The seventh day of Christopher Nota's Article 2 inquest will start shortly.
Area Coroner for Essex Mr Sean Horstead sits without a jury.
This inquest discusses suicide and self-harm.
I report contemporaneously, as accurately as I am able. This is not a transcript.
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Area Coroner for Essex Mr Sean Horstead sits without a jury.
This inquest discusses suicide and self-harm.
I report contemporaneously, as accurately as I am able. This is not a transcript.
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There are 5 IPs represented by counsel
Chris's family by @TomStoate of @DoughtyStreet
@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
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Chris's family by @TomStoate of @DoughtyStreet
@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
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I attend remotely.
I report as much as I am able, however speech is fast, and *this is not* a full or complete transcript of proceedings.
Where possible I indicate where I have [missed chunks] or where it's [my paraphrase] or I'm uncertain [?]
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I report as much as I am able, however speech is fast, and *this is not* a full or complete transcript of proceedings.
Where possible I indicate where I have [missed chunks] or where it's [my paraphrase] or I'm uncertain [?]
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This inquest discusses suicide and self harm. I am intentionally withholding details, in keeping with @samaritans guidance on reporting from inquests.
My #OpenJustice work is crowdfunded and I report from court in order to provide a degree of scrutiny and raise awareness.
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My #OpenJustice work is crowdfunded and I report from court in order to provide a degree of scrutiny and raise awareness.
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We are due to hear today from two witnesses, Sharon Allison and Melika Cay.
I'll stop numbering tweets from here.
Day 7 will begin shortly.
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I'll stop numbering tweets from here.
Day 7 will begin shortly.
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Coroner says he'll read some statements onto the record before our first live witness.
[This will be very partial summaries because reading happens at speed and I struggle to keep up]
First statement is that of Elspeth Clayton dated 26 October 2021
[This will be very partial summaries because reading happens at speed and I struggle to keep up]
First statement is that of Elspeth Clayton dated 26 October 2021
She's a speech and language pathologist. Worked for EPUT Trust since 1987.
Retired as Associate Director of Learning Disability in Dec [?] 2020, has since returned part time as Director of LD
Retired as Associate Director of Learning Disability in Dec [?] 2020, has since returned part time as Director of LD
Her role was management of LD service within EPUT, and supervision of staff, strategic development of the service, develop and implement collaborative working practices between Trust services and other stakeholders in learning disabilities.
Active involvement with development of Essex LD Partnership
Was unaware of Chris until June 2020. Had written contact with his mother @JuliaCa20602661 over 4 day period.
Was unaware of Chris until June 2020. Had written contact with his mother @JuliaCa20602661 over 4 day period.
17 June received email from Judi Jeavons, ESTEP, due to him unable to be discharged home or to Hart House.
ESTEP team felt needed to be somewhere more secure, inquiring about admission to LD inpatient service.
ESTEP team felt needed to be somewhere more secure, inquiring about admission to LD inpatient service.
She called XX and clinical decision was Chris didn't need such an admission, would be of no benefit to him.
As it was there were no beds available to people with learning disability in Essex.
As it was there were no beds available to people with learning disability in Essex.
26 June received call from Dr Udu, stating Julia had told Dr Villa wanted letter from LD Service regarding involvement with Chris.
She sent letter detailing their role and how best LD services could support Chris and those working with him.
She sent letter detailing their role and how best LD services could support Chris and those working with him.
29 June received response from @JuliaCa20602661 detailing concerns about letter, and services that I have no responsibility for.
[missed chunk]
[missed chunk]
She concludes: At no time did I have contact with Chris himself, only his mother. The LD service did not rescind support for Chris at any time, were cooperative at all times and were working with colleagues to support Chris's health needs.
Next Lorraine Pocklington 29 Oct 2021
Worked at @SouthendCityC for 20+ years. Carers Link Worker.
Her role was to conduct Carers Assessment.
She'd never met Chris. Only had contact with @JuliaCa20602661 in relation to her assessment.
Worked at @SouthendCityC for 20+ years. Carers Link Worker.
Her role was to conduct Carers Assessment.
She'd never met Chris. Only had contact with @JuliaCa20602661 in relation to her assessment.
15 May referral from Sophie Vincent and Kirsty Lister, to arrange carry out carers assessment for mother/carer Julia.
Booked on 19 May. Planned call to carry out assessment.
Booked on 19 May. Planned call to carry out assessment.
Offered carers counselling and caring support with Southend Carers. Declined support and requested cleaner to be funded. Advised not possible as carers assessment leads to one off funding [think he said]
Next Amy Glover, employed by @SouthendCityC seconded to @EPUTNHS as social worker
Uploaded previous assessments onto Liquid Logic as EPUT team doesn't have access to it to source funding.
ESTEP would continue to lead on care and source suitable support for Chris.
Uploaded previous assessments onto Liquid Logic as EPUT team doesn't have access to it to source funding.
ESTEP would continue to lead on care and source suitable support for Chris.
Our team uploaded professional evidence onto Liquid Logic as Care Coordinators don't have access to the system, so our team had to input third party onto system and ensure providers are paid by Southend Borough.
She did not meet Chris.
She did not meet Chris.
Was copied into variety of emails where ESTEP were taking lead. To her recollection Christopher's mother had contacted LD services to complain about previous social worker and request services [think he said]. She forwarded to Care Coordinator.
Unfortunately unable to access Liquid Logic since leaving team... recollection after Hart House was sourced, believe was uploaded around beginning of June. Herself and Chris's Care Coordinator had call to check information all correct, none missing.
Then sent to panel. Placement was agreed following this. Believe further discussions between ESTEP and SBC re covid test before discharge to Hart House.
Believes she was asked to end Chris's placement after Chris died to ensure the provider was no longer paid.
Believes she was asked to end Chris's placement after Chris died to ensure the provider was no longer paid.
Final statement is Sophie Perzuma [?] team manager at young person's drug and alcohol team YPDAT. She confirms she worked in that team, held her role since 2019, with team since 2015.
Introduces team, Coroner says already read onto record with respect of her colleague Mr Hart so he doesn't repeat those.
In her role as team manager she has day to day supervision of staff, oversight all cases and referrals.
In her role as team manager she has day to day supervision of staff, oversight all cases and referrals.
22 June late afternoon received call from Richard Weidner at ESTEP.
Briefly discussed Chris Nota who she'd not heard of previously.
He explained briefly Chris was a cannabis user and had been for some time.
Briefly discussed Chris Nota who she'd not heard of previously.
He explained briefly Chris was a cannabis user and had been for some time.
Wanted to know whether we were best placed to help him or whether STARS would be better to refer him to.
Fairly usual occurrence for ESTEP team to contact before referral. Indicated could potentially refer case to us.
Fairly usual occurrence for ESTEP team to contact before referral. Indicated could potentially refer case to us.
Said would consider face to face meeting as ordinarily was case at that time were working from home by telephone.
23 June team administrator emailed 09:54, acknowledged receipt and let RW know would be discussed at next team meeting
She was on annual leave 23-26 June
23 June team administrator emailed 09:54, acknowledged receipt and let RW know would be discussed at next team meeting
She was on annual leave 23-26 June
29 June, following Monday, she returned to work from annual leave, by which time had been copied into a variety of different emails about Chris from ESTEP and Dr Carla Villa from EPUT and Sam Ball CCG.
Also received email from Jamie x inquiring whether any engagement with Chris
Also received email from Jamie x inquiring whether any engagement with Chris
30 June said had received referral previous week, not yet assessed.
Chris had been at Basildon Unit since Friday, secure unit so wouldn't be able to assess as wouldn't have access to him.
Said would assess when discharged
Chris had been at Basildon Unit since Friday, secure unit so wouldn't be able to assess as wouldn't have access to him.
Said would assess when discharged
Received email from RW saying discharged.
Allocated assessment for 1 July
Understood from referral Chris had been using drugs since 14 and this was first she knew of him, aged 19
Allocated assessment for 1 July
Understood from referral Chris had been using drugs since 14 and this was first she knew of him, aged 19
1 July allocated Chris's case to Dave Hart, dedicated team member for older young people had left fairly recently. Dave was longest serving team member and had experience with working with older clients.
Agreed Dave to have follow up video call 3 July but Dave was not able to arrange with Hart House that conference
6 July she discussed case with Dave, they agreed he should meet Chris face to face.
6 July she discussed case with Dave, they agreed he should meet Chris face to face.
Arranged for 8 July 3pm at Hart House. Dave attended with view to meet Chris. Unfortunately the staff did not know where he was.
Heard of suicide locally. She contacted ESTEP to check that it was not Chris, Mr Weidner confirmed that it was.
Heard of suicide locally. She contacted ESTEP to check that it was not Chris, Mr Weidner confirmed that it was.
She carried out internal risk management Need to Know assessment, sent to her manager.
Coroner calls Sharon Allison, who is joining via Teams.
She gives an affirmation.
Coroner calls Sharon Allison, who is joining via Teams.
She gives an affirmation.
C: You've provided a statement... do you have access to that statement
SA: yes I do
C: and you've refreshed your memory by reading it today
SA: yes I have
She confirms her full name
SA: yes I do
C: and you've refreshed your memory by reading it today
SA: yes I have
She confirms her full name
C: before I start are you aware a Niche report was compiled in relation to Christopher's death
SA: yes I am
C: and have you read that Niche report?
SA: yes I have
C: and you've read and understood the fgindings and recommendations the report made
SA: yes I have
SA: yes I am
C: and have you read that Niche report?
SA: yes I have
C: and you've read and understood the fgindings and recommendations the report made
SA: yes I have
C: you're a Consultant Clinical Psychologist, within EPUT since June 2006
SA: yes that's right
C covers qualifications
C: Prior to working ESTEP you'd worked privately with dyslexia institute [think he said] worked in NHS since qualified
SA: yes that's right
SA: yes that's right
C covers qualifications
C: Prior to working ESTEP you'd worked privately with dyslexia institute [think he said] worked in NHS since qualified
SA: yes that's right
C: Were clinical psychology service in Aspergers Service and managed paediatric psychologists who worked in South Essex
SA: yes that's right
C: Held that role since xx but worked with adults with autism since qualifying in 1993
SA: yes that's right
C: Held that role since xx but worked with adults with autism since qualifying in 1993
C: so the cohort you're familiar with contains people with learning disabilities and autism
SA: yes that's right
C; will cover some emails... email you sent to Dr TF about your meeting, a 40min conversation with Chris.
SA: yes that's right
C; will cover some emails... email you sent to Dr TF about your meeting, a 40min conversation with Chris.
C: You make reference to fact you don't consider yourself in an expert as there's always more to learn.
May be throw away comment or can I just be clear. Do you regard yourself as an expert in learning disability and autism or not?
May be throw away comment or can I just be clear. Do you regard yourself as an expert in learning disability and autism or not?
SA: I wouldn't use that term... I have experience and skills but that's not a term I'd use. It doesn't mean to say I'm not qualified to do the role I have.
C: Ok, would you recognise there are experts in the field of learning disability and autism?
C: Ok, would you recognise there are experts in the field of learning disability and autism?
SA: yes sir, there are people who term themselves that
C: so let me ask it this way, is there anyone you'd regard is an expert in the field, regardless of what they term themselves, what's your view?
C: so let me ask it this way, is there anyone you'd regard is an expert in the field, regardless of what they term themselves, what's your view?
SA: yes there are people who trained me in diagnostic assessments, people in other settings
C: experts in learning disability and autism.
I want to be clear that you recognise is cohort of practitioners who'd be regarded as expert in field not only by themselves but by you?
C: experts in learning disability and autism.
I want to be clear that you recognise is cohort of practitioners who'd be regarded as expert in field not only by themselves but by you?
SA: yes sir
C asks her tell a little about the service
[missed it]
C asks her tell a little about the service
[missed it]
C: you say you worked across 3 services, main role as lead for Aspergers Service.... its a small service with part time OT, two assistant psychologists and PT psychologist in Under 5 diagnostic service and one day a week into this service.
C: In service you work with adults 18 and above who do not have a confirmed learning disability.
To be crystal clear is there a commissioned service to those who have a confirmed learning disability and have autism?
To be crystal clear is there a commissioned service to those who have a confirmed learning disability and have autism?
SA: that's the other service I work in sir, that's the learning disability service... if they have autism spectrum as well as learning disability they'd come under that service
C: with respect size of service, obviously its small in size, yourself, 2 part time therapists and part time psychologist. Is there any psychiatric input into your service at all?
SA: no there isn't sir
C: is that something which would improve service provision or not?
SA: no there isn't sir
C: is that something which would improve service provision or not?
SA: No, I don't think it would.
Where we sit we have links to adult psychiatrists in mental health services, we're not missing that element we have access to that in other arenas
Where we sit we have links to adult psychiatrists in mental health services, we're not missing that element we have access to that in other arenas
C asks names of consultant psychiatrists she has regular contact in respect of learning disability and autism service provide
SA: sorry sir was referencing Asperger Service. In terms of LD service Dr Picton, Dr Udu and Dr XXX the three in the south
SA: sorry sir was referencing Asperger Service. In terms of LD service Dr Picton, Dr Udu and Dr XXX the three in the south
C: do they have what you would identify as expertise in respect of autism
SA: I think that's a question you'd have to ask them.
SA: I think that's a question you'd have to ask them.
SA: They have expertise and training of learning disabilities, and experience and skill of working with individuals with autism because it's a common presentation that we see in individuals with learning disabilities. Yes that's right
C: so you'd like me to ask them, you say they';re experienced but you don't know whether they're experts
SA: I don't know if they'd consider themselves experts
SA: I don't know if they'd consider themselves experts
C: may be difficult but will ask anyway... can give impression frequency with which cohort of patients you deal with with confirmed learning disabilities also have confirmed diagnosis of autism.
Sense of what the proportion is of your services users.
Sense of what the proportion is of your services users.
SA: I can't give you an exact figure but number of individuals work with in LD services who also present with autism spectrum disorder, whether diagnosed or not.
It's not uncommon.
It's not uncommon.
C: I'm not after a precise number, your experience impressionistic to help me get perspective on this. 10, 20, 30, 40% what would you say?
SA: there is a figure but I can't call it to mind at the moment sir
C: right, thank you.
SA: there is a figure but I can't call it to mind at the moment sir
C: right, thank you.
SA confirms most of contact through MDT and discussions, only met Christopher once
C: You met him on only one occasion, that was about 40mins or so
SA: yes that's right
C: You met him on only one occasion, that was about 40mins or so
SA: yes that's right
C: you were, I think, after Chris's admission to Cedar Ward in April 2020, was contact with LD service and he was discussed at learning disability MDT first on 20 April
SA: yes that's right
SA: yes that's right
C: same day message passed on from Chris's mum Julia that recommended he be under Aspergers Service and you emailed consultant on ward to clarify, was that Dr Thies Flechtner is that right?
SA: yes that's right
SA: yes that's right
C: I'll forward because at that time only had documentation from GP and school... 28 April was email that assessment from GOSH passed on by Chris's mother. You received 28 April is that right?
SA: that's right
C: assessment conducted by Prof Skuse and his team at GOSH
SA: that's right
C: assessment conducted by Prof Skuse and his team at GOSH
SA: yes that's right
C: were you familiar with him?
SA: yes I know of him
C: well known in the field of autism?
SA: yes yes
C: self evidently assessment was from 12yrs prior to Chris's period on ward in 2020
SA: yes that's right
C: were you familiar with him?
SA: yes I know of him
C: well known in the field of autism?
SA: yes yes
C: self evidently assessment was from 12yrs prior to Chris's period on ward in 2020
SA: yes that's right
C: you reviewed assessment and report that the reports did not appear to match his achievements in terms of schooling; I'm not sure he achieved many qualifications, the fact he'd been through mainstream school is that what you allude to?
SA: yes that's right
SA: yes that's right
C: that in itself was something of an achievement. You're aware in Prof Skuse report, of how much was made of need for schools to make allowances and assist him, that was quite clear
SA: uh hum
SA confirms re-assessment at that time wasn't wise because Chris was quite unwell
SA: uh hum
SA confirms re-assessment at that time wasn't wise because Chris was quite unwell
C: you're aware Chris's mother was raising concerns about his autism, features of autism and keeping him safe, you're aware of that?
SA: yes
C: You attended the professionals meeting 7 May
SA: yes
[missed chunk]
SA: yes
C: You attended the professionals meeting 7 May
SA: yes
[missed chunk]
C: discussion about need for assessments to be as robust as possible... weren't likely to be done in foreseeable future
SA: yes that's right
C: risk of relapse is there, particularly if he continues to use cannabis
SA: yes
SA: yes that's right
C: risk of relapse is there, particularly if he continues to use cannabis
SA: yes
C: which would skew, on top of which the ongoing complexity of PPE in covid and how that would also affect the outcome
SA: that's correct
SA: that's correct
C: did you have an impression of how long it might take for an autism and learning disability assessment to take place, or simply not possible to say given factors I've mentioned?
SA: i don't think there was a specific timescale in mind but it would have bene something that I would have been reviewing. I'd have hoped within 2 to 3 months we'd have done that
C: that type of timescale though, not a matter of weeks, measured in months. Thank you.
C: that type of timescale though, not a matter of weeks, measured in months. Thank you.
C: Other witnesses have made point that in absence of those updated assessments it was important that the existing diagnosis of a learning disability and autism weren't ignored, they were taken into account and care management and treatment bore those in mind.
C: Would that be consistent with your view?
SA: yes, not aware anyone dismissed he had a learning disability or autism, was more the mismatch between what was reported 12yrs previously and what was reported by those having contact with Chris on daily basis.
SA: yes, not aware anyone dismissed he had a learning disability or autism, was more the mismatch between what was reported 12yrs previously and what was reported by those having contact with Chris on daily basis.
C: in one email Dr TF said she didn't consider herself an expert and was inviting your input... is there challenge to those who dont feel confident in fields of learning disability and autism, is there challenge in picking up, as Prof Skuse makes clear and Julia made clear
C: on a number of occasions, is masking difficult to pick up for clinicians not familiar with autism
SA: clinicians will have contact in mainstream services with people with learning disability; are often circumstances where LD team have contact with colleagues in...
SA: clinicians will have contact in mainstream services with people with learning disability; are often circumstances where LD team have contact with colleagues in...
SA: mainstream services who might present with learning disability and/or autism so dont think is something they're unfamiliar with.
SA: I'm familiar with masking, my experience with people across time I've worked in these services, is that the masking is not possible on an extended basis.
SA: Often see individuals will manage for period of time, then will be a crash where can't continue with that behaviour and masking.
Then have to take themselves away and reset.
Then have to take themselves away and reset.
SA: If talking about period of time Chris was on Cedar Ward, he was on there for significant period of time, what commonly hear is individuals with an autistic spectrum disorder will struggle with new settings, its unfamiliar, is structure but not one used to...
SA: common report is they see behaviours more exacerbated in those settings. Sorry sir when I say behaviours I mean signs and symptoms of autism
C: so harder to mask in those settings over a sustained period
SA: yes
C: so harder to mask in those settings over a sustained period
SA: yes
C: can I ask general proposition please, even with identified mild learning disability, with autism if not at high end of scale, what if any impact can that combination have on an individual's ability to make decisions about their own safety
SA: can I confirm when you say higher do you mean those less impaired by autism?
C: sorry, milder autism and milder learning disability... would impact on ability to keep safe, or may do so?
SA: it may do so but I'd want to look at it on an individual basis
C: sorry, milder autism and milder learning disability... would impact on ability to keep safe, or may do so?
SA: it may do so but I'd want to look at it on an individual basis
C: if looking on individual basis and is also use of substances, in Chris's case cannabis, would you have any concerns about individual having understanding of risks involved with taking illicit substances as consequence of their LD and autism
SA: I'd want to explore that with them carefully and think about the questioning to explore that
C: so mental capacity assessment, questions would have to be framed in careful and specific way
C: so mental capacity assessment, questions would have to be framed in careful and specific way
SA: they would have to be framed in careful and specific way, and maybe framed in different way, and would have to check that both parties are thinking about the same thing
C: yes, thank you.
C: yes, thank you.
C: Any circumstances where there's a concern about someone's ability to keep themselves safe, with a learning disability and autism. Does MCA require specific knowledge to frame those questions, reframe if needed, check understanding?
C: Is that something a practitioner, clinician, does have to have, if not expertise, some real experience to conduct safely do you think?
SA: again I'd go back to within mainstream services clinicians are regularly experienced working with individuals with learning disability...
SA: again I'd go back to within mainstream services clinicians are regularly experienced working with individuals with learning disability...
SA: or autism, so some experience to draw on, but ideally would be helpful to have someone with other experience to draw on.
I'm aware capacity assessments Chris had, if ok to talk about that at this point?
C: yeh sure
I'm aware capacity assessments Chris had, if ok to talk about that at this point?
C: yeh sure
SA: Kirsty had asked for help from LD and Asperger Service for assistance with capacity assessments undertook.
Discussed in LD team and decision made that Sam Salici should be involved, in hindsight I think it would have been better for me to be involved rather than Sam.
Discussed in LD team and decision made that Sam Salici should be involved, in hindsight I think it would have been better for me to be involved rather than Sam.
SA: Although I'm aware of Sam I wasn't aware of her background, her manager recommended she was appropriate person to be involved with those.
That was a judgement I trusted.
That was a judgement I trusted.
SA: With hindsight I think it would have been better if I'd been involved in that process bit not aware would have made substantial impact on outcome.
I reviewed questions and they were looking to ask in different ways, looking to check his understanding.
I reviewed questions and they were looking to ask in different ways, looking to check his understanding.
SA: I can't comment would made difference to outcome of assessment, but with hindsight being aware of Sam's experience would have been better if I was involved rather than her.
C: thank you. You set out at beginning your service is small one. Was she part of your team?
C: thank you. You set out at beginning your service is small one. Was she part of your team?
SA: No, she's part of wider LD MDT but not directly in any of the teams I work in.
C: that was assessment on 9th June postponed to 10th, following your visit on 8th June. At second assessment Melika Cay was involved, do you know her?
C: that was assessment on 9th June postponed to 10th, following your visit on 8th June. At second assessment Melika Cay was involved, do you know her?
SA: I know Melika a little better than Sam Salici, and I know we have worked together with some individuals with LD and autism.
C: do you have confidence she'd be able to conduct a MCA assessment having worked with her before or not?
C: do you have confidence she'd be able to conduct a MCA assessment having worked with her before or not?
SA: yes I don't have any concerns about her conducting an assessment
C: The Niche report, you've seen criticism of way assessments were conducted and recorded. Do you accept those criticisms or do you challenge those criticisms?
C: The Niche report, you've seen criticism of way assessments were conducted and recorded. Do you accept those criticisms or do you challenge those criticisms?
SA: ummm. As I said I think capacity assessments were asking questions in right way, were rewording and checking Chris's understanding. In hindsight, again, would be better if I was involved not Sam Salici
SA: so I suppose to some extent I'm not agreeing entirely with Niche's view on those capacity assessments
C; ok, can you tell me specifically which aspects you don't agree with.
Mental capacity assessments did not adequately put out separate elements saliently...
C; ok, can you tell me specifically which aspects you don't agree with.
Mental capacity assessments did not adequately put out separate elements saliently...
C reads: and did not explore masking [think he said] Kirsty Lister tried to consider impact of autism but she was not experienced in understanding autism in patient's presentation.
Anything you object to in that paragraph?
Anything you object to in that paragraph?
SA: they weren't undertaken by Kirsty in isolation. They were undertaken by Sam Salici who'd not...
C: done it before
BB interjects
C: done it before
BB interjects
C: forgive me counsel, she had been present and taken part by providing Easy Read material and rephrasing, that's the limit of her experience isn't it
SA: sorry sir that's still participation isn't it
C: we'll pause and look at the note then please.
SA: sorry sir that's still participation isn't it
C: we'll pause and look at the note then please.
C: Ms Ballard I'm looking for evidence that Miss Salici had done more than what I've indicated.
[discussion missed]
C: with respect I don't think my summary was in any way substantially inaccurate. So Ms Allison which aspects do you not accept?
[discussion missed]
C: with respect I don't think my summary was in any way substantially inaccurate. So Ms Allison which aspects do you not accept?
SA: there's reference to Kirsty and her experience and understanding of impact of autism on patient's presentation. It wasn't Kirsty in isolation there were other clinicians involved with her.
C: on first occasion Sam and second with Sam and Melika Cay
C: on first occasion Sam and second with Sam and Melika Cay
SA: Sam still has experience of autism and learning disability
C: experience of the impact on presentation... you think that went beyond the provision of Easy Read material and rephrasing?
C: experience of the impact on presentation... you think that went beyond the provision of Easy Read material and rephrasing?
SA: in order to be able to rephrase have to pick up on subtle nuances that individual had not understood to do that. Would be better if I'd done that but we had Sam there and she's still able to pick up on those and rephrase things for an individual in that setting.
C: what about criticism the MC assessments did not adequately set out salient information for each decision separately. Is that fair criticism or not?
SA: they were clear about what they were conducting assessments for and the areas they were doing that
C: right
SA: they were clear about what they were conducting assessments for and the areas they were doing that
C: right
SA: sorry I don't think I'm quite understanding what you're asking me, I apologise
C: that's ok, think is relatively straight forward.
Just trying to establish which aspects of this paragraph in Niche report you don't accept.
C: that's ok, think is relatively straight forward.
Just trying to establish which aspects of this paragraph in Niche report you don't accept.
C: You say you don't accept criticism Care Coordinator tried to consider impact, but was not experienced.
You make point Sam Salici in your view was and could conduct them.
You make point Sam Salici in your view was and could conduct them.
SA: yes and Kirsty wasn't completing them in isolation and in second one Mel Cay was also present so another perspective, and another clinician who had experience of working with individuals with LD and/or autism
C: ok, then I moved on to asking you about your view on suggestion assessments did not adequately set out the salient information for each decision separately, and did not consider masking or executive functioning explicitly. Your answer to the first one was well they did.
SA: are you asking me sir about what's documented
C: yes, you've read the MCAs
SA: I have
C: you've seen the documents but I think you disagree by conclusions at para ... in which respect do you disagree
SA: in terms wasn't enough experience
C: yes, you've read the MCAs
SA: I have
C: you've seen the documents but I think you disagree by conclusions at para ... in which respect do you disagree
SA: in terms wasn't enough experience
C: yes we've dealt with that, now looking at suggestion MC assessments did not adequately set out salient information separately. You consider they did?
SA: they were clear about areas they were covering, understand documentation perhaps was not as clear as it could have been
SA: they were clear about areas they were covering, understand documentation perhaps was not as clear as it could have been
C: thank you. And did not consider masking or executive functioning explicitly, do you think that's unfounded?
SA: they wouldn't have asked questions about executive functioning in way I would have...
SA: they wouldn't have asked questions about executive functioning in way I would have...
SA: I'd have conducted a specific assessment, they wouldn't say they were asking about it but would look at areas under that umbrella... organising, planning, motivation, his ideas around following through with things.
SA: they were asking about those things in context of assessment but yes that's right they wouldn't have specifically said we are looking at executive functioning.
C: well the criticism, we'll hear from authors in due course, they say did not explicitly state, but you're saying its implicit?
SA: yes, i'm sorry that was hard work, I don't mean to be so difficult
SA: yes, i'm sorry that was hard work, I don't mean to be so difficult
C; no, it's your evidence. So you're saying didn't do it explicitly because it was implicit
SA: yes as part of their questioning they were asking about the relevant areas
C: thank you
SA: yes as part of their questioning they were asking about the relevant areas
C: thank you
C: then 7.13 says outcome of capacity assessments changed the way decisions around the management of Chris's risk were made.
Some of MCA documentation is confusing as to the accepted conclusion of the assessors, therefore clarity on statutory framework to be used is unclear.
Some of MCA documentation is confusing as to the accepted conclusion of the assessors, therefore clarity on statutory framework to be used is unclear.
C: Did not follow guidance in MCA Code of Practice about how to deal with disagreements. Any comments to make about that?
SA: No I don't have any comments to make about that
C: would you accept that as fair criticism?
SA: No I don't have any comments to make about that
C: would you accept that as fair criticism?
SA: in terms of first line of that point, I think umm, there was some debate around the drug use and his capacity around managing medication and drug use
C: yeh
SA: and so I can understand and appreciate that would present as being confusing potentially
C: yeh
SA: and so I can understand and appreciate that would present as being confusing potentially
C: ummm. Would you say it is in any way, taking other way around, any way clear what is being expressed there?
Doubts and reservations appear to be expressed on the 10th.
Let me ask this way, when you read it what do you think they meant, had capacity or didn't have capacity?
Doubts and reservations appear to be expressed on the 10th.
Let me ask this way, when you read it what do you think they meant, had capacity or didn't have capacity?
SA: so they were in the absence of being able to prove otherwise, they were saying he had capacity
C: right. Do you think that's clear from how it's written or do you accept it is confusing?
C: right. Do you think that's clear from how it's written or do you accept it is confusing?
SA: I think there was some confusion around that, so I can understand that might potentially present as confusing.
C: given there was that confusion, as authors of report suggest...
C: given there was that confusion, as authors of report suggest...
C: can you see how confusion leads to authors assertion that clarity as to what statutory framework to use for next steps was unclear, arising from that confusion
SA: I don't know is the honest answer
C: alright. Thank you.
[Court is adjourned for 10min break, Back at 11:30]
SA: I don't know is the honest answer
C: alright. Thank you.
[Court is adjourned for 10min break, Back at 11:30]
C: thank you Ms Allison we'll continue. You saw Chris on 8 June on unit and fed back on 9th, emphasising it was not a formal assessment
SA: yes that's right
C: it was impressionistic, based on what you'd read about him and how you found him on that day?
SA: yes that's right
SA: yes that's right
C: it was impressionistic, based on what you'd read about him and how you found him on that day?
SA: yes that's right
C; you're at pains to emphasise in all the documentation that this was not an assessment
SA: yes my reason for seeing him is we'd been talking about him a lot, heard from other clinicians involved with him, felt important from my point of view to go and meet him.
SA: yes my reason for seeing him is we'd been talking about him a lot, heard from other clinicians involved with him, felt important from my point of view to go and meet him.
SA: Particularly with the mismatch between assessment when he was 7 and what was being reported by clinicians seeing him.
C: yes, you set out in summary....
C: yes, you set out in summary....
C: You'd seen Chris 40mins, didn't object talk to you... sustained eye contact.. spoke to him about support, his needs and feelings he'd experienced when he took the overdose. That was within a few hours of him being discharged
SA: yes that's correct
SA: yes that's correct
C reads: he told me he didn't want support on discharge, even in graded way.
If he had feelings he had again when he took overdose he knew he could speak to his mother and friends, and would not do that again.
If he had feelings he had again when he took overdose he knew he could speak to his mother and friends, and would not do that again.
C: Did not want to talk to me about school saying was in past and he did not enjoy his time. I reported, that's to your colleagues, was difficult to say about his learning disability, but presented as somewhat naive.
C reads: my view was placement where he was encouraged to be independent and saw as stepping stone towards greater independence would be a good idea... but I did not think he needed a highly specialised placement at this point in time.
C: So the outcome of your meeting with him, is you didn't think it was unsafe on discharge from mental health assessment unit, where he'd gone following overdose, for him to return to Hart House?
SA: what I said was he didn't need a highly specialised placement, with respect to autism placement, I didn't think he needed at that point in time and I was thinking what he was asking for and wanted to do, and how support in least restrictive way.
SA: he wanted to be independent, develop skills, be an adult and grown up. So was thinking about what was best for him and support to enable him to do that.
C: what about the issue of keeping him safe. I'm presuming that features in part of your appraisal or assessment of him?
C: what about the issue of keeping him safe. I'm presuming that features in part of your appraisal or assessment of him?
C: You had in the back of your mind, or the forefront of your mind, risk?
Can I ask you to address that, what did you consider was the level of risk and how did you think that could be safely managed in the community?
Can I ask you to address that, what did you consider was the level of risk and how did you think that could be safely managed in the community?
SA: in terms of managing it safely in community it's about having a supported setting where he's given some structure, and builds relationships with staff around him, so he can develop a trust in those individuals.
SA: So there's a consistency not having to deal with a lot of people from a lot of services; consistent group he can develop trust in so he can talk to people when he's feeling what he's felt before.
SA: So he can have that structure to his days, that gives him activities, gives him something he's enjoying and is helping him progress to where he wants to be.
C: were you aware at time of yr visit his mother Julia had expressed in robust terms, her concerns that Hart House was not an environment where he could be kept safe. Were you aware of that?
SA: I'm aware of those concerns but can't recall when I was made aware of those concerns
SA: I'm aware of those concerns but can't recall when I was made aware of those concerns
C: you were obviously aware, because you were sat in it, he was in the mental health assessment unit following an overdose within hours of him being discharged, apparently against advice, from Cedar Ward.
C: Let me ask you again with respect to immediate management of risk, in those circumstances, did you have concerns if he was discharged back to Hart House his risk to self could be managed appropriately?
SA: I think everybody had concerns about him, and how his risk was managed.
In terms of having a setting to go back to that was supportive, where he was given that structure, I was of view would help in managing risk to come extent.
In terms of having a setting to go back to that was supportive, where he was given that structure, I was of view would help in managing risk to come extent.
C: ok. Did you, and I again I appreciate it wasn't a formal assessment, it was very much a conversation and your impressions of him over 40min conversation in MH assessment unit....
C: Did you at that time discuss with him his use of cannabis, it doesn't feature in the paragraph I read out. Was it something you discussed with him at all?
SA: umm no. We talked about the overdose which had happened and what he'd done. We didn't talk about his cannabis use.
SA: umm no. We talked about the overdose which had happened and what he'd done. We didn't talk about his cannabis use.
C: any particular reason you didn't discuss his cannabis use at all with him?
SA: no particular reason, I wasn't there to conduct a risk assessment with him, or a formal assessment with him
C: ok
SA: no particular reason, I wasn't there to conduct a risk assessment with him, or a formal assessment with him
C: ok
SA: sorry sir, they were conversations other professionals were having with him
C: but part of what you opine is "I did not think he needed a highly specialised placement at this point of time"
SA: in terms of his autism
C: but part of what you opine is "I did not think he needed a highly specialised placement at this point of time"
SA: in terms of his autism
C: I'm just wondering how you separate out consideration of his autism disjunctively from risk and his cannabis use.
Why are they treated as silos and not all part of a holistic picture?
SA: sorry sir my brain didn't engage properly can you repeat the question for me please
Why are they treated as silos and not all part of a holistic picture?
SA: sorry sir my brain didn't engage properly can you repeat the question for me please
C: yes. You haven't mentioned cannabis, think you told me you didn't discuss it at all, no particular reason but you weren't there to conduct a risk assessment or formal assessment.
I've referred you to your line, did not think highly specialised placement was needed.
I've referred you to your line, did not think highly specialised placement was needed.
C: So my question was whether you were considering that issue in respect of his autism, quite separately and distinct from, in a silo from his cannabis use, his risk?
SA: I don't think I was considering them separately, but I was thinking about an autism unit and where that would fit in relation to him.
An autism unit wasn't what I thought would be best for him at that point in time.
An autism unit wasn't what I thought would be best for him at that point in time.
C: but that consideration, did that in any way, take into account his use of cannabis, take into account in any way his risk to self?
Silence
Silence
C: when you came to conclusion he did not need specialised placement, did that take into account his risk to self and/or his use of cannabis?
SA: can you just give me a minute to think before I respond
C: yes, take your time, from my perspective it's an important issue.
SA: can you just give me a minute to think before I respond
C: yes, take your time, from my perspective it's an important issue.
SA: in terms of risk to self and cannabis use, again, I'm thinking about what he was expressing wanting to do, and how he was wanting to progress, and that wherever possible it's better for us to work with people in the community, and support them in the community
C: yes
C: yes
SA: and in terms of his cannabis use, that is something that we'd need to seek support of the drug and alcohol teams, whichever they may be.... We'd seek to involve them with helping us support him in the community.
C: right, OK. Am I right in understanding was no aspect of a risk assessment of any kind being undertaken by you when you met Chris for that 40mins
SA: that's correct
SA: that's correct
C: you made a call to Hart House on 19 June, were informed Chris was returning to them at 1pm. Called again on 23rd and spoke to manager
SA: yes
C: we'll hear from her in due course...
SA: yes
C: we'll hear from her in due course...
C: she reported they'd been working with him around daily living skills, previously day he's worked the washing machine... was some difficulty setting daily tasks for him as he was leaving to spend time with his family.
C: Did you get information about the amount of time he was spending in bed?
SA: no I don't recall
C: was there any mention by the manager that the reason his mother was collecting him was because she was concerned about the lack of activities arranged for him?
SA: no I don't recall
C: was there any mention by the manager that the reason his mother was collecting him was because she was concerned about the lack of activities arranged for him?
SA: no I believed since he'd been away from home they'd been enjoying time with him.. that's what they were enjoying from that contact, that was my understanding of it, is it ok for me to talk about this now?
C: yes, of course, please.
C: yes, of course, please.
SA: we talked about trying to do things in graded way, so spend time in placement for perhaps one activity, then let him spend time with his family so we weren't taking away from that experience, or his time with his family
C: this is all before the incident on [detail withheld], not the final incident. There's no mention of the penultimate incident, any reason for that. Were you on leave?
SA: No I don't think I was on leave. My last contact with the placement was on the 23rd
SA: No I don't think I was on leave. My last contact with the placement was on the 23rd
C; what about with respect to your colleagues Dr Carr, Dr TF or the ESTEP team, did you have any contact after 23rd prior to professionals meeting in July
SA: other than email contact and I can't recall email contact I don't believe I did
SA: other than email contact and I can't recall email contact I don't believe I did
C asks if she was aware of incident on 26th
SA confirms she was
C: it doesn't feature in your statement, wonder if anything wish to say of how that impacted on your views, about safety, risk, managements, placement following your previous conversation?
SA confirms she was
C: it doesn't feature in your statement, wonder if anything wish to say of how that impacted on your views, about safety, risk, managements, placement following your previous conversation?
C: Was there anything at all that impacted on what you previously thought?
SA: obviously greater concern about risk, that was something everyone shared about how to manage his risk. That was a continuing concern.
SA: obviously greater concern about risk, that was something everyone shared about how to manage his risk. That was a continuing concern.
C: were you aware the ESTEP team had unanimously arrived at the view they could not keep Chris safe in the community.
Were you aware of that, was that communicated to you?
Were you aware of that, was that communicated to you?
SA: I honestly can't recall if at the time that was communicated.
It might have been I was copied into emails about it but I'd be talking about something I couldn't recall
It might have been I was copied into emails about it but I'd be talking about something I couldn't recall
C: thing is you're the specialist lead in the area of autism, you'd provided opinions to professionals of how a specialist placement wasn't necessary in mid June.
C: Just wondering if you had any further recollection of way in which incident of 23 June impacted on your position, caused you to review it? Revisit it?
SA: we'd have discussed in our learning disability MDT meeting and discussed as team in terms of our involvement and where we should be, how we should be linking in with ESTEP team.
In terms of me specifically no I didn't have any specific contact about that, not that I recall.
In terms of me specifically no I didn't have any specific contact about that, not that I recall.
C: right, at the professional's meeting on xx you attended that, what was your contribution to that please?
SA turns to minutes
C: were concerns discussed there about Chris and his safety that you recall?
SA turns to minutes
C: were concerns discussed there about Chris and his safety that you recall?
SA: yes, we discussed about risk. That was always a concern and was discussed then.
C: forgive me, it wasn't a concern specifically for you when you saw him for the 40mins, you've made it clear risk wasn't a concern then.
There was no risk assessment of any kind.
C: forgive me, it wasn't a concern specifically for you when you saw him for the 40mins, you've made it clear risk wasn't a concern then.
There was no risk assessment of any kind.
SA: because I didn't conduct a risk assessment didn't mean I wasn't concerned... wasn't conducting formal risk or any other assessment... was sensible for me to go meet him not just read documentation...
C: do you accept your opinion appears to have had some purchase with other clinicians, Dr Carr and Dr Thies Flechtner.
SA: yes
SA: yes
C: alright, so you've corrected me and said you did have.
Let me ask again, although wasn't formal risk assessment and wasn't purpose of your visit, did you have any concerns when you saw him on the one occasion you did?
Let me ask again, although wasn't formal risk assessment and wasn't purpose of your visit, did you have any concerns when you saw him on the one occasion you did?
SA: yes because he was continuing with cannabis use and he'd overdosed which was why he was on the unit at the time
C: I'm struggling a little Ms Allison, why those concerns dont appear to feature in your expressed view he didn't require a specialised placement at that time.
C: I'm struggling a little Ms Allison, why those concerns dont appear to feature in your expressed view he didn't require a specialised placement at that time.
C: keeping him safe didn't appear to feature in the opinion you expressed
SA: yes, it wasn't about a placement, it was about a placement in terms of an autism placement.
That was the placement I didn't feel was appropriate at that point in time.
SA: yes, it wasn't about a placement, it was about a placement in terms of an autism placement.
That was the placement I didn't feel was appropriate at that point in time.
C: suppose it follows you didn't at any point prior to his death come to the view that a highly specialised placement was required for him?
SA: not an autism placement no.... because we also considered about him being admitted to Byron Court, the LD inpatient setting here.
SA: not an autism placement no.... because we also considered about him being admitted to Byron Court, the LD inpatient setting here.
SA: And Dr Udu shared his views about that, Gemma Robertson shared her views about that.
My view, as part of that, was that he, it wouldn't have been something that would have been in his best interests because he would have been people who were very unwell, who'd have...
My view, as part of that, was that he, it wouldn't have been something that would have been in his best interests because he would have been people who were very unwell, who'd have...
SA: been less able than him, and I think he'd have found that difficult for him to think about and consider. And it's another setting for him, and would be more restrictive.
We did consider inpatient learning disabilities setting.
We did consider inpatient learning disabilities setting.
C: yep. It may be Ms Allison you'll be taken to some of the email exchanges, I'm not going to go through those myself at this point.
SA: ok
SA: ok
C: Those are my questions for the moment for you, may have few more. I'll hand you over to Mr Stoate who asks questions on behalf of Chris's family.
TS checks he can see and hear him. She can.
TS checks he can see and hear him. She can.
TS: You say in your statement on 29 April the LD consultant and I reviewed the documents, had conversation with ward consultant.
Review suggested did not match Chris's achievements in terms of schooling.
SA: yes
TS: what did you understand those to be?
Review suggested did not match Chris's achievements in terms of schooling.
SA: yes
TS: what did you understand those to be?
SA: he'd continued in mainstream education. He had an EHCP but he'd continued in mainstream settings. The idea of attending college was discussed, and an apprenticeship as well
TS: Did you hear, or have you read Julia's witness statement, Chris's mum?
SA: yes
TS: Did you hear, or have you read Julia's witness statement, Chris's mum?
SA: yes
TS: I'll put some of it. Salient features... stop at park on way home from school would sometimes return bruised, or with cigarette butts put out on his arm... so he was bullied. Sometimes would return exhausted and stressed, would lie on pavement...
TS: Was very stressed by exams and left school before he could take them. [Detail withheld - incidents of self harm]
Julia presents in her witness statement, would you accept Ms Allison, a picture that doesn't tally with the phrase his achievements at school.
Julia presents in her witness statement, would you accept Ms Allison, a picture that doesn't tally with the phrase his achievements at school.
TS: I'm not seeking to belittle Chris obviously, but you're putting store on his achievements at school.
How much of that did you know at the time?
SA: I didn't know any of that at the time
TS: he left school without any GCSEs were you aware of that?
SA: I was
How much of that did you know at the time?
SA: I didn't know any of that at the time
TS: he left school without any GCSEs were you aware of that?
SA: I was
TS checks another aspect
SA: I'm aware of that from her statement, yes
TS: hmmm.
Do you think that might have changed your view about any perceived discrepancy between the GOSH report and what you describe as his achievements in schooling, had you had that background?
SA: I'm aware of that from her statement, yes
TS: hmmm.
Do you think that might have changed your view about any perceived discrepancy between the GOSH report and what you describe as his achievements in schooling, had you had that background?
SA: think it would be helpful to have that background, but we were very mindful of was a mismatch between the report we had sight of from Great Ormond Street and how he was presenting to those seeing him on the wards and ESTEP team.
SA: Was mismatch we couldn't ignore in terms of thinking about his presentation and how we were working with him.
TS: Ms Allison sorry to cut in, you've given that exact evidence to the coroner.
I'm just focusing specifically on schooling, you've now agreed would have been helpful to have some of that information
SA: yes that would have been helpful
I'm just focusing specifically on schooling, you've now agreed would have been helpful to have some of that information
SA: yes that would have been helpful
TS: was really discrepancy, this was a young man who was in mainstream education and desperately struggling through it
SA: from what you've described and his mum says, yes
SA: from what you've described and his mum says, yes
TS: you say your contact with Chris and his family was through [meetings and emails] I met Christopher directly on face to face basis only once on 8 June 2020.
You never met Julia, his mother at all did you?
SA: No I didn't
You never met Julia, his mother at all did you?
SA: No I didn't
TS: she said she was repeatedly kept out of meetings, and wasn't at meetings you were at. Do you understand that view?
SA: yes. There was a meeting due to take place that was cancelled because Hart House wasn't available.
SA: yes. There was a meeting due to take place that was cancelled because Hart House wasn't available.
TS: hmmmm.
Can you see Ms Allison if she had been invited to any meeting at which you were present from April onwards, she could have told you about her experience of Chris and schooling couldn't she?
SA: yes she could have done
Can you see Ms Allison if she had been invited to any meeting at which you were present from April onwards, she could have told you about her experience of Chris and schooling couldn't she?
SA: yes she could have done
TS: you're aware of importance to involve families aren't you [paraphrase]
SA: yes, there were other professionals talking to her
We were looking for additional information and were doing that through the ward he was on at the time but yes we could have gone to her
SA: yes, there were other professionals talking to her
We were looking for additional information and were doing that through the ward he was on at the time but yes we could have gone to her
TS: with respect Dr Allison
SA: Yes we could have gone to mum directly
TS: she wasn't exactly hiding was she?
SA: no she wasn't hiding
C: forgive me Mr Stoate, why didn't you go to his mum?
SA: Yes we could have gone to mum directly
TS: she wasn't exactly hiding was she?
SA: no she wasn't hiding
C: forgive me Mr Stoate, why didn't you go to his mum?
SA: because we spoke about ensuring we didn't involve too many people in terms of contacts....
we were linking into Cedar Ward and gaining information through them, we had contact with ESTEP team and were gaining information through them
we were linking into Cedar Ward and gaining information through them, we had contact with ESTEP team and were gaining information through them
C: sorry, you didn't want to be going to too many sources that's reason you didn't go to mum?
SA: sorry sir that's not what I meant. It's about having too many routes of contact
SA: sorry sir that's not what I meant. It's about having too many routes of contact
C: can I ask again. Why didn't you go to mum, who was four square and central in her availability and the expression of her concerns?
SA: because other professionals in the wider team that were working with him were in contact with mum and were passing information on
SA: because other professionals in the wider team that were working with him were in contact with mum and were passing information on
C: Dr Thies Flechtner for example.
So is your answer that Dr TF was in contact with Julia, so there was no need for you to be in contact with Julia?
So is your answer that Dr TF was in contact with Julia, so there was no need for you to be in contact with Julia?
SA: that's part of the reason.
When we were looking to do updated assessments obviously we'd be in contact with the family and mum directly as that would be part and parcel of completing those assessments
C: the ones that were postponed for months?
When we were looking to do updated assessments obviously we'd be in contact with the family and mum directly as that would be part and parcel of completing those assessments
C: the ones that were postponed for months?
SA: the ones postponed because it wasn't appropriate to do them then
C: yes for months.
So you weren't anticipating or making any contact yourself from Head of Aspergers Service, learning disabilities.
You had no interest in talking to Julia yourself?
C: yes for months.
So you weren't anticipating or making any contact yourself from Head of Aspergers Service, learning disabilities.
You had no interest in talking to Julia yourself?
SA: I don't think that's correct, it's not that I didn't have any interest.
There were a lot of services involved with him and his mum, we were getting information from other sources at that time.
There were a lot of services involved with him and his mum, we were getting information from other sources at that time.
SA: Didn't think was appropriate for me to get contact because I was getting information from other sources.
C: forgive me Mr Stoate for taking over like this.
C: forgive me Mr Stoate for taking over like this.
C: It was critical aspect of your opined view, your opinion and concern of ward of this discrepancy between how he presented to clinicians and his achievements at school.
C: Mr Stoate is making point a primary source of information was the mother who wasn't explored in that respect.
I'm struggling to understand why she wouldn't be an obvious person, the first person you'd go to when you've got this discrepancy, the disconnect.
I'm struggling to understand why she wouldn't be an obvious person, the first person you'd go to when you've got this discrepancy, the disconnect.
C: You've got disconnect.
She's his mother, she was there throughout schooling.... it seems obvious but any reason why you didn't do that?
SA: because that information was coming from other clinicians involved with him
C: thank you
She's his mother, she was there throughout schooling.... it seems obvious but any reason why you didn't do that?
SA: because that information was coming from other clinicians involved with him
C: thank you
TS: thank you sir. You obviously considered the GOSH report into Christopher
SA: yes
SA: yes
TS takes to record says: Chris is good at remembering information that he has been taught.... but has difficulty applying... important be aware of discrepancy in abilities as it may mask some of Christopher's difficulties
SA: have to say achievements probably isn't the right phrase to use
TS: No.
TS asks if she ever intended her impression after 40 min conversation with Chris to ever be taken, and used above the report of Great Ormond Street
SA: No I didn't intend that
TS: No.
TS asks if she ever intended her impression after 40 min conversation with Chris to ever be taken, and used above the report of Great Ormond Street
SA: No I didn't intend that
TS: Hart House... you advised visual cues, clear language and checking his understanding due to his autism. Have I correctly summarised your involvement with Hart House?
SA: yes
SA: yes
TS: Did you feel the Hart House staff were sufficiently skilled and experienced to deal with challenges Chris, as acknowledged complex case, likely to present?
SA: I didn't know Hart House... my understanding was they'd done assessment and agreed it was suitable placement....
SA: I didn't know Hart House... my understanding was they'd done assessment and agreed it was suitable placement....
SA: I didn't talk to her [Helen, manager at HH] about his drug taking or risk, those weren't conversations I had with her
TS: You advised on visual cues, checking understanding etc did that cause you any concern you'd need to do that?
TS: You advised on visual cues, checking understanding etc did that cause you any concern you'd need to do that?
SA: no I'd do that with any setting... in light of his diagnoses... it would be checking and advising
TS: you wouldn't need to point that out if he was in a specialist placement would you
SA: I would check those as well
TS: you wouldn't need to point that out if he was in a specialist placement would you
SA: I would check those as well
TS: right. Do you recall whether they had experience of working with people with autism?
SA: I can't find the note but my understanding was they had worked with people with autism before
SA: I can't find the note but my understanding was they had worked with people with autism before
TS: you say you didn't talk to Helen on this occasion about Christopher using cannabis so how was he to avoid using cannabis while he was at Hart House?
SA: it was about setting daily tasks and keeping him busy [paraphrase]
SA: it was about setting daily tasks and keeping him busy [paraphrase]
TS: but on 23rd they say they're struggling with that, setting activities
SA: yes we discussed how they could work on that
TS: but with no mention of cannabis at all.
SA: that's right
SA: yes we discussed how they could work on that
TS: but with no mention of cannabis at all.
SA: that's right
TS: seems like it should be central to discussion if part of the reason for having Hart House and that structure was to avoid him using?
SA: yes it should, but I wasn't the only one having conversations with him.
SA: yes it should, but I wasn't the only one having conversations with him.
TS: right. Capacity assessments, you've said in hindsight would be better for you to be involved
SA: yes
TS: it shouldn't be a matter of hindsight should it, it should be important to know who was carrying them out at time?
SA: yes
TS: it shouldn't be a matter of hindsight should it, it should be important to know who was carrying them out at time?
SA: as mentioned before Ms Salici's manager identified person most appropriate to be involved in that process
C: can you tell me the name of the manager you spoke to please
SA: Gemma Robertson
C: can you tell me the name of the manager you spoke to please
SA: Gemma Robertson
TS: I wish to make it clear, through me, that Julia has no personal criticism of the people who undertook those assessments and tried their best, but Ms Salici, for example, in her evidence to me said... my note... given centrality of drug use and medication...
TS: I said did you feel qualified to undertake such a potentially important assessment.
Her answer probably no, I didn't have enough information about his past either, only now learnt about that, and I don't feel I was the right person...
Her answer probably no, I didn't have enough information about his past either, only now learnt about that, and I don't feel I was the right person...
TS: my role to provide Easy Read information and try to rephrase but as decision maker I didn't feel I was probably appropriate, as I didn't know him that well and didn't know his history.
TS: Your response to the coroner when asking about Niche criticism's of capacity assessments, was it wasn't just Kirsty Lister in isolation, it was also Sam Salici
SA: yes
TS: you didn't know about her experience?
SA: no I didn't
SA: yes
TS: you didn't know about her experience?
SA: no I didn't
TS: I asked her specifically if she was appropriate person... [reads what she said] does that change your answer to the coroner?
SA: it wasn't my decision... but she has experience of people with learning disability and autism given the nature of service she works in, but it doesn't change my position no.
TS: when asked if she was appropriate she said no, probably no
TS: when asked if she was appropriate she said no, probably no
SA: yes but again I wasn't the person who suggested she undertook that role.
That was a decision her manager made and I trusted that decision... I know she works with individuals with learning disability and autism, so she has clinical perspective to bring
That was a decision her manager made and I trusted that decision... I know she works with individuals with learning disability and autism, so she has clinical perspective to bring
SA: she's used to working with those individuals. I'm really sorry I'm not sure I'm answering the question you're asking, I am trying.
TS: Did Ms Salici or anyone else come back to you and say I'm not convinced I'm qualified for this job
SA: no
TS: Did Ms Salici or anyone else come back to you and say I'm not convinced I'm qualified for this job
SA: no
TS: had they done what would you have done?
SA: I'd have made arrangements to do so, or to be there as well
TS goes to email from Sam Ball, refers to email below.... that's an email from Tsitis Adiuwku [?] of EPUT
SA: I'd have made arrangements to do so, or to be there as well
TS goes to email from Sam Ball, refers to email below.... that's an email from Tsitis Adiuwku [?] of EPUT
TS asks whether SA recalls email from Sam about pausing autism assessments
SA: I dont recall exactly when conversation happened but conversation with Sam through email directly, was same thing I know raised a number of times in these proceedings in terms of reasons why we...
SA: I dont recall exactly when conversation happened but conversation with Sam through email directly, was same thing I know raised a number of times in these proceedings in terms of reasons why we...
SA: wouldn't do updated assessments and implications for those. We've talked about we'd look to review that.... more likely to be months before we do that. In terms of autism assessments postponed during covid, that's not the case but we were being very careful in terms
SA: of assessments were doing them. Obviously this was the start of the pandemic, prior to this been completing face to face.
They're quite long assessments... we were looking at how we could do that and not stop process of flow through...
They're quite long assessments... we were looking at how we could do that and not stop process of flow through...
SA: trying to do some parts virtually through MS Teams, but very mindful for some people wasn't appropriate. So needed to do face to face contact along side that.
Had to be cautious about that, room space and use of PPE... were exceptions to individuals using masks.
Had to be cautious about that, room space and use of PPE... were exceptions to individuals using masks.
TS: you talk in yr statement about professionals meeting held on x July 2020 with senior managers of EPUT in attendance. Discussed Christopher's presentation and needs and treatment going forward... discussion about need reassessment, need for outcomes of assessment to be robust
SA: yes
TS: It was also discussed the outcome of the assessment would not change the way care was provided to Christopher by EPUT.
What does that mean?
TS: It was also discussed the outcome of the assessment would not change the way care was provided to Christopher by EPUT.
What does that mean?
SA: professionals working with him were holding in mind he had autism and a learning disability, so doing assessment wouldn't have changed how we worked
TS: it might have changed the care going forward though, is that right?
TS: it might have changed the care going forward though, is that right?
SA: it might have changed some things but don't think it would have made a big change.
Would have been those three teams, ESTEP because of his psychosis, the LD team because of his learning needs, and our very small autism service in terms of his diagnosis of autism.
Would have been those three teams, ESTEP because of his psychosis, the LD team because of his learning needs, and our very small autism service in terms of his diagnosis of autism.
SA: Young person's drug and alcohol team were just at point of getting involved, but that wouldn't have changed because of any updated assessments. Wouldn't have made a difference to their involvement.
TS: Sorry sir, I'll take that up with others, I'm mindful of the time.
TS: Sorry sir, I'll take that up with others, I'm mindful of the time.
TS takes to Julia's statement, around time of Chris's final discharge to Hart House reads:
I felt an impending sense of doom for Chris... chaotic conversations in which ESTEP told me he'd refused rehab....
I felt an impending sense of doom for Chris... chaotic conversations in which ESTEP told me he'd refused rehab....
TS: Kirsty told me Sharon Allison had agreed to a suicidality test the day after he was discharged. Organised to take place in hospital.
I thought it was important as autistic people 9 times more likely to commit suicide, however this test never happened.
I thought it was important as autistic people 9 times more likely to commit suicide, however this test never happened.
SA: that's not something I agreed I'd do
TS: do you recall any conversations with Miss Lister around that time, of Chris's discharge?
TS: do you recall any conversations with Miss Lister around that time, of Chris's discharge?
SA: I can't recall directly, I'd have to go back and check. I categorically did not agree to do anything like that. I never said I'd do that and wouldn't have said I'd do anything like that.
C: a suicidality test, is that form of words you've come across?
C: a suicidality test, is that form of words you've come across?
SA: no and it's not a phrase I'd use either
TS: are you aware of the significantly increased risk of suicide in autistic people?
SA: yes
TS: did that feature in any conversations around discharge, particularly in June, given what had happened prior to that
TS: are you aware of the significantly increased risk of suicide in autistic people?
SA: yes
TS: did that feature in any conversations around discharge, particularly in June, given what had happened prior to that
SA: I don't recall any discussions directly, but everyone was concerned about his risk. Very aware of mum's concern about risk as well, that was something people were aware of.
TS: those are my questions
No questions from Ms Nash
TS: those are my questions
No questions from Ms Nash
AD: Ms Allison can you hear me? I ask questions on behalf of Southend Borough Council as it was then known. You gave evidence earlier, Mr Stoate gave you some evidence you gave about qualifications of Sam Salici.
AD: You also set out some views about Melika Cay's involvement in capacity assessment in 18 June.
Do you accept Melike Cay could have no clinical involvement in the assessment of Chris as she was not a clinician and was an employee of SBC?
Do you accept Melike Cay could have no clinical involvement in the assessment of Chris as she was not a clinician and was an employee of SBC?
SA: no she's not a clinician but had involvement in process and had experience of learning disability and autism
Ms Khalique doesn't have a question but wishes to clarify something that has come out of Ms Allison's evidence.
Ms Khalique doesn't have a question but wishes to clarify something that has come out of Ms Allison's evidence.
Mr Ball is unable to identify an email exchange with Ms Tx but email is now identified in Ms Allison's evidence, we weren't able to locate that, but thank you.
Ms Ballard checks Ms Allison can hear and see her - she can
BB: You know I ask questions on behalf of EPUT
SA: yes
Ms Ballard checks Ms Allison can hear and see her - she can
BB: You know I ask questions on behalf of EPUT
SA: yes
BB: First of all can I ask you with regards to communication with mum, is this right, was decision taken that Kirsty Lister was going to try to be in essence a single point of contact for mum?
SA: yes that's right
SA: yes that's right
BB: with the aim of trying to improve communication is that right?
SA: yes
BB: to ensure the vast amount of helpful information mum was feeding into various professionals would come into only one conduit, is that right?
SA: yes
SA: yes
BB: to ensure the vast amount of helpful information mum was feeding into various professionals would come into only one conduit, is that right?
SA: yes
BB: is that what you had in mind in not communicating with Ms Hopper around the time of assessments?
SA: yes, I just didn't put it so clearly
SA: yes, I just didn't put it so clearly
BB: the GOSH report please, you've said were discrepancies between what was reported in report and seen on ward.
Discrepancies you identified were not just in the letter of the professor but also in the assessments undertaken, is that right?
Discrepancies you identified were not just in the letter of the professor but also in the assessments undertaken, is that right?
SA: yes, more specifically in the cognitive assessment
BB: those discrepancies, do you still stand by them today...
SA: umm, yes, because is it ok to expand
BB: of course
BB: those discrepancies, do you still stand by them today...
SA: umm, yes, because is it ok to expand
BB: of course
SA: throughout the cognitive assessment report which Dr Sarah Ball referenced when she gave evidence, there's numerous points where it's highlighted about his engagement with the process.
SA: They indicate the outcome was likely to be the lowest point at which he was functioning, and was likely to be an underestimate of his functioning... doesn't quite match with level of detail given to it in the report
BB: when you were assessing Chris though was no doubt of a diagnosis of autism or learning disability is that correct?
SA: I obviously wasn't assessing him, but no doubt he did present with some learning needs and an autism spectrum disorder...
I don't believe that was doubted by anyone
I don't believe that was doubted by anyone
BB: you expressed an opinion in your email in mid June, at this point in time Chris would not benefit from placement in a highly specialist autistic placement.
Why is that? Why did you express that opinion please?
Why is that? Why did you express that opinion please?
SA: because the difficulties reported were around his drug use, and although in recovery, his psychosis. In terms of autism specialist unit, it would be, sorry I'm trying to be clear when I say it.
SA: So the psychosis wouldn't be something he'd be admitted to an autism specialist unit for, and the drug use would be, that would need to be seen as part and parcel of his autism, which wasn't view the professionals working with him, including myself were seeing.
SA: I'm sorry I don't know i've been particularly clear
BB: Why was view taken from what you were seeing that the drug use was not part and parcel of Chris's autism presentation?
BB: Why was view taken from what you were seeing that the drug use was not part and parcel of Chris's autism presentation?
SA: because my understanding from the information I had was he'd been using since he was age 14, so he continued to be using, so was dependency on it.
When he was on ward he had period of time when he didn't have access to substances, my expectation was not only would ward
When he was on ward he had period of time when he didn't have access to substances, my expectation was not only would ward
SA: be environment he'd struggled, particularly around masking, signs and symptoms of autism would have been more pronounced.
If drug use was part and parcel of his autism we'd have seen an exacerbation of his signs and symptoms of autism on the ward.
If drug use was part and parcel of his autism we'd have seen an exacerbation of his signs and symptoms of autism on the ward.
SA: He was reasonably settled, that was in my view what I was seeing. Very similar to what other people were seeing as well. Don't know if I've answered you correctly Ms Ballard, if I've answer your question.
BB: I'll seek clarification if I need to.
BB: I'll seek clarification if I need to.
BB: Have you worked with people with an autistic spectrum disorder and reliance on substances. If so what kind, previously or since?
SA: Sorry I'm losing my voice. We've had people, the Aspergers service I work in is a community based service.
SA: Sorry I'm losing my voice. We've had people, the Aspergers service I work in is a community based service.
SA: We see people in community settings, there are individuals who misuse alcohol as way of coping, around specific set of circumstances.
Not everyone I see but not uncommon will use alcohol when demands on them socially are overwhelming.
Not everyone I see but not uncommon will use alcohol when demands on them socially are overwhelming.
SA: So what they might do is drink before going into setting, and within setting, to help manage for period of time need to. Or might have plan to consume alcohol to help manage feeling of being overwhelmed and anxious... its not uncommon but not everyone I see that misuses.
SA: Have experience of people who've misused drugs in similar way, they're fewer and haven't seen anybody over last year with that presentation. Again is around managing a specific set of circumstances, not an ongoing process they've done.
BB: Have you been involved please with organising the admission of patients on autistic spectrum disorder into specialist placements before and if so, in what circumstances
SA: one admission in recent years, and two other who I've liaised. With Maudsley Unit around gentleman with eating disorder as part of his autism [will withhold incase this is identifiable information] was difficult process because made contact with unit originally...
SA: coordinator for unit, had to talk number of times to get to point where they agreed to do assessment for him... then other two individuals is it ok for me to say, I'm mindful of time?
BB: I think that's sufficient on that, sir those are my questions
BB: I think that's sufficient on that, sir those are my questions
C: were they admissions in respect of drug use?
SA confirms they weren't
C: when you said in your statement you didn't feel at that point of time he required specialised admission, where were you thinking of, was it the Maudsley or others?
SA confirms they weren't
C: when you said in your statement you didn't feel at that point of time he required specialised admission, where were you thinking of, was it the Maudsley or others?
SA: Maudsley is one i'm most familiar with
C; are there others?
SA: there are other settings, yes
C: help me with where they might be?
C; are there others?
SA: there are other settings, yes
C: help me with where they might be?
SA: Priory has one, know that was referenced in relation to Chris. Cygnet used to provide one as well, can't recall all of them. Maudsley I'd go to as first point of contact.
C: ok, thank you very much Ms Allison.
Coroner thanks her and she's released at 1pm
C: ok, thank you very much Ms Allison.
Coroner thanks her and she's released at 1pm
Court is adjourned, back at 2pm
Back in court
Melika Cay is the next witness. She gives an affirmation
C: Ms Cay you've provided a detailed statement, I'm grateful to you for it.
Melika Cay is the next witness. She gives an affirmation
C: Ms Cay you've provided a detailed statement, I'm grateful to you for it.
C: You'll perhaps appreciate given stage you give your evidence in inquest, have fairly good idea of chronology, date of meetings, emails from various points.
Coroner says he'll focus on specific points
Coroner says he'll focus on specific points
C: Practice Lead within Community Team for People with Learning Disabilities. One of two in SBC team CTPLD, before that you were social worker with same team.
MC confirms she qualified as a social worker in 2012
MC confirms she qualified as a social worker in 2012
C: your counsel quite rightly emphasised you're not a clinician in that sense, you work as a social worker. You do conduct capacity assessments in role as social worker. You're familiar with the process and set out in your statement
MC: yes
MC: yes
C: At time you were involved with Chris had you conducted many MCA assessments?
MC: Yes MCA is one of our main pieces of legislation that comes into play in practice. I've conducted numerous capacity assessments throughout my career
MC: Yes MCA is one of our main pieces of legislation that comes into play in practice. I've conducted numerous capacity assessments throughout my career
C: thank you, leading them, writing them up
MC: yes
MC confirms she's experience of working with people with learning disabilities and autism throughout her career
MC: yes
MC confirms she's experience of working with people with learning disabilities and autism throughout her career
C recaps her evidence about MCA assessments, presumption of capacity, has to be overturned on balance of probabilities, is time and decision specific
She confirms
Discussion re types of situations that likely to lead to capacity assessment
She confirms
Discussion re types of situations that likely to lead to capacity assessment
C: what makes those more complex than run of the mill straight forward MCAs
MC: the frequency would undertake decision, as opposed to consent for Care Act Assessment, they happen daily, but more complex around sexual relationships or illicit drug use aren't as common.
MC: the frequency would undertake decision, as opposed to consent for Care Act Assessment, they happen daily, but more complex around sexual relationships or illicit drug use aren't as common.
MC: The level of risk associated with those things is what makes them complex.
C: because they're high risk, potentially
MC: yes
C: so that added layer of complexity means the stakes are higher
C: because they're high risk, potentially
MC: yes
C: so that added layer of complexity means the stakes are higher
MC: yes and you may involve other professionals and their expertise to ensure that assessment is robust
C: I know you weren't involved in the first assessment, have had some evidence about that... as example involvement of Ms Salici, Speech and Language Therapist
C: I know you weren't involved in the first assessment, have had some evidence about that... as example involvement of Ms Salici, Speech and Language Therapist
C: the Easier to Read documentation in advance, rephrasing of questions. A particular and specific role she'd contribute
MC: yes
C: what would you bring Ms Cay to an assessment that others might not?
MC: yes
C: what would you bring Ms Cay to an assessment that others might not?
MC: my experience of doing capacity assessments in my day to day practice, and my experience of working with people with learning disability and autism
C asks about her familiarity
C asks about her familiarity
MC confirms her case load throughout her time at SBC consists of people with learning disability and on occasion also autism
MC highlights changes: if individual had autism and no learning disability then pathway they'd follow is mental health.
MC highlights changes: if individual had autism and no learning disability then pathway they'd follow is mental health.
C: If had a learning disability and autism, commonly pathway individual would follow is learning disability pathway.
MC: However are situations where query about someone's presentation and primary need, in those situations the two teams will come together and agree on a way forward. Decision normally made by team manager.
C: that was at the relevant time in June 2020
MC: yes
C: that was at the relevant time in June 2020
MC: yes
C: The LD pathway, that';s EPUT is it or SBC?
MC: either, it would depend, either EPUT or SBC CTPLD
C: how would decision be made between which pathway?
MC: whether learning disability or mental health? That's decision usually taken by manager or senior management.
MC: either, it would depend, either EPUT or SBC CTPLD
C: how would decision be made between which pathway?
MC: whether learning disability or mental health? That's decision usually taken by manager or senior management.
MC: Senior manager for Adult Social Care CTPLD and whoever is in attendance from mental health services
C: so if query around presentation teams would put their heads together, EPUT teams or?
MC says either combination
C: so if query around presentation teams would put their heads together, EPUT teams or?
MC says either combination
C: where appears to be dispute of who should be taking lead, as was in this case, what's your understanding of how that should be resolved?
MC: through a multidisciplinary team meeting
MC: through a multidisciplinary team meeting
C: jumping forward think you're aware ESTEP saying he can't keep himself safe in the community, we cant keep him safe. Were you aware of that in respect of Chris?
MC: no I wasn't. There was a change, some emails went round, Judi Jeavons said his presenting need was no longer his psychosis so more appropriate team would be learning disability, so that would be EPUT LD team. I can't recall them saying about safety
C: ok. I've jumped forward will come back to that....
So, two stage test, that first stage is tick as far as Chris is concerned. Second stage, whether person able understand information, retain information, weigh up that information...
So, two stage test, that first stage is tick as far as Chris is concerned. Second stage, whether person able understand information, retain information, weigh up that information...
[example of nuance for weighing up decisions re sexual relationships]
C: What would be an equivalent example with regards to drug use, illicit drug use. What type of issue would you be looking to weigh up?
MC: specifically to Chris
C: What would be an equivalent example with regards to drug use, illicit drug use. What type of issue would you be looking to weigh up?
MC: specifically to Chris
C: yes, specifically to Chris, and specifically to his cannabis use. What kind of issues?
MC: the impact that might have on individual's mental wellbeing and physical health. Impact on someone's finances.
MC: the impact that might have on individual's mental wellbeing and physical health. Impact on someone's finances.
C: would, within mental wellbeing and physical health, would that include whether they understand the risks involved?
MC: yes
C: you were aware Chris's first episode of psychosis was associated with his use of cannabis
MC: yes
MC: yes
C: you were aware Chris's first episode of psychosis was associated with his use of cannabis
MC: yes
C suggests had been query re capacity, given two assessments conducted
MC: my understanding is first assessment caused Kirsty to doubt he had capacity around his drug use
C [missed]
MC: my understanding was first assessment was around his capacity to understand his medication
MC: my understanding is first assessment caused Kirsty to doubt he had capacity around his drug use
C [missed]
MC: my understanding was first assessment was around his capacity to understand his medication
C: and limited to that
MC: yes
C: and if he lacked capacity a best interests decision would be made
MC explains what that means highlighting least restrictive means
MC: yes
C: and if he lacked capacity a best interests decision would be made
MC explains what that means highlighting least restrictive means
C: you say MHA gives powers to detain and treat people with declining mental health in interests of their safety or those of public... your engagement with Chris, you didn't have any role with regards to MHA assessment
MC: No, I'm not an AMHP, that's not my role
MC: No, I'm not an AMHP, that's not my role
C: you were aware of IQ58 and autism, you said slightly incongruous he wasn't on the radar of your service without that presentation, was slightly unusual?
MC: yes from my experience, it's unusual for someone with a learning disability and autism not to receive a referral through to our team pre 18
C: you say important to make distinction between adult social care and health [paraphrase]
C: you say important to make distinction between adult social care and health [paraphrase]
C: We've heard evidence of Ann Igoe and colleague with respect of provision of support. I'm confusing myself. EHCP, that's completely separate to this. Forgive me.
I want to turn to 7 May when you were first, first referral to you. First time you became aware of Chris?
MC: yes
I want to turn to 7 May when you were first, first referral to you. First time you became aware of Chris?
MC: yes
C: with your manager Matthew Harding asking you to attend a meeting
MC: yes
C: I've had various evidence about that meeting, described as robust, you remember it as such?
MC: it was a lengthy meeting, lot of information discussed and shared.
MC: yes
C: I've had various evidence about that meeting, described as robust, you remember it as such?
MC: it was a lengthy meeting, lot of information discussed and shared.
MC: I was of view was clear plan from end of that meeting as to who would take lead and for what. So yes would say was robust meeting
C: this was 7 May?
MC: yes
C: you say Dr TF and her colleagues had no reason to doubt Chris's capacity to consent to treatment
MC: yes
C: this was 7 May?
MC: yes
C: you say Dr TF and her colleagues had no reason to doubt Chris's capacity to consent to treatment
MC: yes
C: he was voluntary patient and cld discharge at any time
MC: yes
C covers other aspects; she confirms
C: lengthy discussion about IQ and diagnoses... you listen to MDT highlighting discrepancy between what his mother was saying his abilities were and what others had observed
MC: yes
C covers other aspects; she confirms
C: lengthy discussion about IQ and diagnoses... you listen to MDT highlighting discrepancy between what his mother was saying his abilities were and what others had observed
C: Had you seen the GOSH assessment?
MC: No, I wasn't aware of it before the meeting, was aware in the meeting, but because was no role for us following meeting, it wasn't shared with us.
MC: No, I wasn't aware of it before the meeting, was aware in the meeting, but because was no role for us following meeting, it wasn't shared with us.
C: I think common ground, no one was disputing was diagnosis of autism and learning disability, was the nature and extent of both
MC: yes that's correct
MC: yes that's correct
C: you say it was agreed all of his needs could be met in a low level supported placement.
Was it then concluded, reported in the MDT, Chris had been very clear he was not going to abstain from taking illicit drugs.
Was it then concluded, reported in the MDT, Chris had been very clear he was not going to abstain from taking illicit drugs.
C: Was it your understanding in relation to cannabis and cocaine or just cannabis?
MC: at that time I think cannabis and cocaine because that's what they said contributed to his psychosis.
MC: at that time I think cannabis and cocaine because that's what they said contributed to his psychosis.
C: consequently was concluded wasn't in Chris's best interest to follow LD pathway... so neither LD pathway, through SBC or NHS EPUT was considered appropriate?
MC: yes through NHS LD EPUT, NHS EPUT specifically ESTEP and team with Care Act Responsibilities
MC: yes through NHS LD EPUT, NHS EPUT specifically ESTEP and team with Care Act Responsibilities
C: was decided was best placed to follow mental health pathway and supported by ESTEP and EPUT LD Team who'd do assessment in that context
MC: yes
MC: yes
C: you haven't met Chris, hearing about him for first time. Information shared, you say you did not disagree, you were coming in blind, weren't really in position too, but what you were hearing sounded coherent to you? It made sense?
MC: yes
MC: yes
C: were you aware of concerns of Julia, Chris's mother, about which pathway she felt was appropriate?
MC: I don't recall whether I became aware after or in the meeting?
MC: I don't recall whether I became aware after or in the meeting?
C: you don't remember it being discussed in the meeting. You say 'I also queried whether Chris would benefit from an independent advocate' on a number of occasions you were pushing for that to be investigated, but it never happened?
MC: no
MC: no
C: part of your initial reasoning for that was it seemed Chris's mother had distinct views, had low IQ and autism, and couldn't cope without 24hr support, which differed with Chris's views that he wanted to live in the community. Based on what you're hearing?
C: Not a conversation with Chris?
MC: No
C: and you press for independent advocate to reconcile those views [paraphrase] you pushed on a number of occasions, did that happen?
MC: no I don't believe so
C: was there any indication of why it wasn't pursued
MC: no
MC: No
C: and you press for independent advocate to reconcile those views [paraphrase] you pushed on a number of occasions, did that happen?
MC: no I don't believe so
C: was there any indication of why it wasn't pursued
MC: no
C: you say could not see a reason for your team to be involved... for YPDAT to be involved, would Chris have to consent to that?
MC: yes as an adult, he'd consent for that, or independent advocacy
C: so you say you could not see a reason for your team to be involved
MC: no
MC: yes as an adult, he'd consent for that, or independent advocacy
C: so you say you could not see a reason for your team to be involved
MC: no
C: did you become aware that Julia was very much of a view that the team should be involved?
MC: yes
C: how was that handled?
MC: there were lots of meetings I wasn't privy to, I was approached by my manager who said I'd be a secondary advisor
C: for the capacity assessment?
MC: yes
C: how was that handled?
MC: there were lots of meetings I wasn't privy to, I was approached by my manager who said I'd be a secondary advisor
C: for the capacity assessment?
MC confirms for basis throughout, to advise on learning disability and autism
C: you're now becoming involved
MC: yes
C: you're part of the SBC learning disabilities service, by definition is your service now engaged with care and support?
MC: no
C: some other arrangement?
C: you're now becoming involved
MC: yes
C: you're part of the SBC learning disabilities service, by definition is your service now engaged with care and support?
MC: no
C: some other arrangement?
MC: could say was unusual arrangement, decision had been made for me to be a support to Kirsty around learning disabilities and autism, and to give advice to Kirsty as and when required
C: He's [Matt Harding, her manager] is saying to Julia EPUT lead and have responsibility.. was he canvassing for your involvement? Was it informal arrangement?
MC: Decision was clear we weren't to be involved, it lay with NHS services, but it was felt because Chris had diagnosis of learning disability and autism I'd support Kirsty around those
C: difficulty I have is its very clear your service wasn't going to be involved, but then your service is involved
MC: Yes its difficult I wasn't involved in that discussion, I was advised I'd give advice to Kirsty in a secondary role around LD and autism
MC: Yes its difficult I wasn't involved in that discussion, I was advised I'd give advice to Kirsty in a secondary role around LD and autism
C: why wouldn't EPUT learning disability service be the people to provide that?
MC: I don't know
C: so as service you're not involved but you've got a secondary supportive role
MC: yes
MC: I don't know
C: so as service you're not involved but you've got a secondary supportive role
MC: yes
C: you say you'd be limited in advice you could provide to Kirsty as you'd not met Chris.... so generic advice
MC: yes, around reasonable adjustments could be made, generic advice based on my experience working with individuals with learning disabilities and autism
MC: yes, around reasonable adjustments could be made, generic advice based on my experience working with individuals with learning disabilities and autism
C: rather than Chris, yes. Reiteration of Sophie Vincent, student, being supervised. 19 May you reiterate offer of independent advocacy.
C: 2x May you have email forwarded to you from Chris's mother that Chris was due to be discharged, you weren't involved in any discharge planning?
MC: no [she confirms she fed into advising on assessments]
MC: no [she confirms she fed into advising on assessments]
C: 1 June another email from Mr Harding regarding Chris's collapse and taken to hospital... you raise concerns about your role, your individual role not SBC role, do I understand it now?
MC: yes
C: and the overall complexity and risk of case.
MC: yes
C: and the overall complexity and risk of case.
C: I was seeking clarity of my role and remit, highlighted he was discharged from Cedar Ward on X May without any support... Dr TF advised as Chris was voluntary patient and was asking to leave, could not stop him... this is all coming to you after the event?
MC: yes
MC: yes
C: I believe my concerns were escalated to EPUT... you were being asked to do something but your hands were tied behind your back. Correct me if I'm wrong?
MC: it made it difficult yes. I've thought about this. In secondary advisory role do you need to be informed of everything?
MC: it made it difficult yes. I've thought about this. In secondary advisory role do you need to be informed of everything?
MC: You're approached as and when, however given what was happening it would have been helpful to know more and be kept up to date
C: do you know Kirsty Lister, had you worked with her before?
MC: no
C: and its a secondary role to support her as care coordinator
MC: yes
C: do you know Kirsty Lister, had you worked with her before?
MC: no
C: and its a secondary role to support her as care coordinator
MC: yes
C: on one hand you're waiting for her to contact you with what support she needs, on other hand you're receiving emails saying he'd discharged and back in hospital
MC: yes, and not just Kirsty, there were others involved that could have kept me up to date
MC: yes, and not just Kirsty, there were others involved that could have kept me up to date
C: so you're saying if I am going to be involved then I need to know what's going on.
There's a storm going on and Julia is expressing grave concerns
MC: yes and he's back in hospital having collapsed
[missed chunk]
There's a storm going on and Julia is expressing grave concerns
MC: yes and he's back in hospital having collapsed
[missed chunk]
C: by 4 June you're raising concerns, again, about where Chris's voice was in this and you raise again independent advocacy
5 June attended MDT, was agreement Chris to remain in hospital while supported living placement was found. Sharon Allison had agreed to meet with Chris
5 June attended MDT, was agreement Chris to remain in hospital while supported living placement was found. Sharon Allison had agreed to meet with Chris
C: 8 June seemed to reinforce decisions from 7 May. You understood wasn't an assessment was a 40min meeting, based on her reading at that point?
MC: yes
C: 9 June Kirsty and Sam Salici were going to undertake a MCA assessment for Christopher's illicit drug use.
MC: yes
C: 9 June Kirsty and Sam Salici were going to undertake a MCA assessment for Christopher's illicit drug use.
C: I highlighted hypothetical situation, if he was deemed to lack capacity with regards to his drug use, what would the best interests decision be?
C: Expand on that a little bit. What would constitute lacking capacity to understand risk of his drug use, how would you approach it in a MCA?
MC: as part of capacity assessment shall I run through
MC: as part of capacity assessment shall I run through
C: I understand process generally, how would you find out if this chap with LD and autism understood the risk of using drugs?
MC: presenting the relevant information, from that assess their ability to understand, retain, weigh up and communicate that.
MC: presenting the relevant information, from that assess their ability to understand, retain, weigh up and communicate that.
C: would it be, if you have a big spliff do you know what's going to happen? Open questions, closed questions? Do you realise how unwell you became?
MC: depends on the individual [fuller answer]
MC: depends on the individual [fuller answer]
C: we'll come to what you contributed 8 days later but you're flagging a concern around that topic here
MC: yes food for thought... best interests decisions need to be made with least restriction on freedoms
MC: yes food for thought... best interests decisions need to be made with least restriction on freedoms
C: if he doesn't understand risk... he's recovering from drug induced psychosis few months earlier, what were range of best interests decisions that might be available? Spread of options?
MC: I'd consider, you'd think about restrictions around finances, again is least restrictive options.
C: that's one, what else?
MC: education about drug use
C: yeh
MC: it's really difficult because
C: they're least restrictive, if you go up scale?
C: that's one, what else?
MC: education about drug use
C: yeh
MC: it's really difficult because
C: they're least restrictive, if you go up scale?
MC: then thinking more restrictive and entering realms of Deprivation of Liberty
C: DOLS?
MC: yes but that's more specifically around care and support
C: DOLS?
MC: yes but that's more specifically around care and support
C: so if someone doesn't understand risk of taking drugs and he or she has learning disability and autism, what are best options?
MC: in least restrictive way?
C: those and moving up... restricting finances, drug education, what more?
MC: in least restrictive way?
C: those and moving up... restricting finances, drug education, what more?
MC: I guess restricting an individual's movements, it was difficult, I posed that question as food for thought for clinical team
C: I can see you raising the issues but they don't avail themselves of answers do they.
C: I can see you raising the issues but they don't avail themselves of answers do they.
C: is the use of a restriction on his liberty, is that an option that would be considered?
MC: I dont know that would be for them to consider if decision was he lacked capacity, and following appropriate pathway for that
C asks what would be
MC: I dont know that would be for them to consider if decision was he lacked capacity, and following appropriate pathway for that
C asks what would be
MC: Chris was in Supported Living scheme so would be REX application to court, from my experience of DOL in Supported Living in community, all information would need to be provided to court and ultimately the judge would make decision
C: alright. Discharged to Hart House 15 June, 16 June get email from RW he'd had seizure, injured his face. RW felt was likely to do with drug use, he was admitted to hospital.
C: You questioned whether panel meeting would be helpful. You wanted to be clear on what happened that led to seizure and who was going to do what. That meeting never happened
MC: no
C: any idea why?
MC: I dont know
MC: no
C: any idea why?
MC: I dont know
C: xx June Judi Jeavons email about advocacy service, she's looking to get details and wanted to let you know outcome of MCA assessment (drug use) because that would indicate what advocacy provided
C: Later that day you became aware you'd conduct MCA assessment. Chris seemed to be presenting more able than a lot of people in your team.
MC: yes
C: How long did that meeting go on for?
MC: yes
C: How long did that meeting go on for?
MC: [missed] 30 or 40 minutes, and the period I guess where we were escorting him to the ward
C: on top of that
MC: yes
C: you were concerned if he was in a supported living placement with people with learning disability he might feel isolated
C: on top of that
MC: yes
C: you were concerned if he was in a supported living placement with people with learning disability he might feel isolated
MC: yes some individuals may not be able to communicate verbally, some attending day service, some attending educational setting, some cant access community independently
C: sure.
C: sure.
C: Just want to ask about drug use, you say very able, had lots of insight.... [missed] did say sometimes took break, made reference to his tolerance levels [missed]
C takes to records and asks if MC has seen before
MC: I read the write up, not the full capacity document
C takes to records and asks if MC has seen before
MC: I read the write up, not the full capacity document
C: why not
MC: I can't answer that
[Coroner reads from record]
C: Christopher responded with the past is the past, shrugged, it's my decision. His attitude was very blase... he closed that part of conversation down...
MC: I can't answer that
[Coroner reads from record]
C: Christopher responded with the past is the past, shrugged, it's my decision. His attitude was very blase... he closed that part of conversation down...
C: Christopher was reassured he wasn't in trouble and he replied what will be, will be.... when asked about cannabis use and seizure, he said sometimes helped with seizures [can't catch most of this]
C: Christopher stated he wanted to give Hart House another go, was no evidence to suggest he'd used drugs in run up to his seizure... [reads more]
That seems to give different flavour to what you describe as really astute insight about his drug use...
That seems to give different flavour to what you describe as really astute insight about his drug use...
C: to degree he's mentioning tolerance, can be adverse consequences to his drug use but he's closing down the conversation and not wishing to go further
C asks why she didn't read it.
C asks why she didn't read it.
MC: I read the write up of the capacity assessment itself, yes, that was the explanation Chris gave around control of his drug use and tolerance levels
C: yes but no link between him becoming unwell and his drug use
C: yes but no link between him becoming unwell and his drug use
MC: it was difficult because we had no evidence he had used cannabis that night
[missed chunk]
MC: Hard to move questioning forward without becoming oppressive
C: do you simply accept what someone says?
[missed chunk]
MC: Hard to move questioning forward without becoming oppressive
C: do you simply accept what someone says?
MC: there was rephrasing but it wasn't because Chris didn't understand, it was because we were trying to open conversation up.... can only go on information and evidence we've got, would have been unreasonable to conclude he lacked capacity on basis of the information...
MC: he's willing to share
C: how can you assess if he's not willing to share
MC references principle one... have to assume capacity
C: what information were you testing in respect of his capacity for drug use; what information were you checking to see if he retained?
C: how can you assess if he's not willing to share
MC references principle one... have to assume capacity
C: what information were you testing in respect of his capacity for drug use; what information were you checking to see if he retained?
MC: Chris was able to understand drug use could cause psychosis... that discussion about tolerance level was about his preference
C: thank you, may be some more questions on that topic for you. You say we had lengthy discussion and on balance decided he did have capacity?
C: thank you, may be some more questions on that topic for you. You say we had lengthy discussion and on balance decided he did have capacity?
C: That's in relation to illicit drug use?
MC: yes, I want to make it very clear that Kirsty was the decision maker, but Sam and I were there to support
C: to be clear you agreed with Kirsty's decision
MC: yes
C: and you say you read the relevant assessment
MC: yes
MC: yes, I want to make it very clear that Kirsty was the decision maker, but Sam and I were there to support
C: to be clear you agreed with Kirsty's decision
MC: yes
C: and you say you read the relevant assessment
MC: yes
C: 24 June email from Kirsty Lister saying she spoke to Chris's mother for 45mins, this was calm before storm, quite a positive exchange at this stage
MC: yes
MC: yes
C: wasn't until 29 June email sent from Chris's mum to Matt Harding on 27 June that Chris was on his way to hospital having [withheld].
End of your statement was discharge planning meeting but you were not included in meeting.
End of your statement was discharge planning meeting but you were not included in meeting.
C: Can I just ask you, its not spelt out, what your response was and what you thought when you heard this news? Three days after it's happened, he's still on unit.
MC: uh hum
MC: uh hum
C: there was apparently a meeting to discuss Chris's discharge, 3 July, but that was after he was discharged wasn't it?
MC: I'm not sure when he was discharged
C: you're still not sure?
MC: I'm not sure when he was discharged
C: you're still not sure?
MC: no there's lots of information I've been made aware of. My involvement ended with capacity assessment.
C: were you involved in email exchanges, you weren't aware ESTEP Team were saying they couldn't keep him safe
MC: not that I can recall
C: were you involved in email exchanges, you weren't aware ESTEP Team were saying they couldn't keep him safe
MC: not that I can recall
C: you must have been quite concerned when you heard that weren't you?
MC: which bit
C: [withheld] that bit
MC: naturally I had concerns because of Chris's risk taking behaviour however he had input from relevant professionals in assessing and reviewing that risk
MC: which bit
C: [withheld] that bit
MC: naturally I had concerns because of Chris's risk taking behaviour however he had input from relevant professionals in assessing and reviewing that risk
C: he did. That's what we're here to review in part.
Did it cause you to review the MCA you were involved with for this cannabis smoking, recently recovered from psychosis, young person with learning disability and autism?
Did it cause you to review the MCA you were involved with for this cannabis smoking, recently recovered from psychosis, young person with learning disability and autism?
MC: was plan for him to discuss with drug and alcohol service in more informal setting, to help Chris make decisions around drug taking.
[Court is adjourned for 10min break. Back at 15:20]
TS: Did you ever at any stage see a copy of or read the GOSH report?
MC: no
[Court is adjourned for 10min break. Back at 15:20]
TS: Did you ever at any stage see a copy of or read the GOSH report?
MC: no
TS: not prior to your capacity assessment of Chris?
MC: No I was asked on the day and asked to meet Kirsty and Sam urgently, so on reflection would be beneficial to read report, but it hadn't been shared with me
TS: you first became aware a month earlier
MC: yes
MC: No I was asked on the day and asked to meet Kirsty and Sam urgently, so on reflection would be beneficial to read report, but it hadn't been shared with me
TS: you first became aware a month earlier
MC: yes
TS: it wasn't shared with you
MC: no
TS: why didn't it come to you?
MC: I don't know
TS: did you ask for it?
MC: no
TS: You talk about comment from GP, going into meeting blind, but in background you're aware of concerns raised by Julia, Chris's mum
MC: no
TS: why didn't it come to you?
MC: I don't know
TS: did you ask for it?
MC: no
TS: You talk about comment from GP, going into meeting blind, but in background you're aware of concerns raised by Julia, Chris's mum
MC: my reference to going in blind was the MDT
TS: were you aware Julia would have been very keen to speak to you?
MC: no
TS: Did Mr Harding bring anything to your attention?
MC: no
TS: were you aware Julia would have been very keen to speak to you?
MC: no
TS: Did Mr Harding bring anything to your attention?
MC: no
TS: You were here when I put information to Ms Allison about Christopher's experience of school, were you aware of that?
MC: I wasn't aware, no
TS: Would it have been helpful to be aware of that?
MC: I wasn't aware, no
TS: Would it have been helpful to be aware of that?
MC: It wld have been helpful however in relation to that MCA assessment I'd been present at MDT, had emails forwarded onto me which very much spoke about what was happening and concerns. I had conversation with S Allison after she spoke to Chris, so I had that preparation for it
TS: was that the extent of your preparation for that assessment?
MC: it was more than that... [missed] my experience of working with individuals with learning disability and autism, and undertaking capacity assessments, I brought forward when undertaking
TS: You've read it?
MC: it was more than that... [missed] my experience of working with individuals with learning disability and autism, and undertaking capacity assessments, I brought forward when undertaking
TS: You've read it?
MC: I've had sight of it yes
C: sorry what does that mean; which bits have you read
MC: I've read the recommendations
C: Niche report brought to your attention, have you been provided with it?
MC: its in the bundle
C: have you read any of it, not had sight of it?
MC: no
C: sorry what does that mean; which bits have you read
MC: I've read the recommendations
C: Niche report brought to your attention, have you been provided with it?
MC: its in the bundle
C: have you read any of it, not had sight of it?
MC: no
C: can I ask why not, I asked this of a colleague of yours yesterday, why not?
MC: My understanding is wasn't shared with us until mid August, I didnt receive bundle until last week. I focused my time on my involvement, and statements of those I had contact with.
MC: My understanding is wasn't shared with us until mid August, I didnt receive bundle until last week. I focused my time on my involvement, and statements of those I had contact with.
MC: My understanding is Niche report is for EPUT
C: it's EPUT commissioned yes. You heard this morning it deals with the capacity assessments that took place.
MC: from this morning yes
C; but you weren't aware of that before questions today
MC: I wasn't no
C: it's EPUT commissioned yes. You heard this morning it deals with the capacity assessments that took place.
MC: from this morning yes
C; but you weren't aware of that before questions today
MC: I wasn't no
C: slightly different to yesterday I think, given report... you were only provided with the bundle on Friday
MC: yes
C: i'll not take that up with you, inquest had been up and running for a week by then
MC: yes
C: i'll not take that up with you, inquest had been up and running for a week by then
TS: sir I suppose question arises on what basis this very detailed statement was made
C: that's a very valid question, you recall in some detail capacity assessment, what did you use to provide that statement
MC: I was provided with a chrono - I can't pronounce it
C: that's a very valid question, you recall in some detail capacity assessment, what did you use to provide that statement
MC: I was provided with a chrono - I can't pronounce it
C: chronology?
MC: no a chronolater [sp?], and I was provided with access to my notes on Liquid Logic.
C: ok, Mr Stoate
MC: no a chronolater [sp?], and I was provided with access to my notes on Liquid Logic.
C: ok, Mr Stoate
TS: did you hear this morning, 5.7 of Niche report staff considered Chris's capacity at regular points but failed to take into account extent he could mask his understanding... [reads]
TS: failed take in to account extent to which he could mask his understanding. What would you say to that?
MC: what's the question sorry?
TS: what would you say to that criticism of an independent report, that's looked at this documentation, all of it?
MC: what's the question sorry?
TS: what would you say to that criticism of an independent report, that's looked at this documentation, all of it?
MC: it's difficult, don't want to criticise that report.
Was formal capacity assessment undertaken, took into account reasonable adjustments to include Chris in that process.
Was formal capacity assessment undertaken, took into account reasonable adjustments to include Chris in that process.
TS: having not read the GOSH report you wouldn't have seen the recommendations that say look practitioners need to be really careful when assessing this young man, he's good at remembering things and spitting it out again but may not be full picture.
TS: You encountered that didn't you, he was using stock phrases, the past in the past...
MC: completely understand what you're saying... but he just didn't want to answer those questions... have to assume capacity unless have reason otherwise
MC: completely understand what you're saying... but he just didn't want to answer those questions... have to assume capacity unless have reason otherwise
MC: based on information Chris was willing to provide would be unreasonable to conclude lack capacity
C: if someone sits in capacity assessment and give one word answers, refuse to engage, does manner of response feed in. If they're just not engaging
C: if someone sits in capacity assessment and give one word answers, refuse to engage, does manner of response feed in. If they're just not engaging
MC: would depend if they could communicate verbally
C: if they're known to be able to speak
MC: there were periods of time where Chris was able to engage in conversations...
C: if they're known to be able to speak
MC: there were periods of time where Chris was able to engage in conversations...
MC: he had that clear description about tolerance and his control over drug use and his understanding of drug use can impact on his mental health.... it wasn't just no comment, no answer, there were other bits to that.
MC: I think some of his not wanting to answer was his insight and awareness of recreational drug use and how that's perceived.
TS: do you think lack of answers could be because he could not, not would not, answer?
TS: do you think lack of answers could be because he could not, not would not, answer?
MC: that's why rephrasing, but my view was he wasn't choosing to answer
TS: your view. Niche report refers to @nicecomms guidance on decision making, are you aware of those? nice.org.uk/guidance/ng108
MC she says she would be
TS reads from guidance
TS: your view. Niche report refers to @nicecomms guidance on decision making, are you aware of those? nice.org.uk/guidance/ng108
MC she says she would be
TS reads from guidance
TS: Ms Cay you're well aware by now that Julia takes an entirely different view, and has always done, about Chris's capacity to understand the risks to him from illicit drug use.
You're well aware of that now?
MC: now, yes
You're well aware of that now?
MC: now, yes
TS: the guidance says should identify people, and use that information, to form complete picture. Did you ever take any steps to speak to Julia?
MC: no that wasn't part of my role... Kirsty was lead and spoke to mum....
MC: no that wasn't part of my role... Kirsty was lead and spoke to mum....
TS: did you ever say NICE Guidelines say should have complete picture, what's the complete picture Kirsty?
MC: no but the guidance for MCA doesn't say they have to be present
MC: no but the guidance for MCA doesn't say they have to be present
TS: no it doesn't say present, but says to put together information. I'll put to you what I put to Ms Allison, you don't have to go searching do you?
MC: I appreciate what you're saying
MC: I appreciate what you're saying
TS: You formed your view on a 40min conversation with Chris and a conversation with Ms Allison after her 40min conversation, but you didn't speak with @JuliaCa20602661
MC: I didn't
TS: why not
MC reiterates that her role was in supporting Kirsty
MC: I didn't
TS: why not
MC reiterates that her role was in supporting Kirsty
TS: 1 June you raise concerns 'about our role and the ongoing complexity and level of risk of this case'
We were given a chronology from SSPA [Southend Safeguarding Partnership - Adults] and reads from it
TS: to be clear, is that from an email, they're your words?
We were given a chronology from SSPA [Southend Safeguarding Partnership - Adults] and reads from it
TS: to be clear, is that from an email, they're your words?
MC: wouldn't know where comes from but do make reference in my witness statement where I raised concerns
TS: left us with very vulnerable 19 year old with IQ58 in situation vastly complex and risky. You were aware weren't you?
MC: yes
TS: left us with very vulnerable 19 year old with IQ58 in situation vastly complex and risky. You were aware weren't you?
MC: yes
TS: but still family aren't consulted when few days later you're undertaking capacity assessment?
MC: on 18 June, yes
TS: what was your interest in whether or not the IQ was to be reviewed or not?
MC: on 18 June, yes
TS: what was your interest in whether or not the IQ was to be reviewed or not?
MC: was very aware were discrepancies, conversations had about whether it was going to be reviewed or not
TS: hmmm
MC: I was in a very difficult position in terms of my role and remit, lots going on I wasn't aware of but I did raise that accordingly with senior management
TS: hmmm
MC: I was in a very difficult position in terms of my role and remit, lots going on I wasn't aware of but I did raise that accordingly with senior management
TS takes to record and reads email from Mel
TS: I believe a safeguarding has been raised however it wasn't very clear what the concern is... other than his mother does not want him to return to Hart House.
MC asks for clarification
TS: I believe a safeguarding has been raised however it wasn't very clear what the concern is... other than his mother does not want him to return to Hart House.
MC asks for clarification
TS highlights three safeguarding concerns raised... one by ????, one by Acute Trust, one by Hart House
MC: I wasn't aware of the others but its now coming to my mind
MC: I wasn't aware of the others but its now coming to my mind
TS: I believe it has... your response suggests you weren't aware. That's not what is summarised in the Niche reports is it?
MC: No
TS: what was your role in coordinating safeguardings in response of Chris, why was Lynn Scott asking you?
MC: I can't answer that
MC: No
TS: what was your role in coordinating safeguardings in response of Chris, why was Lynn Scott asking you?
MC: I can't answer that
TS asks where Lynn sits; MC confirms she's Director of Social Care
C: Matt Harding is between you and her
MC: yes
C: She's asking you a question, you don't know why she's asking you a question?
C: Matt Harding is between you and her
MC: yes
C: She's asking you a question, you don't know why she's asking you a question?
MC: Imagine its relating to Chris having seizure, injuring his face and ending up in Southend Hospital
TS: You go on and say sounds like it's self-neglect.. believe HH will raise safeguarding query around exploitation...
TS: You go on and say sounds like it's self-neglect.. believe HH will raise safeguarding query around exploitation...
TS reads: Kirsty is an experienced CPN however it doesn't appear that she has support from mental health adult social care.
So you're raising Kirsty doesn't have support?
MC: yes
TS: [missed]
MC asks for clarification of what the 3 safeguarding alerts were
So you're raising Kirsty doesn't have support?
MC: yes
TS: [missed]
MC asks for clarification of what the 3 safeguarding alerts were
TS confirms first was unsafe discharge from hospital
TS: Did you ever read the safeguarding incident report, how would I phrase it, before you conducted your capacity assessment?
TS: Did you ever read the safeguarding incident report, how would I phrase it, before you conducted your capacity assessment?
MC: yes I was aware of incident before seizure, and some of questions in the capacity assessment linked to that.
Richard W was of view that seizure was caused by smoking cannabis, we had no evidence to suggest or prove otherwise
Richard W was of view that seizure was caused by smoking cannabis, we had no evidence to suggest or prove otherwise
TS: You say you were inclined to agree with him? Why was that?
MC: He was adamant he hadn't...
TS: Were you aware of his history, the full extent of him smoking cannabis?
MC: I wasn't no
TS takes to email from Dr Udu
MC: He was adamant he hadn't...
TS: Were you aware of his history, the full extent of him smoking cannabis?
MC: I wasn't no
TS takes to email from Dr Udu
TS reads: Dear Mel, please see below email [from Carla Villa] in my view this is mainly a social care issue, could you kindly work with ESTEP in urgently identifying an LD Supported Living placement that can manage his risks and vulnerability... [reads more]
TS: Do you recall that email?
MC: I do now
TS reads her reply to Dr Udu:
Today when trying to explore his cannabis use and the impact this may have he was reluctant to discuss and shit the conversation down...
MC: I do now
TS reads her reply to Dr Udu:
Today when trying to explore his cannabis use and the impact this may have he was reluctant to discuss and shit the conversation down...
TS reads: I would agree that there are some ASD traits however the IQ of 58 does not feel to be a true representation of him now.
TS reads:
I do not believe LD services are appropriate for his needs and I would be concerned about the impact of him living/being surrounded by those who are functioning far less than he is. This would have a detrimental effect on his development and motivation.
I do not believe LD services are appropriate for his needs and I would be concerned about the impact of him living/being surrounded by those who are functioning far less than he is. This would have a detrimental effect on his development and motivation.
TS: So the Consultant Psychiatrist says go find specialist placement, and you say its not required?
MC: with respect to Dr Udu he's not my line manager... I was feeding back from capacity assessment.... not in my remit to source
MC: with respect to Dr Udu he's not my line manager... I was feeding back from capacity assessment.... not in my remit to source
C: sorry is this a matter of principle you're saying I'm not taking orders from him?
MC: we're separate
C: he's a Consultant Psychiatrist specialising in learning disability, he's got his training, you've got yours... and you're saying it's not appropriate?
MC: we're separate
C: he's a Consultant Psychiatrist specialising in learning disability, he's got his training, you've got yours... and you're saying it's not appropriate?
MC asks to read emails again
TS: on the face of it, you've got Dr Udu, the Consultant Psychiatrist with Specialism in Learning Disability, saying in my view this is a social care issue, could you kindly work with ESTEP find a LD Supported Living placement that can manage...
TS: on the face of it, you've got Dr Udu, the Consultant Psychiatrist with Specialism in Learning Disability, saying in my view this is a social care issue, could you kindly work with ESTEP find a LD Supported Living placement that can manage...
TS: his risks and vulnerability.
That seems very clear.
MC: I appreciate that was what Victor was saying, but I'm an employee of the council, not sure it's for him to say... within mine I've given him feedback from capacity assessment and what the plan was.
That seems very clear.
MC: I appreciate that was what Victor was saying, but I'm an employee of the council, not sure it's for him to say... within mine I've given him feedback from capacity assessment and what the plan was.
MC: I haven't really acknowledged about need to commission services because my understanding was that wasn't my role.
My role as instructed by senior management was to support Kirsty. Reframe questions and form opinion.
My role as instructed by senior management was to support Kirsty. Reframe questions and form opinion.
TS: Having read that back, do you think you've made that clear to Dr Udu?
MC: with regards to what?
TS: I'm not trying to be difficult, Dr Udu says [reads] you don't do that, you tell me and the learned coroner its not your role to do so.
MC: with regards to what?
TS: I'm not trying to be difficult, Dr Udu says [reads] you don't do that, you tell me and the learned coroner its not your role to do so.
TS: You don't say Dear Dr Udu, that's not my role, please raise it elsewhere
MC: valid point, but I do raise that Chris wants to return to Hart House
MC: valid point, but I do raise that Chris wants to return to Hart House
TS: you say he isn't concerned about not following rules of Hart House as he is of view he can just return to mum... were you aware of the risks Julia was raising about her inability to keep him safe?
MC says she wasn't fully aware to extent she is now
MC says she wasn't fully aware to extent she is now
TS reads rest of her email
TS: you appear to have real concerns about this service.
MC: I'm unfamiliar with the service, I'm unfamiliar with Hart House however the agreement was Sharon Allison and Sam Salici were going to support Hart House
TS: you appear to have real concerns about this service.
MC: I'm unfamiliar with the service, I'm unfamiliar with Hart House however the agreement was Sharon Allison and Sam Salici were going to support Hart House
TS: did Dr Udu ever come back to you and ask if you've done that?
MC: not to my recollection
TS: did anything from your managers come back saying its not your role?
MC: I'd have to rely on my recollection which wouldn't be fair in this arena
TS: right
MC: not to my recollection
TS: did anything from your managers come back saying its not your role?
MC: I'd have to rely on my recollection which wouldn't be fair in this arena
TS: right
MC: however I stress I wasn't working in isolation... with respect to Dr Udu that's not his role to delegate to me
C checks who copied in
C: Range of EPUT, any reason you didn't copy in Matt Harding or Lynn?
MC: No, probably would have been a conversation I had with them
C checks who copied in
C: Range of EPUT, any reason you didn't copy in Matt Harding or Lynn?
MC: No, probably would have been a conversation I had with them
C: So you've just replied all
MC: Yes
TS: Final question, and I do note the time...
MC: Yes
TS: Final question, and I do note the time...
TS: Your team, you've given evidence to the coroner about its involvement, formal, informal and so forth.
Is it right you weren't involved in the discharge planning meeting for Chris before his final discharge on 29 June?
Is it right you weren't involved in the discharge planning meeting for Chris before his final discharge on 29 June?
MC: my recollection was no I wasn't involved with that. After the capacity assessment my involvement was less and less in terms of what I was being told.
TS: having had the involvement you've had before then, do you think you should have been?
TS: having had the involvement you've had before then, do you think you should have been?
MC: I don't know to be honest with you, that decision wasn't mine to make.
Obviously I wasn't included or invited to that, or knew it happened, so couldn't say
Obviously I wasn't included or invited to that, or knew it happened, so couldn't say
C: You expressed your views and opinions to Dr Udu on 18 June, how Hart House might benefit from autism training... then lo and behold a week or so after that he's [withheld] and ended up back in hospital.
C: You were aware I think on 29th he was back to Basildon Assessment Unit having [withheld]
MC: Yes I'm only finding out about that two days after
MC: Yes I'm only finding out about that two days after
C: appreciate that, but having found out on 29th, and what you'd said about Hart House and your other opinions expressed to Dr Udu.
What's your reaction when you see that?
Were you curious, keen to know, what the plan was going forward?
What's your reaction when you see that?
Were you curious, keen to know, what the plan was going forward?
MC: yes that's why I liaised with Kirsty Lister, then I wasn't advised he was discharged, in the absence of knowledge
C: Did you have any idea what plan was when he was on Basildon Unit? [lists]
MC: All I was aware was he was a voluntary patient
C: Did you have any idea what plan was when he was on Basildon Unit? [lists]
MC: All I was aware was he was a voluntary patient
C: You liaise with Kirsty Lister, she's closely involved since April, you've been involved with supporting her. You've had capacity assessment over 5hrs together... what do you discuss with her?
MC: I can't recall that I'm afraid. Can you tell me when he discharged?
MC: I can't recall that I'm afraid. Can you tell me when he discharged?
TS: 29 June he discharged himself against medical advice
C: Well, 29th... self discharged against advice, according to the form
MC: I didn't know that, I wasn't told
C: Well, 29th... self discharged against advice, according to the form
MC: I didn't know that, I wasn't told
C: did Kirsty Lister share with you what would happen, or did you ask what's going to happen next?
It would seem the most screamingly obvious question to ask
MC: and I might have done but I can't recall that.
It would seem the most screamingly obvious question to ask
MC: and I might have done but I can't recall that.
C: help me, take yourself back to that phone call with Kirsty. You've found out, you liaise with her, over the phone?
MC: It would have been over the phone
MC: It would have been over the phone
C: we'll hear from her, she must have been at her wits end... ESTEP are clear they can't keep him safe, he [withheld] can you not recall anything?
MC: no, now you say it I'm not even sure if it was a telephone conversation or whether it was an email I sent
MC: no, now you say it I'm not even sure if it was a telephone conversation or whether it was an email I sent
C: there it is, that's the evidence, I'll leave it there.
No further questions from Mr Stoate
No questions from Ms Nash or Ms Khalique
No further questions from Mr Stoate
No questions from Ms Nash or Ms Khalique
BB: I ask questions on behalf of EPUT you're probably aware of that by now... you say you've had opportunity to look at statements relevant to your evidence
MC: yes
BB: Just want to take you to Kirsty Lister's statement [she does]
MC: yes
BB: Just want to take you to Kirsty Lister's statement [she does]
BB reads: A discussion was held in respect of Christopher benefitting from a further capacity assessment in relation to his drug use by a specialist in capacity assessments and drug use.
BB reads: Melike Cay was going to look into this as she recalled an instance where this had happened before.
BB: Do you recall that conversation?
MC confirms she does
BB: Do you recall that conversation?
MC confirms she does
BB: Can you help us with how you recall the conversation going.
Why did topic around need for further education around drug use come up?
MC: I think Sam was also part of that discussion, it was very appropriate to have that conversation...
Why did topic around need for further education around drug use come up?
MC: I think Sam was also part of that discussion, it was very appropriate to have that conversation...
MC: we were mindful Chris was making unwise decisions and therefore would benefit from input from specialist service to provide focused education around drug use to help him make more informed decisions
BB: think we've already dealt with that to manage risks about how he presents; this seems to be different point, benefit from further capacity assessment in relation to drug use and you're going to look into it.
BB: Says you recall instance when it happened before, does that jog your memory?
MC: hard to say, Kirsty isn't here, don't want to assume...
MC: hard to say, Kirsty isn't here, don't want to assume...
MC: We were very clear he had capacity, however it is time and decision specific, so if at time of that focused intervention around his drug use they felt he lacked capacity then they could do that capacity assessment.
MC: With regards to mental capacity can look into... that was really me having a conversation with Kirsty about where there's been complex decisions...
MC: I was referring to sexual intercourse assessment in our decision and recalled instance where SBC had commissioned a psychologist to undertake a capacity assessment
C: right
C: right
MC: was using as an example, are there any services can commission to provide specialist support around his drug use and my understanding was that's the YPDAT team
BB: She appears to be left with impression you'll look into that
BB: She appears to be left with impression you'll look into that
MC: I cant comment on that I'm afraid, I wasn't decision maker or lead
C: well you've raised it, would it seem reasonable to assume if you raised it, you're the one who'd look into it, albeit in the context you tell us now of a sexual decision
MC: different decision
C: well you've raised it, would it seem reasonable to assume if you raised it, you're the one who'd look into it, albeit in the context you tell us now of a sexual decision
MC: different decision
C: so reasonable you'd look into it, not anyone else
MC: I dont know what I'd look into
C reads: Discussion is with yourself, Sam Salici and Ms Lister correct?
MC: yes
C: it appears to be canvassed he'd benefit from further capacity assessment on top of assessment just held?
MC: I dont know what I'd look into
C reads: Discussion is with yourself, Sam Salici and Ms Lister correct?
MC: yes
C: it appears to be canvassed he'd benefit from further capacity assessment on top of assessment just held?
MC: I'm not clear on that because we were clear in the decision; Kirsty wrote up discussion and shared following day, that's where we made reference to specialist input so I dont know
C: I'll explore it with you.
In respect to Christopher benefitting from a further capacity assessment in relation to his drug use, by a specialist in capacity assessments and drug use.
In respect to Christopher benefitting from a further capacity assessment in relation to his drug use, by a specialist in capacity assessments and drug use.
C: The inference there is, does what it says on tin, would benefit from further assessment in respect of aspect to which you've assessed him.
Why would that arise if you were content as you say you were?
Why would that arise if you were content as you say you were?
MC: Exactly, my view was he'd benefit from specialist team around his drug use
C: its about his capacity, that's what's referenced there
C: its about his capacity, that's what's referenced there
MC: focused time and education to explore more, with view to Chris to be bit more receptive, if they had reason to doubt his capacity then assessment could be conducted by them
C: the other inference might thought reasonably drawn from that entry is actually someone specialist in this nuanced and difficult area, with particular specialism in capacity and drug use is sensible, because we don't have it
MC: yeh
MC: yeh
C: you're telling me that inference isn't what you recall the discussion was about?
MC: no, he'd benefit from further input, if that then led to further capacity assessment then that would be for that person to do
MC: no, he'd benefit from further input, if that then led to further capacity assessment then that would be for that person to do
C: doesn't look like that's what is written there, but we'll hear from Ms Lister...
I go back if I may to nuanced aspect, I started my questioning around this, some more challenging than others such as illicit drug use, or sexual practices and understanding of consent...
I go back if I may to nuanced aspect, I started my questioning around this, some more challenging than others such as illicit drug use, or sexual practices and understanding of consent...
C: ...contraception and so on.
I think earlier you recognise, because you draw them out as examples, this is more complex area. It's not straight forward.
I think earlier you recognise, because you draw them out as examples, this is more complex area. It's not straight forward.
C: I think your evidence here is your'e talking of an analogous situation where this had happened before and was another complex issue
MC: yes
C: and on that occasion assessment was better conducted by specialist in that area
MC: yes
C: and on that occasion assessment was better conducted by specialist in that area
MC: yes the local authority commissioned a specialist, there were numerous assessments that ruled person had capacity, but risk behaviours were still happening, so LA commissioned independent person to conduct assessment
C: right, so that's something you knew had happened previously.
So with greatest respect, assessments had been undertaken by you and others with less experience...
So with greatest respect, assessments had been undertaken by you and others with less experience...
C: why wouldn't this be a case where the LA would commission someone with requisite experience in drug use to conduct assessment?
MC: that's why I was discussing with Kirsty, but I don't know why comment I'd look into it
C: leave that aside, but you were discussing?
MC: that's why I was discussing with Kirsty, but I don't know why comment I'd look into it
C: leave that aside, but you were discussing?
MC: yes, but Kirsty was the decision maker.
I was giving examples of what we'd done previously in social care.
It wouldn't be my role and remit to commission it
I was giving examples of what we'd done previously in social care.
It wouldn't be my role and remit to commission it
C: right, but you're suggesting it might be useful to commission a specialists in capacity assessment.
We've done it before, Kirsty it might be worth thinking about in this case commissioning a specialist in capacity and drug use.
We've done it before, Kirsty it might be worth thinking about in this case commissioning a specialist in capacity and drug use.
MC: yes that wasn't to undermine the decision we made
C: but you're suggesting a specialist might help... but someone could commission it and you're suggesting it might be a sensible thing to do
C: but you're suggesting a specialist might help... but someone could commission it and you're suggesting it might be a sensible thing to do
MC: it was more food for thought and that's what led to the input from the young person's drug and alcohol service
C: right, ok, well we'll pick that up with Ms Lister but it does seem you were in fact talking about further capacity assessment for his drug use by a specialist in capacity assessments and drug use; rather than once he's had input maybe he can be revisited.
MC: capacity could be revisited yes
C: appears from that further assessment you had in mind something relatively soon, not down the line, but you can't recall
MC: no
C: appears from that further assessment you had in mind something relatively soon, not down the line, but you can't recall
MC: no
Miss Denton takes her to an email: there is a piece of work that needs to be done around his cannabis use. Probably in a less formal capacity as he is likely to be more receptive and engaged.
Does that jog your memory?
Does that jog your memory?
MC: yes it goes back to that input from the young people's drug and alcohol team
AD: what do you mean by that, could you expand please
AD: what do you mean by that, could you expand please
MC: we were mindful Chris didn't want to engage in discussion around his drug use, and that's ok, but I think we were all of opinion he needed space and time, that relationship based practice, to explore in relaxed environment with someone he'd built rapport with...
MC: that's not to say he hadn't a rapport with Kirsty, in less formal
AD: let me stop you there, in less formal capacity does that help with whether you thought needed another capacity assessment at that point
MC [missed]
AD: let me stop you there, in less formal capacity does that help with whether you thought needed another capacity assessment at that point
MC [missed]
AD asks who undertook referral to drug and alcohol service
MC: I'm not entirely sure, I believe Kirsty but I'd have to check
AD: No further questions sir.
Coroner thanks Melike Kay and she's released at 16:30
MC: I'm not entirely sure, I believe Kirsty but I'd have to check
AD: No further questions sir.
Coroner thanks Melike Kay and she's released at 16:30
Short discussion re timetabling arrangements.
Court was adjourned shortly after 16:30
Back at 10am tomorrow.
All my reporting from court is thanks to my crowdfunders. Thanks also to those following, sharing and discussing tweets.
chuffed.org/project/openju…
Court was adjourned shortly after 16:30
Back at 10am tomorrow.
All my reporting from court is thanks to my crowdfunders. Thanks also to those following, sharing and discussing tweets.
chuffed.org/project/openju…
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