Thread by @ChrisNInquest

We're shortly going to be starting Day 3 of Chris Nota's Article 2 inquest which is being heard by Mr Sean Horstead at Essex Coroner's Court.

It's a hybrid hearing, with some witnesses attending remotely.

We're due to hear from two live witnesses today.

1/

A reminder that this is contemporaneous reporting, it is not a transcript and should not be relied upon as such.

Reporting is as accurate as I can manage and I will flag when I am uncertain of spelling [?] or when substantial chunks of discussion are missed.

2/

Chris's inquest discusses suicide and I will be intentionally withholding some detail of what is discussed in court, in line with the @samaritans guidance on reporting inquests.

3/

All my work reporting inquests into the deaths of learning disabled and autistic people is crowdfunded, and I'm very grateful to those of you who read, share, comment, discuss and support my work.

4/

I hope through the power of #OpenJustice to raise public consciousness and awareness of the care and treatment provided to learning disabled and autistic people.

List of counsel for interested persons follows

5/

Chris's family are represented by @TomStoate of @DoughtyStreet instructed by @rachelharger

@EPUTNHS by Briony Ballard of @serjeantsinn

Hart House by Laura Nash of @SJBnews

@SouthendCityC by Alex Denton of @ropewalklaw

Southend CCG, now @MSEssex_ICS by Nageena Khalique KC

6/

I'll stop numbering tweets now and coverage will start shortly on this thread.

Coroner's officer is just checking those attending remotely can see and hear proceedings.

7/tbc

Dr Sarah Ball gives an affirmation

C: you've provided a statement dated 18 Oct 2021 and believe you have a copy with you

SB: yes I do

C: I'll take you through that... you confirm the statement is based on a review of clinical notes available on mobius and includes information written by @EPUTNHS services during Chris's time with EPUT, and historical documents...

Also her notes and recollections of conversations with Julia

Doctorate in Clinical Psychology... at time worked as highly specialist clinical psychologist from Oct 20?? and held role at time of Chris's involvement

C: you explain ESTEP is community based team supporting people experience first incident of psychosis...

Kirsty Lister was a care coordinator is key member of staff leads on identifying needs and coordinating aspects of mental health treatment

Under care of psychiatrists... team members include psychologists, support workers, and employment specialists [think he said]

C asks SB how she'd be involved as lead

SB: I wasn't lead clinical psychologist in the team

C: were you not the lead psychologist for Chris?

SB: I was the most involved psychologist for Chris, but were others present at MDTs etc, but I had most involvement, including attending meetings with Julia

C: you set out you didn't meet Chris directly over the time of 9wks he was with your team; any reason why you as most involved of clinical psychologist didn't actually meet him?

SB: I think Chris was only in community for short period during that time, about 16 days, think it is worth noting the context, it was covid times, he was very much only with us in the community for a short period of time.

SB: being mindful of what we knew of Chris, his autism and learning needs we were really conscious of not throwing other professionals at him if it wouldn't add something clinically...

SB: not sure what it would add me meeting him in person, or remotely, beyond what I was offering to the team on consultant basis...

SB: we knew we weren't in position to do assessment of his cognitive function at that stage, not sure benefits of me seeing him in person, versus hearing about him remotely from team

C: was that discussed, was that part of a strategy

SB: I honestly can't recall, I know with confidence if was discussed that would be my position, wouldn't be typically for us to immediately meet people when they joined our service.

Would build relationship with care coordinator first, in this case Kirsty...

SB: if I was involved in any formal assessment I'd have met him in due course

C interjects: I need to focus where we go a little bit. With respect to your role per se, I asked why no direct contact with you...

C: you'd have a role in conducting any psychological assessments, would you have any other role beyond that, if so what would that look like?

SB: potentially if clinically appropriate may be role for me to offer him some direct psychological intervention...

SB: there hadn't been a specific need identified, but as psychologist in that team was our bread and butter, assessment and intervention and consultative work I was doing with team

C: what was the, you set out the limits of your team's experience with autism.

C: Can I ask you specifically about yours.

Did you... what was nature and extent of your knowledge and experience of autism per se?

SB: sure, I have worked with a number of people who have autism and varying levels of cognitive ability.

I wouldn't say I have specific expertise of working with people with autism, my experience was supporting people experiencing a first episode of psychosis.

SB: I wouldn't have been in a position to conduct an autism assessment because I didn't have additional training in autism.

C: You say you weren't able to access the EPUT MDT meeting minutes. In preparing a statement for coroner's inquest would you not be provided with the relevant MDT meeting minutes; I know you're in a different team

SB: I wasn't no

C: So your evidence is based on recollection not notes

SB: I think I would have expected if they were part of the evidence, because they were records from the team and many others had access to them they'd have appeared, there wouldn't have been anything specific...

SB: ... that referenced me, would be summary of discussions and actions decided in those meetings.

C: you were a party to those meetings, contributing to discussions and have contribution to outcome.

C: Seems sensible you to seek, or be provided, to access to records to which to a degree you're having to rely on your memory rather than the documents.

SB: I dont remember that being discussed at time I was asked to make a witness statement.

C: Anyway, your recollection about the discussions included not limited to frequent discussion re Chris and presenting risks, particularly relating to self harm and suicide.

C: You have clear recollection from those early MDT meetings, that element of Chris's presentation was a cause for concern.

Was there a RAG system applied you recall in respect to his risk presentation?

SB: I couldn't tell you from recollection what the RAG rating would have been for him but that information should be available elsewhere.

C: you describe significant ongoing risks of self harm and suicide

SB: yes various people in the team were saying we didn't feel we could keep him safe in the community and we were concerned about his risk

C: what was earliest point in time you recall being involved in an MDT meeting? Was it in the April or May?

SB: we would routinely, if we were in work, be in the MDT discussions. If I was working that day I'd have been in the MDT meeting.

C: prior to his initial discharge from Cedar Ward were you aware of Chris?

SB: no, my involvement generally was quiet peripheral throughout his case, certainly I wasn't aware of his case before that

C: you describe meeting on 8 June with Julia, in addition to conversations in MDT, you were part of meeting with Julia on 8 with Kirsty Lister, Judi Jeavons [others] you attend to support collective understanding, of Chris's needs and Julia's needs for example...

C: you describe your role as being more observational and main conversations between Julia, Kirsty Lister and Dr Villa.

Do you recall making any particular observation at that meeting?

SBo: from what I recall I didn't speak... my role was to consider anything else we might want to consider

C: you fed back following day to Dr Atwood, what's her role please?

SB: she's another clinical psychologist in the team... was important us have discussions within the team

C: you set our your view... based on the meeting... you thought Julia had felt listened to by your team during the meeting on the 8 June.

She shared her traumatic experience with respect to her brother, who'd taken his own life at a similar age to Chris.

C: Was spoken about how distressing that was for Julia, and compounded the anxiety she felt about keeping Chris safe.

That was a known component about Julia's concerns. Kirsty was offering weekly calls at that time.

C: Were you aware of the nature and extent Julia was feeling excluded from the discharge processes, care management... were you aware of that from that first meeting, or the MDTs?

SB: I certainly had a sense of that from this meeting, don't know if I was aware of it to extent Julia might have felt that herself....

SB: as whole team we were acutely aware of, through meetings with Kirsty and with mum, the team were very much trying to address with mum in the process

C: you mention Julia was very positive about involvement of the ESTEP team, that's how you describe it, that how you felt?

SB: that was my experience at time, the communication I observed in that meeting and other discussions in team, was Julia felt we were working hard to try and support Chris, but she had felt we were doing a good job, that was my sense.

C: right, right, others may pick up on that issue in due course.

Can you remember the nature of upset she was expressing 8 June, a month before Chris sadly died?

SB: from recollection I think one of primary concerns Julia had was about where Chris was going to live, placement after discharge... I've written here she wanted him to have access to a specialist placement,

SB: I know discussions at commissioning level far beyond my pay grade about that.... she felt she wasn't being supported by services.

C: Do you recall if the ESTEP meeting made any comment or contribution towards Julia's wish for Chris to have a placement at the Priory?

SB: I can't recall, I know that was not new information to the team, I know there were many discussions taking place in many different arenas.

When Sam gave his evidence, there were many discussions taking place about placement Chris would be suited to.

C: my question is not about what you've found out since or heard yesterday, but your knowledge as senior member of the team on the 8th, whether expression from team don't think is likely, unlikely, possible

SB: I don't recall the team giving a view on that option... have vague recollection the team had discussed what would be necessary for that outcome, one of the core things would be funding and whether panel approved for this placement...

SB: ...wasn't in our power as team to have a final decision over

C: you noted discussion re role of substances and Julia felt strongly Chris lacked capacity to make decisions about using drugs...

C: Julia said couldn't keep him safe at home... who was going to formally communicate this, Julia or Dr Atwood

SB: Julia was going to communicate that to the ward, my impression was she may have already communicated that but...

SB: ...they'd be another formal communication to the ward from mum that was how she was feeling

C: were you aware this first experience of psychosis was on the background of the S136 in London; discharge; immediate leaving home; altercation with member of public; police picked up; then under section.

You were aware first incident was likely to be drug induced?

SB: I think that was understanding of team at time... timescale when first had psychosis and drug use that was working hypothesis of what going on

C: so if allocated to ESTEP team and thought is first psychosis is related to drugs, generally what's the approach to keeping someone safe?

SB: depends on exact circumstances... two very broad stroke things would be trying to treat or intervene with the psychosis as needed...

SB: ...and help somebody understand link between their drug use and their psychosis and support them to abstain or reduce their drug use

C: will probably come onto it in more detail with yourself

SB: can I just add if we were really concerned about risk and someone needed to be an inpatient would be a number of other professionals involved, it wouldn't just be us in community trying to keep people safe, would be effort to work together to keep someone safe

C: I understand that I'm trying to understand what the ESTEP contribution to that would be.

Rightly or wrongly Chris was under the care of ESTEP until his death, can you assist me in respect of keeping safe in context where it appears...

C: there wasn't a psychotic dimension in the last period, but was or appeared to be an escalated or elevated significant risk to self as and when he consumed cannabis, so within that context, I understand ESTEP team position is we can't deal with this, we can't keep him safe...

C: hence the reaching out if I can use that horrible phrase, teams to other teams to, another horrible phrase, step up.

C: What were the limits of what you as ESTEP team can do with respect to keeping someone safe when high risk of suicide or self harm if they consume drugs, and there's an identified link between that?

SB: If I understand correctly one of the important points is as I'm sure you can imagine, you can't forcibly stop someone from using substances, unless they're detainable in our arena, under MHA, due to their mental health not drug use alone.

SB: That's not in my expertise to comment on, whether someone is detainable... in absence of being able to detain someone for their mental health its incredibly difficult and its hard for us as services if someone chooses not to stop using substances...

SB: we can continue to work with them, align with their level of understanding, we can connect them with drug and alcohol services, didn't know a lot at time as my role was quite peripheral...

SB: but I understand there were a lot of other services being brought in to try help Chris with drug issue, but there are limitations as to what we can do.

C: with respect to capacity... how do you see considerations of capacity fitting into, if at all, risk and risk management in context of someone like Chris.

SB: Again I wouldn't consider myself an expert in the MCA...

SB: my understanding is if someone doesn't have capacity, they wouldn't meet detention under MHA then you'd need to consider going down the DOLS route.

That's outside the remit of my expertise and I understand Kirsty had liaised and met with Julia...

SB: to really think about what the options might be if Chris was deemed not to have capacity

C: yes, in your professional expertise do you ever assess capacity, is it something you're trained to do?

SB: not trained any more than any other clinician within the Trust.

It's essential the person who knows that individual best assesses capacity, as mentioned earlier I hadn't met Chris.... wasn't any clear clinical rationale...

SB: that's not my area of expertise compared to other people involved like David Fisher Hope [?] and I didn't know Chris....

C: I didn't mean you turning up and doing that, I had more in mind any contribution you made to MHA assessment...

C: given in one view it was four square and central Chris's capacity with respect to understanding drug overdose, the effects of cannabis and keeping himself safe in that respect.

Did you make any contribution to that process or not?

SB: There was one MDT meeting I reference in my statement, following on from that I went away and made reflections and emailed Kirsty about additional things might ask to check capacity; may have been things Kirsty would have already thought of...

SB: those were things I'd have done to check

C: Need for learning disability and mental health services to work together was recognised by yourself early on?

SB: yes

C: you noticed there seemed to be uncertainty amongst services about his current cognitive needs... had you at this stage read the GOSH reports from when he was 7yrs old?

SB: I cant recall at that stage but I certainly read it when it was made available by Julia; we had final reports from GOSH not the original paperwork now in the bundle

C: Sure. I'll just turn to the GOSH report...

C reads from report's conclusion: Christopher does meet criteria for childhood autism, aspergers syndrome not appropriate due to general developmental delay and delay in speech... school appears to have over estimated his abilities, he's a lovely boy with much charm...

C reads: secondary school will be considerable challenge for him

C: scrolling back cognitive assessment... conducted 18 Jan 2008 by Louise Slater, this shows degree of quite serious learning difficulties in all aspects of his abilities...

C: mild to moderate learning disabilities... in respect of his verbal communication skills and ability to process... surprising school indicate attainments are generally average, note he has a full statement of special educational needs

C: there's a school report section, I don't turn to that... in view of Prof Skuse that was perhaps surprising

C reads more from report: interestingly Christopher did have significant autistic features in respect of his social skills and communication skills...

C reads: consistent with parental report...

C: that's picking out elements. In those broader terms you were familiar with this, or became familiar with them while Chris was under the care of ESTEP?

SB: yes

C: Can you assist me with what you considered to be, the salient elements 11 or 12 years after that, for how to safely manage Chris in the community from an ESTEP perspective?

SB: I'm not entirely sure I understand the question

C: I'll ask again. I've been through conclusions of Prof Skuse's report with you... in summary... my question is geared to how that report, fed into, any contribution that you might have personally been able to make to team discussions...

C: or team discussions you recall with respect to keeping Chris safe?

SB: was certainly part of working formulation from start Chris had autism and learning needs, don't recall that was in any dispute, but I had heard people were basing his presentation and querying whether...

SB: reports might be under-representation of his abilities... we were working with what we had, how Chris was presenting, what we knew his difficulties, information from Julia, was all feeding into what we were doing to try to keep him safe.

SB: The support, liaison with other services, involving different teams with different specialities, he spent quite a bit of time as inpatient, those were part of the picture as far as ESTEP team were concerned.

SB: We also wanted an up to date assessment when possible to do so, quite typical to repeat some of these assessments if these were done in childhood, not unusual to do that to understand someone's current needs.

In absence of that were working with what we knew.

C: were you ever aware of scepticism outside the ESTEP team of the nature and extent of autism for Chris, for example from those on the inpatient ward?

SB: I have recollection of emails from people, might have been inpatient staff, might have been psychiatrists

SB: can't exactly remember, who were saying Chris's presentation, way he came across clinically didn't quite marry up with picture in reports.

They were keen for him to be reassessed.

I dont know if that made any difference to how they were approaching his treatment or care.

SB confirms to Coroner ESTEP team were basing their treatment on what they knew of Chris's assessment from GOSH, what they knew from mum and other parties

C interjects to ask who other parties were

SB: other services working with Chris, all services were working together, he was only in community for 16 days, we probably had least amount of time

C: understand that, Dr Ball, so sorry, if other parties are for example clinicians on ward who appear to have scepticism?

C: was their scepticism something that fed into your approach as a team at ESTEP?

SB: I dont believe so, in services we may have difference of opinions... certainly we were all in agreement would be helpful to re-do assessment when possible

SB: beyond that don't believe would have changed what we as a team were doing.

C asks whether anyone in the ESTEP team had formal training to conduct an autism assessment

SB confirms they didn't

[Interruption where Dr Ball is answering the Coroner's questions before they're finished; unclear whether due to delay as she's attending remotely; Coroner flags and asks for pauses]

[Missed chunk - discussion on training required to do formal diagnostic autism assessment]

SB: there's a difference between diagnosis assessment and working with someone and diagnosing generally with someone working with with mental health and autism needs

C: that's basis on which I ask next question, in respect of someone conducting a mental capacity assessment who doesn't have the training in respect of autism to level we discussed

SB: to my knowledge wouldn't be pre-requisite

[missed chunk]

C: one of concerns Julia repeatedly raised, I'm exploring during this inquest, whether a clinician who doesn't have experience or training in autism is equipped to conduct a mental capacity assessment of someone with a learning disability and autism.

C: I want to ask you as a psychologist with experience of autism, whether you think there are limits on individual conducting capacity assessment without knowledge and experience or substantial training in autism

SB: I dont know.

Dont think would made difference in how Kirsty approached that assessment, the principles of assessing somebody and thinking about their individual needs would all be taken into account

SB: when thinking about someone's ability to take information, understand it and formulate a response, should be familiar regardless of what someone is presenting with.

In psychosis many things affect someone cognitively when having those experiences

SB: I don't know whether Kirsty would feel she had sufficient experience in autism, that's something to ask her.

My opinion, largely a guess, is I don't think it would have made a substantial difference to the conduct or outcome.

SB: It is a very formalised process, if you follow those steps, then the outcome should be robust.

C: thank you.

[Missed chunk about limitations/inability to access or conduct formal autism assessments during covid]

[Also missed detail of discussion about cognitive assessment from GOSH

SB says that there's a lot of comment on Chris's behaviour during testing that she thinks indicates he wasn't giving his best possible at the time - this was when he was 7/8yrs old]

C: So this isn't the fact that it was 12yrs prior to Chris's presentation. You're challenging the validity and findings of Prof Skuse's report at the time?

SB: Prof Skuse would have signed it off I don't know to what extent he'd be involved in the write up of it.

C: Hang on, on what basis do you say that?

SB: From my experience as a clinical psychologist, and conducting many assessments

C: is that something you'd do in your assessments

[SB interjects again, Coroner says he needs to explore her answers and needs some order]

C: I dont think you've ever compiled an autism report or learning disability report have you?

SB confirms she hasn't

C: This combines both learning aspects and autism, you've made it very clear you have no specialism in autism

BB: Sir, I just interject to assist the witnesses answers related only to the cognitive assessment

C: I have that very much in mind.

Do you feel your lack of expertise in autism allows you to explore the cognitive element dis-conjunctionally from his autism?

SB: yes... I'm very much focusing on this, what the author herself has written, supervised by senior clinical psychologist, similar to role I held in ESTEP, she says these scores may be slight under interpretation, I'd be curious given amount she's written of his behaviour

SB: I'm not critiquing anything they did, or her summary, I'm just saying this is where the question mark has come from about the validity of the scores.

No one is saying he doesn't have learning needs, this report has a lot about his behaviour and distractibility during testing

SB: which would lead to question of whether Chris was able to perform to his best ability in the testing.

It's not saying anyone was saying he didn't have needs, we just wanted to do it now, 12yrs on, as adult, see whether his behaviour and attention was different.

SB: It's not just about overall summary, is about pattern of scores in different domains, where difficulties and strengths are, and using that to guide placement....

C: thank you, with respect to amount of attention focused on his behaviour, do you think that might have had something to do with his autism?

SB: It may have done, but the reason for his distractibility doesn't change [his ability to engage in the testing - my paraphrase]

SB: There's lot that suggests Chris as a little boy found it difficult to concentrate on the assessment, very understandable, therefore may be an under representation of what his abilities were.

SB: So makes sense why people were keen to reassess him, we want to plan his care with best possible information of what his needs are now.

We want to help him as a person understand all these different elements, a good cognitive assessment looks far beyond an IQ summary score.

C: thank you. You don't disagree was a finding, aged 7, he had learning difficulties, or do you dispute?

SB: that was understanding of team, we cant possibly know how much his distractibility would change his performance on those scales...

SB: I dont recall anyone saying he didn't have learning needs or he didn't have autism

C: did you and your team consider that Christopher Nota, you were approaching him on the basis he had learning disabilities, learning needs?

SB: that's my understanding

C: and that he had autism

SB: yes

C: it was the nature and degree of impact of his autism, and nature and degree of his learning disabilities, that were accepted to exist, that needed to be assessed in due course

SB: that's what plan was

C: plan, in intervening period, was to manage his risk of self harm and suicide as best you could as a team

SB: yes

C: You became aware by 29 June, your colleague Richard was not confident could keep this young man safe in the community...

C: with any amount of monitoring and expertise from services; I know you hadn't seen him, was that a view you agreed with?

SB: I think that was the view of the whole team, that we couldn't keep him safe at that time

C: reiterated by Judi Jeavons and Dr Villa... ESTEP team were unanimous in its view you couldn't keep Christopher safe in the community

SB: yes... that was a shared view

C: you emailed Kirsty with regards to capacity assessment taking place that day,. you say Chris seems able to hold information and retain it but not necessarily understand it... advice ways to check comprehension not just repetition...

C: wouldn't they be standard practice in a competent mental capacity act assessment?

SB: Imagine they might be, not sure if I was telling Kirsty anything she didn't already know.

SB: I was emphasising would pay lot of attention to aspects like this to be really sure about some of the observations Kirsty had made

C: If someone can retain information in short term and repeat it, is concern they're not just parroting back something they've said to them, that comprehension of information is critical part of capacity assessment

SB: yes

C: so any ambiguity would call into question the assessment itself?

SB: if ambiguity we'd ask more questions, and check they were able to feed back in their own words that demonstrate comprehension. I was not involved in the capacity assessments as you know [fuller answer]

[missed chunk]

Ends with conclusion and stressing deeply affected team, his family and everyone who knew Christopher... you offer condolences... you note that at the end of your statement.

We'll have a short break, 15mins.

Coroner gives SB warning about not discussing her evidence.

[Court is adjourned, back 11:50]

Tom Stoate for family

TS takes to record of meeting with Mrs Hopper. Present Judi Jeavons, Dr Carla Villa, yourself, Richard Weidner and Kirsty Lister

TS reads note

Julia had confirmed that Chris had autism and complex needs... assessment completed by world renowned expert at GOSH

TS reads contemporaneous note

Mrs Hopper explained she thought EPUT were not supporting Christopher's autism and learning disabilities as the right services were not involved in his care. She said we were failing him under the @NICEComms guidance.

TS reads note: Mrs Hopper gave detailed experience of wards Christopher had been on and was very unhappy about this... felt he should have been admitted to autism unit when assessed in London...

TS reads note: Mrs Hopper described several "screaming matches" with Dr Thies Fletchner over autism support, she's of the opinion she'll be left picking up the pieces when Christopher dies

[Missed most of this]

TS reads: Ms Hopper reports she's been trying for 5yrs to get help for Christopher and they were lucky he did not die last weekend... also feels she's been let down by the learning disability service where she believes he should be.

TS reads: She feels capacity assessment should be conducted by people with specialist knowledge of learning disability and autism and those without knowledge will miss nuance...

Further discussion about Christopher not being able to go home, she loves him and misses him a lot, but doesn't believe he'd be safe at home.

Ms Hopper wishes him to go to the Priory, this was unlikely to be achieved, however we'd share the request?

TS: pausing there. The note is 'we' but it's Kirsty Lister's note, she signed off.

Any idea why Ms Hopper was told this was unlikely to be achieved, about the Priory, however we'd share the request?

SB confirms she thinks it was about funding

TS reads: Confirmed Sharon Allison would visit Christopher today to get a feel, but not for a comprehensive assessment.

TS: You and your team are informing Julia, Christopher's mum, that Dr Sharon Allison was visiting to get a feel, its not an assessment

SB explains would be normal procedure to visit someone, get to know them before conducting an assessment

TS reads: Ms Hopper would like Christopher to have 6-9mths in the Priory or however long will take, then step down facility [missed lot]

TS reads: Ms Hopper expressed concerns and lack of confidence in the learning disabilities worker, we expressed we'd found them very helpful.

TS reads: Mrs Hopper thanked the eSTEP team for their involvement and expressed we were trying to help her, but that we are not the appropriate service for her son.

TS: Does that accurately reflect Ms Hopper's views towards ESTEP, grateful for what trying to do but not appropriate service for Chris?

SB: my recollection at time, Julia felt needs were primarily related to learning disability and autism...

SB: my recollection she was appreciative of what we were doing but weren't addressing what she felt was Christopher's needs at time

TS reads: advised in communication with unit and trying to delay discharge until adequate care package in place

TS reads: Risk... if discharged without adequate care package in place, as demonstrated last week

ESTEP to liaise with x and y... to establish support for Christopher to become independent in the community.

TS: Yes?

SB: Yes

TS: Ultimately by 29 June Mr Weidner expresses view in email chain to which you're copied that he could not keep Christopher safe in the community... did you have view on that?

SB: I think view RW shared was very much the collective view of team at time; trusted colleagues who had contact with Chris, they were saying they were concerned so we as a team should be very concerned about this.

TS: Can I ask you very briefly please about an IQ assessment. You offered possibility to Miss Lister than ESTEP could do an IQ assessment on Chris and a broad learning disability assessment if the LD team didn't have resources.

SB: we did, and we were very mindful that's not what Julia wanted... and that she wanted an IQ assessment would be done by someone who had specialist knowledge in autism

TS: you also state that you don't routinely do IQ assessments as they were suspended... [my paraphrase]

TS: it was a real consideration, wasn't primary consideration, doing a lengthy assessment knowing he was using cannabis and recovering from psychosis, would be unfair and unethical to put him through something that may not result in reliable record of his needs.

SB: if you do a cognitive assessment with someone there's a minimum period of time before could repeat that, 6mths in extreme circumstances, usually a year.

SB: So if did it when knew were situations could skew results we'd not be able to repeat for 6mths-yr so we may miss something that was really important

TS: So ESTEP did not undertake a cognitive or IQ assessment of Chris?

SB: absolutely, it's not what Julia wanted us to do, it's not what we wanted to for the reasons set out

TS: so the one that stood was the GOSH assessment of 58

SB: that's the cognitive assessment part yes, that and the autism assessment, they're two sides of one whole

TS: yes... but Prof Skuse report was 58 and for reasons expressed ESTEP didn't conduct another one

SB: yes... sense was Chris was presenting in different way... that was information we had, so that was the information we were going on.

TS: finally then you say you were acutely attuned to Chris's needs adn the severe risks he presented with, severe risks?

SB: yes

TS: that's in your statement now, was that characterisation of severe risk known by the whole team then?

SB: yes... we were putting in email exchanges, normally we're more circumspect, I think that was very clearly conveyed at the time that we thought the risks were severe.

TS: One final question, you mentioned placement at Priory muted, specialist learning disability and autism placement somewhere like Priory, we expressed unlikely achieve but would express it.

TS: What Ms Hopper would like to know is what role you would have, or should have had, in preparing an application to that tertiary panel for funding. Not just saying is unlikely but finding out from panel whether Chris could have that placement, at that time in early June?

SB: My understanding as team we were all informing conversations taking place with commissioners and other people in order to explore options for different placements for Chris. There were other people in our team, senior managers and others, having conversations about placements

SB: My role was, and should be I think, to inform that as part of a team discussion. If we were at stage of preparing written application for panel I'd very happily contribute any psychological input...

TS asks if she ever expressed explicit support for this placement

SB: I didnt directly myself, I wasn't involved with any conversations with those people; as I understand it were others from my team having multiple conversations about Chris's placement

No questions from anyone else.

Dr Ball is released at 12:18

Samantha Salici gives an affirmation

C: You provided statement 12 Nov 2021

SS: yes

C checks she has a copy of her statement - she does

C asks her background and training

SS: I qualified 2009 into adult learning disabilities team, started as Speech and Language Therapist as Band 5, worked upto Band 6. Was working between the inpatient ward and community service. Over years learning disability service did change quite a lot.

SS: By the time I met Chris we were in the Enhanced Support Services. That was, basically, a split between inpatient and community service, to prevent admission into inpatient ward.

SS explains role of SALT to ensure patients understood what was presented to them, provide Easy Read information etc

SS had assisted a few capacity assessments; providing Easy Read information prior to assessment.

SS: on wards would often have assessments, I'd provide Easy Read, go through with client beforehand, support during assessment, rephrase sentences if needed. I'd never led one so to speak

C: does it follow you wouldn't complete the paperwork and formal documentation, wouldn't be part of your role

SS: No, but I might sit with the person while they were doing it.

C: you met Chris thru the adult learning disabilities team, can you recall when that was?

SS: It wasn't that long before we actually met, maybe two or three days before I met Chris

C: You met Chris on the 10th of June?

SS: yes

SS confirms she was asked to provide some Easy Read information about cannabis use, and contribute to an assessment

C: Had Chris been provided with the Easy Read information before the assessment was conducted?

SS: I emailed the hospital and providing them with the Easy Read information before hand. Not sure if he had chance to read it before, but we did provide it to him at the time as well

C: you asked to see Chris, he was still in bed at that time, can you remember what time of day it was

SS: not sure, think it was after lunch

C: He was still in bed. You were waiting about 20mins, he arrived, was polite, said hello but appeared very tired.

SS: yes

C: you say he was awake but never appeared alert throughout the whole session

SS: yes

C: you say Chris read the information and was able to relay back some of the information through the session. Did you give him the document, he read it, then you asked him about it?

SS: yes

C: you say he was able to relay some of the information he read, I assume that means not all of the information?

SS: yes

C: Is Easy Read material designed to be easily comprehended and understood

SS: yes, it breaks it down, takes out ambiguous term, spacing, font size we use. We get straight to the point, rather than being fluffy

C: so he could relay some of information not all

SS: yes

C: You say he struggled to see how cannabis impacted on him personally, even when directly pointed out by Kirsty

SS: yes that's right

C: so he didn't appreciate his psychosis or ill health was related to his use of cannabis?

SS: yes he couldn't see the negative impact it was having on him

C: he confidently shared his plans to have a year in supported living before move to independent living

SS: yes

C: you say you had to rephrase some sentences for Chris to understand, sometimes helped, does that mean sometimes it didnt?

SS: I hadn't met Chris before that day, so couldn't say was whether it was due to his over tired, or his comprehension.

SS: Sometimes I wasn't sure whether he had understood.

C: you were aware he was assessed as having learning disability and autism?

SS: yes

C: so if someone is tired, you mention he became more awake but never presented as alert. How long did the session last altogether?

SS: I want to say about 1 to 2hrs, maybe it wasn't that long. Sorry I can't quite recall.

C: your impression. You say he showed very little, keeping neutral facial expressions even when discussing difficult topics like the impact of death and how this could impact his family

SS: yes he didn't show any expression, death is quite a big deal, but I didn't notice any change in expression or emotion really

C: You say meeting ended positively with Chris looking forward to Supported Living; you say you met with Kirsty to review session, we agreed Chris had capacity around options of accommodation...

C: however, when it came to talking about cannabis use and potential detrimental effects his capacity was questioned as he struggled to really see any negatives to using... furthermore when discussing his medication and inappropriate use..

C: When you say his capacity is questioned, does that mean you dont feel he did have capacity around cannabis use and medication

SS: sorry that wasn't very clear.

SS: I think we were struggling to really determine whether he did or not.

When we talked about cannabis use, he didn't see the negative.

SS: He didn't want to see the negative impact that was having, it wasn't necessarily that he didn't have capacity, but he refused to talk about it.

SS: We were struggling to understand whether he had capacity, but didn't want to say he did, because we couldn't het to the bottom of whether he understood

C: presumption as I understand it is that someone has capacity, that's starting point?

SS: yes

C: so if after you've assessed them, you can't sustain that assumption, then it calls into question whether someone has capacity doesnt it?

SS: yes

C: is that what you mean when you say there were questions, you couldn't stay with presumption of capacity, was insufficient clarity in how he was presenting, his answers to questions and how he approached the questions, for you to say he does have capacity?

SS: that's right, yes

C: that's same for cannabis use and medication?

SS: that's right

C: you say he made a strong denial that the drugs could have led to a seizure

SS: that's right, that was his view

[missed bit]

C confirms that answers Chris gave was because he didn't, and couldn't see the link between his cannabis use and mental health

[focus on couldn't not didn't want to see link]

SS: I think that's probably the right way to put it, yes

C: were you present with Kirsty as she went on to write up the report or was that something you left to her?

SS: no, I was present

C confirms SS met Chris again on 18 June at Southend Hospital, was with social worker Mel Kay [?] and Kirsty Lister

C: did you understand you were there for another capacity assessment?

SS: well it was a spontaneous meeting... when I arrived was told we were going to see Chris...

C: you were there to assess Chris and collectively assess his capacity

SS: I can't remember if it was a planned capacity assessment, or whether it was something we thought it was important to do, I'm sorry I can't remember.

C: did you take with you any of the Easy Read material on this occasion?

SS: no I didn't

C: once you met, before you went in to see Chris did Ms K or Ms L say we're going to conduct a mental capacity assessment, these are the issues we're going to consider

SS: I think we did, I'm sorry my memory isn't brilliant, but we did have a discussion about how to approach

C: do you know why you were asked to attend? You were't told why you were going there as you had on first occasion?

SS: no... can't remember... I know I was asked to attend but can't remember if I was told if it was MCA or not

C: you met Chris in the garden... you say he consented verbally to the session, you don't say he consented to the assessment

SS: sorry I might not have written it down, he did consent to the assessment

[missed chunk]

C: you say following session, Kirsty, Mel and myself sat in family room at hospital and wrote up MCA. Said he did have capacity around accommodation, and rules of Hart House, however he didn't like all of them... discussion of drug use was closed down by Chris...

C: you're not very clear as to whether or not you considered he had capacity or otherwise, what was conclusion reached by you and team?

SS: I don't think we assessed capacity then around drug use.

SS: We discussed it but it wasn't formally done, was more in passing in conversation from the information he offered to us

C: what were you there to do? If you say this was formal, even if you weren't given forewarning, were you asked take Easy Read materials with you?

C: I think your evidence this is formal capacity assessment, you were present with Mel as she did that. What was the purpose of the MCA assessment, was it solely relating to accommodation? Were you assessing his drug use? His medication compliance? Or not?

SS: I think it was more about his understanding of keeping himself safe, so wandering around at night time, meeting up with people, it wasn't necessarily focused on the drug use, altho it was mentioned.

Granted I think we probably should have assessed that more.

SS: If I had been more prepared I'd have bought Easy Read information to support the assessment.

C: I'm struggling a little with this, if purpose was to assess understanding of his ability to keep himself safe...

C: I think was common ground his use of cannabis was what made him unsafe

SS: yes

C: I'm struggling to see how an assessment of his understanding of keeping himself safe, couldn't involve expressly and explicitly his understanding of illicit drug use

SS: yes you're right. I dont quite know how we came to that, it wasn't really discussed within the feedback, the report.

C: Ok, so in the discussion between yourself, Kirsty and Miss K there wasn't really a discussion about this aspect of keeping himself safe

SS: sorry, there was a discussion... around his drug use, and the suggestion he would step back from using drugs, because of his levels of tolerance.

SS: He said that he was becoming more tolerant with the high amount of drugs he was using, so he was going to step back and stop using drugs. It was becoming more expensive for him and he was taking too much. that was the discussion, and I suppose, that's where it led to.

SS: The discussion that he was going to step back from using the drugs.

C: alright, thank you.

TS: MCA is designed to protect people who may lack capacity to make decisions around their own care and treatment?

SS: yes

TS: how many capacity assessments had you. been involved with? Was it a regular part of your role?

SS: not regularly, on the ward we had a lot of Easy Read information so ward staff could take part in that.

SS: I had been involved with some around accommodation and people's future and where they'd move to following discharge from ward. It wouldn't be a frequent part of my job, but I have been involved in a few of them. Maybe once every 4 to 6 months I suppose.

TS: right. So you've been involved in a few, your recollection is in context of placements to which someone might be moving on after being on a ward?

SS: yes

TS: we know the MCA in relation to assessments of someone's capacity can cover day to day things, what someone may wear or buy in weekly shop, can't it?

SS: yes

TS: right up to serious life changing decisions, such as whether to leave your own home and goto a care home or consent to major surgery

SS: yes

TS: wide spectrum of what can cover

SS: yes

TS: in relation to Chris two of specific issues at least raised in your assessments, yours and Ms Lister's are around medication

SS: yes

TS: making decisions about what medication had and whether had in his possession, that sort of thing.

TS: Pausing there you and Ms L saw him in aftermath of having overdosed on prescribed medication didn't you?

SS: that's right yes

TS: and drug use, in context of being concerns about that, and whether playing any role in psychosis, suicidality or other concerns, is that fair?

SS: yes

TS: on scale... where would you put medication in relation to recent overdose, and drug use in context of suicidality?

SS: very important, really important

TS: very important consequences for Chris's safety?

SS: yes

TS confirms with SS Ms Lister brought her in so Chris could 'put his best foot forward' - she agrees

TS: Did you feel qualified to undertake such an important capacity assessment at that time for Chris?

SS: probably no, I didn't have enough information about his past either. I've only now learnt of the complexities of Chris's case. I don't necessarily feel I was appropriate to assess him in that manner at that time.

SS: I feel like my role was to provide Easy Read information, try and rephrase, but as a decision maker, I didn't feel I was probably appropriate having not known him very well, or his complex history.

TS: Ms Salici you spent a reasonable amount of time with Chris

SS: yes

TS: you did your best no doubt

SS: yes

TS: but acknowledge your limitations within that, is that fair?

SS: yes

TS: did you raise those limitations at time, did you say I'm happy to help but I may not be the right person to conduct a capacity assessment with this seriousness

SS: because I hadn't had whole information, looking back now having been able to read Chris's file.

I hadn't prior knowledge, at time I felt ok, and confident about providing Easy Read information to Chris. Helping and supporting Kirsty.

SS: Only stepping back now, obviously, I've only recently found out how complex a case this was.

I knew about the drug overdose and the query whether it was an accident and he'd had a suicide attempt, in itself, really complicated matters...

SS: but I hadn't been aware of the whole, all the other difficulties before he'd faced. In hindsight I probably wasn't the best person to assess him, or support the assessment, but at the time I felt I was capable of doing it, not having realised the complexity of Chris's case.

TS: this question might sound obvious Ms Salici, but in order to conduct a capacity assessment you need to be fully appraised on pertinent history and risks someone may present, is that fair?

SS: yes. And have a good rapport with Chris. I did try to read up notes, but they were limited on EPUT notes pages, I felt there was an urgency to this assessment, as there should be, so there might not be the time to gather the information about Chris.

TS: I'll turn to a slightly different issue if I may Ms Salici. Were you involved in providing input into a support plan for Chris at Hart House following his discharge?

SS: no, I don't think I was

TS: to be clear, context of this, Chris's mum has real concerns about the expertise and ability of Hart House, staff there, best intentions otherwise, to support his particular complexity as you described it.

TS: Whether you were involved, did anyone ever ask you as a SALT to provide any input into that discharge plan for Chris to Hart House?

SS: no

TS: having been someone who completed capacity assessments... would you have expected to be asked?

SS: yes and I'd have happily prepared Easy Read information and feed back on his communication as I'd seen it, but I wasn't asked.

We weren't quite certain about how much involvement I would have in Chris's case. If I was asked obviously I'd have tried to support.

TS: tell me if better question direct to Ms Lister, you've told us you weren't appraised of full background record... did you think to speak to Julia, before conducting the assessments you undertook?

SS: It was difficult to know how much information I should know. I was there to rephrase questions asked and provide Easy Read information, I dont know how much information I should be privy to prior to assessment, or in continuing my work with him, that was still very unclear.

SS: if I had of known I don't know if I'd have approached things differently, I'd still have brought Easy Read information and rephrased things. I don't know how much information I should have known, in relation to my role in Chris's case.

TS thanks Ms Salici

C: do you understand your role for first assessment and second one, doesn't sound as though it was a planned assessment on the 18th.

Looking at the first assessment which was planned, you were there to perform role done on occasions with others...

C: provide Easy Read material and if necessary rephrase a question to ensure person had understood. You weren't told you'd be contributing specifically to the mental capacity assessment itself

SS: i'd been told I'd be supporting the mental capacity assessment, my view to rephrase, provide Easy Read information, and have discussion with Kirsty afterwards, for her to bounce off...

C: you didn't think was necessary to have fuller history or speak to Julia, you didn't think sounding board role required you to have more knowledge of Chris

SS: it probably did, but I didn't know if it was a one off assessment or I'd be seeing Chris again

C: but even so it's still very important assessment

SS: yes

No question from Alex Denton but she confirms M Kay was a social worker within SPC

SS: yes, but she still oversaw learning disability, so we worked quite closely together. Sorry I misunderstood the question

C: no it's not your fault, what was oversight role?

SS: any clients we saw, if she were allocated social worker, we might work together with clients

C: I see; a contribution, in partnership with the learning disability team but separate from. Ms Nash?

Ms Nash: no questions sir, but to clarify chronology, conversation with Hart House took place on 23 June

Ms Khalique: I represent the CCG, I don't have direct questions in relation to our involvement with you in this, but because you touched on issues around mental capacity...

NK: ...I've a few questions to ask you which may assist the court, if I may

SS: yes

NK: your role in this assessment was more around facilitation, making sure the questions were understood by Christopher, is that right?

SS: yes

NK: can I take you through a few basic principles of the mental capacity act...

[Court is adjourned for short break to discuss witnesses arrangements.

Back at 13:30. Some issue has been raised about live tweeting, not sure what. Will update later if able]

[Court is now adjourned for a lunch break.

Back at 14:30]

We're back in court, afternoon of Day 3 of the inquest touching on the death of Christopher Nota

Back with Ms Samantha Salici

Nageena Khalique for CCG/ICB

SS confirms she agrees with first principle, that everyone must be assumed to have capacity unless proven otherwise

NK asks whether she assumed that at first assessment

SS: my role to provide information in as accessible as possible way...

NK: ties in with another principle of MCA... all practicable steps have been taken.

NK: Were you trying to take all practicable steps so he could make decisions?

SS: yes, provide as much accessible information as possible so he could come to the decision...

NK: So far all very MCA compliant, now can I ask if you recognise the principle that you cannot treat someone as lacking capacity because make unwise decisions [my paraphrase]

SS confirms she does

[missed chunk]

NK: as far as the collective view as it were was, that there was recognition he was, you described him as being interactive, engaged well, then not keen to talk about drug use [2nd assessment] that right

SS: yes

NK: in your view was he showing a level of understanding about how drugs could cause some difficulties?

SS: yes he was showing how they can impact on people, but he couldn't relate it to himself

NK: but he did also say he wanted to take a break from drugs, does that reveal a level of understanding on his part?

SS: yes I think so, the understanding of what he could tolerate and manage. For us we felt he was showing some understanding of when he needed to stop.

C: Just around the issue of tolerance. He wanted to take a break from drugs due to becoming too tolerant to them... everyone agreed this was a good decision.

Without coining the song, the drugs dont work, it was the case wasn't it, or was it, you tell me...

C: what he was saying there is it wasn't so much he was concerned about the effects on him, but that he was too tolerant to them.

He was using them and they weren't having an effect on him?

SS: yes I think that was where he was going with that, it wasn't giving him the feeling he got when he took drugs that he enjoyed, and he said it had become more expensive and he was having to take more to have an effect

NK: later in your statement you say you, collectively, Kirsty L, Mel K and you I believe.

Came to decision he had capacity about his accommodation and the rules of Hart House

NK: you did say for drugs use he needed further support from someone close like a support worker who could educate him about that. Was that because you thought he needed more practicable steps in order to make those decisions fully?

SS: yes, coming from background where we try to give people as much information as possible so they can make the best decision, that's what we thought would benefit him...

SS: whether due to his learning disability, autism and didn't understand, or an addiction to drugs, we felt he needed more information to come to the best possible options and decisions for him.

NK: so he wasn't at that stage to be treated as unable to make a decision?

NK: Chris was not to be treated as unable to make a decision around drug use unless a practicable step of support worker was taken to enable him to make that decision, in other words to educate him about it.

SS: yes we thought a support worker would be someone he could build up a rapport with, who'd provide support

NK: You were aware of some history. Were you aware a mental capacity assessment is time specific?

SS: yes

NK: so at the time you were asking questions about cannabis use was it clear in your mind that Christopher had some past experience of cannabis use and it had a negative, or adverse, affect on him?

SS: yes

NK: are you aware the MCA... assessment has to be issue specific

SS: yes

NK: so here you're asking specifically about cannabis use, and specifically at this time

SS: yes

NK: It's not a retrospective... were your questions featured on the here and now, not his past use?

SS: When we were in Basildon Hospital he wasn't accessing cannabis at the time.

NK: I'm asking you about assessing him on 10 June

SS: he was in Basildon Hospital

NK: Sorry my mistake, 18 June

SS: yes, his specific cannabis use, at that time

C: just want to clarify one of questions NK put to you, that Chris was not to be treated as unable to make a decision around drugs use unless the practical steps for a support worker to educate him had been taken.

I want to come from the other end of the telescope, so to speak.

C: Did you feel without that education, without that support, he was able to make informed decisions about his drug use at that time, or not? Was that the reason he needed that education?

SS: its that confusion we felt when talking to Chris, about the kind of he didn't want to talk about negative effects... and we couldn't do that in those sessions...

SS: we wanted to explore that further, someone close to him, who had a rapport, could really find out his understanding and produce him with the right education, that's where we were coming from with that comment

C: thank you. Ms Ballard.

BB: TYVM. Can I first of all, you know I ask questions on behalf of EPUT don't you.

SS: yes

BB: Can I check you don't work for EPUT now, that's right isn't it?

SS: yes

BB: When I look at your statement, this is not a criticism at all, I dont see a parapgraph saying you'd looked at notes when you came to make that statement?

SS: I was sent some of my notes from the actual assessments, so I was able to get some information from that

BB: so you had access to some records; do you know whether they were for example Kirsty Lister's note of your assessment on the 10th and 18th?

SS: I can't remember if they were Kirsty's or if I'd written notes, I think it must have been Kirsty's

BB: Ok. The other information on which you're providing evidence, ie, how you came to undertake the assessment on the 10th... and the 18th... am I right that's purely from your memory thinking back now?

SS: As in how I was asked to come, yes that's right

BB: So you've not been shown emails or notes of meetings to jog your memory of how those assessments came about

SS: no

BB: that's how we must understand your answers thus far, you're trying to do your best but that's based on what you remember

SS: that's right

BB checks if she has bundles in front of her and takes her to an email chain

BB: does that help jog your memory about the circumstances?

SS: yes

BB: It appears to suggest had been a long meeting on 9 June about how to best manage Christopher and his care

BB: one of the outcome action points for that meeting was need for an urgent mental capacity act assessment undertaken before Chris was due to be discharged from the assessment unit at Basildon, is that right?

SS: yes

BB: and this was a collapsing timeframe because they couldn't hold onto him because his mental health was stable

SS; yes

BB: so there needed to be an urgent assessment by services working together, is that right

SS: yes

BB: and it is in that context that you offered your services?

SS: yes

BB takes through email chain and asks SS to read

BB: I just want to try and summarise those rather than read onto record, Judi Jeavons came back to you to say thanks for responding, you'll be paired with XX because we can't get hold of Kirsty at the moment... you're provided background to Chris...

BB: then Gemma Robertson, more senior to you at that time in the learning disability team, comes out of her meetings, looks at email exchanges and thinks its unwise you and Justine would conduct

BB: and she thinks its wise to wait until the following day when you can attend with Kirsty, is that right?

SS: yes

C: and the reason for that, summarise please

BB: because capacity assessments should be undertaken by someone who best knows the individual and neither you or Justine had met Christopher before, and limited experience of team, so wisest was to wait until next day, 10 June.

BB: Does that jog your memory of how that assessment came about?

SS: yes

C: were you aware that it was you and Justine, the initial plan?

SS: I thought it was me and the care coordinator, so I received an email and agreed, then Gemma stood in and said that's not the care coordinator, does Justine know Chris and put a halt and waited for Kirsty.

C: Did you know Justine hadn't completed the capacity assessment before?

SS: Think we had a conversation on the telephone, and she said she hadn't much experience of MCAs, so that's why we thought it best to wait for Kirsty.

C: Who had some experience of writing up MCAs, because you said you hadn't done that before yourself?

SS: no

C: Sorry Ms Ballard

BB: Bundle 4, p411

BB: We can see from that entry that Justine in fact, whether on way or already there when decision taken to halt assessment on 9 June, she had a conversation with Christopher at that point, part of that was to inform him that yourself and Kirsty would attend the next day

BB: In order to conduct a capacity assessment, and there were topics she discussed with Christopher for him to consider in order for him to get most [?] out of the assessment

SS: yes

BB: This is the record, there are others in the MCA paperwork, this is the freehand records that Kirsty Lister makes. Is that familiar to you, have you seen that before?

SS: yes

BB: just so I understand the end result with regard to cannabis use at end of this assessment was you'd understood what Christopher was saying was in relation to tolerance, was taking too much, costing him too much, so he'd have a 6 month break at Hart House

BB: I paraphrase because we've been through it.

SS: that was the second assessment, on the 18 June

BB: thank you, very helpful, with regard to 18 June can I ask you to go back to your statement... you say I met Chris again at Southend Hospital

SS: yes

BB: I paraphrase because we've been through it.

SS: that was the second assessment, on the 18 June

BB: thank you, very helpful, with regard to 18 June can I ask you to go back to your statement... you say I met Chris again at Southend Hospital

SS: yes

BB: You were with Mel Kay the social worker from the local authority, Kirsty Lister his care coordinator... you met before seeing Chris to get a background from Kirsty

SS: yes

BB: background provided to you orally, before you went to see Chris, by Kirsty, is that correct?

SS: yes

BB: thank you sir that is all my questions

Coroner thanks Ms Salici and releases her at 15:08

Coroner reads statement of Dr Milind Karale, Medical Director for Essex for @EPUTNHS

Summarises his background. He's a consultant psychiatrist, one session, does not have clinical expertise of managing patients with learning disabilities.

He had conversation with Ms Cooke about suitability of Chris for a learning disability inpatient unit - was advised that Chris wasn't suitable.

Coroner would like date of when the LD services established Chris was not suitable for an LD unit.

Subsequently clarified but doesn't believe was as early as the 18th.

Next statement he reads is that of Anne Eigo [sp?] works as contract officer commissioning team for adult social care at @SouthendCityC

Outlines changes in her role

When I had job title specialist case officer, parents understood my department at time was solely Education.

My job title changed to Education, Health and Care Plan Coordinator that led to change of perception, that we had power to coordinate within health and social care which was not the case.

Her responsibility was purely education... reforms 2014 Education, Health and Care Plans replaced Statements of SEN...

Would gather information about young person's needs, often only able rely on what parents or caregivers told me, very difficult access information from health, the NHS, in terms of social care had read only access...

Describes funding available

Parents can apply for an EHCP at any time, do not have to prove the school can not meet the young person's needs...

Outlines process of applying for an EHCP Level 3 Funding and those involved > panel > assessment > if issued additional funding

My team responsible for 640 plans across Years 9 - 20

C: that might be a typo I suspect

Counsel clarifies likely to be age in years

Two case officers responsible for all those plans.

Would try attend all annual reviews for Year 11 onwards... often not informed was taking place

Explains process after review.

I was responsible for all case work for Yr 11 onwards, up to Yr 20, that involved EHCP for young people through to further education and college

Last until young person is 25yrs old

[Missed huge chunk]

Chris had an EHCP which is how I became involved in his case...

First time met Chris and his mother was Yr9 annual review on 17 March 2015

Chris Yr9 annual review took place at mainstream high school, Chris had just turned 14 at time.

Meeting was with view to turn his SEN statement into an EHCP

3yr period to transition all pupils on statement of SEN, 800 at time, onto EHCP. Did not include new pupils coming into the system.

Chris was able to talk about his learning disability (autism)... Chris was having a high level of support in school...

School was waiting for specialist autism report requested with review to further ongoing support Chris would need going forward....

v1 of EHCP issued on 25 Oct 2016, delay from meeting in March and finalising in Chris's case was in no way unusual at that time

In v1 there were not health and/or social care provisions, version of this plan provided additional educational support

No health/social care involvement was listed, which was not unusual, although would gather any information together relating to health...

[Missing most of this, Coroner reads at speed, is background to the EHCP development for Chris]

v2 signed off 30 March 2017, after draft sent 2wks earlier.

Review had taken place 12 Dec 2016, she did not attend it as did not know about it.

At time Chris's mother was saying he was struggling.

He received 25hrs support. School had provided additional support from MIND counsellor, and reduced number of subjects studying.

Health needs refers to him not keeping an appointment with EWMHS as offered group therapy and his inability to open up to others.

Was no social care involvement.

No mention of suicide attempt in notes of meeting Dec 2016

Next involvement 24 July 2017 wrote South Essex College to ascertain whether they'd be able to meet Chris's needs for a course he was interested in, Level 1 Sport and Leisure

Their response was they could... issued 2 August, stating South Essex College as preferred FE provider

27 April 2018 - end of first year

She describes as a "real pleasure" to see how Chris was getting on [fuller statement]

Next involvement EHCP review 13 May 2019 when she was on annual leave.

Julia wrote on 13 May to let know annual review had taken place at college and asked whether EHCP could be paused until Chris returned from Portugal

His mother indicated he was stressed at South Essex College and needed advice on apprenticeships

17 May spoke to her. At time wasn't clear whether he'd continue at college or go down apprenticeship route.

His mother had said he'd go to Portugal to his grandfather for the summer as he'd been impacted by the death of his grandmother and one of his great aunts.

[missed chunk]

Chris has got his Level 2 BTEC in Sport and Leisure, but didn't take English and Maths GCSE as he was stressed.

Suggested he meet Connexions service.

January 2020 sent information about Princes Trust Scheme

9 April 2020 received email from Chris's mother, and a number of other professionals, indicating Chris had become seriously ill and he needed what she described as a proper EHCP, which she described as lapsed... I telephoned her upon receipt of this email, spoke to her for 36mins

Julia explained Chris had been admitted to Cedar Ward as his mental health had deteriorated.

With view to trying to help Julia I telephoned Cedar Ward and send them copy of most recent EHCP plan and the GOSH report.

As result of doing so, received email from NHS commissioner who wanted to know if Chris had been admitted due to acute illness or mental health, I said he'd been sectioned and provided details about Chris, and his autism [more detail]

Next involvement 15 April 2020, number of emails from various parties including my line manager and NHS commissioner.

Indicating amongst others Chris's EHCP would need amending due to his current mental health needs.

[Missing lot of this]

Chris had been sectioned, staff had indicated wasn't therapeutic environment for him... Julia had asked he be transferred to the Priory... she explained Chris's anxiety had been crippling, he just wanted to be with his grandmother who had died in 2016

[Missed chunk]

I asked whether any assurance could be given about his mother's concerns he'd be discharged without plans or medication, as had happened when he left Homerton Hospital

I sent a further email explaining circumstances about Chris's discharge from Homerton, and his section and admission to Cedar Ward subsequently

16 April Julia emailed 10 people including Ofsted... she made reference to Chris's suicide attempt and self harm...

She attached blame to the CCG for the EHCP failing. She made mention of her being in touch with Chris's GP... she said she wanted to know why Chris was without support, and made reference to his case worker, me, as having done nothing wrong.

I contacted her giving her details... none of this fell within my remit so to speak, but wanted to try and help.

Emailed Sam Ball again, explaining Julia wanted Chris transferred to the Priory and their specialist LD/autism unit

[More detail - can't catch]

17 April, Sam at CCG replied overnight and indicated Chris's mother "may have a point"... I suggested a conference call with him.

Julia indicated she believed the CCG had a duty to provide the package...

I called her and explained I have no input over any clinical input into Chris's case.

Reiterated at this point I was purely Education, I was trying to progress Chris's case as high as I could, with a view to assist

21 April received email from colleague Sarah Range... 26 emails on Chris's case alone... I asked Sam Ball to contact Julia directly as she was becoming frustrated having to come through me in Education.

[Missed chunk]

At same time emailed copy of GOSH report to Dr Thies Fletchner.

Dr TF's need for up to date assessment was discussed, as well as social care assessment which Sarah Range had asked the ward to conduct on three separate occasions

She explains she has a duty to keep Chris's family involved.

NHS view was that Chris had capacity because he was 19 and they'd solely liaise with him regards to his treatment at the time.

29 April became aware Chris suffered from epilepsy

[missed chunk]

Emailed LA social care department as Julia had made a complaint...

2 and 4 May 2020 Julia emailed Lynbritt Gale [?] with a formal complaint

I explained her concerns related to health, not education.

I explained any decision would be determined at a multi disciplinary team meeting

Julia replied indicating a learning disability was for SBC to deal with and not health.

I emailed my line manager, and also emailed LA colleague, Matt Harding, to discuss who was to conduct a Care Act Assessment for Christopher.

At this stage Matt Harding suggested I take a step back.

That was the end of my involvement until having heard someone had died, I wrote to my line manager to ask whether it was Chris as I suspected it was.

[Sorry didn't catch much of that]

C: Mr Stoate, I appreciate a lengthy detailed statement was read, I appreciate not all areas, as in Julia's statement, there will be a number of areas that aren't accepted as expressed.

C: The view as I understand it was being pragmatic the statement was to be read. I understand the frustrations.

C reads Matt Harding's statement

He's a service manager in social care. Has a social work degree from Australia in 1998, joined SBC as social worker in 1999.

From 2017 onwards he's a line manager of a number of team managers in social work teams in the local authority

[He describes the process of assessment/involvement of adult social care]

Care Act Assessment would be carried out if person appeared to be in need of care and support

Also responsibilities under the MCA where reason to doubt someone able to take a specific decision, for example, manage finances or receive care and support

[fuller - cant catch]

Care Act is primary legislation for us, only get involved if people have care and support needs under the Act

MCA assessment only carried out if we have reason to doubt person's capacity...

All LA social workers have mandatory training around the MCA, with refresher training every 2yrs

[missed chunk]

Referrals can be by person themselves, family member, GP, or member of public

There are 2 LD teams, the LD social work team in the local authority ie my team, involved to extent care act needs identified and for which LA commissions care package.

Then Essex LD Partnership provided by EPUT, clinically led, and range of professionals involved... all of which provided by NHS.

We have no control over the LD decision making in the NHS, we do however work in partnership to achieve best outcomes.

First aware Chris's case in early April 2020, at time was still team manager for that team

My colleague, a social worker, in LD social work team, had been called by Chris's mother Julia.

Chris had gone missing, admitted to Homerton, received NHS treatment, admitted to Cedar Ward... advised to speak to NHS service, advised EPUT would consider which services were most appropriate for Chris as he was an NHS patient

By 29 April I'd had number of conversations with Julia, she was of view LD local authority team ought to be involved with Chris's case as he'd been diagnosed with learning disability and autism.

I took pragmatic decision to allocate a member of my team, M Kay to attend a professionals meeting on 7 May 2020.

Number of professionals, to discuss how best to support Chris...

and discuss on one hand his mother's views that further to GOSH assessment when he was 8 that he had learning disability and autism, and the medical views on the other that he had capacity and presented much more ably than that

Agreed M Kay would attend meeting on 7 May and after that would decide which service would carry out a Care Act Assessment.

There were a number of emails, MK confirmed she'd liaise with EPUT on 7 May.

Meeting was I understand "robust" was clinically led meeting by number of professionals allocated to Chris during time admitted to hospital.

If I understand matters, consensus was Chris's IQ was not reflective, and how he presented on the ward was much more able, and concluded his needs best met by NHS professionals and they'd carry out the Care Act Assessment.

I think at the right time also a further cognitive functioning assessment and autism assessment, which needed to be delayed until illicit substances did not play a part.

MK attended meeting, but MK was not a decision maker. We have no control over NHS services or decision making

I let my manager know the MDT was robust, and it was concluded by the mental health professionals that they'd conduct the necessary Care Act Assessment

I telephoned Julia and let her know the outcome, she'd not been invited to the meeting.

Few days later she emailed to ask who the social worker in EPUT would be.

I informed her it would be Sophie Vincent, a student social worker at EPUT under mental health who'd be carrying out the Care Act Assessment for EPUT.

15 - 16 May 2020 number of email exchanges with Kirsty Lister, the care coordinator for EPUT ESTEP.

She'd spoken to Chris's mother on two occasions indicating ESTEP would carry out the assessment.

Was email traffic indicating Julia felt no-one was involving her.

18 May 2020 I conveyed to Julia, clinical professionals had taken view they'd make assessments, however I allocated MK to assist in a secondary role.

Was right EPUT took lead as this was complex case and involved psychosis and substances... thought MK could take role alongside Kirsty Lister and Sophie Vincent.

I was not involved further [he switched jobs]

That concludes the statement of Mr Harding.

That's as far as we'll go today, it's an effort to read it out but much harder to hear it read. I'll conclude there.

[Court is adjourned. Back at 10am tomorrow]