Thread by @GeorgeJulian

It’s the final day of the inquest touching on the death of Robert Chaplin at Chesterfield Coroner’s Court.

Coroner Peter Nieto was in court, together with Robert’s mother, Pamela. Other people joined remotely.

[Pic via @DerbysPolice]

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The coroner explained how all that was left was for him to give his summing up, findings and conclusion.

Then he’d complete a form called the Record of Inquest.

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Coroner explained that the test he had to apply to evidence was the balance of probabilities, to find something did or didn’t happen. Had to find more likely than not something happened, it’s probable.

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Coroner also reminded the court that the coroners court does not determine liability of any type in relation to a person’s death.

It’s main function is:

“to try and understand as best we can how Robert came by his death”

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C: this is day 4 of Robert’s inquest. It started Monday, heard 3 days of evidence. Heard in two ways, firstly read out some documents, mostly statements, reports, from people who have not come to court where agreed can read out their evidence, so that it’s before the court

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Also heard evidence in court from a variety of people [listed who he’d heard from]

The coroner started by reading out his conclusion, which is a short form narrative conclusion that states:

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Narrative conclusion: Robert died due to an unsurvivable hypoxic brain injury following prolonged cardiac arrest caused by being punched. His pre-existing cardiac disease was contributory to the cardiac arrest.

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Narrative conclusion cont: Both Robert and the man who punched him were staying at a learning disability residential facility, both had complex needs and challenging behaviour, and Robert was intoxicated with alcohol to some degree at the time of the incident

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The coroner reminded the court that he’d made an anonymity order relating to the person who punched Robert, who was known throughout the inquest as Witness A.

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This order was made due to Witness A’s mental health, safety and wellbeing, principally due to issues of self-harm and the fact that he would otherwise be at serious risk.

The order was not opposed.

The coroner continued

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C: On the evidence I do not find it is probable any acts or omissions of staff of @derbyshirecc learning disability services, or @derbyshcft have contributed to Robert’s death.

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He explained that he had reached that conclusion because on the evidence he heard.

Robert “had by necessity to be placed at Morewood”

and that the

“risk of death due to altercation between Robert and Witness A can not reasonably have been foreseen”

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C: Robert died at Queens Medical Centre Hospital in Nottingham on the afternoon of 24 January 2020 following diagnosis of an unsurvivable hypoxic brain injury

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Coroner explained Robert had been punched by fellow resident at Morewood. Robert then went into cardiac arrest, that in turn caused the hypoxic brain injury

C: Robert was aged 49 at the time of his death and clearly a great loss for his family and those who knew him well

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Coroner explained Robert had a learning disability, bipolar disorder, autistic spectrum disorder and some physical health problems including diabetes and scoliosis.

He also had issues with alcohol use.

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His behaviour could be challenging, including being verbally aggressive. He had support from mental health services and adult social care learning disability services.

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Coroner explained due to his previous hospital admissions, including compulsory admission due to his mental ill-health, Robert was entitled to after care funding under section 117

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Coroner outlined how Robert came to be at Morewood, following his tenancy breaking down after he could no longer be supported, due to only one PA being available.

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Morewood was described as a @derbyshirecc residential facility for people with learning disabilities, offering respite and short term placements.

The coroner highlighted the evidence given about changing resident profile since 2017, 2018

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C: change in needs of the service users referred, from people with primary learning disability needs, to people with learning disability and additional needs, in particular mental health issues and substance misuse

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C: at inquest staff from @derbyshcft and @derbyshirecc expressed views that this change reflected difficulty in sourcing placements for learning disability service users with complex and multiple problems, increased demand for services, and funding pressures

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C: These placement issues were stated to be national issues.

While changing service user profile presented challenges to Morewood staff, it was stated staff were adequately trained

Coroner then outlined the background on Witness A.

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Coroner then detailed what happened on 9 January and that Robert was detained under S136 of the Mental Health Act by police, who took him to the Radbourne Unit for assessment.

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Assessors included Robert’s previous psychiatrist, Dr Horton. Robert was not assessed to require compulsory admission and did not wish to be admitted. Robert returned to Morewood that day.

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Coroner said in his plan Dr Horton requested that Robert be referred onto the intensive support team

C: it does not appear that request was conveyed to the intensive support team

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C: Under agreed arrangements potential hospital admission should trigger a LAEP, local area emergency protocol, to consider alternatives to admission.

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C: This did not happen, but in any event Robert was not admitted to hospital, although there was then a requirement for an urgent multi-agency meeting to review Robert’s support and treatment arrangements.

This did not take place before his death

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Coroner said there were three issues considered at Robert’s inquest:

1) suitability of Morewood for service users with complex needs

2) were Robert and Witness A receiving appropriate services beyond Morewood, and if not did this contribute to Robert’s death?

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3) assault on Robert by Witness A and Robert’s death

In regards to 1) suitability of Morewood for service users with complex needs.

C: Inquest heard facility was able to accommodate people with learning disabilities and additional needs, including challenging behaviours

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C: although clearly putting people together with such needs will create volatility at times

The coroner went on to say that this was clearly the case when Robert and Witness A were at Morewood and that there had been such incidents prior to Robert being assaulted

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C: Ideally people would have tailored placement, ideally Supported Living placements, but the inquest heard that for reasons stated to apply nationally, there are a shortage of such placements.

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C: In this context there was clearly no option but for Robert and Witness A to be placed at Morewood, given situations at time of placement. Along with other service users with similar problems, while longer term options were sought.

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C: All in all whilst not ideal for people with complex needs, from evidence presented to inquest, do not see situation different to general picture nationally regarding placement availability and shortages.

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C: In relation to the national issue, it is complex issue and beyond the scope of this inquest, depends on national policy and funding issues… this inquest is not the forum for a forensic inquiry…

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C: Imagine difficulties in sourcing learning disability placements and resources, probably a subset of wider picture for social care and mental health provision generally

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C: If it had been clearly established on the evidence that Morewood was totally unsuitable for either Robert or Witness A, would say there would be need to look at that in more detail, although evidence was it was not.

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C: Although not ideal, the placement was not inappropriate for either of the men.

Coroner then discussed Robert being given £30 to take to the pub.

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C: Robert could not be denied that money. Seems sensible to me, would be that member of staff have a conversation with Robert about that [whether take less]… also given clashes occurred earlier in day…

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C: also in hindsight seems to me Robert’s degree of intoxication must have had some relevance to the altercation between Robert and Witness A.

Whether Robert would have accepted that advice can not be known.

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Point 2) were Robert and Witness A receiving appropriate services beyond Morewood, if not did this contribute to Robert’s death?

Coroner outlined both men were receiving learning disability and social care social work input.

Both men had frequent contact with professionals

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C: Where there were gaps, further input was sought, although referrals not always accepted

In relation to joint working and care planning

C: Was close cross disciplinary working but does seem to me further work could be done in this area

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Despite saying that the Coroner said

C: that doesn’t seem to be issue clearly seen to be relevant to Robert's death

Robert should have had an urgent MDT meeting following the Mental Health Act assessment on 9 Jan 2020

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C: Altho this did not happen there’s no evidence there would have been any changes to his provision that would have likely prevented incident on 23 Jan

Psychiatrist had asked IST to provide input. Although that did not occur, is not clear that would have prevented incident

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C: Robert's stay was planned to be temporary... significant effort was made by the social worker to source an alternative placement

Moving onto Robert being struck the coroner said:

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C: On evidence had Robert not been punched by Witness A he would not have died on 24 January 2020

There is a direct and causal link between the punch and Robert's cause of death

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C: As to the immediate circumstances, in my judgement Robert's consumption of alcohol must have influenced his mood and behaviour

Coroner outlined that insults were made by Robert towards Witness A

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C: Both men expressed aggressive and violent comments but I don’t see that could be taken to mean either meant deliberate harm to the other, especially given their learning disabilities and autism

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C: While there is evidence Witness A delivered a hard punch... the post mortem did not find injury from the punch itself

No evidence fall contributed to death

Cardiac diseases is contributory, if had not been present then unlikely Robert would have suffered cardiac arrest

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C: For that reason will add in to Robert's cause of death at 2 cardiac disease

In my judgement there have not been any acts or omissions by health or social care staff that have more than minimally contributed to Robert's death

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C: Incident would not have occurred if both men had not been placed at Morewood, but for reasons discussed their placements were necessary and there were no available alternatives

Robert's death was caused by Witness A's punch and Robert's pre-existing cardiac disease

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C: Do not consider short form conclusions would properly describe the nature of Robert's death

I considered accident and unlawful killing

Accident would be deficient and lacking in providing description of nature of Robert's death

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C: In relation to unlawful killing, unlawful manslaughter, seems to me grounds for that not established, as evidence Witness A was acting in self defence and his understanding of consequences of his actions must be questionable given nature of his problems and issues

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C: So short form conclusion of unlawful killing would not be substantiated. Would be inappropriate.

In any case, circumstances set out on the record of inquest do describe the key events in relation to the incident

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C: Moving on to record of inquest as it will be completed

Coroner confirmed Robert's name and cause of death as:

1a hypoxic brain injury
1b consequences of altercation
2 cardiac disease

How, when, where and in what circumstances Robert came by his death were recorded as:

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Robert died in hospital on the afternoon of 24 January 2020 following diagnosis of an unsurvivable hypoxic brain injury.

He had been punched by a fellow resident the previous evening at the learning disability residential facility where they were both staying.

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Robert went into cardiac arrest and the resultant interruption of circulation and oxygen supply to his brain caused brain injury.

The physiological stress of the altercation and assault induced cardiac arrest in the context of Robert’s pre-existing cardiac disease.

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Both Robert and the other resident who punched him had learning disability and additional complex needs.

Alternative placements were being sought for Robert and at the time of his death he was on the waiting list for another placement.

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The other resident was staying for one night’s planned respite.

On the day of the incident, 23 January 2020, there had been some volatility amongst the residents at the learning disability residential facility, including Robert and the other resident who later punched him.

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In the afternoon, Robert asked staff for £30 saying he was going to the pub.

When he returned in the evening it was clear he had been drinking alcohol with some negative effect on his mood.

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Just after 22:00 Robert was making offensive comments to the other resident and this then developed into an exchange of heated verbal threats.

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Robert confronted the other resident in close proximity with raised fists, and the other resident then punched Robert on the neck which caused Robert to fall back onto the floor.

A member of staff had entered the room and tried to separate them and diffuse the situation.

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On the account given by the resident to the police, and on the evidence of the member of staff, there is reason to believe that the other resident punched Robert out of fear for his own safety.

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The Coroner then checked Robert's details with his mum, so he could pass them onto the registrar so they could issue a death certificate.

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C: Sorry it's taken some time to get to Robert's inquest.

There was a lot of information to collate and receive, and probably some delay due to backlog of listed inquests due to period time we couldn't use courts due to covid lockdown periods as well

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C: I don’t know you necessarily agree with my conclusion, but I hope the inquest has been of some help to you in some way

We’ll provide your details to registrar, they’ll be in touch when certificate is available. It may be a week or two because Robert died over 12 mths ago

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C: Mr Coburn, Mr Spencer, thank you for your assistance through the inquest, and thank you to those witnesses who came to court to give their evidence

Coroner said he'd send record of inquest to Mrs Chaplin, @derbyshirecc and @derbyshcft

Mrs Chaplin thanked the coroner

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That's it. Robert's inquest is over.

I've found this inquest incredibly sad to follow and report.

I can not help but think if Mrs Chaplin was legally represented there might have been other matters explored, and potentially different conclusions reached.

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Thank you to everyone who has followed the tweets, RT'd them, commented, reflected and shared their thoughts.

Lots to unpick here I think, but not today.

If you'd like to support my #OpenJustice reporting, you can do so here chuffed.org/project/openju…

Thank you

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