Thread by @GeorgeJulian

Today was Day 3, and the final day of evidence (four witnesses) in the inquest touching on the death of Robert Chaplin

Area Coroner Peter Nieto sitting at Chesterfield Coroner's Court. Mr Paul Spencer represents @Derbyshirecc and Mr Andrew Coburn represents @derbyshcft

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Usual disclaimers apply, my reporting is based on notes I've taken contemporaneously, as accurate as I am able to be.

I've not live tweeted this inquest as I had no contact with Robert's family, and I won't live-tweet without their explicit permission/invitation.

2/

My #OpenJustice reporting is crowdfunded chuffed.org/project/openju…, thank you to everyone who supports.

I report to raise awareness of the premature mortality of learning disabled and autistic people, so thank you to those of you reading and commenting too.

3/

First witness today was Angela Cunneyworth

AC: Currently I’m a social worker employed by @Derbyshirecc. I work with the enhanced support team, and I worked in the enhanced support team at the time of the incident

4/

C: the enhanced support team is a specialist team which works with people with learning disabilities, is that right?

AC: That’s correct yes

5/

C: now, I think it would be very helpful if you could help me understand the split in roles and responsibilities between the mental health trust @derbyshcft, which also provides learning disability services doesn’t it?

AC: Yes

C: And the local authority?

AC: Yes

6/

C: @Derbyshirecc, I guess there's a lot of cross over I imagine? But you all have distinct responsibilities?

AC: Yes, ultimately as social workers we're responsible for doing the Care Act assessments and looking at packages of care and support for the clients we work with.

7/

AC: That’s quite a wide variety of packages we can put in place to support clients in the community

C: essentially Care Act responsibilities

AC: And case management responsibilities as well, yes

C: and arrangements where funding is required for services and support?

8/

AC: That would be our responsibility but also we have clients, because Robert had been in hospital under Section 3, there was Section 117 funding as well. Generally funding is split, we’d pay so much and the #nhs for want of a better description would fund it as well

9/

C: that’s something we’ve not touched on yet in this inquest

AC: No you’ve not, obviously Section 117 is only for people who'd been detained under Section 3

C: That was still in place?

AC: Yes he’d not been discharged from Section 117 no

10/

C: Robert wasn’t paying any contribution towards his placement?

AC: No under Section 117 there is no contribution no

C: he retained all his benefits?

AC: Yes, they wouldn’t have been affected

11/

C: you mentioned case management as well. For Robert he also had a mental health psychiatric nurse didn't he?

AC: He did yes

C: I heard from her y'day. He was under care programme approach, I believe CPN said she was care coordinator for the CPA arrangements and care plan

12/

AC: Yes

C: how did that work with you then? You mentioned your team also provides case management, how does that work when you’ve got somebody who’s got health input in terms of a CPA coordinator?

13/

AC: Its generally building that relationship with your health colleagues to determine which areas you’re going to be responsible for, ultimately we’d be responsible for Robert's social care needs, that’s not to say there's no overlap…

14/

AC: if work with someone with a mental health problem, it's good to know how that will affect them in the social care we do.

Me and Jo had a good relationship, would speak… I’d try to ring her or drop her an email

15/

C: so you thought you had a good understanding with the CPN around your respective roles?

AC: Yes, as Joanna said yesterday, she used to see Robert at least twice a week because of the underlying mental health presentation he had

16/

C: Sorry just to go back, enhanced support team, is that specific for people with a learning disability?

AC: And autism

C: And autism, yes. Are there any other teams that work with adults with learning disability?

17/

AC: We have area teams and there are workers who’ll work with people w learning disability in those teams.

We tend to get referrals when there are other complex behaviours, area teams have higher caseload than we do so we’re able to give enhanced level of support to client

18/

C: so people who need more contact and have higher support needs?

AC: Yes [fuller answer - missed]

C: paragraph 5 you explain what Robert's diagnoses were, mild learning disability, autistic spectrum disorder, bipolar affective disorder.

19/

C: trying tease out... what was yr understanding of Robert's main issues, problems?

AC: Because Robert been to mental health team before, my understanding was mental health was overarching presentation, obviously with autism diagnosis as well, they can interact quite a lot

20/

C: heard lot of information yesterday about Robert's background situation and he had a combination of supported accommodation and went to stay with his parents at times as well?

AC: Yes Robert had lived with his mum in past, he’d had a number of tenancies...

21/

AC: generally private landlords mum had arranged. I’d been aware he'd been at The Grove, assumed that was a council based tenancy because of nature described.

His last flat was a private landlord tenancy

22/

C: it seems he was on the edge of being able to live in his own place, but not quite able to sustain that?

AC: He needed support from someone else to be able to live independently

23/

There was a discussion about the potential for people to find Robert challenging

AC: I’m a social worker, I'm used to people, I didn’t find him challenging, but others in the community might

C: take him the wrong way, find him aggressive in his language?

AC: Yes

24/

Then the discussion moved to alcohol and how Robert presented after alcohol

AC: When I do my assessments we involved families because I like to be person centred, so I’d got a lot of background info from mum about how Robert could present when he’d had a drink.

25/

AC: Mum was concerned he did used to goto the pub and have a drink. She never said he drunk to excess but he would consume alcohol and that would affect the way he was with mum

C: would amplify his behaviour?

26/

AC: I think Jo described it as he’d become more disinhibited if he was under the influence… swear a lot more... make inappropriate comments to people

27/

We then heard about Robert living in his flat with support from personal assistants

C: He was getting support from some personal assistants but were difficulties in arrangements for support were there?

AC: Yes he had a couple of PAs, one called Paul, one Nathan.

28/

AC: There was an issue with Nathan. Direct payments are there to be used, they can be used by, so for instance mum was in charge of DPs, she’d employ PAs.

There was a problem with Nathan that was identified, which unfortunately mum served notice on Nathan’s employment

29/

C: Mum managed DPs, managed benefits as well?

AC: Yes that’s right

C: It wasn’t on an appointeeship basis?

AC: No it wasn’t. I had several conversations with mum about passing that responsibility onto another service, to try

30/

AC: the money could be a big issue between Robert and his mum.

Robert would become verbally aggressive towards his mum.

I did speak to her on several occasions about transferring that to someone, but she refused

C: as in who?

31/

AC: There’s an agency called Dosh and another @MoneyCarer, so they’d make sure Robert was getting his benefits, they could become deputies. So if Robert wanted a certain amount of money there were forms you filled in to get that authorised

32/

AC: for some people who struggle with finances is a good way of having a little bit of control and a little bit of monitoring

C: yes you mention deputyship there didn’t you. In your view do you think an application for deputyship would likely have been successful?

33/

C: what I’m asking is do you think it could be argued Robert didn’t have capacity to manage his own finances?

AC: There is a capacity assessment on our system that does acknowledge Robert did lack capacity in relation to his finances

34/

AC: so yes, we could have applied for deputyship but obviously mum could contend that application if we went down that route

C: what was Robert's mum’s attitude to that? Did she say no its ok I can do it?

AC: That’s what she said yes

35/

C: I imagine that was a bridge that needed to be crossed at some point

AC: Yes, it would have been very challenging

C: but if Robert had moved on from Morewood would need to have been managed for him?

AC: Yes would have been that ongoing line of conversation with his mum

36/

C: if Robert had his own money do you think he wouldn’t have been able to manage?

AC: He wouldn't be able to pay bills... he could do basics but when it came to, the capacity assessment did show...

C: he wouldn’t have known to put money aside, no?

AC: No

37/

Discussion then moved on to Robert's last flat

AC: so that couldn’t be sustained, it broke down, well it didn’t break down, mum served noticed and the rug was pulled out from under our feet to some extent.

38/

AC: At that time when Robert was struggling, and there were issues with PAs, we were looking at perhaps providing a package of support from community organisation... while we found another PA

C: did he go back to his parents as interim arrangement then?

39/

AC: The plan in May was Robert to goto Morewood for a period of respite because we were having troubles with PA and having conversations with mum about agency coming in around PAs to sure up where wasn’t support. Robert was going in for respite until got care package sorted.

40/

AC: As Robert went into Morewood for respite, that’s when mum served notice on the flat

C: then you mentioned Shirebrook Apartments [?], some people thought would be good option for Robert, but that didn’t work out because Robert and his mum didn’t think so?

41/

AC: That placement was initially sourced by Philip [?], everything had gone through, funding was agreed, at the last minute mum and Robert said no. We revisited again in January, but again unfortunately

C: mum was less keen?

42/

AC: I think it was the distance, but to be fair the distance might have been a positive

C: so back with his mum and dad and things start to get difficult?

AC: Robert would always gravitate back to his parents, they’re his mum and dad at the end of the day

C: Yes

43/

C: you mention Cherry Tree, that’s a rehabilitation hospital?

AC: Yes I think that was mentioned by mum at the time

C: was sense from mum he needed somewhere more supervised?

AC: Yes I think that’s what Pam thought, yes

44/

C: you mention Robert going to the pub, but also say he was quite vulnerable to exploitation by others?

AC: Yeh I think mum was voicing concerns about some of the people he might have been in touch with at the pub

45/

C yes, so following notice on flat you say your efforts to seek out suitable alternative accommodation continued relentlessly

AC: Yes. The plan was not for Robert to be at Morewood for a prolonged period of time....

46/

AC: We have a list of available accommodation within our Supported Living providers, so I was looking at those as potential alternatives

C: Yes, what were the stumbling blocks for him, or difficulties, in finding alternatives for him?

47/

AC: Lots of the provision we have is for, very long established Supported Living placements, and the providers that work and provide support there, tend to work more with your generic learning disability client.

48/

AC: Not with people who have, I think you described it as needs you can, I wont say low level needs but not complex behaviours that Robert could present with… might be they need support with personal care needs, prompting, physical disabilities, but generally more low level

49/

AC: Not with the challenging behaviours that Robert could present with

C: Robert fell almost two main areas of difficulty or needs, mental health and learning disability

AC nods

50/

C: in short you’re saying there aren’t many placements that would provide for somebody with Roberts needs?

AC: No, unfortunately there isn’t. We are now fortunate now we have what we would call enhanced care providers.

51/

AC: Providers who have no problems working with people who present with challenging behaviours.

Their staff are trained to work with more challenging people.

52/

AC: Whereas places, if you were looking at generic learning disability residential placements, for people with Robert is the risk police would be called all the time, with enhanced care provider the expectation is police aren’t the first point of call, would have MDT meeting

53/

C: what's the usual solution in these circumstances, get own tenancy and get support in?

AC: Under Building Right Support, guidelines we work under, the government would like everyone with learning disability and people who come out of hospital to have their own front door.

54/

AC: Provides extra level of support, tenancy and care provider should be separate. If you run into problems with care provider can bring in other care providers. If notice served on tenancy then you’re protected…

55/

C: so you need providers experienced in people with those sorts of needs

AC: It gives you that safeguard

C: are there many of these providers around?

AC: No not really, not as many as there are for people with a generic learning disability, no

56/

C: would they tend to be people who support people with mental health problems generally, but say can also work with people with learning disability?

AC: Generally providers who can work with people with learning disability, autism and mental health, go hand in hand

57/

Coroner asked whether might have been a benefit to Robert having a community learning disability nurse

AC: Sometimes having community learning disability team can be helpful, they come from that perspective of learning disability, it might have been beneficial

58/

C: does your team and trust learning disability service have the same criteria for accepting people into services? When I say criteria, I’m saying definition

AC: Of learning disability? No we don’t

C: you don’t have same thresholds or criteria?

AC: No, no we don’t

59/

C: Robert’s stay at Morewood becomes a temporary stay, evolves from respite to temporary stay?

AC: Yes that’s right

C: did you feel Morewood was able to meet Robert's needs?

AC: Yes

C: the clientele that Morewood had seemed to change noticeably from about 2018

AC: Yeh

60/

C: hearing what you’re saying about ppl w more predictable LD needs, as opposed to people with milder LD with additional problems such as MH needs or substance misuse. Was that yr observation? Don’t know if you worked with them before that point?

AC: No, no, I cant comment

61/

C: Robert did have similar mix to what I described, you thought Morewood was able to meet his needs in all those respects?

AC: Yeh I had good rapport with Igbal, if there were any issues he’d have contacted me and we’d have discussed how to support Robert.

62/

AC: We had a really good MDT around him too

C: others at Morewood with similar problems, maybe some a bit more volatile at times, were you aware of other people with those needs?

AC: I was aware of Witness A because I work with Jess, and I'm X's case manager at the moment

63/

C: did you have any concerns about that mix if you like?

AC: Not me personally, obviously I cant speak for my colleagues who were working with some of the other clients

64/

C: volatility between those people could boil up into arguments, perhaps a little bit of physicality as well, were you aware of those?

AC: I was aware of the altercation between X and Robert, and the fact Robert had been moved upstairs which I thought at time was good plan

65/

C asks Angela Cunneyworth if she was concerned about mix of people at Morewood

AC: Not necessarily, because obviously there were extra levels of support for X at that time

C: what about Robert's use of alcohol if you put that into mix as well, whilst he was at Morewood?

66/

AC: The problem with Robert's alcohol intake was there was no set pattern to it.

Robert could go long periods of time where he wouldn’t have any alcohol.

I think at that particular time, Robert might have gone out a little bit more...

67/

AC ...to kind of socialise and to perhaps get away from Morewood, because of the altercations that were taking place at that time.

It might be Robert went to the pub more at that particular point of time.

C: did you think his use alcohol presented more risks?

68/

AC: Meetings I had with Robert, generally conversations we had about alcohol, and I knew Jo was supporting him go to AA.

I was having open conversations, generally encouraging him to goto AA, they were positive steps for Robert if was issue around amount he was drinking

69/

C: to be clear by tje time of Robert's death, there wasn’t a probable placement identified for him. You were still exploring options?

AC: No. He was on the waiting list at Tree Tops but they were full at that time, they’d have had to assess Robert

70/

C: but there were still ongoing efforts to find places?

AC: There were yes

Next discussion moved onto the Local Area Emergency Protocol/Multi Disciplinary Team meetings not taking place following Robert's MHA assessment on 9 January 2020

71/

C: the last witness yesterday said ideally MDT meeting should be arranged reasonably quickly, in a week or so, obviously it didn’t happen like that

AC: No it didn’t

C: can you remember what the difficulties were in getting that organised?

AC: No I cant sorry

72/

C: what issues would that have covered?

AC: We would have been looking at issues at Morewood at that particular period of time.

Part of what I’d be doing is pulling together a placement spec, we’re looking for a service but what does it need to look like.

73/

AC: For me as Robert's social worker it was about finding placement where he could stay and have a good life.

You want that for your clients ultimately.

It would be a collaborative approach to what is it we’re looking for

74/

C: you say meeting would have taken place but unlikely would been major changes for Robert very quickly after the meeting, in terms of placements

AC: That's right

C: because there wasn’t a placement on the table was there

AC: No there wasn’t

75/

C: do you think it could have looked at whether Robert needed additional input or support?

AC: Yes could have looked at that, whether there was additional support we could have offered Morewood at that time

76/

C: do you think might have focused on Robert's mental health given the MHA assessment and his presentation on mental health, we heard of some decline

AC: Would have looked at mental health, wld have looked from autism perspective and learning disability perspective as well

77/

C: but no quick change in relation to placements?

AC: No, no

C: we were looking yesterday at Robert being given some money on 23rd, after he said I want money to goto pub.

78/

C: He was given significant amount of money really in terms of amount of alcohol cld potentially purchase with that money, do you have any thoughts about that?

AC: When you were having that conversation yesterday, I did recall myself and xxx had conversation with Robert

79/

AC: ...in some point in June to help Robert around managing his money.

Asked how much money he needed on a daily basis. Robert said £70 a day, that was obviously a no no, we needed to be realistic.

We had conversation and agreed on £25 a day, didn’t have to spend every day

80/

AC: he’d come each morning, ask for £25 at Morewood and he'd be given that.

That worked to a certain degree, but we couldn’t manage Robert going to the bank and drawing money out, he might go to his mum’s and demand money from her.

81/

AC: Probably with Robert, you have to look at the broad spectrum of risk.

If we limit money he could go to his mums and put her at risk. He could go to the bank.

C: did he have his own bank card?

82/

AC: I don’t know.

The people at the bank knew him very well, he could go and withdraw money.

Might have had a debit card as well

C: so, discussion about money management, was that formulated in a plan?

83/

AC: That was a verbal agreement between Robert and myself, and [cant hear] was involved as well

C: there’s nothing written, no contract?

AC: I have a case note but there’s no written agreement

C: wld that have helped?

84/

AC: Robert would have to sign it and agree it, but it might have helped if he’d agreed, yes

C: thank you

No questions from Mr Coburn. Over to Mr Spencer.

PS: one issue, the learned coroner asked you about the meeting in January after the MHA assessment

AC: Yes

85/

PS: You may recall you were asked the question ‘had there been a meeting,… is it right it's unlikely be any major changes’ you agreed with that.

I recorded you saying that’s right. They’d be no changes in accommodation at that time

86/

PS: you went on to say you’d look at whether needed more support, coronial proceedings are not about hindsight, was your view at that time he needed more support or was the support in place adequate to meet his needs?

87/

AC: The support in place was adequate for Robert, for Robert it was adequate at that time, yes.

But would it have helped Morewood, because of clients there, might have been as part of MDT could have looked at putting in extra support

88/

PS: X had her own 2-1 members of staff

AC: Yes

PS: did anyone from Morewood come to you and say needed additional support?

AC: No

PS: did you discuss with Morewood

AC: I didn’t no

PS: was it because Robert needs were being met at Morewood

89/

AC: Robert's needs were being met at the time by Morewood staff

PS: Coroner taken you through your involvement with Robert since 2018. Coroner identified with you initially Robert had his own privately rented accommodation.

90/

PS: In October 2018 you were looking at Shirebrook Apartments, you’ve given evidence about that, you then looked at Cherry Tree, Parkwood, Maple Mews it that right?

AC: Yes

91/

PS: there was then the placement at Morewood, you continued to look for other placements, including Clay Cross [?] whether that might be suitable

AC: Yes

PS: then Tree Tops

AC: Yes Robert was on the waiting list for Tree Tops

92/

PS: then you were looking at Ashleigh?

AC: Yes I did visit Ashleigh, unfortunately that was deemed not appropriate

PS: you went to extensive efforts to try and find placements to meet his needs

AC: Yes

93/

PS: and either they weren’t suitable, or a combination of Robert and his mother would intervene to object to a placement that you thought was suitable and had been found

AC: Yes that’s true

PS: those are my questions sir thank you very much

94/

Coroner thanked Angela Cunneyworth and released her.

[That was first witness Day 3. Are three more, but I'm knackered and we're not in court tomorrow until 2pm (for Coroner's summing up and conclusion) so I'll stop now and return tomorrow with the rest]

95/ tbc tomorrow

[Morning all, back to it, this reporting covers the final three witnesses to give evidence at the inquest into the death of Robert Chaplin, yesterday, Day 3

The coroner is summing up and concluding this afternoon]

96/

Coroner calls Jessica Sims who swears an oath and confirms her signed statement is hers.

Coroner reminds court we're referring to the person she is referencing as Witness A [there's an anonymity order in place to protect their identity]

JS is employed by @Derbyshirecc

97/

JS: At time in question I was social worker, also with enhanced support team, working with adults with learning disability and autism.

The team has developed and focus now on delivering services in community not inpatient settings...

98/

JS: ...as result of that all of our roles have become more complex over time

C: that was your job at the time?

JS: Yes, I’m still in the same team, but now I'm a senior practitioner, very similar role but provide supervision to colleagues

99/

JS confirmed she was, and still is, Witness A's social worker.

When asked if she'd like to add anything to her colleagues description of how their team works, she responds

JS: Possibly, we've had extensive training in working with clients with challenging behaviours

100/

JS: we're very skilled in delivering positive behaviour support plans, trauma informed plans, we write very detailed assessments

C: in relation to Witness A could you summarise please, what Witness A's main needs and issues were around Jan 2020 time

101/

JS: Yes, his main needs at the time are very similar to what they are now, his primary needs are around harm to self and anxiety with low level environmental damage.

He needs a large amount of emotional reassurance.

102/

JS: he can go to staff throughout day and they have to provide the reassurance he needs, which Morewood were very good at

C: what are his reactions in stressful situations? How would that affect him?

JS: You can read it in his face...

103/

JS: You can see when Witness A is anxious. He responds very well to staff redirecting him. As he did at the time of the incident, he did take himself outside for a vape, he can seek reassurance, he was a very anxious person

104/

C: he could become more anxious in environments with more heightened emotions? [think he said, note is a little hard to decipher, apologies]

JS: Yes, he’d find that very unsettling and become very anxious

105/

C: he’d himself use techniques and would follow advice from staff, in terms of taking himself out

JS: Yes that’s correct. We’d done work on removing himself from a situation, and he’d seek support from staff

106/

There was a discussion about Witness A's age at the time of Robert's death. He was 18

C: As young person, under 18yr old he’d been receiving services is that right?

JS: He had, he’d lived in a children's residential placement with other young adults

107/

JS: he was a looked after child, at the time he was 18 he’d taken the decision he’d live back at home with his mum and two younger siblings

C: yes. He was a looked after child but also had clear care and support needs?

108/

JS: Yes he has adult care and support needs around his learning disability and autism

C: which, obviously child care services were involved with him as a young person, did he have input from any others services, child and adolescent mental health services, CAMHS?

109/

JS: Yes they were involved, didn’t need too much involvement.

Was a settled period when Witness A was 18, he did have some involvement post-18 from CAMHS, which was really helpful as they knew him best.

They did a couple of joint visits with me to support him and his mum

110/

C: did he have a transition plan?

JS: Yes I knew him for a year prior to turning 18. I knew his needs, had good relationship with his children's social worker, we had a care plan in place for him turning 18

111/

C: that’s social care. He didn’t transfer to adult mental health services?

JS: He didn’t. CAMHS felt he didn’t need to, and they knew him best

C: there was a pending referral to mental health services?

112/

JS: Yes IST supported Witness A with move to Morewood, then felt risk was low and wasn’t needed.

Around December time Morewood re-referred and that was pending

C: that was to adult mental health?

113/

JS: IST

[NB: I think terms IST intensive support team and EST enhanced support team are being used interchangeably - not 100% but I think they're the same team]

C: was he not waiting for a psychiatrist?

JS: He was already open to psychiatrist, he’d had medication review

114/

C: What was the referral in December for?

JS: Witness A had made reference to self-harm and it was to support him with his mental health

C: and that was back to IST?

JS: Yes

C: Thank you.

115/

C: Witness A's formal identification of problems, diagnoses, included mental health problems?

JS: Anxiety and depression, ADHD, learning disability, autism and OCD

C: when he turned 18 he went back to stay with his mum, is that right?

116/

JS: He did. Prior to 18 he moved back to his mum, that was a joint decision between children and adult services that was the appropriate move

C: that was her choice, his choice?

JS: They both wanted that to happen

117/

C: his mum thought she’d benefit from some respite is that right?

JS: Yes Witness A can be quite intense with his need for reassurance, and giving the same correct answer through the day and night is a challenge.

118/

JS: It's not something an individual parent could reasonably manage, so yes overnight respite was assessed as the right way to go.

C: things got to a head didn’t it, to a point where his mum said I cant cope with this?

JS: Yes she said I cant cope with this any longer

119/

C: your paragraph 7, mum couldn’t cope, he ended up staying with a variety of people. You arranged for him to go to Morewood as an emergency admission on 15 Nov, short term admission and he went back to his mums at Christmas time?

JS: That’s correct yes

120/

C: after that was plan to have respite, was that weekly?

JS: Yes, the original plan was one night a week, we reverted back to that

C: was that going to be, not a long term, but a medium term arrangement to continue with one night a week?

121/

JS: Yes that could have gone on as long as was necessary.

As it was Witness A and his mum wanted to consider Supported Living, we started to explore that

C: that would take a while?

122/

JS: It would take a while, process had started but was no immediate need at that time, it was a longer term plan

C: when you say he’d had issues previously with using substances, but that was not as a regular thing?

123/

JS: No not regular. No addictions, no particular concerns, it wasn’t an aggravating factor on the day

C: No. Primary risks, in risk assessment, is self-harm?

JS: Yes that remains the case

C: did you feel Morewood would meet Witness A's needs?

124/

JS: Yes I witnessed Morewood meet Witness A's needs very well, good case management

C: No concerns whatsoever?

JS: No, no concerns

125/

Coroner asks JS if/what she knew about the other residents at Morewood

JS: I had good knowledge of Robert, X and Y, as had been an altercation that affected my client

126/

C: so you’re aware at times there were altercations, and at times they’d bubble up to physicality?

JS: Yes that’s common. I was content with the safety plan in place following safeguarding alert with X and Witness A, I had no concerns

127/

C: imagine in situations where people might be arguing and shouting, pushing and shoving, that would cause him to be quite anxious would it?

JS: It could cause him to be anxious, yes

128/

JS: I do believe events earlier in day added to his anxiety, but I believe he listened to staff well and followed their instruction

C: Before 23 January, is it right there hadn’t been any incidents of Witness A being directly violent or anything else?

129/

JS: We had to search. When I worked with him wasn’t aware of anything. Low level, he doesn’t have a criminal record, he still doesn’t have a criminal record, wouldn’t flag anything

C: so you weren't aware of any?

JS: No no

130/

C: although you do say had been incidents of him damaging property if he was frustrated or anxious?

JS: Low level property damage, punching walls, throwing fire extinguishers. What I describe as low level, but not pulling radiators off walls or smashing windows

131/

C: what would be the purpose? To release anxiety, or to warn other people I’m anxious and stay away?

JS: Both. He describes it quite insightfully as both

132/

C: Don’t know if it's a conversation you've had with him at all.

Had he ever indicated he was anxious, for example, he’d smashed a pot or threw a cup or something.

If whatever it was made him anxious, the stimulus continued, had he ever indicated what would happen then?

133/

JS: Yes his techniques would be to seek staff support, or go outside for fresh air

C: if he damaged something, but what was making him anxious continued, did he ever say what would happen then?

JS: I’m not sure on that no

134/

C: was just any occurrence where he’d done that, but things would carry on, got more anxious?

JS: No, the peak of the event is usually he’d throw something, or punch wall, and then calm down.

This was more prolonged and out the ordinary

135/

C: so whatever he did would promote a response from people?

JS: Yes, and someone would meet his needs, yes

136/

C: following the incident on 23 Jan 2020, was Witness A moved to another location?

JS: He was bailed back to his mum’s house over the weekend, incident being a Friday. That lasted a short period of time, then we moved him to a similar service to Morewood

137/

C: similar set up?

JS: Yes a @Derbyshirecc run respite centre

C: and he remains at that placement now? I’m not asking for location or name at all, just what the set up is now for him

138/

JS: Yes.

He remained at the placement similar to Morewood for 9 months, during that time he benefitted from an action plan, Better Lives team, he now lives in Supported Living [describes].

He hasn’t put anyone at risk since he’s been there, other than himself

139/

C: wld you describe that as a less restrictive placement? I'm not suggesting Morewood was restrictive

JS: No Morewoord wasn’t restrictive, but Supported Living is a less restrictive placement

Shared staff during the day, five 1-1 hrs during day

140/

C: so certainly hadn’t gone to anywhere with more supervision or oversight?

JS: No, no and he still shares with others

C: he’s not subject to any restrictions

JS: No DOLS, no restrictions

141/

No questions from Mr Coburn for @derbyshcft

Over to Mr Spencer who represents @Derbyshirecc

PS: just one area, @derbyshcft conducted their own investigation, for their own lesson learning purpose.

142/

PS: Obviously the evidence given about their findings is not evidence for the coroner, the findings and actions were.

Can I ask you were you contacted as part of that?

JS: I was not contacted

143/

PS: That report came through yesterday evening to us, I make no complaint about that.

Can I ask have you had an opportunity to read that?

JS: Yes, I read that last night

144/

PS: You’re named as one of the key people involved in the incident. The root cause at 2.4 is said to be the lack of appropriate residential provision in Derby, Derbyshire

The coroner has explored that, is difficulty in finding placement for people at significant need

145/

JS: yes, absolutely. That’s national finding, not specific to Derbyshire

PS: Other finding was clients living in arrangements not suitable to live with each other.

Coroner has explored how Witness A came to live in Morewood, was it suitable service to meet Wit A's needs?

146/

JS: It was. It's registered to meet needs of clients with challenging behaviours, and met needs very well

PS: a contributing factor transition from child mental health services to adult mental health service needed to be more effective for joint needs.

147/

PS: Is that a matter for you or solely for the trust?

JS: I did see good practice where CAMHS did do joint visit with IST and myself to support Witness A and his family

148/

PS: you said to the coroner was quite significant transition period between CAMHS and adult services, about which you were involved?

JS: It was extensive between children social care and adult social care

149/

PS: so did you have any concerns about transition from children social care to the service you’re involved in?

JS: No, no concerns

150/

PS: also says contributory factor environment not equipped to support individuals with challenging needs, do you agree or disagree with that?

JS: Disagree with that… good staff with training and oversight from a very experienced management team

151/

PS: sir those are my questions

C: thank you very much for coming to give evidence, if you need to leave court you’re welcome to do so. Now

PS: sir timetable, we’re well on track can I invite you to have a short break before we do

C: was just going to suggest that...

152/

[I'm going to take a short break, make a brew, deadhead the hanging basket outside my front door and water it before the sun gets too hot.

Will be back shortly for the last two witnesses. If anyone is still reading this, thank you for doing so]

153/ tbc

Next witness Stuart Clensy @derbyshcft, gives an affirmation

C: you’re going to give evidence in relation to the Trusts’s internal review in relation to Witness A and also the review in relation to Robert. Wonder if you could explain your job role please

154/

SC: Currently I'm Area Service Manager for Inpatients, Forensic Services and Short Breaks for Learning Disabilities across @derbyshcft and @DCHStrust

Coroner checks if he'd any involvement with Witness A or Robert's. He'd been at a referral meeting for Witness A in Dec19

155/

C: perhaps if we start with Robert then. In relation to both reviews, what was it that prompted the reviews?

SC: It was triggered by the seriousness of the event, and internally we do to see if lessons learnt and issues with our systems

156/

C: just looking at this, you were part of the team, or group who carried out the review?

SC: Yes

C: you were coordinator for the review and writer of the report?

SC: The vast majority of it, yes

157/

C: ok, in relation to Robert then.

We've heard quite bit of evidence about Robert's background and history.

You do provide a background summary of social history and service contact.

158/

C: To produce the report, provide that information, you’ll have gone through trust's records and then consulted with key people who had contact with Robert is that right?

159/

SC: Yes initially I was asked to do a paper top exercise, due to us being in the first wave of covid and impact on services.

Initially desk top exercise... later changed to interviews

160/

C: yes. The way these reports work, is there, reports shared with families and carers are they?

SC: Eventually yes

C: and are comments invited back on the report, or people can respond if they wish?

SC: Yes

161/

C: did you have any responses from Robert's mum?

SC: X who was on report, finalised report at end, due to my changing role, I had given feedback to teams

C: was there anything identified by Robert's mum, that you felt were outstanding issues or comments?

162/

SC: I’m not aware of any

C: just thinking best way of doing this really, we’ve heard lot of info about Robert already. Let me just see.

Coroner summarises and SC agrees

163/

When the coroner asked about Robert's problems with alcohol, and whether that was SC's understanding, he added in a concern he had around Robert's physical health

SC: Can also add in physical health, scoliosis, seemed to be a growing line of issues with his physical health

164/

Discussing Robert's support, and difficulty with tenancies

SC: Yeh it would fluctuate, I think there was a stable period in early 2000s when he had warden facility and meaningful activities, felt that was the most stable period in his life...

165/

SC: ...and reduction in substances, he’d have one or two pints, rather than few more. That was the most stable in his mood and behaviour

C: unfortunately the warden was stopped and that led to it not working

166/

SC: Yes there seemed to be a fall out, but the model seemed to be working for him

C: problems with maintaining his tenancies with support, difficulties identifying suitable placement for him to move to.

167/

C: Seemed to be some apartments identified for him with support. He was unsure, his mum didn’t seem to be in favour, in terms of distance primarily. So that didn’t proceed and he ended up going to Morewood.

168/

C: initially as an emergency placement, that then became intermediate placement pending finding something suitable and right for him. Is that it in a nutshell?

SC: Yes, while the search continued for more appropriate placement for him

169/

C: At the time of his death Robert was on the waiting list for a placement called Treetops, waiting for bed become available and to be assessed. There were also still efforts to find other placements for him?

170/

SC: Yes, and I would concur with the social worker about difficulties locally and nationally with specialist placements for such complex people

C: in terms of input, Robert had mental health input primarily through his @derbyshcft CPN?

SC: Yes

171/

C: he’d had an informal arrangement with the IST.

I think he probably pushed that arrangement, but he’d contact them if he thought he needed to talk.

And they provided contact, for his mum to contact in stressful times as well?

172/

SC: Yes, I think historically they’d been codependence used and Robert had an open referral

They were trying to move away from that codependence to more specific pieces of work

But that structure of Robert calling IST if he wanted to talk and offload, was always there

173/

C: and from the local authority @Derbyshirecc he had a specialist learning disability social worker allocated to him didn't he?

SC: Yes

174/

C: he was attending AA groups, or in contact with AA, but also referred to alcohol services but didn’t want to take that up I think?

SC: That’s correct. Although I did get from reading notes he attended AA more as a social event rather than in order to change behaviour

175/

C: he ended up staying at Morewood because wasn’t advisable for him to go back to his parents and essentially there was an ongoing search for an appropriate placement.

176/

C: In yr review, you’ve looked I suppose at the adequacy of services provided to him, nature of services, how appropriate they were and whether there's anything you can identify in what was provided to him that may be relevant to, I’ll call it the incident, on 23rd

SC: Yes

177/

C: Anything particularly you identified?

SC: The feel, Morewood and how he came to Morewood felt that was the best option.

But that doesn’t mean that it met Robert’s needs ideally, you know.

178/

SC: The search to move forward, to have a person centred approach is what we’d be looking at. A service more specifically tailored to his needs

C: so, little option but for him to go to Morewood at the time, first occasion, had to go somewhere safe

179/

SC: Yes it was the best option on the table

C: but you didn't feel it was the right placement in terms of meeting his needs?

SC: No. But with parameter of demands and issues with providers, it was the best option

180/

C: in relation to your comment Morewood didn’t fully meet his needs, would that be fair comment in terms of your thought?

SC: I think that, we would be looking at a service that would be meeting his needs much better, that would be ideal moving forward.

181/

SC: Looking at the complexity of him, and changing physical health needs, I think there’s a different look to what we’d have had a year ago for Robert.

There was clearly a change in his physical health

C: yes

182/

C: in terms of that comment about Morewood not meeting his needs.

Is that couched in terms of didn’t meet his needs so therefore shouldn’t be at Morewood.

Or saying didn’t meet needs fully but had to be Morewood because nowhere else to go?

183/

SC: Second one, met some of his needs, didn’t meet them all, but it was the best option on the table

C: in terms of needs it did not meet, you’ve mentioned the physical difficulties becoming more predominant

SC: Yes

C: you don’t feel that need was necessarily met

184/

SC: The structure and routine in that ward.

Earlier was clear structure [for Robert], but less structure and routine at Morewood

C: as in what sort of things?

185/

SC: If you have structure, routine and activities meaningful for you you wouldn’t necessarily be looking to goto a pub to escape activities

C: even mundane things like doing personal tasks, like sorting and cleaning your space, shopping?

186/

SC: Yes or gardening, I think in 2001 gardening was a really big activity, that was part of search for future accommodation, linked into an allotment

187/

C: do you think that’s something Morewood could have provided?

Or should have been from other people working with Robert could have tried to address?

Suppose he could have been linked up to gardening group external to Morewood or other group?

188/

SC: Challenge for Robert would be his ability to travel if it wasn’t on his doorstep, don’t know if he’d have engaged with it

C: we heard he found he was socially anxious in groups at times

189/

SC: Problem with social disorder is you misinterpret social cues and suddenly start to feel awkward in social situations.

I'm hypothesising, that may be why he sought to drink alcohol, to dampen some of that…

190/

C: so if you like having a plan for day, structure at Morewood. Any other areas where you feel his needs weren’t met?

SC: No, I think staff were caring. When I spoke to manager Igbal was a real warmth

PS: I’m sorry I'm struggling to hear

191/

SC: There was a real warmth, that was something I got from everyones notes. About Robert.

C: what about the mix of residents. We heard number of people at Morewood at same time as Robert with other similar needs, could be clashes of personalities as well

192/

SC: This is always the case with complex people, we place them with other complex people, that causes clashes and issues with that.

Larger the establishment the more clashes that’s likely to facilitate.

193/

SC: We would also say Witness A, being 18, his needs would be very different to someone Robert’s age. who’s 49

C: yes there's more in review you did in relation to Witness A, but quite an age span in terms of residents

194/

SC: Yes and if you have such a wide ranging group, ideally you’d be looking for other people with similar interests to accommodate with similar age group

This is the issue when the options on the table are limited

195/

C: are they the main points you’d make in terms of where you saw Morewood arguably didn’t fully meet Robert’s needs?

SC: Yes

196/

C: obviously the incident, issues you consider in terms of relationship to your analysis of what happened, what was provided, and whether you say any of that as contributory or leading to incident itself.

197/

C: Did you make any connection between the issues you outlined and the incident that occurred?

SC: Umm, I don’t think I could have predicted that incident from looking at the profile of Witness A and Robert.

198/

C: you've mentioned you feel if Robert had had more structure to his day and his week, that might have discouraged him from drinking as often, or as much.

Is there anything, any comment you’d make in terms of access to alcohol, or access to money isn’t it?

199/

C: And then if was known he’d purchase alcohol was there any issue in that you’d see?

SC: I suppose the problem is that Robert deemed to use alcohol to befriend people and form relationships, in the community, which is ideally what we want.

200/

SC: Its how we use alcohol in a sustainable way, and people’s liberties really, and where do we intervene

C: you don’t make a particular issue out of that as such in terms of how it's managed?

201/

SC: I think I would have liked to see closer working with substance teams and those people involved, to see if there was ways we could liaise

C: Robert seems to have declined the alcohol service involvement

SC: Yes

202/

[This evidence from Robert's CPN for comment on this

https://twitter.com/GeorgeJulian/status/1546926730132295681

... perhaps the workers/service's ability to make reasonable adjustments to work with people with a learning disability might play into this, not simply a straight decline. I don't know]

203/

C:anything else you’d say in relation to areas where you think things should have been done differently or have you covered that really?

204/

SC: There’s improvements we could have done differently, and there was things we were aware of at the time.

That we were moving to improving the referral triage process, was piece of work being worked on at the time

205/

C: does that relate to this issue about CPN referring Robert for Community LD nurse?

SC: Yes, sometimes what we have is a referral coming in and a response letter going out.

206/

SC: What was put in place couple months after the incident was a contact of a clinician, so dialogue could be had.

C: so not just a rejection?

SC: a discussion and engagement and finding of what people wanted

207/

SC: the first referral to the learning disability team was simply ‘Robert has a learning disability’

c: no detail

SC: there was no detail, or what was being sought, no

208/

C: so not necessarily case decision made Robert didn’t meet criteria for that service, was more along lines of what task or issue do you want us to address?

SC: yes it was what was the purpose of the referral, and what specific need?

209/

c: yes. Was hoping to move onto any changes considered or implemented.

You’ve covered one there, referral process and triages system.

If you don’t get a clear, if request isn’t clear, there isn’t an automatic rejection would be a conversation

210/

SC: yes, or phone up the triage person and have a dialogue, and they’d help you formulate your referral

C: wider context here, difficulties with provision and also funding as well.

211/

C: some things might want to change may not be so easy to do. Other than that triage point any other things done or changes?

212/

SC: we’ve moved to a new electronic system with the community mental health team and learning disability team have come together with, and we’re moving to one care plan system there

[think those were the teams he named]

213/

SC: We’re developing pathways, and we’ve formed an alliance with another trust so we provide an equitable service across Derbyshire

C: one care plan where someone has social care and mental health needs, one care plan right across?

214/

SC: Within @derbyshcft would be one plan, could have physios, OT etc

C: it wouldn’t extend to local authority @Derbyshirecc social work?

SC: Not at this moment, no

215/

C: I understand care plan may have different purpose in the local authority, but would be benefit I suppose in having one document even if it had six different components?

SC: Totally. Would be an aspiration to have a shared care plan across the system

216/

C: I think you identified, you goto a root cause identification of root cause don’t you. That’s in relation to the placement is it you feel?

SC: I feel that there’s a shortage of suitable accommodation for people with complex needs, nationally and locally

217/

C: in terms of the incident arising from the placement. I suppose as a matter of fact it took place in the placement didn't it?

SC: Yes

C: So you cant escape its linked to placement.

218/

C: In terms of placement being causal. Can you go that far? Or is that circumstantial?

SC: I think its circumstantial, but if you put people with complex needs together

219/

C: in terms of what Morewood cld have done about things given situation was in.

Those people had to be there, nowhere else for them to go.

Do you think is possible Morewood cld have done anything more to stop what happened from happening?

SC: Not from my interpretation

220/

C: It's more about circumstances?

SC: Yes, yes

C: in relation to availability of placements, I suppose that’s a difficult issue, to put it lightly

221/

SC: It's complex.

There’s system wide response looking into it.

There’s funding, I think as Angela put it you can choose to have less complex people, less demanding on services, so people often choose that.

222/

SC: The cost of accommodation and availability of such accommodation.

The recruitment of staff, since covid shortage of available staff and recruitment significant delaying factor.

Than enticing providers into area that are approved at set standard

223/

C: thank you.

One thing I missed, we know Robert was taken to S136 suite on 9 Jan.

He wasn’t admitted.

Should then have been an urgent, or fairly swift MDT meeting.

That didn’t happen by the 23 Jan

SC: yes

224/

C: We heard from Ms Cunneyworth, the social worker for Robert, there wasn’t a very clear agreement in terms of whose responsibility it was to coordinate that meeting

225/

SC: In place now is a thing called the Dynamic Risk Register, which meets weekly to look at cases and RAG rates of people’s risks.

People are able to come together, it’s a health and social care, across Derbyshire system, where solutions can be discussed and moved forward

226/

C: urgent cases if you like, pressing matters?

SC: Anyone RAG rated at amber or red, which is at risk of admission or placement breakdown

C: so now that situation is happening now. Are you saying Robert's case would be considered within that process?

SC: Yes

227/

C: that’s a weekly meeting is it?

SC: Yes that’s weekly, would have been escalated to that

C: who would be responsible for bringing that to the meeting though?

SC: Any member of the MDT that’s involved would have brought that to the meeting

228/

C: After assessment of Robert at the 136 suite. Would it be for the assessing psychiatrist? Or AMHP? Or?

SC: I'd expect either the CPN, or social worker, or learning disability nurse, or the IST

229/

C: there's still room for ambiguity there, in terms of who is picking it up. They’d all say I thought you were doing it.

SC: We’d say you can always over-refer but we wouldn’t sometimes, don’t always have nurses involved or social workers involved...

230/

SC: ...so wouldn’t be down to one specific professional. We wouldn’t say is always learning disability nurse's responsibility to refer.

C: who would you say would be primary coordinator in situation such as Robert?

231/

C: he’s got a CPN, learning disability social worker. They’re two main people who had contact with him on coordinator type basis, so who would you think?

SC: I’d have thought the CPN. The Care Programme Approach coordinator, which is the CPN in this case

232/

C: because they’re the care coordinator of the CPA?

SC: Yes

C: thank you very much

Over to Mr Spencer

233/

PS: Mr Clensy, I think you know I ask questions on behalf of @Derbyshirecc. Good afternoon <checks watch>, no good morning to you

C: sorry I just realised we didn’t do Witness A's report, we'll do Robert and come back

234/

PS: As far as the process is concerned for your reviews, the documentation you reviewed is listed 2.1 on p22 of 35.

This is review in respect of Robert, you look at electronic patient records, emails between health and social care services?

SC: Yes

235/

PS: You then look at trust policies, your internal policies?

SC: Yes just internal

PS: Then you say this root cause analysis, utilised for purpose of this investigation, human factors approach considered throughout this review, we'll come back to that.

236/

PS: For purposes of Witness A what documentation was looked at for analysis? Is it the same type of documentation?

SC: Yes

PS: can the coroner take from that you did not look at witness statements prepared for purposes of this coronial investigation?

SC: No

237/

PS: So you didn’t have those.

Going back to investigation in respect of Robert, you identify key people involved in the incident, para 1.7 p 21 [lists names]

Not one of those individuals agreed to speak to you as part of your investigation. Do you agree?

SC: Yes

238/

PS: for purposes of investigation into Witness A we see those listed p11 [lists names]

Coroner heard from two of those witnesses, of those who spoke to you for the purposes of your investigation

Did you attempt to contact Jessica Sims?

239/

SC: I contacted her manager to see if she wanted to engage in the process

PS: did you specifically ask her?

SC: No

PS: Can I ask why not?

SC: Because at the time was asked, was for table top review initially

240/

PS: do you accept firstly as result of not speaking to vast majority of key individuals, particularly those the coroner is speaking to, not having access to coroner statements, that your review prohibits you from reaching forthright conclusions of potential root causes...

241/

PS: and limiting factors?

SC: It has limitations yes

PS: do you think you’d have benefitted from hearing the evidence given to the coroner on Monday and yesterday?

SC: Yes

242/

PS: can I ask why you weren’t present to hear that evidence as your view might change?

C: Mr Spencer I know there’s some linkage in processes, but they’re separate aren’t they. The review and this process.

PS: you think that’s an inappropriate question?

243/

C: I understand the question about why Mr Clensy didn’t contact people for the purposes of the review, but access to statements, that’s a different process

PS: they’re an IP, they have access to them, in terms of reaching forthright conclusions

244/

C: can see arguable need to contact everyone with key involvement with Robert. There wasn’t consultation with everyone was there, I understand that point

245/

PS: can I deal with it this way, as result of the gaps identified, information you’d have liked, the coroner ought to approach with some caution your contributing factors you identified?

246/

SC: I'd have air of caution regarding them, I’d always have air of caution on one side of review [cant hear]

PS: pursuing this have you visited Morewood?

SC: No that wasn’t part of it

247/

PS: do you think it wld have been helpful to visit Morewood to have understanding of environment, staff team and services users post event? Wld that have been helpful for you?

SC: Not with brief of what I was asked to investigate, no.

PS: I see. Thank you very much indeed

248/

[Sorry, I have to go grab my neighbour's paper and grab some breakfast, will then come back for more from Mr Clensy]

249/ tbc

Over to Mr Coburn for @derbyshcft

AC: Thank you. I’ll take you to [can't hear] and we may come back to the report.

Would you be able to update the court of the liaison post with learning disabilities?

250/

SC: As part of reviewing our systems internally we have put in learning disability and what we’d call neuro-developmental services, autism and learning disability support, for inpatient services and community mental health teams

AC: what do they support with?

251/

SC: Reasonable adjustments and understanding people’s learning disability and autism and how that impacts, and overshadowing

AC: do they help with referrals?

SC: They can, and they would guide them in to refer to appropriate teams and what we’d be looking for

252/

AC: so as you transition from one

SC: Yes, transition, but also as resource base, rather than put referral in, have you tried this to make more accommodating

253/

AC: it's identified that you weren’t here for yesterday's evidence.

In questions to Ms Osgood I asked whether she could see reasonable adjustment to package of care Robert received, if there was a Local Area Emergency Protocol [meeting]

254/

AC: she said from mental health perspective she couldn’t see any change in care package. Are you able to add to that or not?

SC: I'm not

AC: in terms of the dynamic risk register, who is around the table?

SC: Senior clinical leads from health, social care and the CCG

255/

AC: health providers, social care providers, commissioners?

SC: Yes

AC: in terms of the report itself, and one you conducted for both. You spoke to Mr Igbal, did he furnish you with details about Morewood?

256/

SC: Yes.

He was very happy with the support he received from health and couldn't see any flaws or limitations.

They were available as and when needed.

The only issue he highlighted was referrals to Morewood. He had very little say in the people he was able to accept

257/

AC: in terms of root causes and contributory factors, are you looking at service improvements or death?

SC: Mainly making services better as we move forward

258/

AC: so list is how as an organisation and system we can improve?

SC: Yes. Can can we get better? How can we deliver better services

AC: Thank you, I don’t have anything else

259/

C: Mr Clensy, my mistake, we didn’t cover the report for Witness A.

I’ll paint a pen picture:

We heard Witness A, as a child was placed away from his family as a Looked After Child.

He had diagnoses of, quite a list actually...

260/

C: just going back to what anxiety, depression, obsessive compulsive disorder, autism, learning disability and ADHD

SC: Yes

261/

C: We heard just before he got to 18 was agreed for him to go back to live with his mum. Which he did, and she found it quite difficult to cope with amount of support he needed, particularly in terms of reassurance.

262/

C: So she wasn’t able to do that any more. Short period time staying with various ppl, then placed at Morewood as emergency placement for 2wk period.

Then negotiated with his mum to go back, and have one night week respite at Morewood

263/

C: with longer term ambition to find him a Supported Living placement in due course?

[Not sure if this was C or SC]: Overwhelming issue was anxiety, might lead to minor, smashing items, but he’d usually take himself out the way

264/

SC: I’d go to say the worst risk was he’d target himself and self harm.

The breaking or damage, in reviewing his notes, is any confrontation he had in situation.

If anyone threatened him he’d go and self harm as a result

265/

SC: that was a really key factor in looking at his presentation.

He was a person who’d take himself out of that, and then seek reassurance.

Or self harm and then seek reassurance

266/

C: yes, yes.

His main involvement with him was learning disability social worker.

He’d had previous contacts and support from IST I think, around supporting him going back to his mum.

SC: Yes

267/

C: Was referral in December for mental health input in relation to self harm risk

SC: It was input for psychology specifically. But once again you’d hope that consent would be sought before the referral

268/

C: yes.

I think your main comment really, your finding is again, relating to the suitability of Morewood for Witness A. Along similar line for Robert is that right?

SC: Yes

C: Given complexity of his needs and nature of his needs?

SC: Yes

269/

C: in relation to incident occurring, would you describe that as identification of aspects you thought unsuitable, relationship to those and incident is circumstantial rather than any purposeful act or omission by Morewood staff?

SC: That's a fair comment yes

270/

C: key aspect of learning was referral issue. Was there anything else in particular from Witness A?

SC: Was also pathways looking at developing, and obviously ongoing training issues for wider services, and learning disability and autism

271/

SC: and that supported by LD liaison post within those services, to help provide support for people in services.

C: was there any issue in relation to transition?

272/

C: We heard young ppl with identified eligible needs should have a transition plan to transfer to adult services

SC: Yes

C: That happened in relation to social care. He had CAMHS involvement, but there wasn’t a transition to adult mental health services is that right?

273/

SC: No there wasn’t

C: should there have been?

SC: I think this is challenge with transitions in health.

What was that specific transition to and was Witness A engaged in that and willing to transition into adult services?

274/

C: did he have an adult psychiatrist who was overseeing his medication? I might have misunderstood that point

SC: I don’t remember picking that up

C: he would have been receiving medication for some of those problems he had?

SC: Yes

275/

C: I think the social worker's evidence was he had a psychiatrist involved after he was 18. Thank you.

Anything else you’d comment on in relation to Witness A?

SC: No

276/

C: picking up on Mr Spencer's point, @derbyshcft reviews arose about Derbyshire healthcare provision really.

Can see good argument when a lot of support from social care to consider that support and input and comments from people?

277/

SC: That would be reasonable, and how we work as system together.

When we work as system together we develop better.

C: that didn’t happen fully in relation to the two reviews.

For Witness A a key person, learning disability social worker who was primary lead

SC: Yes

278/

SC: you know I go back to the idea is what can we do to be better.

You know the learning is, we can always get better MDT working, and improve that

C: when you’ve got people with a lot of input from agencies, really its a team, isn’t it

279/

C: I'm not really, seeing a review just looking at one aspect of provision, is probably missing out a lot of the picture isn’t it?

SC: It is, yes

C: Mr Spencer, anything arising?

PS: no I’ve already covered those points and nothing arising

C: Mr Coburn?

280/

AC: no I’m alright, thank you

C: just on that last point Mr Clensy.

About the breadth if you like, of the review.

Strictly the review is into @derbyshcft Derbyshire healthcare provision isn’t it?

SC: It is

281/

C: is there anything that precludes... review looking more widely in terms of totality of the provision? Particularly when there are key people outside @derbyshcft?

SC: I think it's the terms of reference of what the review was asked for, I was working within those TORs

282/

C: Terms of Reference could be specified to include that where relevant couldn’t they?

SC: Yes

C: who sets the Terms of Reference, is that the review group?

SC: In this case it was the general manager

283/

C: have you been involved in other reviews, similar reviews?

SC: Yes, and I’ve done quite few LEDER reviews, that’s much wider

C: any experience where terms of reference for similar cases have gone wider to also consider, for example, social care provision and input?

284/

SC: I’ve done that in LEDER reviews but not in an internal health ones

C: Robert would have fallen under a LEDER review wouldn't he?

SC: Yes

C: I don’t think we’ve had a LEDER review, it would have taken place by now wouldn't it?

SC: It would have yes

285/

C: did you have sight of it at all?

SC: No

C: LEDER review would have looked at all relevant organisation and scrutinised wouldn’t it?

SC: Yes

C: I’ll release Mr Clensy... thank you very much

Stuart Clensy is released. Court adjourned for lunch. Final witness next.

286/

C: We’ll hear from our next witness in a moment, there's something I mentioned to Mr Spencer, I will mention while you’re here Mr Coburn

The press have asked for a copy of Ms Sims statement in relation to the anonymity of Witness A

#OpenJustice

287/

C: I don’t know if that is in relation to an application to revoke the order, but in order for that to be done they would need to know the grounds in the statement. Mr Spencer?

288/

PS: over short lunch Miss Brewin* and I have reviewed the statement, making further suggested redactions, internally within legal team at DCC. Should have that this afternoon.

[*Miss Brewin is instructing Mr Spencer, I believe she's the in-house solicitor @derbyshirecc]

289/

PS: Have no objection to member of press having statement, but would have a concern if there's wider circulation. There is a twitter feed following this case.

Subject to you agreeing they have redacted statement, not exhibits, would be no objection to the application.

290/

C: just statement. Whether or not in relation to potential application or not, I think the issue was journalist couldn’t hear everything read out from it.

PS: that’s fine and of course it is open to you to set aside, and/or journalist make an application to overturn that

291/

C: yes. For consideration by that journalist, not for general circulation

PS: yes

C: just relatedly in terms of going on to social media, Twitter or any other social media.

292/

C: There might have been some comments posted on social media, perhaps of slightly disparaging nature in relation to participants in Robert’s inquest

293/

C: Obviously if they are infringing the prohibition on observation by remote means, that might be something I need to take action on.

It might be that they actually don’t relate to any power I do have.

294/

C: I wld ask people to be mindful of what they put onto social media, wld hope that would avoid any derogatory comments or any unfair comments.

I just say that at this moment.

If anyone is aware of anything they think I shd look at, and can look at, then I certainly will

295/

[This conversation is between an IP and coroner, albeit in open court. I shd be used to it by now, but I'm not.

I do everything in my power to report as accurately as humanly possible. I am interested in #OpenJustice, and I want ppl to engage with the coronial process]

296/

[When these conversations are held it always feels like the inference is I should some how be held accountable for conversations that emerge from my reporting.

Or that it's a uniquely Twitter/social media phenomenon. Have you ever read the comments on a Guardian article?]

297/

[I am always grateful for anyone who highlights errors in my reporting.

And for those who DM or comment with more explanation where I may have misunderstood something. Always.

Similarly I'm pleased people are engaging with the often unobserved coronial process]

298/

[I'd have hope counsel and coroners would both welcome that.

I often feel like attempting to reduce premature mortality of learning disabled and autistic people is a completely futile exercise, but for now, this is my small part in trying to address it

#OpenJustice]

299/

C: right. We’re going to hear from our last witness now. Mr Dominic Sullivan please

He gives an affirmation. He's the Asst Director for Adult Social Care @Derbyshirecc

300/

C: can I ask you please if you look behind tab 20, that is a report which you produced in relation to the death of Robert?

DS: it is

301/

C: in terms of the report, it goes to 14 pages, dated x May 2021 and then appended to it are some documents which are essentially care planning documents aren’t they?

DS: yes

C: they’re all in relation to Robert are they or some in relation to Witness A?

302/

DS: I think majority in relation to Robert, yes

C: I think you’ve been in court for the whole inquest haven’t you?

PS: sorry for interrupting there’s also an updated action plan sent to your office last week, we have spare copies here

C: yes I do have that, thank you

303/

C: you provide a helpful description of provision in Derbyshire, can you explain what provision exists of

DS: yes, Morewood itself is a unit spread over two floors. It’s a large unit, got 5 bedrooms upstairs, 5 downstairs with separate lounges and space for people.

304/

DS: It is set in Alfreton Park, so while it's surrounded by green fields, it's also conveniently located for Alfreton centre, a short walk away, so people can access the community

305/

C: and there are three other residential centres aren’t there

DS: Yes older, different design but basically similar function

306/

C: I notice you make comment in the third paragraph, to the change if you like, of the profile of service users referred.

We've touched on that through the inquest as to why that might be, any comment you want to add on that?

307/

DS: increasingly young people coming through with multiple presentations.

Some of it trauma based wear and tear on them impacted on their mental health.

They may be on autism spectrum which may or may not have been recognised

308/

DS: through the Care Act we have a responsibility to those individuals, who previously may have fallen foul through service provisions.

[He gives example of autistic people going to university and having unmet social care needs - didn't catch exact wording]

309/

C: we've touched on availability of placements, but it's a slightly more complex picture, more people identified, as eligible for a service?

DS: Yes

C: thank you.

310/

C: then purpose of your review, perhaps you could explain why a review was undertaken

DS: As internal management review to look at practices of our staff, in terms of social work support both parties receive, but also role of unit itself and support available in the unit

311/

C: you provide a summary of Robert’s relevant history, obviously we’ve gone into that in some detail. Don’t know if additional points you’d add really?

DS: I think from evidence I’ve heard over last couple days, sort of, has reinforced my view that I think...

312/

DS: Robert was clearly a character, at one level quite an able person, but on another level a vulnerable person.

I think he had an established lifestyle at age of nearly 50 at time of his death, which challenged and had challenged for many years service provision.

313/

DS: He didn’t fit easily into the service model.

And also I think loneliness, and not fitting in, was probably his biggest driver in terms of many of his actions.

314/

C: we’ve heard about the main difficulties Robert had, but do you agree with those? Nature of problems, or labels, would you agree that those whats been described?

DS: Yes I think its difficult when we label people, you can forget there’s an individual at heart of that...

315/

DS: who has light and shade at heart of their personality as we all do… who makes lifestyle choices and how he chooses to present himself to the world [think he said]

C: then you go on to consider aspects of Robert's care planning, can you take us through that

316/

DS: Care plans, my remit was to look through that.

See was it fit for purpose? Were there any additions that might have made a difference to the support he received?

And check people were up to date in what they needed to be to provide a service to him

317/

DS: Risk assessment, things along those lines.

So work was undertaken to look at how we support him from what was a temporary arrangement to a more permanent place he’d call his home.

C: anything you’d identify in particular?

318/

DS: While I found, I think its top p5, I find there was a lack of formal risk assessment.

And I think the information Morewood would have themselves, they knew him, they knew Witness A, there was very little that could have changed what they were doing.

319/

DS: Even if risk assessments had been more detailed, the member of staff on duty did exactly what you’d expect to do.

Placed herself between the two people, sought to deescalate the situation.

320/

DS: From that point of view would be chapter and verse in terms of how you’d manage an incident of that nature

C: you say in relation to risk assessment, you identify specifically, risk to injury or worse from reprisals to Robert’s behaviour

321/

C: that may have been in context of other clients, but not only clients at Morewood, could be other people in the community as well?

DS: I looked at that in terms of his history, as we’ve heard, Robert could be, what’s the word, spiky.

322/

DS: A spiky, combative, almost barrack room lawyer. He’d have a term of what was right or wrong and if other people weren’t living up to what he perceived, should be doing... I think he was actually quite protective of Morewood, and the staff there.

323/

DS: Which I think that feeds him in to egging a car of someone double parked [think he said]

We’ve also heard of his racism, in relation to other person resided who was mixed race, and unit manager themselves had been on receiving end of that.

323/

DS: That could also provoke a reaction from wider community. That was also a need that could have been firmed up.

C: you concentrate on Morewood then, don’t you, in next section of report. We've a reasonable description by now in terms of layout and set up

324/

C: perhaps you could give an explanation of what you looked at in relation to staffing

DS: Was it sufficient. Level of experience of staff.

In terms of numbers and experience I found it was appropriate.

C: does that include training as well?

DS: Yes, yes

325/

C: I was asking staff members about their training, they told me what training they got. I wasn’t, still not entirely clear, what sort of depth of training there was, specially in relation to mental health and substance misuse?

326/

DS: We do have range of training, specific training around those things, most of training is identifying issues and making appropriate referrals

C: so awareness of what to do next sort of thing?

327/

C: staff were describing, as you put in report, they notice significant difference in sorts of needs people had when coming to the centre?

DS: Yes that is the case...

328/

C: there comes a point in December where there’s several residents with behaviours that perhaps present particular challenges to staff.

Particularly those people in combination, was that a noticeable difference from before?

329/

C: December suddenly three people who perhaps, challenging, but also together might be quite volatile?

DS: Yes but ultimately we have very little control over the nature of people who are in emergency situations.

330/

DS: We have an element of being the service of last resort for people.

Key is around effective management.

As you’ll have heard in the case of one person in particular, that meant she came with her existing, although agency staff, existing staff

331/

DS: ...who were working with her in a residential home who refused to have her back

C: in fact your p6, 3rd para down, info that woman X, a number of physical assault incidents, relating to other residents and also staff?

DS: Hmm

332/

C: you mention physical restraint but don’t think we need to go into that, isn’t any incidents of physical restraint and incident itself, as evolved, was fairly quick

DS: Wouldn’t have thought given the individual that restraint would be appropriate

333/

DS: ...could result in injury of staff member

C: p8 you talk about specialist health support and availability, as we know there were a number of people involved with Robert.

Not sure if there’s anything you want to highlight from that in particular?

334/

DS: No think that’s fairly self explanatory...

C: does seem to be an issue in what might be expected to happen after the Mental Health Act assessment on 9 January

DS: Um hmm

335/

C: having said that, it cant clearly be said anything different would have happened that might have changed what happened. Is that fair?

DS: That’s fair comment yes

C: seems a lot of effort was put into trying to find a move on placement

336/

C: but they weren’t easiest to find essentially, is that right?

DS: Yes, as we’ve already heard, it was trying to find something that satisfied both Robert and his mother, and their expectations of what might be available to him, and the location.

337/

DS: And wider issues as system, nationally, of identifying providers for people, who on one level are quite simple, but their needs are complex… because needs less… self determination gets people into scrapes [missed large chunk]

338/

C: going onto your page 10, there are 11 key points you identify aren’t there. Could you take us through each point.

DS: In terms of just summarising, I think it is a well run service, that assessment has been shared by @CareQualityComm

339/

DS: its got a long established experienced team of care professionals who can meet challenging needs of its service user group.

One who gave evidence earlier was a qualified social worker, so broad skills set there.

340/

DS: While we needed more detail in terms of care plans and associated documentation.

And more timely review.

They were still describing the basic needs of individuals, and what staff needed to do to respond to that

341/

DS: What started as a minor altercation did escalate quickly.

Couldn’t have been anticipated.

Nor could member of staff present have intervened in a way that would have prevented the blow from being delivered

342/

DS: I've identified, and other witnesses have, need for more provision for people with minor learning disability, autism, particularly when associated with substance misuse, young ppl with chaotic lifestyles.

343/

DS: That is very difficult to commission for reasons we’ve already heard.

Think there is an issue in having specialist wrap around support for staff team in specialist units. It is a residential social care unit, not a mental health unit.

344/

DS: That’s been reinforced by Derbyshire Safeguarding Adult Board's review undertaken as a parallel process.

C: you're referring to the Intensive Support Team specifically on that aren’t you?

DS: Yes IST provides health support, but its not a wrap around 24hr service

345/

C: did you see that having relevance to the incident on 23rd?

DS: Think relevance as protective measure of sustaining people in their placements, identified by SAR20A Safeguarding Adult Review. Having consistent, to support providers to prevent a breakdown in first place.

346/

[You can read the summary of the Safeguarding Adults Review on the Derbyshire Safeguarding Adults Board website here derbyshiresab.org.uk/site-elements/…]

347/

DS: Whether that could have prevented Robert leaving his original flat, giving up his flat, that would be conjecture on my part.

Whether would have sustained X with her original provider, again it's conjecture.

But it has been identified as a gap in services.

348/

DS: In terms of other points, concluded was appropriate in terms of both Robert and Witness A, of what was available at time.

Morewood provides a skilled, welcoming, supportive environment to people who are in crisis.

349/

DS: Would have been wholly inappropriate for either of them to end up in homeless hostel or B&B.

They’d both have been vulnerable.

Witness 1 would have been prey to people who didn’t have his interests at heart

350/

C: both were facing homelessness at the point they were admitted, placed at Morewood?

DS: Witness a was originally homeless, Robert became homeless when his tenancy was given up in June

351/

DS: Point 9 then AD overruling deputy manager concerns about placement of other resident X.

Did have impact on dynamics of building.

My view was very much met with wider statutory responsibilities to protect vulnerable people, had to be taken into account.

352/

DS: Protective factor was she was accompanied by staff team, small team agency staff providing support to her.

C: concern was X would be too disruptive and too demanding on staff time to support?

DS summarises situation, ending: we have a duty to intervene

353/

Coroner discussed with Dominic Sullivan action plan and progress they've made on it.

Convo covered things like recording, information sharing, management reports, regular audits, new risk assessment checklist, shared learning event, pathways and operational fidelity group

354/

C: Can I just ask you two things actually, going back to specifics.

You looked at what happened on the day, 23 January, if it's difficult for you to answer please do say.

355/

C: From what you go through appears to be incidents or arguments that happened at Morewood, in the afternoon. Robert and two women, X and Y, and also Witness A becomes involved in some way, appears to be angered by what was said, or arguments.

356/

C: Witness A goes to get a ladle, intimating he was getting angry, might do something.

We then know Robert asked for money for the pub.

He's given £30, comes back, appears to be intoxicated.

357/

C: Um, wonder whether you think, theres a number of events occurring on that day that might have prompted some response by the team at Morewood?

In terms of, things are getting a bit edgy here, Robert has come back, he’s had a lot to drink.

358/

C: Do you feel there’s anything should be done differently on the day, buy the point of the evening?

DS: Difficult to comment on that. Given size of building, ability to separate people, strategies to deescalate.

Would be the approach people would, and did, take

359/

C: on the issue of Robert being given £30.

I did ask Mr Mohammed could the worker have had conversation with Robert: do you really need that much, why don’t you just take £10?

There doesn’t appear to be a conversation along those lines

360/

DS: Doesn’t appear from the records.

I think what staff there do, having been a residential manager myself many years ago, Robert is there by his own volition, he’s not subject to any DOLS, we’re assisting him to manage his money.

361/

DS: believe conversations had taken place. A lot of it, spending wasn't on alcohol, was on things like walking sticks, cameras.

Equally £30 at price of beer and things, while Robert is a large bloke, its unlikely he’d have spent that all on alcohol

362/

DS: He'd present, again I never met Robert, reading reports about it...

He’s an individual presenting this blokey, working man, in his high vis trousers with his mates down the pub, he’d buy other people drinks.

363/

DS: I think concern might be much more than him getting absolutely plastered, it was established he’d put it on. Is more about his vulnerability to others, buying other people drink

364/

C: Catherine Thorpe said she noticed him to be unstable, he appeared to be intoxicated to some extent.

Ok, thank you

No questions from Mr Coburn for @derbyshcft
No questions from Mr Spencer for @Derbyshirecc

Mr Dominic Sullivan is released.

365/

[What happened next was the coroner gave his initial indication of where his thinking was at.

I'll not share it here. I'll post his final conclusions later today]

366/

[The coroner did that so that counsel could consider his thoughts, and then they returned after a short break to make oral submissions on the law, and to some extent what we've heard.

Court was adjourned until 2pm today, Thursday 14 July]

/END