Day 2 Robert Chaplin's inquest at Chesterfield Coroners Court today.
You can read about Day 1 here
Today we heard evidence from the Registered Manager at the Morewood Centre, a Community Psychiatric Nurse and a Service Manager #OpenJustice
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You can read about Day 1 here
https://twitter.com/GeorgeJulian/status/1546859146091413513
Today we heard evidence from the Registered Manager at the Morewood Centre, a Community Psychiatric Nurse and a Service Manager #OpenJustice
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Area Coroner Peter Nieto was sitting.
Robert's mum wasn't in court today.
Mr Paul Spencer was representing @Derbyshirecc and Mr Andrew Coburn was representing @derbyshcft
@CareQualityComm are an interested person, but were not in court, for the second day running
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Robert's mum wasn't in court today.
Mr Paul Spencer was representing @Derbyshirecc and Mr Andrew Coburn was representing @derbyshcft
@CareQualityComm are an interested person, but were not in court, for the second day running
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[There is no requirement for IPs to be in court, but I'd think given their regulatory function, and the seriousness of what occurred that @CareQualityComm would at the very least attend to hear the evidence from the Registered Manager, but they were not present]
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Before live evidence the coroner read two documents onto the record under Rule 23.
The first was a record of Mental Health Act Assessment of Robert, that took place 9 January 2020
(Robert died on 24 Jan following an injury sustained when another resident punched him)
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The first was a record of Mental Health Act Assessment of Robert, that took place 9 January 2020
(Robert died on 24 Jan following an injury sustained when another resident punched him)
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The report of the MHA assessment was written by the AMHP Mr David McGill. The coroner commented on the fact it was a very detailed report, including information from the social work assessment
It described Robert as a "local character... well known to services"
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It described Robert as a "local character... well known to services"
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Circumstances leading to referral were: Robert currently lives in a care home, was picked up by Police today at his parent's address, shouting, and threatening to burn the house down
Robert arrived at the Radbourne Unit at 2pm on 9 Jan 2020
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Robert arrived at the Radbourne Unit at 2pm on 9 Jan 2020
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His diagnosis was recorded as: learning disability, autism and bipolar. Has epilepsy and uses a stick to mobilise due to scoliosis in his lower back.
[This was the first time we heard Robert has epilepsy, his mother, and witnesses yesterday, had not mentioned it]
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[This was the first time we heard Robert has epilepsy, his mother, and witnesses yesterday, had not mentioned it]
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[Suspect this is error due to a drug Robert was prescribed for mood stabilisation, also commonly used for epilepsy]
Assessment background recorded Robert had tried to live independently in his own flat on numerous occasions but it had always broken down after a short period
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Assessment background recorded Robert had tried to live independently in his own flat on numerous occasions but it had always broken down after a short period
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When Robert had his own flat at The Grove in Ripley, he coped. Assessment said it worked due to on site warden, Robert receiving services in his own home and being able to access support at a day centre on site.
Failed when warden withdrawn and services greatly reduced.
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Failed when warden withdrawn and services greatly reduced.
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Assessment recorded Robert had long history of alcohol abuse, that he liked to goto the pub to socialise, altho he was often taken advantage of by people he thought were his friends.
Robert had "long history of engagement with learning disability and mental health services"
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Robert had "long history of engagement with learning disability and mental health services"
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It recorded Robert relied on his mother and community support workers to deal with everyday tasks, and he appeared to have good repertoire of language and a friendly manner. However he relied on stock phrases which disguised how little he understood of what ppl were saying
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The assessment acknowledged that Robert's learning disability was much more significant than believed, many behaviours put down to bipolar disorder and mental health issues were actually down to confusion and Robert's inability to express himself
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Community Learning Disability Team previously involved with Robert, predated mental health services, but this stopped when his psychologist retired.
Robert then moved to MH services.
In 2020 he remained under Community Psychiatric Nurse even tho CLDT had taken over again
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Robert then moved to MH services.
In 2020 he remained under Community Psychiatric Nurse even tho CLDT had taken over again
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Robert was now under learning disability psychiatrist.
Was recorded that longer term Robert almost certainly needed Supported Living, Shared Lives or even residential care.
His mother does a great deal for Robert, washing, cleaning, handling bills and records, medication
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Was recorded that longer term Robert almost certainly needed Supported Living, Shared Lives or even residential care.
His mother does a great deal for Robert, washing, cleaning, handling bills and records, medication
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"Pam increasingly worried regarding what will happen when she's no longer able to do this"
Robert's mum was also caring for her husband, Doug, who has dementia, and had cared for her daughter until her recent death from cancer. She was now also raising her grandchildren.
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Robert's mum was also caring for her husband, Doug, who has dementia, and had cared for her daughter until her recent death from cancer. She was now also raising her grandchildren.
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Assessment recorded "social worker struggling identifying longer term placement... Igbal Mohammed states Robert's presentation is not out of the ordinary, but he is more agitated recently"
Assessment also recorded that Robert reported he was
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Assessment also recorded that Robert reported he was
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"assaulted by a service user on Monday and has an ongoing feud with another service user due to racist beliefs... Robert came down yesterday and started an altercation with her. Robert may also be unsettled because he'd been asked to move upstairs"
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Assessment on the day section recorded:
Robert said he was fed up living at Morewood... no-one was looking after him... denied paranoid thoughts, low mood or suicidal ideation... Robert stated wanted Police to pick him up because something would be done about his placement
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Robert said he was fed up living at Morewood... no-one was looking after him... denied paranoid thoughts, low mood or suicidal ideation... Robert stated wanted Police to pick him up because something would be done about his placement
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The assessment recorded that Robert didn't find his last hospital admission useful so he was prepared to go back to Morewood. Long history of alcohol misuse, history of domestic violence, fire setting and expressed some thoughts of sexual violence
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Admission not intended therefore nearest relative not required for the purpose of assessment.
Dr Horton knew Robert well and considers Roberts behaviour within normal range; no evidence Robert or others were at risk or support for mental health was required.
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Dr Horton knew Robert well and considers Roberts behaviour within normal range; no evidence Robert or others were at risk or support for mental health was required.
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Summary given that Robert stated:
* he was unhappy at Morewood and wants to move
* he's only meant to be there temporarily and already there 6mths
* feels LD social worker and placement staff are failing him
* assaulted three times this week but no action taken.
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* he was unhappy at Morewood and wants to move
* he's only meant to be there temporarily and already there 6mths
* feels LD social worker and placement staff are failing him
* assaulted three times this week but no action taken.
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Robert said he brought himself to attention of Police today not because he was in mental distress but because he wanted their involvement and action taken.
Decision to discharge from Section 136, he was offered a taxi home but stated he preferred to take the bus.
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Decision to discharge from Section 136, he was offered a taxi home but stated he preferred to take the bus.
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Outcome: LAEP (Local Area Emergency Protocol) referral completed by Paul Emerson, CLDT advised of outcome.
Coroner then read statement of Dr Andrew Horton, Consultant Psychiatrist @derbyshcft onto the record
He'd assessed Robert on 9 Jan with Mr McGill and Dr Rashid
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Coroner then read statement of Dr Andrew Horton, Consultant Psychiatrist @derbyshcft onto the record
He'd assessed Robert on 9 Jan with Mr McGill and Dr Rashid
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Robert under his care previously and was discussed at Amber Valley MDT Meeting on 8 Jan
Was taken to 136 suite on 9 Jan 2020
"Was aware he was shouting and ranting in the street and at times his head could be a mess"
He drank more over Christmas, this made things worse
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Was taken to 136 suite on 9 Jan 2020
"Was aware he was shouting and ranting in the street and at times his head could be a mess"
He drank more over Christmas, this made things worse
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"Living in Morewood was difficult as Robert reported being assaulted by another resident which unsettled him"
Robert wanted different accommodation.
He was "unhappy with limited support from professionals but agreed to support of Community Psychiatric Nurse"
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Robert wanted different accommodation.
He was "unhappy with limited support from professionals but agreed to support of Community Psychiatric Nurse"
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Assessing team discussed Robert’s presentation and agreed no indication for hospital admission, his medication could be reviewed in the community which he agreed to
Dr Horton considered that Robert “presented as he had previously” when under his care
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Dr Horton considered that Robert “presented as he had previously” when under his care
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Robert was not detained under the Mental Health Act as there was no immediate risk warranting admission.
Agreement was he’d receive community input, which would be the least restrictive option.
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Agreement was he’d receive community input, which would be the least restrictive option.
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The first live witness was Mr Igbal Mohammed, the @carequalcomm Registered Manager of Morewood Centre.
It seemed to me that Mr Mohammed said as little as possible in his answers to the coroner as he attempted to take him through his statement.
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It seemed to me that Mr Mohammed said as little as possible in his answers to the coroner as he attempted to take him through his statement.
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He has been the registered manager at Morewood since 2005. He told the court he’d worked in learning disability services throughout his career.
He described clients at Morewood as having “acute learning disabilities” asked to explain that further by the coroner he replied:
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He described clients at Morewood as having “acute learning disabilities” asked to explain that further by the coroner he replied:
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“The clients we get referrals for, could be on spectrum of autism, depending on where fall on that spectrum, would have acute learning disability or other end, mild learning disability.
So would depend on referral and client themselves".
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So would depend on referral and client themselves".
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"Robert would fall in the middle, depending on how he presented in his mental health, potentially leading to acute end of the spectrum.
He could also function day to day, was able to go shopping, do day trips, make day to day decisions without support”
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He could also function day to day, was able to go shopping, do day trips, make day to day decisions without support”
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Asked about the change in clientele that he, and his support worker colleagues, had referred to Mr Mohammed responded:
"I think part of that is services changed, Care Act, we do try to support clients we do get referrals for"
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"I think part of that is services changed, Care Act, we do try to support clients we do get referrals for"
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"When we get emergency referral if we don’t accept where will they go to?
They’re potentially homeless.
So as the local authority we’re not in a position to turn people away for short period of support, or long period of support"
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They’re potentially homeless.
So as the local authority we’re not in a position to turn people away for short period of support, or long period of support"
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On further questioning from the coroner about how suited Morewood was for supporting people with quite challenging behaviour, he stated:
“Again my colleagues touched on it yesterday..."
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“Again my colleagues touched on it yesterday..."
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"Jenny had 32yrs experience, Cath 20, myself 20, as a staff team, a skilled staff team, we are more than capable of supporting those …. complimented by our health colleagues and support from IST”
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Coroner said [reading statement]: you say traditional learning disability referrals remain, but you also receive frequent referrals for those with very mild LD.
They wouldn’t really fit into acute learning disability you mentioned towards the beginning of your statement?
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They wouldn’t really fit into acute learning disability you mentioned towards the beginning of your statement?
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C: Then you go onto say these clients’ primary issues are mental health related, challenging behaviours, drug or alcohol dependency issues, and increased difficulty managing collective risk arising in unit.
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C: Wld you say was noticeable difference in terms of referrals getting over few yrs prior to Robert’s death?
IM: I wouldn’t say noticeable, but clients we wld get in that wld require acute element of support. As I say we were skilled enough as a staff team to manage this
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IM: I wouldn’t say noticeable, but clients we wld get in that wld require acute element of support. As I say we were skilled enough as a staff team to manage this
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[I don't often add commentary to my inquest reporting, but I have to say this feels like a remarkably unaware statement to offer at the inquest into the death of someone, who died following a fight, in the service that you are the registered manager for]
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Coroner asked if were rules/contract for residents sign or alcohol policy
IM: There’s no alcohol policy… if a client wants to, and they have capacity, they can go to the pub and have a few drinks like anyone else. We’d encourage that as part of life skills, regular life.
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IM: There’s no alcohol policy… if a client wants to, and they have capacity, they can go to the pub and have a few drinks like anyone else. We’d encourage that as part of life skills, regular life.
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When pushed by the coroner about what happens if someone is getting into difficulty with their drinking, Mr Mohammed did not really respond other than to state that it’s
“difficult if they have capacity… if there was the potential for violence we’d call the police”
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“difficult if they have capacity… if there was the potential for violence we’d call the police”
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Mr Mohammed confirmed that Robert did not have an appointee for his finances, his mum sorted his benefits passing his money to the Morewood Centre, where staff would hold it and give it to Robert as he requested.
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Asked by the coroner about the frequency of resident assaults on each other Mr Mohammed replied
“they’re not unusual but equally so they do occur”
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“they’re not unusual but equally so they do occur”
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Asked about how the staff would respond, after initially resolving the situation Mr Mohammed said incidents would be discussed in handover meetings
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A week before Robert was assaulted he egged a neighbours car and put drink cans on the windscreen wipers:
C: did anything come of that in terms of discussions or meetings?
IM: No
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C: did anything come of that in terms of discussions or meetings?
IM: No
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C: I’m not sure if the Local Area Emergency Protocol meeting took place. Were there any meetings Morewood were involved with, with social care or mental health services, following Robert’s assessment on 9 January?
IM: Umm, I can’t recall
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IM: Umm, I can’t recall
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C: following that assessment it appears Robert is continuing to drink alcohol and certainly on 23rd it appears to an extent he’s intoxicated.
I think there’s also reference, not come to it yet, but in statement from the either the CPN or Social Worker who we will hear from
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I think there’s also reference, not come to it yet, but in statement from the either the CPN or Social Worker who we will hear from
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C: in relation to Robert stating he continued to drink after 9 Jan. Is it correct to say Robert was still drinking alcohol noticeably after?
IM: He would have a few drinks but he wasn’t always intoxicated
C: not always, but sometimes he was, after 9 Jan?
IM: I believe so
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IM: He would have a few drinks but he wasn’t always intoxicated
C: not always, but sometimes he was, after 9 Jan?
IM: I believe so
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C: would you agree that Robert being intoxicated was an issue of risk for him?
IM: Yes
C: in terms of his behaviour and other people’s reaction to him?
IM: Yes
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IM: Yes
C: in terms of his behaviour and other people’s reaction to him?
IM: Yes
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C: your colleagues yesterday noticed a decline in his presentation from that point, he continued to drink, sometimes to extent of being intoxicated.
I wonder whether that prompted thoughts of Robert’s safety and other people’s safety at Morewood?
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I wonder whether that prompted thoughts of Robert’s safety and other people’s safety at Morewood?
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IM: No, we continued with Robert. We had discussion with social worker around our concerns.
The social worker was actively looking for suitable placement for Robert.
C: so what concerns were voiced to the social worker?
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The social worker was actively looking for suitable placement for Robert.
C: so what concerns were voiced to the social worker?
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IM: Behaviours that have impact on other clients.
Fact he voiced he wanted to move from Morewood.
Recognising we needed to find suitable placement not just dump him somewhere else, but make sure he’s happy, involved in placement
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Fact he voiced he wanted to move from Morewood.
Recognising we needed to find suitable placement not just dump him somewhere else, but make sure he’s happy, involved in placement
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C: did that discussion reach the standard of saying we’re concerned for Robert’s safety and wellbeing, and safety and wellbeing of other clients? Did it get to that point?
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IM: Was always an element of risk to himself, throughout his life, even prior to coming to Morewood Centre because of his behaviours
C: I'm thinking period from 9 Jan, seems circumstances were quite changed, mental health may not be that stable… clashes with other clients
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C: I'm thinking period from 9 Jan, seems circumstances were quite changed, mental health may not be that stable… clashes with other clients
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IM: I think the clashes are around his personality, Robert not really valuing other people’s beliefs, not recognising other people there have requirements.
So the risk was always going to be there, particularly in group living.
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So the risk was always going to be there, particularly in group living.
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Coroner moved on to discuss Witness A
C: Can I ask you about Witness A’s needs and risks… were there any identified risks that Witness A in your assessment… Witness A presented to others?
IM: No, there was no history of aggression from him
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C: Can I ask you about Witness A’s needs and risks… were there any identified risks that Witness A in your assessment… Witness A presented to others?
IM: No, there was no history of aggression from him
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C: It seems on the 23rd, that he’s been perhaps bated or provoked by Robert?
IM: Umm
C: During the evening...
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IM: Umm
C: During the evening...
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C: ...also incidents earlier in day, where Witness A seems to become upset or angry, in exchanges between Robert and one of the women, maybe the two women I’ve just mentioned
IM: Yeh
C: He ended up reacting to that goading to some extent from Robert, towards him?
IM: Mmm
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IM: Yeh
C: He ended up reacting to that goading to some extent from Robert, towards him?
IM: Mmm
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C: there’s a description of Robert appearing to be intoxicated when he comes back from the pub, mentioned in Jake Smithhurst’s statement and also when we heard from Ms Thorpe yesterday.
Her evidence was he appeared to be intoxicated, in his behaviour.
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Her evidence was he appeared to be intoxicated, in his behaviour.
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Do you feel that Robert’s behaviour was influenced by a large degree by fact he’d been drinking, obviously you weren’t there but from what you’ve read and discussed with other people would you say that's a fair analysis?
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IM: I have to consider because Robert’s personality, even when he wasn’t drinking, was quite loud and vocal, he could come out with offensive comments.... Robert sometimes did that for a laugh without recognising the consequences
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C: would you agree there was greater potential for that if he had been drinking?
IM: Yes
C: Robert is given £30 I think by Jake?
IM: I believe so
C: he asks for that and is given that. Says he’s going to the pub doesn’t he?
Silence
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IM: Yes
C: Robert is given £30 I think by Jake?
IM: I believe so
C: he asks for that and is given that. Says he’s going to the pub doesn’t he?
Silence
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C: he’s given £30 do you feel that was a sensible thing for Jake to have done? It’s quite a bit of money to go to the pub with?
IM: Yes as I stated he’s got capacity, on that we wouldn’t be authorised to withhold his money.
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IM: Yes as I stated he’s got capacity, on that we wouldn’t be authorised to withhold his money.
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C: do you think Robert shd have been dissuaded? Or discussion about why don’t take less, do you think it's sensible to take £30 out?
IM: He’s an adult, so we have to treat him as an adult. We can negotiate and say Robert maybe use £10 but it’s his choice, we can only advise
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IM: He’s an adult, so we have to treat him as an adult. We can negotiate and say Robert maybe use £10 but it’s his choice, we can only advise
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C: Yes but do you think there shd have been a conversation?
IM: No, I wouldn’t have thought so.
No. Purely because he’s got capacity, quite often if he did take money out because he’s been recognised as hoarder, he wouldn’t spend all on alcohol, he smoked quite a bit...
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IM: No, I wouldn’t have thought so.
No. Purely because he’s got capacity, quite often if he did take money out because he’s been recognised as hoarder, he wouldn’t spend all on alcohol, he smoked quite a bit...
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IM: ...he’d buy tobacco, he’d come back with a walking stick or a watch or various other things he was interested in, it wasn’t just around his drinking
C: he said to Jake I’m going to the pub
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C: he said to Jake I’m going to the pub
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IM: He’d often say but would often go to a shop and focused on getting something he wanted as well
C: it appears his mental state may have been in some decline at that point, appears he was drinking perhaps more excessively around that period.
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C: it appears his mental state may have been in some decline at that point, appears he was drinking perhaps more excessively around that period.
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C: Also the arguments or altercations earlier in the day, putting all that together, do you think Jake should have said, not a good idea Robert, how about take less?
IM: We could advise
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IM: We could advise
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C: Do you think he should have been advised, appreciate don’t have power to say no can’t have money, but at least should there have been a discussion about it?
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IM: Yeh should have been discussion, where are you going, trying to use again de-escalation if we know there’s going to be a flashpoint, look at it from that point of view
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Later the coroner asked if there had now been any sort of agreement introduced in terms of expectations with clients around alcohol:
C: I appreciate clients coming to you have learning disabilities so you can’t simply give them a form saying read that, sign here, but...
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C: I appreciate clients coming to you have learning disabilities so you can’t simply give them a form saying read that, sign here, but...
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C: ...in terms of giving appropriate explanation in terms of what is expected of them in terms of behaviours, is there anything people now have to agree to?
IM: Ummm there’s always been expectation in terms of drink etc
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IM: Ummm there’s always been expectation in terms of drink etc
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C: have those been explicit?
IM: Not to my knowledge, there may be something in the respite guidance
C: but nothing explicit?
IM: No
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IM: Not to my knowledge, there may be something in the respite guidance
C: but nothing explicit?
IM: No
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C: what about now? Is there anything, I’m loathe to use these terms, agreement or contract, but i’m thinking along those lines? Is there now something, someone wants to come to you, you say if you come to us these are rules we expect you to keep.
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C: Is there anything explicit? They have to sign up to? Agree to?
IM: I’m not sure, if there’s anything, any policy etc
C: obviously you’re the @CareQualityComm registered manager, so given this, Mr Mohammed you should be aware shouldn’t you?
IM: I agree yes
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IM: I’m not sure, if there’s anything, any policy etc
C: obviously you’re the @CareQualityComm registered manager, so given this, Mr Mohammed you should be aware shouldn’t you?
IM: I agree yes
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C: do you know if there is?
IM: I’m not sure, no, I can’t say
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IM: I’m not sure, no, I can’t say
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One other thing that the coroner covered with Mr Mohammed was whether there was an admission policy.
When asked if there have been any changes since Robert’s death, this was how the conversation went.
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When asked if there have been any changes since Robert’s death, this was how the conversation went.
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C: have there been any changes you want to mention in relation to the arrangements at Morewood?
Silence
C: changes of the regime, as it were, at Morewood since Robert’s death, or admission criteria, those sorts of things?
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Silence
C: changes of the regime, as it were, at Morewood since Robert’s death, or admission criteria, those sorts of things?
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IM: Basically we had admission criteria prior to having the new admission policy, we now have a policy in place
C: You now have a policy, did you have a policy before then?
IM: No
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C: You now have a policy, did you have a policy before then?
IM: No
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C: so previously how did you regulate or specify who could be admitted and what type of needs could be met?
IM: We’d make an assessment on the information we’re provided by social worker or referring agency....
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IM: We’d make an assessment on the information we’re provided by social worker or referring agency....
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IM: We’d look at staffing, was something in place in terms of knowledge of service, what can we offer realistically. With policy coming it formalises what was already in place.
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C: so when did the admission policy come in to play?
IM: Last year, late last year, or middle of last year
Shortly after the Coroner finished asking his questions of Mr Mohammed court was adjourned for a short break.
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IM: Last year, late last year, or middle of last year
Shortly after the Coroner finished asking his questions of Mr Mohammed court was adjourned for a short break.
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We returned with one question from Mr Coburn for @derbysnhsft
AC: during the course of Robert’s stay with you, was there ever a point where his placement at Morewood broke down or was it a case of working through behavioural matters?
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AC: during the course of Robert’s stay with you, was there ever a point where his placement at Morewood broke down or was it a case of working through behavioural matters?
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IM: Continued exploration of his behaviours… given his behaviour wasn’t acute all the time, we were able to manage his behaviours
AC: so no? In terms of breakdown?
IM: No
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AC: so no? In terms of breakdown?
IM: No
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Next Mr Spencer, for @Derbyshirecc Mr Mohammed’s employer and provider of Morewood Centre
PS: coroner understood from what you said there was no admissions policy. The coroner has our action plan, that was in place, revised in July 2021, does that jog your memory?
IM: Yes
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PS: coroner understood from what you said there was no admissions policy. The coroner has our action plan, that was in place, revised in July 2021, does that jog your memory?
IM: Yes
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PS: would you like to correct what you’ve said to the coroner? Was there one [admissions policy] in place when Mr Chaplin came to the service?
IM: Yes
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IM: Yes
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PS: I know its difficult in the witness box, the coroner understands people are anxious.
Can you recall now what the admissions policy was? And what circumstances it would cover, circumstances when a patient would be discharged?
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Can you recall now what the admissions policy was? And what circumstances it would cover, circumstances when a patient would be discharged?
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IM: We'd have referral from referring body, risk assessment, have they got for instance an up to date care plan? If not we’d reject the referral.
If client was known to us we’d accept the client if regular users of our service.
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If client was known to us we’d accept the client if regular users of our service.
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IM: If the client wasn’t known to our service than the assistant director would make overall decision, with myself, in relation to recognising other clients we may have, and potential triggers may have.
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PS: policy was revised in July last year. What changes do you recollect now? Know is difficult in witness box. Do you recollect what changes were to policy in July last year?
<Long pause>
IM: I believe there was a template for risk asst, umm, outlining routes for referral
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<Long pause>
IM: I believe there was a template for risk asst, umm, outlining routes for referral
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PS: and today? How many clients or service users do you have at Morewood today? Its registered for 10
IM: We’ve got 6 clients in
PS: Is that because there’s a more cautious approach to taking service users or other issues unconnected with this case?
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IM: We’ve got 6 clients in
PS: Is that because there’s a more cautious approach to taking service users or other issues unconnected with this case?
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IM: Ummm, I don’t understand what you mean
PS: There’s potential suggestion, range, at time Robert was with the service, there was a number of challenging residents at the same time. I wanted to know whether you can help the coroner...
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PS: There’s potential suggestion, range, at time Robert was with the service, there was a number of challenging residents at the same time. I wanted to know whether you can help the coroner...
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PS: ...whether reduced number is reflection on review of the service to take fewer new people, or is it unconnected that there are fewer residents today?
IM: Its unconnected
PS: Do you have the same number of staff in place, with fewer residents?
IM: Yes
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IM: Its unconnected
PS: Do you have the same number of staff in place, with fewer residents?
IM: Yes
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PS: in terms of staffing numbers, was it your view there were a sufficient number of suitably qualified staff on duty at the time of this incident?
IM: Yes
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IM: Yes
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PS: the coroner, quite properly, has raised the issue of whether there ought to be some house rules.
I may inappropriately guide his thinking [?], but effectively a contract between this service and those who come to you.
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I may inappropriately guide his thinking [?], but effectively a contract between this service and those who come to you.
95/
PS: we know the service users who come to Morewood are particularly challenging.
You’re nodding in agreement to that, so record picks this up.
Is this right they frequently come from services where there’s been a breakdown, a previous placement?
IM: Not all the time
96/
You’re nodding in agreement to that, so record picks this up.
Is this right they frequently come from services where there’s been a breakdown, a previous placement?
IM: Not all the time
96/
PS: I don’t mean respite people, but a lot of the service users you take are challenging individuals where there have been difficulties with previous placements?
IM: Yes
97/
IM: Yes
97/
PS: I just want to understand if you have a system of house rules that may attempt to moderate behaviour, drinking or excessive drinking.
How successful do you think those rules would be? Or would it quite rapidly lead to breakdown in placement?
98/
How successful do you think those rules would be? Or would it quite rapidly lead to breakdown in placement?
98/
IM: It probably would lead to a breakdown rapidly, in terms of what we’d want.
PS: if that would rapidly break down, how do you manage risks around alcohol?
IM: Make referrals to colleagues
99/
PS: if that would rapidly break down, how do you manage risks around alcohol?
IM: Make referrals to colleagues
99/
PS: would the staff team talk to somebody? Leave aside Robert, would staff team talk to someone?
IM: Yes they would
PS: What steps would they take?
IM: Verbal conversation, would probably look at person centred work, give them documents
100/
IM: Yes they would
PS: What steps would they take?
IM: Verbal conversation, would probably look at person centred work, give them documents
100/
PS: and again, the coroner quite properly say’s, rather than give Robert £30 why not give him £10 or £15?
I understand the point you make about capacity.
Was there anything more could be done to ensure Robert’s drinking was kept within reasonable bounds?
101/
I understand the point you make about capacity.
Was there anything more could be done to ensure Robert’s drinking was kept within reasonable bounds?
101/
IM: We could have that conversation with him. Encourage him not spend as much, discuss budget.
If he smokes, maybe take £20 out… and he’d have £10 for tobacco
102/
If he smokes, maybe take £20 out… and he’d have £10 for tobacco
102/
PS: The coroner knows you were outside the jurisdiction when this occurred. To what extent were you aware of his drinking to excess or just drinking?
IM: Yes I was aware he used to drink
103/
IM: Yes I was aware he used to drink
103/
PS: What steps did staff take?
IM: I used to have conversations with Robert myself to dissuade him from drinking, and whole staff team would discuss.
PS: in drink would his character change, or worsen with drink?
IM: Probably worsen
104/
IM: I used to have conversations with Robert myself to dissuade him from drinking, and whole staff team would discuss.
PS: in drink would his character change, or worsen with drink?
IM: Probably worsen
104/
PS: Overall what would you say about his character?
IM: He was quite a boisterous character. Quite funny, quite ?? [can't hear] even though the behaviours others might find offensive, quite a ?? [can't hear] man
105/
IM: He was quite a boisterous character. Quite funny, quite ?? [can't hear] even though the behaviours others might find offensive, quite a ?? [can't hear] man
105/
PS: the coroner will hear evidence about difficulty placing Robert at other services.
If the contract you had with him was brought to an end, was there anywhere else suitable and immediately available for him?
IM: There was no suitable placement at that time
106/
If the contract you had with him was brought to an end, was there anywhere else suitable and immediately available for him?
IM: There was no suitable placement at that time
106/
PS: so you and the staff team were left in a situation where you needed to meet his needs, and also meet needs of other service users at Morewood at that time?
IM: Yes
107/
IM: Yes
107/
PS: Do you think the staff team did meet his needs, and meet the needs of others as best they could?
IM: Yes certainly
108/
IM: Yes certainly
108/
PS: This incident, while tragic… the coroner heard just one punch to neck… is that type of incident that sadly from time to time has to happen and you and staff at Morewood have to rise to the challenge of that?
IM: Yes from time to time clients do have altercations
109/
IM: Yes from time to time clients do have altercations
109/
PS: obviously immediate situation needs de-escalated, but what do staff team do in managing?
IM: We look at trigger for example, talked about de-escalation, what trigger led to altercation? Analyse the trigger. Might be in reports case was clash between other clients...
110/
IM: We look at trigger for example, talked about de-escalation, what trigger led to altercation? Analyse the trigger. Might be in reports case was clash between other clients...
110/
IM: could move to another floor, look at alternatives in terms of reducing behaviours.
PS: handover passed to one team going off duty to another coming on?
IM: Yes it is
111/
PS: handover passed to one team going off duty to another coming on?
IM: Yes it is
111/
PS: what advice would they be given to manage Robert and calm situation which escalated due to drink?
IM: We’d talk what led to initial behaviour. Team would advise we tried this approach and it worked, and try again.
112/
IM: We’d talk what led to initial behaviour. Team would advise we tried this approach and it worked, and try again.
112/
C: can I ask you something? I’ve been searching for the word, you tell me if its appropriate, summarised punch delivered by Witness A to Robert, your response essentially was ‘that type of incident, that punch was not an exceptional altercation...
113/
113/
C: ...not a daily thing but those type of incidents happen before’. Is that what you’re saying?
IM: We’ve had clients hit each other, yes
C: When was last time someone hit someone and they fell to floor?
IM: We’d not had incident where someone punched and fell to floor
114/
IM: We’ve had clients hit each other, yes
C: When was last time someone hit someone and they fell to floor?
IM: We’d not had incident where someone punched and fell to floor
114/
PS: you have evidence that female service user was pushed onto a chair and back slapped or punched in quick succession.
It's @Derbyshirecc case those are not unusual to Morewood but those are managed because we have a service user group that are challenging
115/
It's @Derbyshirecc case those are not unusual to Morewood but those are managed because we have a service user group that are challenging
115/
PS: and the alternative to them, is they’re on the streets, homeless and left to the NHS and police to pick up those difficulties.
This service is designed to meet challenging situations as best it can, they’re not unusual.
116/
This service is designed to meet challenging situations as best it can, they’re not unusual.
116/
C: Mr Mohammed, if one of your clients punched another client, would you automatically refer that to the police? How would you deal with it?
IM: We’d inform the safeguarding team, take instruction from them, contact CQC, fill in a body chart, assault form.
117/
IM: We’d inform the safeguarding team, take instruction from them, contact CQC, fill in a body chart, assault form.
117/
IM: ask the client if they have capacity what they’d like done.
C: Robert had complained, I don’t think we’ve anything specific to point to what Robert was complaining about, but when he was assessed on 9 Jan he mentioned he’d been, trying find word, struck in some way...
118/
C: Robert had complained, I don’t think we’ve anything specific to point to what Robert was complaining about, but when he was assessed on 9 Jan he mentioned he’d been, trying find word, struck in some way...
118/
C: ...by another client at centre, do you know what incident he was referring to?
IM: I’ve had a look into that. It was a verbal altercation
C: no blows or hitting? He said he’d been pushed or struck
IM: No. It was purely verbal
C: Purely verbal. Thank you very much
119/
IM: I’ve had a look into that. It was a verbal altercation
C: no blows or hitting? He said he’d been pushed or struck
IM: No. It was purely verbal
C: Purely verbal. Thank you very much
119/
PS: something arising from your evidence, statutory referrals... would you yourself also look at whether particular action needs taken as result of an incident?
IM: Yes
120/
IM: Yes
120/
C: on that point. Have you had to make any referrals to safeguarding and @CareQualityComm in relation to a resident striking another, say, twelve months prior to Robert being struck by Witness A?
IM: Yes
C: you had?
IM: Yes
121/
IM: Yes
C: you had?
IM: Yes
121/
C: you have. Off top of your head, how frequently would you have to do that?
IM: Not very frequently, but again depends on the clients using the service
C: one occasion? Five? Able to give a rough estimate of numbers?
IM: Probably two
122/
IM: Not very frequently, but again depends on the clients using the service
C: one occasion? Five? Able to give a rough estimate of numbers?
IM: Probably two
122/
C: Two over a 12mth period
IM: I believe so
C: just thinking in terms of frequency of these events, 2 over 12mth period, they’re not that common I suppose
IM: It really depends
C: so, do happen but not frequent
123/
IM: I believe so
C: just thinking in terms of frequency of these events, 2 over 12mth period, they’re not that common I suppose
IM: It really depends
C: so, do happen but not frequent
123/
At this point Mr Igbal Mohammed, @CareQualityComm Registered Manager @Derbyshirecc Morewood Centre was released.
At this point court adjourned for lunch.
124/
At this point court adjourned for lunch.
124/
In the afternoon there were two live witnesses, both from @derbyshcft
Joanne Haddon-Reichardt, Community Psychiatric Nurse
and Hannah Osgood, Clinical Operational Manager
I'll come back to their evidence in a while, I need to stop for a bit
125/ tbc
Joanne Haddon-Reichardt, Community Psychiatric Nurse
and Hannah Osgood, Clinical Operational Manager
I'll come back to their evidence in a while, I need to stop for a bit
125/ tbc
OK I’m going to try and keep these witnesses a little shorter. Just because I need to make my little sister’s birthday cake tonight and this always takes way too long and I’m never really sure if people even read such ridiculously long threads.
Onwards.
126/
Onwards.
126/
Joanne Haddon-Reichardt gave affirmation after lunch: I’m a registered mental health nurse, have been for 23 years. I work in a different role to what I did in 2020, at that time I was working with ppl with mental health difficulties that were complex or severe and enduring
127/
127/
C: Thank you. Robert fell within your care because of having complex mental health problems?
JHR: He’d been known to mental health services for quite a number of years. I wasn’t around at the time when services were transferred over to learning disability...
128/
JHR: He’d been known to mental health services for quite a number of years. I wasn’t around at the time when services were transferred over to learning disability...
128/
JHR: ...his consultant service in social care [?? hard to hear]. I remained involved to support monitoring his mental health and administer his monthly depot
C: Wonder if you could help me in trying to understand, different services involved with Robert...
129/
C: Wonder if you could help me in trying to understand, different services involved with Robert...
129/
C: ...and what yr understanding was in terms of how it was rationalised? For a number of different services to be involved with him, if that makes sense? It’s often difficult to understand the way services work together, if you cld help with that I’d be very grateful.
130/
130/
JHR: He’d been identified as having a mild learning disability and bipolar disorder, which falls within mental health services. We do see people who have got mild learning disability with mental health diagnoses as well. Obviously as I was explaining, he was seen by...
131/
131/
JHR: ...a mental health consultant psychiatrist but that was transferred over to learning disability services, obviously for monitoring his medication and altering prescriptions as required, then Morewood was where he was residing.
132/
132/
JHR: Then there was the intensive support team, as well, who were also kind of involved and had been for a number of years.
C: yes. Um, Robert didn’t have a community learning disability nurse did he, is that right?
133/
C: yes. Um, Robert didn’t have a community learning disability nurse did he, is that right?
133/
JHR: He didn’t no, we did refer to the Community Learning Disability nurse team, obviously within health.
Because he got a diagnosis of bipolar and his learning disability was seen to be mild, then that referral was rejected.
134/
Because he got a diagnosis of bipolar and his learning disability was seen to be mild, then that referral was rejected.
134/
C: because of the mental health diagnosis and it being considered his learning disability was mild?
JHR: Yes, bipolar was seen as the primary diagnosis.
C: How does that work as he had a learning disability psychiatrist, is that right?
135/
JHR: Yes, bipolar was seen as the primary diagnosis.
C: How does that work as he had a learning disability psychiatrist, is that right?
135/
JHR: yes, was quite difficult from my perspective. I could go monitor his mental health, administer his depot, keep an eye on other medications.
136/
136/
JHR: I said in my statement that’s where it became difficult, we’ve all got different policies and procedures we work to… would have felt helpful if there was an overarching document really
137/
137/
C: don’t know if you can answer.
Robert was referred to learning disability community team… they said no, don’t think he meets our criteria, then he had the learning disability psychiatrist.
Is that separate? Are those services separate?
138/
Robert was referred to learning disability community team… they said no, don’t think he meets our criteria, then he had the learning disability psychiatrist.
Is that separate? Are those services separate?
138/
JHR: I’d imagine they’re part of the same thing yes
C: that’s illogical really isn’t it?
JHR: Yes
C: You were keeping an oversight of Robert’s mental health and also administering his depot injection, for his bipolar diagnosis?
139/
C: that’s illogical really isn’t it?
JHR: Yes
C: You were keeping an oversight of Robert’s mental health and also administering his depot injection, for his bipolar diagnosis?
139/
JHR: It’s actually an antipsychotic medication, in historical notes is also reference to schizophrenia as well. That isn’t in more recent notes, but he was on antipsychotic depot and antipsychotic oral medication and a mood stabiliser
140/
140/
C: <queries drug name> was it used for epilepsy or mood stabilisation?
JHR: It can be used for both, but he was prescribed it for mood stabilising, for bipolar
C: so depot wasn’t for bipolar?
141/
JHR: It can be used for both, but he was prescribed it for mood stabilising, for bipolar
C: so depot wasn’t for bipolar?
141/
JHR: I assume was prescribed at some time in relation to his schizophrenia diagnosis. Mum from the off when I started working with Robert was concerned about amount of medication he was on… we were actively pursuing that, getting outpatient appointments, was being reduced
142/
142/
C: his depot was reduced at one point wasn’t it?
JHR: He was on 150, that’s the max
C: seems there were times Robert wasn’t accepting his medication, or not accepting all of it?
JHR: I’ve read that, I don’t necessarily agree with that statement.
143/
JHR: He was on 150, that’s the max
C: seems there were times Robert wasn’t accepting his medication, or not accepting all of it?
JHR: I’ve read that, I don’t necessarily agree with that statement.
143/
JHR: From depot point of view there was one occasion he refused depot because it was someone different, I was off sick or on leave and he said no.
Was another occasion when he’d had experiences of diarrhoea.
144/
Was another occasion when he’d had experiences of diarrhoea.
144/
JHR: He’d been to see his GP about it and the GP had said was potentially due to all medications he was on.
I explained he’d been on them for a number of years, wouldn’t suddenly start side effects.
145/
I explained he’d been on them for a number of years, wouldn’t suddenly start side effects.
145/
JHR: That’s what led to him refusing oral medication from Morewood staff… he thought about it over the weekend and did accept depot on the Monday, and I spoke to Morewood staff and he did accept oral medication
146/
146/
JHR: Medication he was refusing was laxido, which you wouldn’t take if you had diarrhoea anyway
[As an aside in questioning of registered manager by coroner, he stated Robert had started refusing to take his medication because his mother had told him he needed to stop...
147/
[As an aside in questioning of registered manager by coroner, he stated Robert had started refusing to take his medication because his mother had told him he needed to stop...
147/
[It’s clear from JHR’s evidence that it was actually on the advice of his GP but it seems inquests are never far from a spot of #familyblame]
148/
148/
The Coroner discussed Robert’s alcohol use/misuse with JHR
JHR: The alcohol was long standing. Some of my colleagues have said already, he could kind of over exaggerate the amount, it was very unclear how much alcohol he’d have.
149/
JHR: The alcohol was long standing. Some of my colleagues have said already, he could kind of over exaggerate the amount, it was very unclear how much alcohol he’d have.
149/
JHR: He’d say he got wasted but then say he only had a couple of pints. But he did see it as a problem, so we organised an appt with Derbyshire Recovery Partnership.
They very much work on premise of self-referral…
150/
They very much work on premise of self-referral…
150/
JHR: we went to one appointment, Robert came out of there and said I’m not going back there Jo. I think it was the way the worker approached the situation really, he was a very proud man, didn’t like to be talked down to.
151/
151/
JHR: Anyway we looked into AA. Thought that might be avenue to go down.
He had periods when he wouldn’t attend meetings, but periods when he did. He had periods he’d go without drinking alcohol, around about Christmas he talked about not drinking for two weeks
152/
He had periods when he wouldn’t attend meetings, but periods when he did. He had periods he’d go without drinking alcohol, around about Christmas he talked about not drinking for two weeks
152/
JHR: but then other occasions drank day to day. There was no clear pattern to it
C: You said it was difficult to gauge, but what was your overall impression, binge drinking on occasion?
153/
C: You said it was difficult to gauge, but what was your overall impression, binge drinking on occasion?
153/
JHR: Yes, alcohol use, reports said he was bored and lonely but it was more complex than that. He found socialising quite difficult in some respects.
He said he had a tankard in each pub, so that connected him. It gave him a level of acceptance, that we all need.
154/
He said he had a tankard in each pub, so that connected him. It gave him a level of acceptance, that we all need.
154/
JHR: He could be vulnerable within that situation, but equally got a lot of respect from those locations, as seen in tributes paid to him after his death
155/
155/
JHR confirmed that Robert wanted to move on from Morewood, when the coroner asked why she responded:
He said at times he felt like he’d been spoken to as a child
156/
He said at times he felt like he’d been spoken to as a child
156/
She said that the staff at Morewood knew Robert well, and he liked them, which was a positive. When the coroner asked if it was the right place for him she responded:
JHR: Was only ever going to be temporary. It wasn’t going to be permanent placement.
157/
JHR: Was only ever going to be temporary. It wasn’t going to be permanent placement.
157/
JHR: It was temporary, a good thing was obviously staff knew him really well, which safeguarded him in some respects, and Angela [social worker] was looking for placements
158/
158/
Asked about her concerns about how care for Robert was split between the learning disability and mental health teams, JHR said:
Split was mainly relating to community nursing aspects of it… from my perspective as mental health nurse
159/
Split was mainly relating to community nursing aspects of it… from my perspective as mental health nurse
159/
JHR: I don’t have training in relation, well I have an e-learning module in relation to autism, I don’t have that experience of working with people with learning disabilities
160/
160/
C: reading through this [JHR’s statement] the sub text, was it your thought, learning disability team should provide the community nursing?
JHR: To co-work yes,
C: not take over fully?
161/
JHR: To co-work yes,
C: not take over fully?
161/
JHR: No, there was also a mental health diagnosis, and learning disability diagnosis and I thought that would optimise care really
Coroner asked if JHR was invited to an urgent meeting following Robert’s MHA assessment on 9 January
162/
Coroner asked if JHR was invited to an urgent meeting following Robert’s MHA assessment on 9 January
162/
C: are you aware of any arrangements made for an urgent meeting?
JHR: It would have been emails just trying to coordinate a huge amount of people’s diaries which can be quite challenging
C: did you receive any notification of meeting?
163/
JHR: It would have been emails just trying to coordinate a huge amount of people’s diaries which can be quite challenging
C: did you receive any notification of meeting?
163/
JHR: I don’t think we got a date as far as I can remember
C: you cant recall a specific date was set up?
JHR: No, I cant 100% recall without going through my emails, but no
C: in terms of coordinating that, who would you think would be coordinator for that meeting?
164/
C: you cant recall a specific date was set up?
JHR: No, I cant 100% recall without going through my emails, but no
C: in terms of coordinating that, who would you think would be coordinator for that meeting?
164/
JHR: We’d have done that collaboratively
C: who would have taken the lead in that, would need one person to pull it together
JHR: I potentially would have done that yes
C: I imagine Robert was on CPA was he?
JHR: Yes
165/
C: who would have taken the lead in that, would need one person to pull it together
JHR: I potentially would have done that yes
C: I imagine Robert was on CPA was he?
JHR: Yes
165/
C: were you keyworker for that?
JHR: I was keyworker yes
C: did you take the lead?
JHR: I would have
C: you didn’t get to a suggested date?
JHR: Not as far as I remember, but as I say I’ve not been through my emails so couldn’t be 100% sure
166/
JHR: I was keyworker yes
C: did you take the lead?
JHR: I would have
C: you didn’t get to a suggested date?
JHR: Not as far as I remember, but as I say I’ve not been through my emails so couldn’t be 100% sure
166/
C: in your statement you don’t mention arranging a meeting do you?
JHR: No
C: just wondering, how sure you are that you were pursing that?
JHR: I am sure we were pursuing that
167/
JHR: No
C: just wondering, how sure you are that you were pursing that?
JHR: I am sure we were pursuing that
167/
C: would seem an important thing to put in a statement wouldn’t it?
JHR: Apologies, that’s obviously my oversight
168/
JHR: Apologies, that’s obviously my oversight
168/
C: another point Dr Horton put in his plan, along the lines of asking the support team, learning disability team, the trust team, to be involved, I think over next few days?
JHR: Yes
C: did you have any discussions with that team at all?
169/
JHR: Yes
C: did you have any discussions with that team at all?
169/
JHR: I cant think that we did
C: Robert wasn’t formally allocated to that team was he?
JHR: The Intensive Support Team, they were like the crisis team for learning disabilities, but he would contact them and he did
170/
C: Robert wasn’t formally allocated to that team was he?
JHR: The Intensive Support Team, they were like the crisis team for learning disabilities, but he would contact them and he did
170/
The coroner then asked Joanne Haddon-Reichardt, Robert’s Community Psychiatric Nurse, about what she knew about altercations between him and others
C: you’ll have heard reference to Robert having arguments, altercations with others staying at Morewood?
171/
C: you’ll have heard reference to Robert having arguments, altercations with others staying at Morewood?
171/
JHR: Robert told me was another female resident who threw a shoe at him, or hit him with a shoe, that was the one I was aware of
C: I was going to finish there, but one more question if I may.
172/
C: I was going to finish there, but one more question if I may.
172/
C: There were occasions where Robert drunk significant amounts of alcohol, was intoxicated on occasions.
From what you knew of Robert if he was intoxicated with alcohol, would there be any issues of risk to him or other people at all?
173/
From what you knew of Robert if he was intoxicated with alcohol, would there be any issues of risk to him or other people at all?
173/
C: in terms of effects on his behaviour or people’s reactions to that?
JHR: Difficult to say, he could be inflammatory, but he also had a real sense of respect for people as well and didn’t like the thought of offending anybody.
174/
JHR: Difficult to say, he could be inflammatory, but he also had a real sense of respect for people as well and didn’t like the thought of offending anybody.
174/
JHR: I suppose there cld have potentially been, if he said wrong thing to someone who didn’t know him, there’s potential for repercussions to that.
C: only reasonable if someone is intoxicated they’re less guarded in their behaviour, might say things wouldn’t normally say?
175/
C: only reasonable if someone is intoxicated they’re less guarded in their behaviour, might say things wouldn’t normally say?
175/
JHR: He did anyway as you’ve heard from my colleagues
C: do you think that might be amplified in a way, if he’d been drinking alcohol?
JHR: Yes potentially
C: thank you. Mr Spencer?
176/
C: do you think that might be amplified in a way, if he’d been drinking alcohol?
JHR: Yes potentially
C: thank you. Mr Spencer?
176/
PS: there were service users at Morewood, who were of mixed race and on occasions Robert, without alcohol, and sometimes with alcohol would use offensive language to them. Were you aware of that?
177/
177/
JHR: He could be offensive, I had heard him say things like that yes, but then normally what he would do is apologise. He’d have conversation with me where he’d be swearing, or make derogatory comments, and quickly afterwards he’d apologise for that.
178/
178/
PS: were you aware if he used inappropriate language to other service users would he apologise?
JHR: I wouldn’t know
PS: were you also aware he’d do that when he was out of drink, on occasion, and that would cause great distress to other service users?
JHR: Yes
178/
JHR: I wouldn’t know
PS: were you also aware he’d do that when he was out of drink, on occasion, and that would cause great distress to other service users?
JHR: Yes
178/
Mr Coburn for @derbyshcft checked with JHR if Robert had been offered a taxi after he went home from the Section 136 suite and she confirmed, he had but preferred to go home on the bus.
179/
179/
Mr Coburn checked when JHR assessed Robert, 5 days after the MHA assessment took place on 9 January, whether her conclusion was similar, that Robert didn’t require detention. She confirmed it was.
After few more points of clarification Joanne Haddon-Reichardt was released
180/
After few more points of clarification Joanne Haddon-Reichardt was released
180/
[OK, am gonna go bake cake and come back to the final witness once its in the oven.
Please do comment, share, RT, add your voice to the discussion. Thank you]
181/ tbc
Please do comment, share, RT, add your voice to the discussion. Thank you]
181/ tbc
OK, here goes, final witness of Day 2 of the inquest into Robert Chaplin.
Coroner calls Hannah Osgood, she swears an oath
HO: I’m currently Clinical Operational Manager of specialist autism team, working to set up new autism specialist service in the #nhs @derbyshcft
182/
Coroner calls Hannah Osgood, she swears an oath
HO: I’m currently Clinical Operational Manager of specialist autism team, working to set up new autism specialist service in the #nhs @derbyshcft
182/
HO: At the time of Robert’s sad death I was the Clinical Operational Manager of the Intensive Support Team, prior to that was a Speech and Language Therapist on that team working with Robert
Coroner asks how long she’d known Robert
183/
Coroner asks how long she’d known Robert
183/
HO: Robert was referred few times since 2015.
As clinician I supported him as SALT, later when managing team I’d speak to him when he called the on-call service if he called on a night I was on rota
184/
As clinician I supported him as SALT, later when managing team I’d speak to him when he called the on-call service if he called on a night I was on rota
184/
C: could you explain what the intensive support team is. Is it still operating?
HO: Yes, it used to be intensive treatment and support service, not IST
C: what’s its purpose and role?
185/
HO: Yes, it used to be intensive treatment and support service, not IST
C: what’s its purpose and role?
185/
HO: it sits in learning disability service and works as crisis team of sorts, for people with a learning disability or autism at risk of placement breakdown or hospital admission.
Works for short periods of time to support placements and prevent hospital admission
186/
Works for short periods of time to support placements and prevent hospital admission
186/
HO: Also on-call service if out of hours at risk, people can call and contact and receive support via the phone
C: at that time did the person need to be on the books of the team to receive a service?
187/
C: at that time did the person need to be on the books of the team to receive a service?
187/
HO: In terms of receiving referred planned care, would receive a referral and discharge after the episode finished, in terms of on-call no, anyone at risk of admission could access our support without referral,
188/
188/
HO: Which Robert did regularly, not because he was at risk of admission, but we’d often speak to him at 23:45 when he’d come back from the pub
C: so you were available for direct contact for clients?
HO: Yes
189/
C: so you were available for direct contact for clients?
HO: Yes
189/
C: so you were available for direct contact for clients?
HO: Yes
C: Robert didn’t fit that, but it was an open door policy?
190/
HO: Yes
C: Robert didn’t fit that, but it was an open door policy?
190/
HO: Yes at times, we’d support him with contracts…. we’d say try and call before midnight, because it’s not a staffed service, is on-call, at home in bed. We’d direct him back to more appropriate support, Morewood staff, we’d never leave him without support
191/
191/
C: we heard he was referred to learning disability community nursing team and told didn’t fit their criteria because in learning disability terms, he was mild, and thought primary issue was relating to mental health, so wasn’t accepted by them.
192/
192/
C: He did have a learning disability psychiatrist, but then he was able to access your service. How did it fit all together?
HO: there were definite flaws at that time which the Trust has recognised and now resolved to prevent things like that happening.
193/
HO: there were definite flaws at that time which the Trust has recognised and now resolved to prevent things like that happening.
193/
HO: Learning disability services in general can not have people just because they have a learning disability, in the same way if you broke your leg you wouldn’t keep seeing someone 5yrs later, unless your leg was still broken…
194/
194/
HO: referrals were coming through, have a learning disability, we want a nurse, without any clear guide of what for.
Think that was contributory factor to why referral wasn’t picked up, with systems in place now that would be explored more with phone-call and discussion
195/
Think that was contributory factor to why referral wasn’t picked up, with systems in place now that would be explored more with phone-call and discussion
195/
HO: We do work really closely in intensive support team with the learning disability community team to co-work cases as well.
There are also some new posts working into mental health from learning disability to bridge that gap to prevent these things happening in future
196/
There are also some new posts working into mental health from learning disability to bridge that gap to prevent these things happening in future
196/
C: are you saying with new arrangements, Robert would be allocated nurse, or its possible?
HO: Its possible, wld have been more discussions around what needed support for… would have been a lot more conversations, and people in place to start those conversations early
197/
HO: Its possible, wld have been more discussions around what needed support for… would have been a lot more conversations, and people in place to start those conversations early
197/
HO: We’d support him to come off the phone fairly quickly and seek more appropriate help like speaking to Morewood staff
There was acknowledgement support wasn’t brilliant, and it was something that Robert and Pam found useful, so morally wouldn’t close it down
198/
There was acknowledgement support wasn’t brilliant, and it was something that Robert and Pam found useful, so morally wouldn’t close it down
198/
C: so it gave his mum and dad a bit of support too
HO: Yes
C: paragraph 5 you say Psychologist King also raised team’s concerns around appropriateness of Robert’s accommodation, 1 Nov, that’s Morewood isn’t it?
199/
HO: Yes
C: paragraph 5 you say Psychologist King also raised team’s concerns around appropriateness of Robert’s accommodation, 1 Nov, that’s Morewood isn’t it?
199/
HO: Yes, if we have contact on-call we discuss case automatically in the weekly MDT meeting.
So we quite often spoke about Robert, there were sometimes he’d call every night.
200/
So we quite often spoke about Robert, there were sometimes he’d call every night.
200/
HO: We were concerned around the nature of provision, not that anything wrong with the service per se, but Robert struggled in big groups of people.
Although he was social, he needed his own space and contact with people on his own terms.
201/
Although he was social, he needed his own space and contact with people on his own terms.
201/
HO: The property was just too big, with too many people.
He was socially anxious, in an environment that could be quite volatile as we’ve heard today.
We didn’t feel that was great for him
202/
He was socially anxious, in an environment that could be quite volatile as we’ve heard today.
We didn’t feel that was great for him
202/
C: was that a concern along the lines of this is uncomfortable for Robert, not putting him at ease if you like.
Or did it also include he’s not comfortable or at ease, there could be serious issues for him or someone else?
203/
Or did it also include he’s not comfortable or at ease, there could be serious issues for him or someone else?
203/
HO: We were concerned the longer it went on might impact on his mental health and wellbeing.
Which looking through notes, hearing from others, seeing increased frustration he was exhibiting....
C: to extent potentially being an incident between Robert and another people
204/
Which looking through notes, hearing from others, seeing increased frustration he was exhibiting....
C: to extent potentially being an incident between Robert and another people
204/
HO: I’d never known Robert be violent but verbal altercations would be predictable for him in that environment.
205/
205/
HO: I was also not aware of the level of violence or aggression that appeared to be going on in the home at that time.
From what I’ve read reading through the bundle, that does concern me he was exposed to that.
C asks clarifying question [missed]
206/
From what I’ve read reading through the bundle, that does concern me he was exposed to that.
C asks clarifying question [missed]
206/
HO: Most people you don’t want living in environment where it's potential volatile… for his wellbeing, and as we heard from other people, Robert was lively in his interactions.
207/
207/
HO: I could see very easily how something could escalate that he got involved in.
That being said I’d never known him get involved in any violence.
C: your understanding was the psychologist raised team’s concerns with the social worker, Angela?
208/
That being said I’d never known him get involved in any violence.
C: your understanding was the psychologist raised team’s concerns with the social worker, Angela?
208/
HO: Yes, from team meeting we’d decide who is going to speak to Angela and would have been assigned to him as the person that day.
C: Through November seemed to be a series of contacts to service from Robert or his mother?
HO: Pam, yes
209/
C: Through November seemed to be a series of contacts to service from Robert or his mother?
HO: Pam, yes
209/
C: was that the usual pattern, or increased level of contact in November?
HO: It's probably less than had been in the past, to certain extent he was always on our radar but not to a worrying amount.
210/
HO: It's probably less than had been in the past, to certain extent he was always on our radar but not to a worrying amount.
210/
HO: when things were bad before he went to Morewood, or when he just got there, we’d support transition in there for him.
He’d call every night then. Fact we had no calls thru December we’d be thinking he was good.
C: so level of contact in November wasn’t an escalation?
211/
He’d call every night then. Fact we had no calls thru December we’d be thinking he was good.
C: so level of contact in November wasn’t an escalation?
211/
HO: No
C: In your paragraph 13 you mention Robert's mum leaving a voicemail saying Robert was verbally aggressive towards her. He didn’t want go back to Morewood, wanted to stay there. 5 days later, we know there was the Mental Health Act assessment of Robert
212/
C: In your paragraph 13 you mention Robert's mum leaving a voicemail saying Robert was verbally aggressive towards her. He didn’t want go back to Morewood, wanted to stay there. 5 days later, we know there was the Mental Health Act assessment of Robert
212/
C: Think you were in court, you heard me make reference to Dr Horton’s plan. Was that plan relayed back to your team? Specific point along lines of ask IST if can be involved for the next few days
213/
213/
HO: There was no mention in the notes from Jordan who took that call that request was made, and Jordan is exceptionally thorough. So I was surprised to see that in Dr Horton's report, because that’s not reflected in our notes
214/
214/
C: so no request received to follow Robert up over those few days?
HO: No, and our good practice is that we’d check in, but not that we’d received a request, no.
215/
HO: No, and our good practice is that we’d check in, but not that we’d received a request, no.
215/
C: I think you’ll be able to help us here I'm sure. The LAEP can you explain what that is and how it works?
HO: Yes, as part of, I’ll give you a load more acronyms, it's part of the CTR process, set out by @NHSEngland under Transforming Care
216/
HO: Yes, as part of, I’ll give you a load more acronyms, it's part of the CTR process, set out by @NHSEngland under Transforming Care
216/
HO: It's about supporting people with learning disability and autism not to go into hospital if don’t need to, part of that is LAEP process. It is basically an emergency MDT, it's supposed to happen pre Mental Health Act assessment.
217/
217/
HO: What should happen is a doctor, or whoever, is looking at the Mental Health Act assessment, they should call the LAEP first.
C: is there a designated person?
218/
C: is there a designated person?
218/
HO: There’s a referral process, the CCG manage them.
There’s a phone number you call it through, within an hour or so everyone should drop everything and get on the call, to see if anything can be done to prevent this person having a MHA assessment
219/
There’s a phone number you call it through, within an hour or so everyone should drop everything and get on the call, to see if anything can be done to prevent this person having a MHA assessment
219/
HO: We do see if someone is in 136 suite, assessments start happening before LAEP has happened. Or if someone is severely mentally ill, assessment shouldn’t not happen while commissioners are getting everyone on the phone.
220/
220/
HO: In case of Robert, it hadn’t happened before the assessment.
I surmise because in S136, as soon as he's deemed not appropriate for admission, the need for LAEP goes.
What would be good practice is a MDT, for same conversation, really, without commissioners chairing.
221/
I surmise because in S136, as soon as he's deemed not appropriate for admission, the need for LAEP goes.
What would be good practice is a MDT, for same conversation, really, without commissioners chairing.
221/
C: so Local Area Emergency Protocol is also used if placement is at risk of breakdown is that right?
HO: Depends where in country you are, have in the past, but focus is about hospital avoidance.
There’s a community CTR, similar function, but more planned.
222/
HO: Depends where in country you are, have in the past, but focus is about hospital avoidance.
There’s a community CTR, similar function, but more planned.
222/
HO: [CTRs] chaired by commissioners with an independent panel who can review what’s going on with the person.
You plan them weeks in advance, they’re a day long process.
223/
You plan them weeks in advance, they’re a day long process.
223/
C: in Robert’s case Section 136 assessment takes place, decision is no admission, so no LAEP required, but nevertheless an urgent MDT?
HO: Good practice would be an urgent multi disciplinary team meeting yes
224/
HO: Good practice would be an urgent multi disciplinary team meeting yes
224/
Coroner confirmed following 9 Jan MHA assessment, was email exchange about an urgent MDT,
C: I think you said urgent MDT, there's probably no definition of urgent is there?
HO: No, I would expect it to probably be quicker
225/
C: I think you said urgent MDT, there's probably no definition of urgent is there?
HO: No, I would expect it to probably be quicker
225/
HO: as things now stand have dynamic support register, another weekly meeting where anyone at risk of, @NHSEngland headed meeting, anyone at risk of hospital admission is rated red, amber, green and discussed in multi agency forum with health, social care and commissioning
226/
226/
HO: Now if MDT hadn’t been called already, would be pickled up at DSR now.
So we do have some assurance would happen now. We have the safety net of the DSR that would have picked it up
C: if had been MDT who would have been invited? IST?
227/
So we do have some assurance would happen now. We have the safety net of the DSR that would have picked it up
C: if had been MDT who would have been invited? IST?
227/
HO: Yes we were invited and wld have attended
C: Morewood, CPN?
HO: Yes, and GP if appropriate, consultant would be there, mum and Robert if he felt appropriate
C: that would consider?
HO: things like nature of placement, medication, support, future plans, risks
228/
C: Morewood, CPN?
HO: Yes, and GP if appropriate, consultant would be there, mum and Robert if he felt appropriate
C: that would consider?
HO: things like nature of placement, medication, support, future plans, risks
228/
C: Just going back a bit now, looking at your paragraph 16, relating to 17 January when understood, not sure if Robert had caused any actual damage to car, but had put some eggs on car?
HO: yes and tin cans on the windscreen wipers
229/
HO: yes and tin cans on the windscreen wipers
229/
C: he was agitated with your colleague he spoke to, lost his temper and put the phone down
HO: yes sometimes as he’d call for a release, that would happen. He’d call back and apologise and we’d speak to him a few more times.
230/
HO: yes sometimes as he’d call for a release, that would happen. He’d call back and apologise and we’d speak to him a few more times.
230/
HO: He didn’t like being aggressive with people. If he shouted at you on the phone he’d probably call you back twice to apologise
Because week before he’d been in S136, and he hung up, I contacted him.
231/
Because week before he’d been in S136, and he hung up, I contacted him.
231/
HO: I left a voicemail and asked staff to contact Joanne, pass it on to her as he wasn’t open to us, and speak to Morewood and check he was ok, considering what happened the week before.
232/
232/
C: don’t know if Robert knew who's car it was? He’d lost his temper with people supporting him, his parents, but was this a different situation? As far as you’re aware?
233/
233/
HO: Not really, because he was also a practical joker. Although it's not great egging someone’s car, I wouldn’t put it in the realms of escalation
Over to Paul Spencer for @Derbyshirecc
234/
Over to Paul Spencer for @Derbyshirecc
234/
PS: just one thing, the MDT, whose responsibility to take a lead would that be?
HO: I don’t know. If someone is open to the team, either Angela or Jo, I’d expect them to talk and decide
235/
HO: I don’t know. If someone is open to the team, either Angela or Jo, I’d expect them to talk and decide
235/
PS: I have instructions from Angela that it wouldn’t be for her to call an MDT
HO: I’d suggest anyone can call an MDT. It should be someone who’s open to them… in the past I’ve called them if things aren’t moving
236/
HO: I’d suggest anyone can call an MDT. It should be someone who’s open to them… in the past I’ve called them if things aren’t moving
236/
PS: so it could be you?
HO: It could, but we’d expect it to be someone he’s open to, to send an email
That's all from Mr Spencer. Over to Mr Coburn for @derbyshcft
AC: have you ever had experience of Robert exaggerating his drink?
237/
HO: It could, but we’d expect it to be someone he’s open to, to send an email
That's all from Mr Spencer. Over to Mr Coburn for @derbyshcft
AC: have you ever had experience of Robert exaggerating his drink?
237/
HO: Yes quite a lot, he’d often call on-call if he’d been to the pub. He’d say he’d had 40 cans and I’d say have you really and he’d say no, he’d had 2. It was part of the banter he had and how he liked to fit in with that culture in the pub.
238/
238/
HO: Majority of times he’d discuss how often he’d had a drink I’d question it and he’d say he was joking and having you on.
AC: Dr Horton's plan is for IST to be involved for couple of days. Are you able to predict what IST would do?
239/
AC: Dr Horton's plan is for IST to be involved for couple of days. Are you able to predict what IST would do?
239/
HO: No we wouldn’t pick up for a few days. Would need a specific plan and referral of what doing it for, would need to be a clear episode of care.
Doesn’t mean couldn’t do it quickly, could have phone referral but would need a reason.
240/
Doesn’t mean couldn’t do it quickly, could have phone referral but would need a reason.
240/
AC: a clear episode of care?
HO: Yes
AC: there's much talk of LAEP. Are you able to predict what outcome of that would be?
HO: I think Angela was looking for placement already, we wouldn't get one magically appear just because we were sitting in a room and wanted one
241/
HO: Yes
AC: there's much talk of LAEP. Are you able to predict what outcome of that would be?
HO: I think Angela was looking for placement already, we wouldn't get one magically appear just because we were sitting in a room and wanted one
241/
HO: There was regular meds reviews… altho good practice to come with coordinated plan and put timescales against it, the outcome is unlikely to be much different
AC: so no material change to the plan or circumstances
HO: No I don’t think so
242/
AC: so no material change to the plan or circumstances
HO: No I don’t think so
242/
AC: TY, no further questions sir
C: can I ask you, you’ve got a lot of experience of working with people with learning disability, if you find it difficult to answer please just say. On 23 Jan we heard about, were you in court yesterday?
HO: No
243/
C: can I ask you, you’ve got a lot of experience of working with people with learning disability, if you find it difficult to answer please just say. On 23 Jan we heard about, were you in court yesterday?
HO: No
243/
Coroner: Been reference to it with Mr Igbal, that there was some highly expressed emotion, some arguments, bit of pushing and shoving between residents and some of that involving Robert.
244/
244/
C: In the afternoon asks for £30 to goto the pub. He's given 30 and goes to pub.
Comes back, appears somewhat intoxicated when he gets back.
Do you have a view about everything going on for Robert over week or two prior, and those heated exchanges on the day?
245/
Comes back, appears somewhat intoxicated when he gets back.
Do you have a view about everything going on for Robert over week or two prior, and those heated exchanges on the day?
245/
C: do you have view whether you think he shd have been dissuaded from taking £30 to the pub?
PS: before witness answers, I don’t know to what extent this witness who has experience in other areas, is familiar working in setting like Morewood with ppl who have capacity
246/
PS: before witness answers, I don’t know to what extent this witness who has experience in other areas, is familiar working in setting like Morewood with ppl who have capacity
246/
C: no, point is Robert’s mental health, if working in Morewood, is just really whether she thinks giving Robert significant amount of money to go purchase alcohol is likely to be useful at that point of time
247/
247/
HO: I appreciate your concern some. Although I've not worked as a registered manager, my career has been advising registered managers. I’d say capacity is tricky around these things, we do need to support people in their unwise decision making...
248/
248/
HO: ...what I would say as caveat listening to people today, I think Robert was as equally disinhibited when intoxicated, as when not.
What I would say would be good practice if concerns around how much he was spending or taking to a pub....
249/
What I would say would be good practice if concerns around how much he was spending or taking to a pub....
249/
HO: Would be supporting him in writing collaboratively a care plan between the home and Robert to help lay out what he’d do at the pub, what he’d spend his money on, to support him in educational way. Could be supported by Joanna, Angela, any other professional involved.
250/
250/
HO: Rather than how much money is wise, would be about home or professionals supporting him making unwise decisions.
Having care plan all staff know about when Robert’s going to the pub, this is plan we can agree.
251/
Having care plan all staff know about when Robert’s going to the pub, this is plan we can agree.
251/
C: you’re not saying on that day, you’re saying in general, Robert's care plan arrangement could have been discussed with all relevant people involved with him, formulate a plan around money and going to the pub
252/
252/
HO: Yes that supports the support worker to have a conversation, 'remember in your care plan we said we’d try this or that', otherwise those conversations can be really tricky for support workers
253/
253/
Back to Mr Spencer for matter's arising
PS: just one matter. You’ve referred to Morewood twice as being a large service.
Its registered for 10. In comparison to other services in Derbyshire, with your extended knowledge do you consider it to be a large service?
254/
PS: just one matter. You’ve referred to Morewood twice as being a large service.
Its registered for 10. In comparison to other services in Derbyshire, with your extended knowledge do you consider it to be a large service?
254/
HO: Compared to historic institutions it's not, but general drive in care has been for smaller services… particularly when Robert has functioned in single living, other services might have two or three people
255/
255/
PS: thrust is smaller services. Do you agree those aren’t funded, meanwhile the regulator @CareQualityComm wants smaller services, there isn’t funding for them
256/
256/
HO: Massive problem across Derbyshire, it's well recognised there aren’t adequate services, they aren’t there. There's lot of work in social care addressing that
PS: are you aware Angela [social worker] had made extensive efforts to find alternative placements?
257/
PS: are you aware Angela [social worker] had made extensive efforts to find alternative placements?
257/
HO: Absolutely, don’t think was much more she could have done, she had worked very hard to find other services
258/
258/
C: we heard change in needs of people referred to Morewood... any thoughts about why that might be?
Would you say that’s perhaps reflection of the changes in availability, or lack of availability of placements, in that Morewood now gets referred people with higher needs?
259/
Would you say that’s perhaps reflection of the changes in availability, or lack of availability of placements, in that Morewood now gets referred people with higher needs?
259/
HO: I think people historically supported in places like Petersham and Morewood are now in small supported living, that don’t cost private providers much to run, people who are easy to support.
C: so perhaps higher support, but predictable needs?
260/
C: so perhaps higher support, but predictable needs?
260/
HO: Yes, complex in different ways, but not concurrent mental health needs, drugs and alcohol
C: those people are more difficult to place
HO: Yes, without getting political
C: might cost more
HO: Cost a lot more, risks are higher for private provider to take them on
261/
C: those people are more difficult to place
HO: Yes, without getting political
C: might cost more
HO: Cost a lot more, risks are higher for private provider to take them on
261/
HO: If private provider can house three people, really predictable who need specialist bathroom and regular support...
versus someone who might break all windows and police might be called and end up in hospital.
Then they’ll take the three predictable people
262/
versus someone who might break all windows and police might be called and end up in hospital.
Then they’ll take the three predictable people
262/
C: Yes. Mr Spencer I don’t suppose anything arises from that?
PS: it’s a national issue, I shouldn’t give evidence, rather than something limited to Derbyshire
263/
PS: it’s a national issue, I shouldn’t give evidence, rather than something limited to Derbyshire
263/
Hannah Osgood is thanked and released
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