt to be in Sammy's best interests?

JD: I believe Patricia would have done anything she could, if it was in the best interests of Sammy

AP: Issues wasn't residential or no change, issue was Mrs AS wanted more support at home, so Sammy could be safe and cared for at home, is that right?

JD: she did, yes

AP: last topic, your contact with agencies as pandemic developed; you've got concerns about support out of school already, then pandemic started to bite. You've read your emails with Siobhan McAree [social worker]

AP: You had concern about Sammy being out of school, you had foundation for evidence because school holidays were difficult for family, basis of what they'd told you and what you'd observed

<reads email from Mrs AS to JD outlining difficulties at Christmas>

AP: Do you remember that email? Mrs AS had read into her evidence, we'd not seen email, there was a foundation for your belief the family would struggle in periods when Sammy was completely away from school?

JD: there was a foundation, yes

AP: before you contacted in March to ask about covid, had anyone reached out to you from LA or CAMHS to anticipate risk management for covid period

JD: I can't recall

AP: family had some support didnt they, two hours support on school days

JD: I wasnt aware how direct payments were used

AP: you were aware they had some support but you felt they needed more support than what was available, is that fair?

JD: yes

AP goes to reply email from social worker, Siobhan McAree

18 March you read it yday, I'll not read it all, reply to your question saying what are we going to do about covid to support this family

You explain your particular concern about holidays

AP: she apologises for not coming back sooner and asks you to update on what CAMHS were doing... says cant have CHIN meeting face to face... goes onto need updated assessment to go back to panel to increase direct payment hours

C: Ms Patrick we've read the entirety of the email, this is already in evidence, can you ask a question please

AP: Ma'am i'll move on, at end of email, increased support would require service manager approval, was no guarantees given further support was likely to be forthcoming?

AP: meeting on 17 April, again, p64 in report prepared by school where summary.

'I stated he did not have capacity to make safe choices in time of anxiety in school around his peers'

JD: yes

AP: that was behind your understanding of whether Sammy should or shouldn't be in school. If shielding list wasnt in place the school would have supported him, regardless of the risk?

JD: yes

AP: you were encouraging the CETR to be progressed is that right?

JD: yes

AP: is that process led by health team?

JD: yes

AP: its a multi disciplinary process isnt it?

JD: yes

AP: Child in Need process is multiagency is that right?

JD: yes

AP: So we've one multiagency process led by LA... been going on for some time, Sammy been child in need for time you'd known him?

JD: yes

AP: now a second multidisciplinary process in the CETR, that was what was being proposed?

JD: yes

AP: proposed at this stage as the pandemic was biting, while Sammy was out of school and without access to all the tools Sammy needed to keep safe. Is that right?

JD: yes

AP: so not consideration of tools needed to keep Sammy safe but decision that another process needed to be progressed as a priority, is that right?

JD: yes

AP: in that meeting was no doubt the concern, reason this was discussed as priority was that at Sammy, when in episode, was at risk of self-harm. Everyone understood Sammy was putting himself at risk during episodes?

JD: yes that was one of priorities

AP: and was no doubt it was understood that at that time Sammy was at risk to his own life [I think]

JD: yes

AP takes to record: Is this a Laleham Gap document or a LA document?

JD: Think was given to school to complete by LA, I cant confirm who was author of the template

AP: was it just for internal school use or to return to LA?

JD: I cant answer that, I'm sorry

AP: page 2, 193 in pdf

JD: OK

AP: says in left hand column questions about risk; some or all element of EHCP can not be delivered at all. We've already heard your view if he was out of school was need for greater support because the risk would increase, is that fair?

JD: yes

AP: is possible

Mrs Alban is considered by us and others as a protective measure, she understands his needs well... no reflection in this document about your particular concerns for extra support is there?

JD: no

AP: but you communicated those concerns in CHIN meeting?

JD: yes, I didn't write this

AP: I know you didn't author this

<reads another column>

AP: that doesnt reflect your concerns does it?

JD: no

AP: but you'd already communicated those concerns to LA in the CHIN meeting hadnt you?

JD: yes

AP: author of report is Les Milton, that's the headteacher isnt it?

JD: yes

AP: Date is 24 April

JD: yes

AP: that was risk assessment completed after Sammy's death, incident that led to Sammy's death

JD: yes

AP: completed, not by you, and doesn't reflect concerns you'd already raised with the local authority?

JD: no

AP: no further questions, thank you

Coroner: I'll press on

JL: <cant hear>

JD: yes level of his behaviour was a concern, but he also met our criteria in other ways too

JL takes to IEP document [I think]

JL: Box 6, my current needs, Prader Willi Syndrome, Autism, and milder learning difficulties, you'd agree with that?

JD: yes

JL: report also includes verbal and spatial abilities in average range, but 123 we'll take you there please

JD checks page number

JL: 123, and spatial verbal abilities... he has reading score in 75th percentile, can you see that?

JD: yes

JL: confident in reading and spelling, good cognitive abilities, you see that?

JD: yes

JL: in relation to learning difficulties Sammy had you'd agree they weren't severe or profound is that fair?

JD: its such a broad term, these were assessment made by professionals, his other needs were barriers to his learning, which made his learning at times more complex

JD: in terms of designation of cognitive ability, I'm not a psychologist, but he met criteria for our school, his cognitive ability were relevant to our school

JL: what were those criteria?

JD <cant hear>

JL: you were asked by my learned friend for family about EHCP... are EHCPs about meeting assessed needs, not about disabilities

JD: EHCPs are about holistic need, my experience of them take focus around support given, particularly when there are other mechanisms for supporting other needs as well

JL: TY one last area, that's in relation to managing and mitigating risks from Sammy's episodes, reality is with all strategies, know how, expertise, all of those which staff were caring it was impossible to prevent episodes wasn't it?

D: I do believe there was a risk however many strategies were in place, a medium to high risk even with strategies, however, the more strategy you put in place, even within medium to high risk range, you can try to minimise those risks

JL: really what you were doing was reducing a very very high risk to something that was medium to high risk

JD: thats what we attempted

JL: but even with all the people there you couldn't always prevent Sammy from self harming, it was impossible

JD <cant hear>

JL: those are all my questions ma'am

C: thank you Mr Landau, I'll now ask Ms Tew, she represents the health trust involved

AT: You saw Sammy in episodes, and when he recovered from episodes as well?

JD: yes

AT: during those episodes Sammy would sometimes attempt to hurt himself and sometimes he'd say he wanted to hear himself

JD: when in episode, the verbal communication was decreased and was more behaviour when he was in that, verbal was very limited

AT: you're trying to stop him from hurting himself physically?

JD: yes

AT: when Sammy was calm and not in episode he didn't express an intention to hurt himself did he?

JD: no

AT: you were at final Children in Need meeting weren't you?

JD: yes

AT: And Ms Rowe attended, she was head of siblings school, she made her own notes and commented on suicide risk, we'll hear from her in moment, it doesn't appear in meeting notes, do you remember any discussion of suicide risk?

JD: specifics like that I honestly cant recall, was so many meetings

AT: reason I ask is you didn't hear him say he wanted to kill himself when he was calm?

JD: I personally didn't hear that no

AT: so your concern were based on how to help Sammy when he was having episodes?

JD: that really was my primary concern

AT: thank you, I don't have any further questions

C: thank you very much, you're free to go. Rather than start a witness at this stage I suggest we take a lunch break now.

Court is adjourned, we'll be back at 13:30