Thread by @ChrisNInquest

Day 8 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.

1/

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

2/

I'm attending remotely.

I report as much as I am able, however speech is fast, and *this is not* a full or complete transcript of proceedings.

My tweets will often not be exactly in real time as I try to capture as much as I can, and then tweet them once a thread is full.

3/

Where possible I indicate where I have [missed chunks] or where it's [my paraphrase] or I'm uncertain [?]

This inquest discusses suicide and self harm.

I will intentionally write [withheld] for some details, in keeping with @samaritans guidance on reporting from inquests

4/

My #OpenJustice work is crowdfunded chuffed.org/project/openju…

I report in order to provide a degree of scrutiny into an often unseen process, and to raise awareness of the premature deaths of learning disabled and autistic people.

Coroners court are open for all to attend.

5/

I believe we are due to hear today from two witnesses today, Dr Karin Thies Flechtner and Dr Greg Wood.

I'll stop numbering tweets from here.

Day 8 will begin shortly.

6/

Coroner calls Dr Thies Flechtner

She gives an affirmation and confirms that she has her statement

C: By way of background please you confirm in your statement you're registered with the GMC, specialist recognition psychiatry since 2001.

C: General adult psychiatrist for @EPUTNHS since 2002. Since Jan 2013 also been clinical director in addition to ongoing role as Consultant Psychiatrist. Is that correct

KTF: That is correct

She works on Cedar Ward... reviews patients once weekly on scheduled ward rounds

C: When you have MDT meetings those notes become part of the medical records don't they

KTF: that is correct

C: who is responsible for compiling the notes in the record?

KTF says minutes would be taken by her PA, approved by MDT following week and then uploaded

C: When someone comes onto the ward for the first time, how soon would you anticipate to see them for first time as consultant and responsible clinician

KTF: If I am not on leave within first 28hrs normally and if weekend 72hrs

C: Thank you. We turn to Christopher's involvement.

Can I confirm this in your statement you say that there were provisions for external staff members, family and friends to participate in ward rounds remotely.

C: I have in mind this was into lockdown of unprecedented coronavirus pandemic. But to confirm were facilities for family members to attend ward rounds and CPA meetings remotely?

KTF: It was possible, we'd ask patient as we did before covid, and if he said yes we would invite

C: A patient with learning disabilities and autism, would there be any particular involvement of the family of the patient?

KTF: We would have contact with the carers and family of every patient, not based on diagnosis but individual situation

C: and that contact would be made proactively by either you or your staff?

KTF: yes

C: and what's the purpose of that contact?

KTF: Oh god, it could be various reasons. First would for example if I feel I've formed an opinion and want to update them on my view of diagnosis...

KTF: ward staff might phone if they need information of how to handle day to day care of patient, what things make him nervous or help him... they'd phone for these day to day care issues

C: So proactive contact when you formed an opinion to update the family about a diagnosis

KTF: that would be when I would phone. But on this case I was on leave which I hadn't realised at time of doing my statement, and he was seen by my colleague Dr Biggs on day of his arrival, and phone call was made by my senior registrar Dr Razell [sp?]

C: thank you, when were you on leave please?

KTF: I think I was on leave on the 8th and I may have returned on the 10th, the 9th or the 10th, honestly I don't know I havent checked this but I know I would be back on the 10th at the latest but don't know if I was in on Monday 9th

C: Can you recall when you returned from leave what information were you provided with by Dr Biggs or Dr Razull specifically in relation to contact with the mother, Julia

KTF: Was told the mother had provided information about preexisting autism and learning disability, Dr Biggs and Dr R had seen in their opinion acute psychotic episode, possibly drug induced

C: Yes, thank you.

C: You've provided background to Chris coming onto ward [C details, what we've heard about Chris in London, released, then sectioned]... when was it that you first met with Christopher, the chronology as you noted, you haven't mentioned your leave period.

C: was 15th your first contact with him?

KTF: that is correct. Dr Biggs saw him on 8th April when he was covering for me and he'd be scheduled 7 days later, 15th, for his next regular ward round

C: would you be responsible clinician from the moment Chris arrived on Cedar Ward?

KTF: I am the responsible clinician for Cedar Ward but whilst I'm on leave Dr Biggs would cover for me and that includes RC role

C: reason i'm asking is why delay until 15th for you to see him for first time

KTF: Because he was seen by Dr Biggs on 8th, he'd done care plan which was shared with me, so if someone seen by consultant then they'd be seen on the same day a week later

C: you didn't see the need to see him before then

KTF: If I had time I would have, but when I come back from leave, 20 patients, half would be new to you

C: So 10 new patients on 20 bedded ward ot be seen as estimate on when you return from leave, but you didn't personally see Chris until the 15th

KTF: No I didn't

C: does it follow you're reliant on what your staff are feeding back to you

KTF: yes because we work as a team... [fuller answer MDTs]

C: your entry with respect 15th says he displayed paranoid delusions ... he felt he should be in jail...

C: admitted used cannabis regularly for many years but did not consider this to be a problem. From early meeting you formed opinion he was still floridly psychotic... you started him on anti psychotic medication

KTF: that's correct

C: So context of his cannabis use, in context of him being quite unwell, but he didnt consider cannabis use was a problem, albeit in that context of him being unwell

KTF: no he didn't

C: you didn't see him I don't think until the following week

KTF: I have to explain I relied on notes, so I've summarised what would be fed back from ward staff, then I saw him personally again 5 days later on 20th

C: right. Ok.

C: You say in period between 16 and 20th he appeared calm and more settled on ward, slightly less withdrawn but appeared lower in mood

KTF: yes

C: you saw him 20th but was still having thoughts about people harming him... he felt it could be anything, can you help me with that? Persecutory elements of his presentation?

KTF: I dont think I've further explored what was behind it.... fixed delusions seem to come less specific which is a good sign for recovery... there's some loosening of delusions

C: so your impression was his psychosis was improving but he wasn't in recovery [fuller] he told you he was done with life, didn't want to live beyond 21...

KTF: yes

C: when I explored, you say, he said all he wanted was death... was there any increase in his observations in light of that suicidal ideation?

KTF: we had discussed but you have to balance the stress of increased observations with the risk...

KTF: he'd made no specific plans at this stage, it was more death wishes. If you increase, particularly for people with autism, this is stressful, checked every 15mins

C: so is answer to question you didn't increase observations?

KTF: no but we discussed it as team, we all discussed we've all noticed he's getting a bit more depressed so we would basically flag it up

C: on 20th what level of observation was he on please?

KTF: general observations

C: which means?

KTF: nurses would know where he was at any time, and they'd check at irregular intervals, 4 times an hour I think but they should know at any given times where the patient is

C: irregular intervals at 4 times an hour, that would be documented?

KTF: if on Level 1 I don't think they'd recommend every single observation

C: sorry going on your evidence

KTF: what I read would be the nursing entries at the end of the shift, what they have observed and how he's behaved

C: your expectation was they'd know where he was at any time and he'd be reviewed at irregular intervals 4 times an hour

KTF: yes

C asks what would expect to see by way of record of those

KTF: I would expect to see in the records that they had the situation under control, that they know what is going on with him

C: you'll not be surprised reason I ask you these questions is because on the 23 April he tried to ligature in his bedroom [withheld]. Did you see him?

KTF: no it was out of hours, I saw him the next day

C: [withheld] when you talk to him on 24th he tells you he has no idea why he did it, thought his mind was playing tricks on him, made him feel tired and sick asked me if I was an illuminati...

C: impression was [withheld] due to psychotic delusions and you increase medication

KTF: yes

C: and were observations increased after that?

KTF: yes would have done the previous day to Level 2 I didn't put that in my statement

C: evidence I've heard is Julia was unaware of this [withheld] suicide attempt.. would that be usual practice?

KTF: no, unless patient specifically said dont tell anyone, I'd expect the charge nurse to try call the mother

C: did you see any record that no such direction from Chris

KTF: no

C: So I can safely assume that didn't happen

KTF: I'm not sure you can safely assume

C quotes NMC code: from legal point of view, if no record, it didn't happen

KTF: my understanding is this is legal view

C: did you discuss with staff if family have been informed?

KTF: no I didn't

C: any particular reason why not?

KTF: I would not normally do, that's for the ward staff... I would not on my ward micro manage details which I would expect should happen

C: right. That's an important consideration that the family are involved in what we can regard a suicide attempt

KTF: yes

C: of someone under your care

KTFL yes

C: if its an important matter who would check the family had been advised of what happened?

KTF: would normally expect discussed in handover by ward manager, if everything had gone as usually would go

C: after [withheld] on 23rd, when was the next MDT meeting, where there would have been an opportunity to discuss what happened, whether family informed...

C: increase medication, so on

KTF: I'd have to check. We have MDT meetings on Wednesday, it would be the following Wednesday

C: so 27 April during ward round appeared drowsy and slightly over sedated... given you've running chronology, is that likely next ward round discussion

KTF: there's difference between ward round discussion and MDT discussion. MDT takes place once week between 10-12 where we discuss every patient on ward.. [fuller answer]

C: looking through your statement I don't see any reference to MDTs in there in which Chris was discussed, I may have missed it. Was he discussed at any MDTs?

KTF: there were MDT meetings but it was in the midst of the pandemic so they were briefer than usual...

KTF: we were running on reduced staff at teh time

C: right, if there were brief MDTs, shorter due to reduced staff.

There's no mention Dr KTF in your statement of any MDTs at which Chris was discussed. Was he discussed in any MDTs?

KTF: yes but briefly.. we had professional meetings where discussion took place, MDTs at this time were fairly technical, where are we with investigations... discharge planning... they were very to the point technical

C: would you expect at an MDT the fact someone had [withheld] be discussed

KTF: of course yes

C: there's no mention of MDT in your statement where that was discussed. Can you help me with that. Do you have recollection of MDT where this incident was discussed?

KTF: we would have discussed on ward, we would not have waited until the MDT meeting

C: i'm trying to get to when did you become aware that the mother hadn't been contacted, next of kin didn't know anything about this?

KTF: when I read the mother's statement in preparation for this hearing.

I wasn't aware of that before then.

C: might be an obvious question but why would it be important for a family member to be informed of a suicide attempt?

KTF: important if she wants to support her son, talk to him, she needs to know what state of mind he's in... to be aware of his risks for him

C: Mr Stoate, I think it's the position that Julia first became aware of this incident with disclosure in preparation for the inquest

TS: that's right

C: so post death.

You see Dr KTF for whatever reason the family weren't told, oversight, miscommunication, which wasn't picked up by yourself or brought to your attention by any member of staff.

C: Chris's mother was unaware of this incident on 23 April until way after Chris's death

KTF: I wasn't aware she was unaware, it was a complete oversight

C: right. But you recognise it would be extremely important information for any NOK to have for reasons you've alluded to and set out... this break down in communication, any contribution she could make was absent that knowledge her son has appeared to try to take his life

KTF: that's correct yes

C: You were unaware she hadn't been told until you got the disclosure for this case

KTF: I had no idea

C: you were aware weren't you that his mother had been raising concerns, particularly in respect of discharge and discharge arrangements

KTF: yes

C: and she'd been doing that since point Chris was admitted due to experience she'd had with Section 136 and him arriving home... [missed chunk]

KTF: yes she told me this

C: we also heard, I think from Dr Ball, that discharge planning should be something clinicians minds turn to on admission.

Something you look forward to from admission to the ward.

C: What are range of options for discharge when this person gets to that stage, and secondly you were aware from the off about the mother's concerns re discharge?

KTF: yes

C: including other aspects.

C: One aspect she shared with Dr B and Dr R were her concerns about his autism and learning disability and how that might impact on how clinicians are approaching him

KTF: first phonecall we ever had she made clear about his assessment and background for autism and learning disability and that she felt his drug use was self medicating

C: thank you... on 28 April the GOSH documentation was provided

KTF: it was direct outcome of our telephone call, I ask her send me as much information as possible

C: so when did you speak to her please

KTF: sorry, can't remember, must be around I assume the 20th, I would not, around there

C: around 20th

KTF: it must have been after my first review with him, I normally try to phone relatives within a week or whenever after I first have my review

C: I don't think you've included that in your statement

KTF: no I haven't

C: why not?

KTF: my statement I mostly focused on treatment of Chris, went through ward round and nursing notes

C: wouldn't discussions with Julia be, the next of kin, be important to care management and treatment.

That's why you contacted her presumably?

KTF: they're important but I wouldn't repeat because its already in my introduction, these things about LD and autism were known from the beginning but it was important we got more details

C: I think you're probably aware part of concerns of family have been nature and quality of contact and communication from clinicians throughout.

You didn't see it sufficiently important to mention you'd had a direct conversation with Julia in statement?

KTF: At time of preparing I was not aware of these things, it was 1.5yrs after the incident and I prepare what I knew of his treatment

C: you make it clear your statement is based on medical records and your recollections

KTF: yes

C: did you make a record of your conversation with Julia?

KTF: I don't remember.

I'm not good at typing, I'd do hand written notes and hope they'd be uploaded. I'd put them in a tray and then they'd be uploaded.

KTF: But I must say again it was covid epidemic but I remember this phonecall.

C: It's important isn't it, its detail from a primary witness of the nature and presentation.

Did you discuss Chris's performance at school?

KTF: no it would not have been on my mind at this time, primarily I was interested in when his behaviour changed.

He had been smoking cannabis for long time, was interested in this time not on school performance but how he was for days and months prior to admission here

C: ok, I'm assuming your interest in Chris's consumption of cannabis wouldn't be in a vacuum, it would be set in the context of his LD and autism

KTF: difficult to understand, i'd probably attend, assess the drug use on its own initially.

KTF: I ask her and I ask Chris himself, then later I'd consider in context of autism but my initial assessment would be separate

C: Ok, I'm assuming your initial assessment was conducted on 15 April?

KTF: yes

C: then over the course of the next days?

On 20th when you had discussion with him, he was done with life, you explored suicidal thoughts with him.

At that point would you be considering his cannabis use in context of his autism and learning disabilities?

KTF: at this stage I was focused primarily on the acute deterioration of patient at high risk

C; so incident on 23rd focused mind even more keenly I'd imagine.

KTF: yes

C: you spoke to him on 24th, again at this point the autism and LD context of his cannabis use wouldn't be at forefront of your mind

KTF: No I remember focused on incident before admission when he [withheld] and tried explore was this a suicide attempt...

KTF: ...just seeking an adrenaline rush, what was it.

He gave different explanations, I was really really interested to understand what was motivation for it.

C: you were aware of an earlier suicide attempt in 2016

KTF nods

C: and self-harm [withheld]

KTF: yes

C: 28th you discuss matters with Julia, altho it's not mentioned in your statement, at what point did the learning disabilities and autism become context when you're looking at his drug use

KTF: that should be in my statement

C: ok, we'll return to your statement and please point it out to me.

[missed chunk]

C: you were satisfied he'd recovered sufficiently to lift Section 2?

KTF: we were coming to end 28 days at midnight, you actively review patient one or two days before it runs out to make active decision

C: midnight on 5th would be when it expired

KTF: yes I would have seen him the day before it ran out

C: you saw him on the 4th or the 5th?

KTF: I saw him on 5th. I'd normally see when 28 day section is running out, I'd see them one or two days before to make final decision

C: you haven't mentioned seeing him prior to 5th

KTF: I lifted it on the 5th so I would have made the decision when I saw him

C: on the 5th

KTF: yes

C: sorry I thought you said normal practice was to see him, a person, a day or two before the expiration of the Section 2. Which was due to expire at midnight on the 5th, if you were seeing him a day or two before I took that to mean you'd see him on 3 or 4th

KTF: I saw him on 5th but it was still active at that time

C asks again why she didn't see him earlier

KTF: I can not say what kind of activities I had that I saw him on the 5th, there must have been some reason

C: should you have seen him a day or two before rather than running up against the clock?

KTF: it doesn't matter, if I do recommendation on 5th we have doctors holding powers, we would have used 5-2 to keep him on ward if we couldn't get AMHP.

KTF: It would have been better to see him on 3 or 4th, but it would make no impact.

C: if you'd seen him on 3rd or 4th he might not have improved as much as he had by 5th.

KTF: I can't remember.. [fuller answer]

C: is this part of the problem not having a complete record

KTF: seeing him on 5th isnt completely unusual, I dont know why I didn't see him on 3 or 4th but seeing him on 5th is safe practice because if I feel he needs further detention he would not have become informal.

C: so he was now an informal patient and can come and go as he pleased

KTF: that's right

[missed chunk]

KTF: there should be a care plan which says how do we manage it, and contingency plan is when we lift section if patient doesn't stick to it...

KTF: would use 5-2 if he had changed in first weeks of May

C: so contingency plan would be... we'll come to the eventual discharge against advice

KTF: mostly when lift section you always take certain risk patient wont stick to voluntary arrangement so you always have contingency plan... either you let him go or use holding powers...

C says he's heard various evidence about professionals meeting on 7 May

C: By this stage I'm presuming you have had that discussion with Julia where she's filled you in

KTF: yes I read all the reports before the meeting

C: was her account discussed during that meeting?

KTF: yes it was noted Julia felt autism and learning disability, in particular autism, was main issue and drug use and psychosis were just additional problems arrived in this context

C: arrived in context of his LD and autism

KTF: I think its in the minutes she considered his drug use as self therapy for his autism... that was discussed and acknowledged by everyone in meeting

C; does that sound plausible to you?

KTF: yes, I explored it with him

C; did it seem a reasonable perspective his mother had, that he'd self medicated the challenges he was experiencing with his autism and LD

KTF: its one possibility but there are others, it was certainly a possible hypothesis

C: so plausible explanation that his drug use, his use of illicit substances, was related to his autism and learning difficulties; that was at least a plausible scenario?

KTF: among others yes

C: that was the perspective of his mother who'd known him throughout the period, before, during and after his cannabis use

KTF: yes

C; an important voice to be heard

KTF: absolutely

C: you met him I think in 3 or 4 ward rounds and discussion following incident.

Were you relying on what was said by the staff about his presentation?

KTFL yes we work as a team

[missed chunk]

C: you say he was voluntary patient between 8-18th... social with patients... good eye contact... I'll set that in context of evidence with respect to the OT's contribution as well.

C: He started leave ward mostly for cigarette smoking, appeared to be on milder end of autistic spectrum, was brighter in mood and no longer talking about suicidal thoughts.

Was there a ward round between the 5th and the 18th? It's not specifically recorded

KTF: I don't remember. I don't know. It may be for example if I was on leave Dr Razull would have done it. Let me think, I honestly can't remember, but there should have been a weekly doctor review even if I was for some reason absent

C; you're compiling your statement from the records, you haven't included a ward round in that two week period between 5 and 18th

KTF: I can not remember honestly if there was a ward round or not after such a time

C: no doubt we can check the record, but it would appear you weren't involved in a ward round in that period on basis you've not included it in your statement

KTF: I'd assume yeh

C: and you can't remember whether you were on leave over that period

KTF: I have no recollection over exact dates, its 2.5 years ago

C: it is now Dr Thies Flechtner but that's why you have access to records to compile your statement

KTF: I have tried

C: hmmm. His plans for future, he was positive mindset. So he said it depends how I feel?

KTF: yeh

C: he couldn't remember when he last felt suicidal, felt medication and time on ward had helped him.

In his view he felt he'd benefit from another week on the ward before he was discharged. Is that important consideration if patient is saying he'd benefit from longer?

KTF: yes it is of course

C: would there be circumstances when you'd go behind that, say they need to leave...

KTF: yes in both directions, can be longer or shorter

C: considering his improvement you say this appeared to be reasonable plan.

C: Was your view he was no longer in need of treatment on an acute inpatient ward, this is 18 May.

He'd prefer to move out of family home into his own accommodation... his mother had previously said she'd be happy for him to return home on discharge if he received...

C: appropriate support in the community

KTF: that's right

C: so in order to cope Julia felt she needed support and robust discharge plan

KTF: yes

C: so if was in place then she'd give it a go

KTF: I don't think the word we used was discharge plan, the word was appropriate support

C: would they not be interchangeable, a robust discharge plan would provide appropriate support

KTF: Not interchangeable, difference... with robust discharge plan would be much wider, for example would include things like where he'd go to work

C: where he'd go to work

KTF: he wanted to do apprenticeship, we'd really discuss discharge plan his perspective.

KTF: Where do you want to be here in a years time. What kind of things do we plan, its a bit wider, but we always use the word support

C: ahh so robust discharge plan is wider, under CPA, with care coordinator, OT and so on...

C: but embedded within a robust discharge plan would be appropriate support for the carer in the home environment

KTF: it was more robust support for Chris... I think she requested Chris received support. The focus was on support for Chris

C: yes, appropriate support for Chris if he was going to be with her, his mother had previously said happy return home if he received appropriate support in the community

KTF: that's my understanding

C: appropriate support in the community, Julia the mother of this 19 year old with LD and autism; again her's is an important voice, what she thought would be important support given he was going to be living with her is vital voice isn't it

KTF: absolutely

C outlines other alternative was Supported Living and Personal Assistants, KTF confirms

[missed chunk]

C: he expressed his wishes to be more independent, given his age, not surprising

KTF: absolutely

C: at this point you write discharge in week, from 18th, provisionally agreed under condition he remained well, and second contingent condition, appropriate after care was put in place.

C: What or how was the appropriateness of after care going to be arbitrated, was that something you had contribution to?

Know through ESTEP and had care coordinator but did you have input whether criteria would be met?

KTF: I would have input through conversation with the OT... her report was forwarded to care coordinator who'd conduct Care Act Asst based on OT report

C: thank you, between next day and 19th continued to present as bright mood, no evidence of psychotic features, presume he's been compliant with his anti psychotic medication?

KTF: yes he has been

C checks medication - good practice continue at least 6 months

[missed chunk]

Coroner asks if at this point [week later] she was considering his drug use in the context of his LD and autism

KTF: his description was he had a group of friends where use of cannabis was part of their social lives, he got into the habit and he considered it a social activity.

KTF: I've specifically explored her sometimes people use cannabis because they feel anxious, gives them confidence or yah, skills to deal with stressful situation he got very dismissive, quite angry and said yeh you would say something like this... [fuller answer]

C: you regarded his reaction as typical 19 year old to a fuddy duddy view...

KTF: in my experience a lot of my patients express, its legal in the US, has many mental health benefits. We hear this quite often

C: did you consider that lack of causal connection, between use of cannabis contributing to his psychotic episode, could be related to his LD and autism?

That lack of insight?

KTF: I considered it but it was unlikely because he reflected that cocaine use might have contributed to his breakdown because he told me he would not use it again at this time because he accepted it might have muddled his thinking

C: so because he attributed what had happened to cocaine... what did you think, did you think it was attributed purely to cocaine or use of cannabis?

KTF: answer is I don't know.

Cocaine has higher tendency to cause psychosis than cannabis, could be that it was cocaine but I told him very clearly no-one can know. I said strongly advisable to stop both, the answer was, well yeh you would say something like this.

C: did you consider whether any contribution to his lack of attribution, causal connection between his cannabis use and his serious psychotic episode, you didn't think was in any way caused or contributed to by his LD and autism; the lack of insight into that causal aspect?

KTF: I was considering it but thought unlikely linked to autism because I've heard it many many times from people in his age group who are not suffering from autism... he told me I've done cannabis since I'm 14 and only got problems here few months ago when I'd started to use...

KTF: things, not only cocaine, think he also mentioned X can buy on black market

C: did you consider in context of 2016 suicide attempt, start of his use of cannabis.

Did you link those two and discuss with him?

KTF: I dont think it was linked, he described very clearly...

C: forgive me, know I'm not considering he'd make that link, I'm asking you whether you'd make any connection yourself between use of cannabis and suicide attempt

KTF: not really because he'd done cannabis before and for 4yrs after the suicide attempt.

I understand from his mother was linked to the loss of his grandmother which I found very convincing.

C: is it often the case there's a multiplicity of factors that lead to suicide attempts... too much alcohol at time of bereavement, or financial pressures...

C: it's unlikely to be simply one element?

KTF: absolutely

C: so death of grandmother might be a triggering event, but unlikely only reason

KTF: I understand he used it occasionally then... at start when he took occasionally, its possible was contributing but didn't consider very likely

C: did you consider from clinical point of view his excessive use of cannabis contributed to this psychotic episode?

KTF: yes it was definitely contributing, I don't know to what extent... I felt cannabis might have been one contributing factor

C: what reliable evidence did you have about the nature and state of his cocaine use?

KTF: Only what he said, considering he was initially in London we'd have no way of finding it after 3 days.

We often don't get urine when patient arrives, they're only in state to give after week or so when we'd only find cannabis

C: did you find he was defending cannabis, against a drug he was putting in the dock, cocaine, which he didn't use that much.

Against cannabis which he liked, did you consider he was setting up cocaine as straw man so to speak?

KTF: possible but unlikely, Chris was very honest about his drug use, had no impression he was in any way trying to deny it.

Told me openly this was why he wanted to be discharged, because there was a meeting at the beach with his drug using friends planned.

KTF: Yes always possibility someone is not honest but it didn't strike me as something that wasn't probable.

C: sorry what wasn't probable?

KTF: that he was dishonest about cocaine, and honest about cannabis use

C clarifies his concern that Chris may not recognise impact of cannabis on him

KTF: fact he's able to recognise cocaine contributed to breakdown, but not recognise was cannabis, think was probably more denial.

KTF: Agree he was protecting cannabis against cocaine, but I've used it many times from non autistic drug users who always say cannabis isn't harmful

C: yews but he wasn't non-autistic, he was autistic and had learning disabilities

KTF: yes but the way he gave his argument was not significantly different to other 19 year olds in this situation.

[Court is adjourned 11:30 for 15mins]

C: on one hand you've got this lad with a learning disability and autism suffering a first episode of psychosis...

C: his mother says she will have him home but only with right support package, on the other hand you've got Chris saying don't worry about that she'll take me in

KTF: that was the situation yes

C: in those situations would you prioritise one view over the other?

KTF: the decision maker is the patient

C: yes but the decision maker is making a decision on the basis of what he is telling you his mother will do, and the mother is telling you I can't do that unless and until there's an appropriate support package in place.

KTF: Hmmm

C: so whatever he's telling you has got to be contingent on whether it's true or not, can it not?

KTF: he had this impression... we were aware from 5th of this discrepancy.

Care Coordinator Kirsty Lister had calls with me...

KTF: I told her it would in my view probably be difficult to persuade him to stay longer voluntarily and I felt at this time he was no longer sectionable.

C: let me pause you there please.

I want to break this down a little bit, stage by stage.

C: You've expressed your view it was unlikely he'd stay voluntarily beyond certain period

KTF: unlikely, I think I said would be difficult to convince him because I'd heard his arguments

C: if he wanted to be independent

KTF: yes its what he repeatedly told us

C: and so if you're faced with that scepticism that you would be able to persuade him to voluntarily stay longer, how did that feed into your contribution to the discharge planning you've reminded me was underway from the day he arrived?

KTF: my contribution was to inform care coordinator it was vital to speed up to get support in place. the team had to think about a contingency plan, there are only two, one is to section him again and the other is to arrange care in the community.

KTF: The section option was no longer feasible at this stage.

C asks what care in the community was

KTF says she understood it to be contact with his Care Coordinator and PAs as per OT assessment

C asks KTF what she remembered Julia's concerns/wishes to be.

KTF: I remember she mentioned a cleaner to give her more time to spend time with her children... cant remember other than she wanted learning disability and autism services directly involved and it was unclear to me how that would look and I advised they would feed in by...

KTF: supervising and advising Kirsty Lister

C: within this where did you place the significance of Chris saying he told us his mother would take him back anyway.

How did that feed in, if at all?

KTF: I assumed that he might be right. I'd never met Julia, but the way she was caring for him, it was like a lot of mothers of 19yrs olds would say if you don't clear your room you have to move out, but the 19yr old say she wont act on it. That's the way I understood it.

C: Did you have any concerns about moving forward on the basis of calling the bluff of Julia?

KTF: absolutely, but Chris is the decision maker

C: she's a decision maker as well.

Her view was she couldn't safely look after him without an appropriate care package.

C: I'll repeat the question.

Did you think it was appropriate to move forward on basis of calling her bluff?

KTF: if it was a bluff he could stay on the ward as a delayed discharge, that was always a part of the contingency plan.

He was aware of this and didn't want to.

KTF: He knew he'd not be discharged until appropriate care with Julia, or what he wanted, supported accommodation was in place.

C discusses ward round.

BB confirms there was a ward round with Dr KTF on 15th.

C: That's an oversight in your statement?

KTF: yes must be

C takes to record of ward round

KTF: I remember vividly he phoned her during the ward round, initially on his phone, then we changed to conference call

C: was this teams or zoom?

KTF: It was just audio, was mobile phone, laptops were still scarce for these meetings

C: early days, yes. So did you have any concerns, there was a verbal argument between Chris and his mother about his wish to be discharged. Julia has given evidence that the phone was on speaker phone, there was a discussion around discharge. Was that your recollection?

KTF nods

C: who else was present apart from yourself and Chris?

KTF: would be junior doctor who took minutes, and a nurse who took minutes, would reduce to minimum persons

C checks which doctor [didn't catch]

C: You've gone into this call knowing there's a conflict, a tension between what Julia is saying on one hand that she was not happy to have her son home until an appropriate package was in place.

C: On other hand you've got Chris who's keen to get out saying, whatever she says she will.

That looks like it's set up for an argument.

KTF: he took us by surprise when he took out his mobile phone and called her

C: yes but you changed it to a conference call

KTF: that was best we could do to hear Julia's side. Took us by surprise, we thought we'd meet in 2 days for CPA meeting

C: you say was verbal argument between Chris and his mother.

Mr Stoate may take this up.

C: You say he insisted on leaving and his mother felt he should stay until his after care package is in place.

So she's not changing her view.

She's remained very clear.

You understood her concern she couldn't keep him safe without a care package?

KTF: Safety was part of it, but I understand it was mostly she felt for years she'd not received appropriate care for autism and LD and this ward stay was an opportunity to rectify this.

KTF: I believe she took some action with commissioners behind this to ensure this time he'd receive proper autism care, rather than safety as well

C: but safety was part of it

KTF: It was my view it wasn't same situation as we had in April

C: no in April he was floridly psychotic, very different now, he was compliant with medication and in remission.

You consider he was medically fit for discharge?

KTF: yes also mention his depression had gone.

KTF: The ward round when he told me he had no hope, he didn't want to live beyond 21, all this was gone.

You treat the delusions then the reasons are gone.

The depression, unhappiness is more chronic issue, more difficult to treat.

KTF: So I was pleased at how bright was Chris.

Not only did he tell us but it was the same for all staff observed during that time

C: to remind ourselves Julia was completely oblivious he'd had a suicide attempt a few weeks earlier?

KTF: he was no longer in psychosis so I felt this risk was a historic risk

C: but I think you recognise she should have been aware of that?

KTF: yes as I said

C: and you assumed she had been told?

KTF: yes I never explicitly mentioned the scenario, its upsetting, and difficult to talk about in front of Chris, but I assumed of course this had been fed back to her

C: do you think it's reasonable for me to take the view that had Julia known about suicide attempt a month earlier that would have increased, rather than decreased, her concerns about the discharge?

KTF: I think you should ask Julia, but I think its reasonable to assume it did

C: you agreed a care package should be in place and he should remain informally on the ward until a package was arranged

KTF: at least

C: if he decided to leave hospital on this day it would be a discharge against medical advice?

KTF: yes

C: why was your medical advice he should remain given he was medically fit for discharge?

KTF: because we'd arranged a full care planning meeting for 2 days after, it was unfinished business

C: so this would be delayed discharge?

KTF: what press call bed blockers, patients in acute NHS beds without medical need but too vulnerable to be discharged into the community.

We call them delayed discharges

C: so if someone is too vulnerable to be discharged into the community, that's not regarded as a clinical need?

KTF: too vulnerable to be discharged without proper accommodation in place. Occasionally we discharge into street homelessness, but very rare.

KTF: In most cases we keep as delayed discharges until appropriate accommodation or care package is in place.

C: what about discharging without appropriate care package in place, on assumption that a parent will, whatever they say, when push comes to shove take their child in?

KTF: It would not be a planned discharge. I would not agree to this.

C: that's not something you've been party to, someone being discharged from Cedar Ward, literally put outside the building because anticipated parent would?

KTF: I told you already, we sometimes discharge to street homeless, its rare occasion but it happens, but I would not have done it in the case of Chris.

It was never discussed here to discharge Chris into street homelessness.

Was never part of any discussion I was part of.

C: I'll take you to an email exchange. This is from Carla Villa... [reads]

By 5 June it appears Julia's concerns since admission in April have been born out by events, would you agree?

KTF: Its difficult for me to understand how a care package of a cleaner would prevent this overdose

C reads: Mother has confirmed she does not want him home as she believes she is unable to keep him safe and objectively was not able to last week.

C: Responsibility for safe discharge is not Julia's is it?

KTF: no

C: Secondly Julia has raised concerns

KTF: yes

C: Events have transpired, in view of Dr Carla Villa, that there's a question mark around safety and discharge

KTF: mmm

C: the concerns Julia had expressed had come to pass. Does it not appear?

KTF: There was always a big unknown at the time of his discharge, what would happen if he took cannabis.

KTF: My view at time was most likely he would not relapse, he was on anti psychotic medication, he would not take cocaine, his depression was in remission.

He'd survived open leave from ward for 2wks.

C: Dr TF he told you in no uncertain terms he absolutely would not stop using cannabis, whether views of youth culture, in association or not with his LD and autism.

He had not seen the link between his cannabis use and illness.

You say it wasn't recognised he'd relapse?

KTF: relapse into cannabis use was clear, but not into psychosis

C asks whether it couldn't have been anticipated that on discharge there was a risk Chris might take a "shed load of cannabis"

KTF: taking illicit use such as cannabis is always a risk, if you go to drug dealer and take cannabis is always risk... people have a good chance so long as they take anti psychotics, and refrain from cocaine, to tolerate occasional cannabis use without relapse.

C reads: at time of discharge he'd told us he didn't intend to refrain from cannabis....

At time of discharge he had capacity to make unwise choices to smoke cannabis.

You considered he had capacity, with his learning disability and autism, for his drug use?

KTF: I considered he had capacity to make this decision

C: full capacity?

KTF: yes.

KTF: I'm not sure you can say completely unrelated to autism because he's one person, but I would not see a direct link that his autism is causing his drug use, but I'd not go as far as to say its unrelated

C asks if considered assessing capacity before discharge

KTF: His mum had queried his capacity, so good practice arrange MCA assessment... would take time to arrange, have to use colleagues in LD, have to give him warning, we'd have to give him chance to bring advocate.

KTF: But what we did, and is allowed under Code of Practice, if someone has capacity, it is considered sufficient to record conversation had with client and on this say consider he had capacity.

KTF: Legal capacity assessment is required if you want to prove someone has no capacity, but because Julia raised concerns it would be good to arrange in future.

C: so Julia raised concerns about his illicit drug use. You considered whether to hold formal MCA assessment but decided against it?

KTF: I dont want to say against it....

C: prior to discharge

KTF: I would have arranged it if he'd agreed to stay, but can not arrange [at short notice - my paraphrase]

C: so you considered it safe to discharge him, but not hold him for formal capacity assessment?

KTF: I was convinced he had capacity

C: whatever concerns of Julia, you had no reason to query it?

KTF: we assessed it, we asked what are pros and cons, what are risks, I asked him to repeat what I'd said.

In way do capacity assessment, implicit capacity assessment part of our daily work on an acute ward.

KTF: We assess capacity and just record the conversation and say has capacity

C: we'll turn to your statement [reads it] so that was the reason he wanted to be discharged that day, to go and use cannabis.

KTF: that was my understanding

C: when I informed him it could trigger a relapse he told me he'd researched this on the internet, accepted cocaine could have but not cannabis [fuller]

Are you considering his responses... those answers in the context of him having ASD and LD?

KTF: yeh

C: Did the ASD or LD have no significance, because other cannabis users that you knew had provided this same reasoning when they didn't have ASD or LD diagnosis?

KTF: I had no indication his understanding in any way was impaired to indicate he lacked capacity.

KTF: His answers were so similar to arguments people use to justify their cannabis use.

C: When he informed his mother about this. So it was him who informed his mother, not the ward?

KTF: we had covid, his mother wasn't allowed on the ward.

C: but she'd already made clear that she wasn't going to have him back

KTF: in the telephone call, if she hadn't told him I can't pick you up he probably would have stayed on the ward because he had no alternative.

KTF: He was stable enough to know street homeless was not an option.

Could have been he might have turned up in evening intoxicated as cannabis, we have policy of warning when you first turn up intoxicated [I think she said]

C: where do you record that Julia had said in that conversation of 26th that she would pick him up?

KTF: it's in the notes.

She was suddenly very worried about him, because he said I'll just go, and she said you stay there and I'll pick you up.

C; that wasn't in the conversation you were party to?

KTF: it was

C: it's just its not in your statement unless I missed it

KTF: p6 when he informed his mother...

C: Christopher decided to take his own discharge against medical advice and signed documents.

Did he sign those then during the conference call?

KTF: no

C: it would be later. I read that as separate. He decided to take against advice and signed document, after the call at some point. then when he informed his mother about this she was angry but told him she'd pick him up and take him home. So was Julia informed after he'd signed?

KTF: no

C: that's how it reads. Can you clarify the position then please.

KTF: it happened the other way round. He informed his mother during the phonecall and he signed later with nurse arranging discharge

C: so you were present in call. She was angry?

KTF: Yes

C: Upset?

KTF: Yes

C: Concerned?

KTF: Yes

C: Scared?

KTF: I dont know I didn't see her, was covid pandemic.

C: your evidence is she said she'd pick him up.

Your evidence was had Julia not said that, it was your view, he'd have stayed on the ward?

KTF: I don't think he'd have stayed on the ward without leaving.

I think he'd have gone to this party and then returned later on in an intoxicated state.

It's an educated guess that's what would have happened.

C: so your evidence is if Julia hadn't said in her anger and frustration, stay there, I'll pick you up, then do you think he wouldn't have signed the discharge against advice?

Presumably you wouldn't let him back in if he'd been discharged by then?

KTF: if Julia had not accepted him at home we'd have negotiated with him more leave as safest option, said go on leave but come back in the evening.

The risks were so high there's no way we'd have discharged this man into street homelessness on this day. No way.

C: so if she hadn't said she'd take him home then you wouldn't have pressed, or provided, this discharge against advice documentation because it wasn't necessary.

KTF: it's not pressed, it has no legal validity this document.

KTF: The main reason is clinical one.. even if we've negotiated what do to keep you safe, it is still not our advice, to make it clear to the patient it is not something we've recommended.

C: it's a document geared towards clarifying and removing liability on behalf of the Trust. Isn't that part of the wording of the document?

KTF: for me as clinician we use to clarify, a lot of people sign it and suddenly realise what is is and agree to stay.

KTF: Use as document to say you can do this, but you do it against the advice of your doctor.

C: you were clear he was taking his own discharge against your advice, wouldn't have done so in your view if his mother in anger and frustration hadn't said stay there I'll pick you up

KTF: no. He had no place to go to.

C: right. Did you consider directly discussing matters with Julia, prior to setting the phone call up as a conference call?

Chris has phoned his mother, you thought you'd turn it into a conference call.

C: did it cross your mind to pause, have conversation with Julia before we have conference call?

KTF: yes it did but I decided against it

C: why was that?

KTF: because of emails and actions already going on with Kirsty Lister, other people at time.

KTF: We'd decided in professionals meeting that the contact should run through one person.

I thought me phoning in this already messy situation would not be helpful.

C: the upshot of that was the discharge process took place over a mobile phone on conference call.

C: With Chris saying one thing, mum consistent with what she'd been saying, and you advising him he'd be taking discharge against your advice.

You can see how Julia would feel her bluff was being called.

She had no choice, she had to pick him up or otherwise he'd be homeless.

KTF: yes but I have to emphasise that the decision maker is Chris...

I have to be clear I advise you not to go but if you go I can't hold you because I'd be illegally detaining him

C: would be different if you took a different view about capacity?

KTF: yes if he had no capacity I could keep him under DOLS

C: your evidence was she was angry, but agreed to take him home, she turned up shortly after this to take him home.

Alright if we return to email chain. Your response continues p383

C: You say he was safe in the community. What do you mean?

KTF: on his leave from the ward. As I understand he came and went he was an informal patient

C: do you know where in the community?

KTF: I was referring to him leaving the ward, over period of last 2 weeks of his stay

C: had he literally left the ward for smoke and come back in, or had he gone into town, travelled distances, had any accompanied leave with anyone?

KTF: he had no S17 leave so was negotiated with nurses.

I can't tell you, if he was sectioned I'd say, but he was informal...

C: I wonder how much of change is caused by drugs... has no intention to stop taking drugs... cant stay Cedar Ward as no tolerance policy.

You suggest emergency housing is priority

KTF: yes

C: then reviewed by Dr Carr, she said only reason he's in hospital is change medication... suggest are factors difficult remain at home... anticipate mum may not agree with decision as looks like she's struggling to cope with him at home...

C: Judi Jeavons on 8 June to Dr Carr and to you, Dr Villa and whole series of other EPUT people copied in. [reads it]

Was agreed given how this failed so quickly when discharged from Cedar Ward... while trying to.... might be better if he remained as inpatient while organised.

C: my concern is it will fail again if we do not have a robust care package in place...

when it fails if he's discharged home this then adds to mum's argument and complaints, and more distressing for Chris too.

C: Dr Villa provides response... same ppl copied in... illicit substances, know Chris has said wont give up but not used on wards as far as know, also said would not use if in supported living... history of illicit drug use will still impact on his suitability for SL....

C: patient's mother has stated she will not have him home.

You knew why that was, concern about adequacy of care plan and support.

C reads: As Trust don't have objective evidence yet against GOSH and cognitive assessment done in 2008... objective score was one of 58, would be grateful if can work together for this young man to make sure he doesn't get lost in our many clinical discussions

C: You send response: agree complex case but in the end it comes down to Chris to make decision around substances... AMU records appears he is stable again... his ADL and cognitive skills are sufficient to keep himself safe if not intoxicated...

C reads: if mother is not having back she has to evict him formally, she has so far carefully avoided doing this. My understanding is his benefits are contributing to household finances, and him doing so will have financial impact on her

Quiet in court please

C reads: if she does not formally evict him he is not formally homeless. The mother will have to evict him.

Dr Thies Flechtner I've a few questions for you.

His ADL and cognitive skills are sufficient to keep himself safe if not intoxicated with cannabis or cocaine. ADL?

KTF: OT report activities of daily living

C: cognitive skills, you're saying learning disability and autism not withstanding those, they're sufficient to keep him safe?

KTF: yes he can go out, socialise with other patients, if he's not intoxicated I have no concern of letting him off ward

C: but he's told you the first thing he'll do is get intoxicated.

In the context of his learning disability and autism, and affected cognitive skills, did you consider he would be able to keep himself safe when intoxicated?

KTF: no one is able to keep themselves safe when intoxicated, that's the nature

C: yes... [missed chunk]... if you have LD and autism and smoke excessive amount of cannabis, take cocaine, then the impact will impact on you as someone with LD and autism wouldn't it

KTF: his argument was he smoked cannabis since 14

C: that might be his argument but it was a risk wasn't it [think he said]

KTF says wasn't known acute risk incidents despite him smoking quite heavily cannabis, prior to his admission

C: yet within couple weeks of this admission he [withheld]

KTF: yes

C: so with the benefit of hindsight, do you still have the view, or did you have the view his ADL and cognitive skills were sufficient to keep himself safe if he was intoxicated...

C: as was readily anticipated he would be?

KTF: if you take unwise decision to take drugs this includes risk, and this risk can include death

C: I'll turn then to second paragraph.

C: She has to evict him formerly but she's so far carefully avoided doing this.

What did you mean by this?

KTF: that relates to the conversation we had directly after the professionals meeting when I told her about the decision and asked her...

KTF: informed her we'd arrange a care package for him. I ask her how she's feeling about his expressed wish to live independently.

I got a bit "yeh yeh if he wants" but it was not clear for me.

C: wasn't it abundantly clear that yes in the long term, but she was concerned in short term?

KTF: for me it was not clear what she wants from this Care Act Assessment.

I ask her what she wants, she comes up with idea of cleaner to spend time with her other children...

C: yes a reasonable request, you're aware, we don't dwell on it but she had other children with significant needs

KTF: yes she was caring for 3 disabled children

C: you're suggesting there to colleagues, a large number of colleagues that what is motivating Julia is financial gain on her part.

KTF: I wouldn't say.

KTF: When someone moves out into care home his benefits will be reduced to pocket money and family who previously cared for lose out.

KTF: We discussed when she requested a cleaner, I said was unlikely the local authority would fund a cleaner, but Chris would use PIP to pay privately for cleaner.

She told me that the impact of her three children had on her, she could no longer work.

KTF: That's why she said she was so exhausted, she had to do cleaning herself.

She felt apart from emotional and physical burden of three disabled children, there is a financial impact.

KTF: There's nothing I think wrong.

I can understand you feel it comes across as offensive, but finances is something we discuss all the time as professionals.

C: well I may or may not be the only person who finds that offensive.

KTF: well...

C interjects: You've given your explanation thank you.

Either she evicts him and he becomes formerly homeless, or she doesn't.

You've set our your reasons for why you think she's carefully avoided doing this.

C: You haven't mentioned there Julia's concerns about not evicting him because she didn't want him unsafe elsewhere

KTF: Dr Carr was aware of this.

This was in context of Carla Villa's email, where do we keep him until we find accommodation.

KTF: Was a clinical discussion and we all agreed hospital was not good place for him.

He would need accommodation, problem is if not formerly evicted it's difficult to arrange.

KTF: Evicting him is the first process, he'll stay on the ward, we'll send this to council with a note describing his needs

C: alright. Turn to email from Blaga Carr please, to you in reply on 8 June copying in same people.

C: She says [reads] if mum doesn't want Chris at home she should evict him and then he can present to council as homeless person.

I do not see good reason for Chris to remain in hospital until accommodation is provided.

C reads: I'll talk to mum in the morning but based on most recent conversations, that's with a nursing colleague, she's not interested in listening.

[missed chunk]

Dr Carr expressed her view as inappropriate, do you have any views on that?

KTF: it was not an appropriate solution, as far as I know she agreed he's too vulnerable for homelessness.

It was discussed at beginning... first of all we have to establish if person is homeless or not, we have to prove this to council.

KFT: Then we assess needs.

I would never send someone like Chris to council to present as homeless.

I don't think Dr Carr has pursued this, this wouldn't work.

We need to consider it in order to get funding for more expensive options.

KTF: You'll often find in our minutes, discharge to homeless centre was discussed and decided as not appropriate, because we have to prove we have considered and declined other options.

I dont think it was ever considered realistic or appropriate way of dealing with it.

C: to be clear I don't think you raised any concerns to what she raised

KTF: I've not seen my response to this

C; you didn't respond

KTF: maybe we had a phone call. I totally agreed they may have considered it, but as far as I understand from her decided this was not appropriate.

C: I think that's the end of my questions for you Dr Thies Flechtner... may be more after lunch.

[Court was adjourned at 1pm, back at 2pm]

TS: Good afternoon doctor, I ask questions on behalf of Chris's family. Discharge planning is something this inquest is looked at in some detail.

Julia's statement did you read it or hear it?

KTF: I read it some time ago, I'd be grateful if you can remind me of details

TS reads from @JuliaCa20602661 statement where she told Dr KTF that they needed to work on discharge plan and she needed to be fully involved, she knew she'd not be enough to keep him safe. Does that sound right?

KTF: I don't remember details but it sounds right to me.

TS: So right from start she's saying we need to work on discharge planning, I wont be able to keep him safe

KTF: yes

TS: You said in your evidence to the learned coroner that discharge planning is of paramount importance, no one can dispute that can they?

KTF: no

TS takes to bundle 4, p 817, @EPUTNHS medical records

TS: This is something called a mental health needs care plan

KTF: done by whom? Could you go up please, trying to see what nurse did

TS: that's one of my questions to you. Are you familiar with the document?

KTF: yes, it's very many pages, you'd find the nurse at the top, or the bottom, who signed it on the last page

TS: 29 of 29

KTF: ideally these plans should be done by his named nurse, just wanted to see if it was xxx

TS: Care plan agreed by patient, patient proxy

KTF: yes should normally here be date and normally its at the bottom of it, I'm really sorry about it.

BB suggests check first place

TS: is that Kirsty Lister 22 May?

KTF: yes

TS: the bit I'm interested in is mental health care needs plan, various sections including mental health observations, compliance with medication, by time get to 9 of 29 we get to discharge planning section

KTF: uh hum

TS: says 21 May 2020, coming up to time when Chris was discharged as we now know

KTF: yeh

TS: discharge planning to reach therapeutic dose of her medication

KTF: I'm not sure this is right patient, it talks of her, at 21 May the therapeutic dose was reached

TS: her family to be invited to ward reviews weekly

KTF: it would be his mother not her family

TS asks why that happened

KTF: I can only say its an error, its obviously the wrong patient uploaded, he was never under AOT, he was under ESTEP

C: but if you look at name, date of birth

TS: yes, Christopher with his date of birth

KTF: sometimes we have e-forms, sometimes people write on word document and copy and paste. This is obviously not the patient we were talking about.

C: we've got the wrong patient. Why, can you help us with why?

KTF: an error has happened. We have an electronic records system. This is not related to Chris.

TS: Dr TF you emphasised the importance of discharge planning didnt you?

KTF: yes

TS: Mum said to you it's really important she's involved with discharge planning.

The worst happens, we come to inquest and I look at discharge plan and what's there, I find a female patients' records. What's your comment on that?

KTF: I can only say the wrong patient's discharge are uploaded. That's obvious isnt it?

TS: Blindingly so, is that regular occurrence

KTF: its not unheard of, humans make mistakes, but its very rare

TS asks who was ultimately responsible for discharge and care planning

KTF says team responsibility

TS: who ultimately?

KTF: ultimately it's the person who filled it in.

TS: it's you isn't it doctor?

KTF: no, whoever has uploaded.

TS: whoever this patient was, her family were to be invited weekly, which Julia asked but that didn't happen did it?

KTF: Chris didn't want his mother there

TS: where's the evidence of that please?

KTF: its an active process

TS: That's your evidence is it, that Chris didn't want his mother involved.

That doesn't fit with your evidence it was an oversight for his mother to be told about [withheld].

Did Chris give his consent?

KTF: at beginning of his stay we have consent to share information; if something like this happens its for nurse on duty to check and if it changes to make note of that

TS: Ok.

C: Mr Stoate, I just wonder. There's obviously an error of some kind to upload incorrect information into document partially completed with Chris's details.

C: For Ms Ballard really, is there a correct version of this document, mental health needs care plan, that does have the correct information?

BB: there are other care plans within the notes sir... similar looking...

C asks if Ms Ballard is assisted in court. She confirms she is every day. C asks her to try locate it.

TS takes to Datix form 9 May: incident description is this patient on general observation nursed in bed area, provided dinner on china plate... patient was upset...

TS: plate was smashed... patient noted to have superficial scratches on his necks and arms, was also hiding pieces of plate in his pocket [withheld detail] an apparent act of self harm

KTF: uh hum

TS: again this came as news to Julia, his mum, in preparation for the inquest

KTF: uh hum

TS: can I put this in the same category as information she really should have been aware of given Chris was going to be discharged into her care

KTF: yes

TS: to fail to give one piece of information may be an oversight, to fail to give another may be something more is it not.

KTF says she hadn't understood it was deliberate self-harm

TS [withheld]: thinking about the scenario to which he might be discharged home, his mother, do you think she'll think that a serious incident or not?

KTF: the mother would yes

C; did you?

KTF: its serious, but on ward we have to balance against serious attempt like [withheld]... it was reported to me, it is an important incident, it should be communicated to the mother, but internally it probably wouldn't be serious category like [withheld]

C; yes, when someone tries to take their life, that's the serious end of serious... self harming in a number of areas

KTF: yes

C: then [withheld] is nonetheless an example of self harm

KTF: yes

C: doesn't require [withheld], you're not saying its not a serious incident

KTF: difficult to say, it's serious but not high risk incident in ward environment. [withheld]

C: his level of observation was raised

KTF: yes

C; you didn't mention it in your statement, can I ask why?

KTF: I don't know if I saw the Datix, but I was informed about it, but I did not consider it for example as a suicide attempt..

C: this is serious... you're not blaming your staff for not alerting you to it?

KTF: no I was aware, next day he was calm, we all considered it, something I considered really in the context of him here having problems with coping aggression and unrest on the ward

C: can I check why you didn't put it in your statement then please?

KTF: I don't know. I did not obviously consider it or...

TS: someone has considered it important to record in Datix form. What's Datix used for?

KTF: untoward

TS: untoward incidents

KTF: there are quite a number, wrong medication dispensed, fire doors locked, its a general system

TS; response was for his observation to be raised to Level 2. Same response as the [withheld]

KTF: yes raising to Level 2 is quite frequent thing when someone is unsettled, it's quite a frequent thing that we change all the time

TS goes to Bundle 9, medical records provided by Chris's family, p1264

Risk assessment: at point of discharge Mr Nota was at low risk of harm to self and others.

His risk is dependent on him continuity to abstain from illicit substances and continue taking his medication regularly.

TS: why was his risk considered low?

KTF: the incidents were considered historic risk.

TS: even with [withheld] and [withheld]

KTF: We'd describe risk exactly on day of discharge

TS: says his risk is dependent on his continuing to abstain from illicit substances.

TS: We've just looked at two risky incidents, were there any evidence they were done under influence of substances?

KTF: first incident was linked to psychotic illness, second incident was linked to another patient on ward, and he was acutely distressed.

KTF: We didn't consider would be relevant after discharge

TS: so he could behave in a risky way, with or without drugs is that right?

KTF: at time of discharge we considered it low

TS: but he categorically told you he wouldn't [refrain from illicit drug use] couldn't a crisis team be involved?

KTF: that was considered, could be a good idea, but not because of his autism. Way crisis team operate is different person visiting in each shift.

TS: first of all let me tell you where I got the good idea from, that was the female patient's discharge plan. When was crisis team discussed?

KTF: at the MDT meetings when we have David x present. We'd only involve crisis team if we feel someone would benefit.

KTF: we did not believe in Chris's case because of his condition of autism, this would be in any way helpful

TS: given you said risk was dependent on refraining from drugs and he'd said he wouldn't what was in place to support him?

KTF: care coordinator to best of her ability and discussion of referral to drug and alcohol team.

I've already accepted it was not a full blown CPA discharge meeting where this would be discussed

TS: so your answer was care coordinator to best of her ability and discussion of referral to drug and alcohol team, yes?

[missed]

TS: I'll put to you Julia's account of discharge itself, distressing evidence, not least for Julia.

TS: On 26 May I received call from Chris's mobile phone was placed on loud speaker to Dr KTF she told me she was having a discharge meeting with Chris and he wanted to be discharged

TS: Pausing there Julia makes no mention of argument with Chris. She says it wasn't a feature of their relationship.

KTF: that's what I remember. Chris insisted he would stay. There was obviously discussion and disagreement. There are minutes from the nurse.

KTF: Should be minutes from doctor also present

TS: I felt she was very dismissive of my concerns. I was desperately concerned was no proper plan in place for his discharge and Chris still presented as suicide risk

KTF: uh hum

TS: pausing there, there was no plan was there?

KTF: there was some plan but it wasn't completed. Care coordinator was allocated... [missed]

TS: Concern Chris still presented as suicide risk, that was without knowing about [withheld] or [withheld].

KTF: uh hum

TS: She said, what is this risk you're talking about

KTF: I was under impression, she'd not seen him for 7wks. She might have taken for granted he was still in similar state to admission. I had feeling she might refer to this irresponsible behaviour in London prior to admission.

TS: I felt unable to say in front of Chris about concerns about suicide... and she didn't know of what happened on ward.

I felt psychiatrist was overly facilitative of Chris leaving, she told me 'your son wants to do this' ....I felt utterly dismissed

TS: she told me Chris could meet me in the car park after his discharge

KTF: the key thing is she requested I not allow him to leave, that's not something I can do. ... process under MCA if disagreements, would be second opinion...

KTF: would be Kirsty Lister with support of the LD team, this is good practice according to the MCA

TS: yes, have you read the Niche report into Chris's death?

KTF: I have

TS: you're aware of conclusion about mental capacity?

KTF: yes [missed]

TS: I emailed SBC... raised safeguarding... rushed to hospital, found Chris with his bags and two nurses, he was clutching a medical disclaimer about discharge against medical advice

KTF: that's not in dispute

TS: this is what I want to put to you. I was angry about this because it was the opposite of what would happen... I didn't hear Dr KTF once suggest that he should stay [my paraphrase] what active efforts did you take to try to persuade Chris to stay on the ward

KTF: two people present, nurse and doctor, both noted I advised him here I'd not recommend today because proper aftercare was not in place.

I explained his mum would not have him and I said stay here until we sort aftercare out.

KTF: He argued, look we discussed last week I'm better, you told me if I adhered to all these things I'd be ready for discharge in week. Which was correct, he was upset, he'd adhered to all these things, he'd been a model patient. I tried to persuade him to wait at least 2 days.

TS: you're aware he was rehospitalised by 30 May having taken all his medication and cannabis

KTF: I'm aware of this

TS: you said when observed on Cedar Ward and drug free his ADL skills were different to what reported by his mother... he's certainly safe in the community.

TS: What made you say that?

KTF: we'd given him unescorted leave for substantial; period of time without incident

TS takes to record

20 May shows positive for THC

KTF: for someone used since 14, will stay for months

TS: says leave to be discussed with responsible clinician in morning

KTF: yes and he says he didn't use any cannabis. Its credible, its simply the way cannabis stays so long in the body

TS: what was reason was done on this occasion please?

KTF: to test whole range of drugs and nurses then note ones found positive

TS: was it suspicion led?

KTF: no routine thing if people have unescorted leave with history of drug use

TS: does it discount fact that he went on leave and used drugs

KTF: would make it highly unlikely anything other than THC, which would stay in

TS: of course but he denies it and says at end that he was worried his leave would be stopped.

KTF: he has never lied about his drug use, before and after

TS: does that provide any evidence that he hadn't gone out, used drugs and come back

KTF: no only provides evidence he hadn't use anything other than THC

TS: yes. Your email about benefits and homelessness. The mother will have to evict him

KTF: yes

TS: Where did the information about benefits come from?

KTF: discussion about having a cleaner about part of after care plan; when I ask her what would be helpful. I explained cleaner's are not funded by LA but he has to use PIP for such a thing

TS: did you know one way or another what, or whether, Julia was claiming any benefits?

KTF: no. But I know she told me consequence of having three disabled children is she couldn't work and that had impact on her finances.

KTF: We also consider when someone moves into care, they'll lose benefits.

TS: She was claiming Carers Allowance £67 a week. You have any issue with that?

KTF: I don't have any issue at all, I think carers are completely underpaid.

KTF: Here, issues that she wants a cleaner, I have no issues with this.

What I have mentioned, it looks offensive if you read emails amongst professionals.

KTF: We always consider before we arrange things like supported housing that carers allowance will disappear, PIP will need to contribute to placement

C: You've written his benefits, what did you know about benefits he, Chris, was receiving?

KTF: I don't know I was assuming he'd be on normal income support

C: you say your understanding was his benefits, what do you know?

KTF: he'd be on income support because budgeting would be taken over by supported accommodation, I don't remember the details.

KTF: He may have been on job seekers allowance or PIP

TS: doctor you've told us the first step is eviction, you're linking that directly to your understanding of the mother's concern about losing his benefits

KTF: has to be considered, if someone moves out when you consider Carers Allowance it's a change, we have to keep it in mind.

If people move into care it has a financial impact on a family, we consider it when an elderly person moves into a care home.

KTF: I can understand why people who aren't professionals find it offensive, but these are things we have to talk about

TS: Julia finds it utterly offensive. More importantly it appears to have coloured your view.

KTF: that was impression I had from her ambivalence [??], where Dr Carr says, she's not having him back at the moment but she wont evict him.

Puts hospital in difficult position, way social care works, if someone isn't homeless we'll get bounced back have you explored X, Y, Z.

KTF: If someone needs accommodation we talk to family they have to evict them. Doesn't mean chuck him out, is just first step to ensure appropriate accommodation for him.

TS: did you hear Dr Carr's evidence?

KTF: I didn't hear but the coroner told me she'd agreed was not appropriate decision

TS: yes... Sarah Range's evidence is she contacted Hart House, about which concerns were repeatedly made by his mother

KTF: I've thought about these emails over lunch and....

TS: I'll get there. Sarah Range said she made enquiries with Hart House, at the same time, because of concerns about imminent homelessness

Sarah Range, Head of Mental Health, in the afternoon, in the aftermath of your email exchange with Dr Carr...

TS: suggestion from Dr F, you, that there's risk of being presented as homeless

KTF: that wasn't coming from me, it was considered as one option by Dr Carr. We both agreed it was not appropriate.

TS: Dr Flechtner if I may, I asked Sarah Range in her evidence, and she agreed this was done in a rush.

Why was it done in a rush? Because the suggestion from you was he'd present as homeless.

KTF: I have not said.

TS: whatever you're telling us now, its crystal clear in your emails, its coloured by your views on Julia and benefits

KTF: it was not, we all agreed this patient was not in the right place in an acute hospital.

He needs supported placement with less change, less patients.

KTF: Hart House has a very good reputation, I felt was much better option than sending him for example to an acute ward. Dr Villa agreed, Dr Carr, was joint decision by everyone involved was best decision

TS: So when MS Range says reportedly there's a suggestion from Dr F?

KTF: reportedly, yeh, I never said.

I have suggested he has to present as homeless, and then that will happen, Sarah Range and SBC will provide some accommodation to him.

That's the way it works.

KTF: If social services had not known there was a risk of homelessness they would not have provided Hart House.

Unfortunately that's way, in this cash strapped climate, we operate

TS: Ms Range says, from correspondence she was copied into, understood Chris's mother was not happy with him moving into Supported Living, and was pushing for place at Priory given his autism and risks from substance use.

TS: Dr Thies Flechtner mentioned his mother was in denial about the severity of his drug use, that Chris was in a good place.

KTF: yes, denial of drug use, is I felt his mother underestimated the impact of drugs on him.

KTF: It's not that we disagreed on diagnosis as such, but the degrees.

I felt the risk from drugs were more significant than the mother felt.

The mother puts the emphasis on autism and learning disability.

TS reads from @JuliaCa20602661's statement where says she felt Chris was self medicating by using cannabis and she was terrified of it

KTF: exactly she felt it was a kind of self therapy, from my experience in last week of May, from our team, we felt he didn't have increased anxiety levels without cannabis. What he told us was it was a lifestyle choice with his friends.

TS: she was terrified of it?

KTF: yes

C: Back of the court can you sit down please

No further questions from Mr Stoate.

No questions from Ms Nash, Ms Denton or Ms Khalique

BB: you know I ask questions on behalf of @EPUTNHS

KTF nods

BB takes to bundle

KTF: two independent records, one would be by a nurse, one doctor

C reads onto record:

Dr F explained his mother does not want to have him back home until there is more support. Christopher feels perfectly fine.

Dr F explained concerns of his mother would prefer to go back home on Thursday when his care coordinator is back from lave.. [cant catch]

C asks if report from MCA was provided to his mother

KTF: its further down, it can not be provided because he is an adult

C reads: Dr F explained Chris is a capacitous adult and he will need to request records and then he can share them with his mother.

C: pausing there, there wasn't a report to be disclosed with respect to capacity assessment was there?

C: You've said a report in that respect can't be provided unless and until Chris provides consent. My question is had he provided that consent what report would have been provided?

KTF: the whole of the notes, consent to treatment, records and conclusion had capacity.

KTF: I think she had expectations we would all the time do full MCA assessment

C: so would be all the records you'd provide with consent

KTF: if I remember that's what she wanted all the notes

C: its recorded here by Dr Romano that it was a request for a report. Your evidence is you'd provide all the records

KTF: yes... capacity is a constant part of our work. Capacity we find it in ward rounds, in short version, not as full MCA separately booked.

TS: sir in case it makes a difference, the previous note shared with you by Ms Ballard, says Christopher gave consent for his medical notes to be shared with his mother Julia

C; were they ever provided as far as you know?

KTF: it would be sent to our medical records office. Absolutely nothing to do with us, if it arrived in correct form they'd have sent it out in 28 days

C reads [cant catch] Chris explained he agreed on admission he wasn't thinking clearly and can't all be attributed to cannabis

C reads: Dr F agreed we can't blame cannabis but it had not made things better for him and may have made mental state worse.

Chris continued to ask his mother to collect him. Dr F explained if he wished to be discharged she wouldn't be able to stop him.

C reads: She explained was Chris's wishes and they could not detain him at present.

Christopher's mother continued to be upset. Feels he should not be discharged. Dr F agrees with his mother and would like to discharge on Thursday.

C reads: Christopher understand he will be discharging today against medical advice, fully understands the consequences of this.

He understands need to take his medications... plan self discharge against medical advice, advised wait for CPA meeting to take place.

Not detainable at present, has capacity to make decision regarding his discharge today, stable in his mental state long time, informal no evidence of acute medical illness

C: there's no reference there to capacity for drug use, would you expect there to be?

KFT: there's not there but had been discussed for previous days

C: but capacity is time specific, would you not think there should be an assessment, however formal or informal, about his drug taking given he was about to be discharged

KTF: with hindsight its always better to record more

C: no Dr TF this issue... there's no reference to his capacity with regard to decision making with respect to illicit substances

KTF: not on this day no

C: should there be

KTF: i'd done week before... in this scenario where so much to be discussed I would not put my priority in another capacity assessment. This was a situation not planned. So much to consider.

C: so not necessary for you to make an assessment on the day he was discharged, you didn't think that was necessary or appropriate?

KTF: there's an assumption of capacity... its very clear to me, I think to most people, he will have capacity.

KTF: We only have to make capacity assessment if there's a particular reason at this moment in time about a decision

C: sorry to press you, but you know he's about to goto Southend and party with his friends. That's what he told you he was going to do

KTF: yes

C: but there's no note about decision making with regards to that process, on that day

KTF: it's implicit, but you're right it's not written down

C: you say it's implicit. Thank you Ms Ballard.

BB: that longer entry written by your ST5 medical colleague present at the meeting records you attempted to persuade Christopher to remain on the ward

KTF: yes it does

BB: with regard to capacity, there's no formal report in MCA pro forma way to be disclosed

KTF: no

BB: and no need to complete one because you'd assessed capacity throughout his stay

KTF: yes that's true. It's rarely done for drug use we do these formal assessments, they're usually done for legal reasons eg guardianship, sending someone for housing.

KTF: Reason we have to formally document but drug dealers would not request before they give you drugs that you have capacity

BB: Christopher's mother's view of link between capacity, drug use, LD and autism is something you considered?

KTF: yes she told me first meeting she felt was self therapy to cope with autism and I explored it as soon as psychotic illness allowed

BB: yes. The fact it's raised by a patient's mother prompts you to explore it?

KTF: yes

BB: but it doesn't mean its true, it depends on what you find?

KTF: yes, with respect to substance use, is frequently disagreement between young people and their parents

[missed chunk]

C reads onto record nurse's record of discharge phone call

Dr Thies Flechtner was thanked and released at 15:25.

Court is adjourned for short break until 15:30

Coroner calls Greg Wood, who gives an affirmation

He's Clinical Director of Psychological Services in @EPUTNHS

He line manages and clinically supervises Sharon Allison of Aspergers Service

They discussed Chris in a supervision session on 23 June

C: you're entirely reliant on what you're being told in supervision session; had you been copied into the tsunami of clinical tooing and frooing of emails and so on?

GW confirms he wasn't

C: you're reliant on what Ms Allison tells you

GW: indeed

C asks purpose of supervision

GW: Line management around her job role and responsibilities of head of service; second is provide case governance advice and supervision.

GW: I'm available for Ms Allison and other reports to run by any difficulties or questions they might have, any clinical concerns, case related or service related. Third element is provide support in terms of their job role. To be concerned about their wellbeing

C: pastoral aspect, ok

GW: Ms Allison raised with me because she wanted to check whether there was anything I disagreed with in respect of what she's saying

C; your advice is contingent on what she says to you. You don't look at records?

GW: no if I had a concern I'd ask her to bring in records, but she's someone with 25yrs experience in this area so I can trust she'll bring me the salient information

C: so her primary concern was how the family would react to getting an assessment?

GW: no that wasn't her concern, she raised it with me and walked me through her thinking whether would be advisable to undertake a LD and autism assessment at that time

C: main inhibiting concern at that time was PPE was it?

GW: it was one of them

C: what were others?

GW: was history of illicit drug use, couldn't be clear that wasn't interrupting with his ability and performance when he came in. Those were the two major concerns.

C: she was concerned about drug misuse may interfere with assessment, and conducting so soon after presenting illness... fragility of psychotic episode. Said likely ASD diagnosis underestimate...

C: she wasn't suggesting was no learning disability and was no ASD, just the nature and scale of them?

GW: the severity yes

C: Ms Allison's concern was his mother felt strongly he had severe ASD and wouldn't [missed it]

GW: a lot of information in making an ASD or LD assessment is about social functioning.

The information is usually gleaned from formal elements of work or schooling, and also from family feedback.

GW: What Ms Allison spoke about was with such a very clear concern it may be that mum's, you know, opinions and feedback around specific questions might be biased in some ways.

C: in what respect?

GW: on questions around ability, social engagement, that sort of thing.

Mum had been very clear she had real concerns about Christopher's abilities, is about getting an independent account.

C: as of 23 June was Ms Allison raising any concerns with respect safety, risk, harm with regard to Chris. Either as had arisen in discharges taken place, and/or in respect matters raised by Julia.

GW: our main focus was question she put to me about assessment but she did mention there were a number of people involved in his care

C: specifically did she raise any concerns about safety, risk, harm?

GW: we didn't discuss all aspects of his care at that supervision

C: did you discuss that aspect?

GW: I didn't raise other than asking what teams were involved and I know she told me there was a consistent care coordinator and lots of teams involved in his care

C: so one of things not raised by Ms Allison, or discussed by you, was risk assessment in relation to Chris

GW: not specifically

C: in generality?

C: Strikes me one of things that might come up in supervision would be challenges in this complex case of managing his safety, which was four square central issue for Julia, about whom discussions had been had

GW: was asking me about the advice she was giving on the assessment, that was what we spoke about

C: wouldn't management of risk, and challenges Chris was presenting with, feed into your advice on the advice she was providing in relation to timing of the assessment?

C: Not ideal he's smoking, PPE, recovering psychosis, however, need to balance that up against need to get this assessment done.

Has to be seen in round against risk this lad is presenting.

GW: there was no question was history of autistic spectrum disorder and a learning disability. She spoke about her role as the Head of the Aspergers Service and Learning Disabilities Psychological Service.

GW: I trust she's experienced enough and would have raised any specific concerns around risk with me if she needed to.

C: did she say she'd had one meeting with him?

GW: she did say she'd met with him

C: you haven't mentioned that in your statement, is that relevant?

GW: she spoke about him in that meeting, his understanding, his ability to socialise, his demeanour.

C; any reason why you haven't mentioned she met him

GW: not specifically no

C: relevant, on reflection?

GW: perhaps

C: any particular reason why you've not mentioned it?

GW: I was thinking of the times I was involved with this case, from my notes that's what I put in this question around suitability for assessment.

It would have been in passing, she'd have said her observation was...

C: she felt he stays with ESTEP team is most appropriate course of action, seemed appropriate to you.

With respect of timing of any assessment what did you conclude in that respect?

GW: because have to wait period 6-9mths between assessments, have to make sure timing is right. Knew it as an important issue in Christopher's case

C: ok, it felt right for you to remain with the ESTEP team?

GW: yes, she gave me history of his drug use and his tolerance of change. She felt having a consistent care coordinator would be important

C: he'd had same care coordinator since April hadn't he?

GW: yes

C: Lynbritt Gale forwarded email from Sam Ball. Your relationship to L Gale?

GW: She was at that time an Associate Director of Mental Health and I work with her.

C: You respond 6 April including feedback you'd received from Elspeth Clayton and information you'd been given by Sharon Allison. Additional information to what you had on 26th?

GW: yes

C reads email: your considered view was greater urgency was treat and manage him, rather than the assessment?

GW: yes I felt there was an appropriate adjustment for his LD and autism

C; you felt there was already?

GW: yes everyone had it in mind with regards to managing his care

C: what about the management of his risk? I’ll come back to that question

GW: the question put to me was would an assessment make a difference to his management, and I thought this was not the right time

C: meeting 7 July, day before the tragic event, was suggested real dynamics in family [?] who raised that? Family intervention?

GW: there were a lot of people there, I've looked at minutes.

GW: Lot of discussion, part of discussion was number of people involved and concern needs to be a consistency in supporting and managing his care, as well as communicating with his mum.

C: were you aware the unanimous view of the ESTEP team was Chris couldn't keep himself safe in the community and neither could they?

GW: Judi Jeavons was present and she acknowledged would be in Chris's interests for ESTEP team to keep supporting him.

C: notwithstanding that they didn't feel they could keep him safe in the community?

GW: was discussion in that meeting about potential consequences of passing Chris's care over to different teams and was felt was more appropriate for team which knew him best to continue his care

C asks notwithstanding were of view couldn't keep him safe

GW: that wasn't made clear to me at that meeting. I wasn't made aware of those concerns at the time.

C: ok, or prior to the meeting?

GW: no

C: the expression of that was within emails confined to ESTEP team. You suggested would be beneficial for YPDAT to be involved and for a family session on drug taking. Do you recall it coming as a suggestion from you in first place, or something you agreed with?

GW: I honestly can't remember but I know I focused on that during the meeting because I had concerns

C: Specifically, what were those concerns?

GW: Christopher seemed, from what people were saying, to settle well when he had a structured environment around him, but when he went out with his friends he'd be exposed to drug use, with potential to make him impulsive.

GW: Concern was he should have adequate and proper assessment of the impact this was having on his life and some treatment.

C: OK. Lot of discussion around capacity, not matter for your consideration at this stage?

GW: no

C: ongoing issue about assessing, but felt not most urgent and would be inappropriate to conduct at that time [lists reasons] and diagnosis wouldn't change immediate care plan.

C: In other words if was assessment and GOSH assessment was correct and he had autism, and learning disability, even of moderate to mild kind, your view was that wouldn't change the immediate care plan?

GW: yes... I look at the formulation of his needs and his behaviours and clearly what we're seeing is when he's out in social context with his friends he was exposing himself to drug use, clearly not good for him

C: and again capacity issues about that wasn't something you were asked to opine about

GW: no I hadn't met Christopher

C: was noted ESTEP team could benefit from specific training around autism and learning disability and Ms Allison offered to provide that. You finish with your condolences to family.

C takes to email exchanges

Discussion re limitations of testing during covid

C: I'm reminding myself with every witness, that this is early days of the pandemic, where things if not unwritten, it's somewhat unknown to paraphrase The Clash.

C: Ms Clayton was firmly of view that LD team weren't the ones to lead but should remain with ESTEP

GW: indeed

C: on ward at Byron currently people particularly unwell... have had evidence that wouldn't be right environment for Chris.

[missed chunk]

C reads email from xx, includes: The narrative of family is Chris has an IQ58 and there's an investment in the family of this being the case. What did you understand that to mean?

GW: was very clear mum had been saying all along she wanted an assessment because she felt he had a severe learning disability and severe autism

C: just sounds like personal gain, the notion of investment?

GW: not at all, goes back to objectivity, was very clear mum had that opinion

[missed chunk]

C: want to say anything about your view family are contributing to viscous cycle?

GW: totally normal that family would want to normalise and have social life.

At the very least having access to drugs would interfere with Christopher's recovery.

C: did you understand Julia had been pushing, pushing, and pushing so that he could be taken out of that sort of social circle.

That was the driving force as I understood it, to stop him going out.

GW: at that stage he was at Hart House. They've expertise in dual diagnosis and so that would be the right place

C: were you aware of [withheld]

GW confirms he wasn't at time of email, but in professionals meeting

C: would that have bearing on whether you felt as implicit here that Hart House was appropriate, that mother's concerns as I've summarised them were perhaps not being addressed sufficiently?

GW: during professionals meeting was a lot of discussion about risk management.

GW: I think everybody was concerned that there is a robust good plan of action to enable Chris to stay safe

C: that doesn't seem to have amounted to much more on the face of it than let's see how he gets on with the YPDAT.

Tell me if there's anything more robust than that?

GW: during professionals meeting was to ensure all teams knew what plan was and the circumstances were.

That the learning disability and autism aspects were adequately provided for in terms of LD team being involved and giving advice.

GW: Sharon Allison being involved and giving advice. Support for ESTEP team was a concern, so suggestion they have direct access to Sharon for support, and some specific training and further support.

GW: The structured environment at Hart House, Helen spoke about her intention to support staff there to try get a more structured programme for Chris.

I had a particular concern that access to drugs was addressed and I was reassured they'd be a face to face meeting the next day

C: how did you envisage access to drugs would be limited given he's free to come and go from Hart House as he wished?

GW: it’s difficult because Christopher was a 19 year old independent person.

GW: What people who'd met him and worked with him felt, was if he had an adequately structured environment around him, it would mitigate those risks.

C: were you satisfied in your own terms that Hart House could meet those needs?

C: You've referred to them as experienced set up, deal with dual diagnosis, mental health and drug issues.

Were you satisfied they were going to be able to provide the structured environment?

C: The family's critique was he was in bed until late in the day, he had no particular structure.

GW: I had no cause to doubt they'd do what they said on the tin. I didn't have huge amount of experience with Hart House but that's what I was led to believe

C: You didn't know Helen Clark or their experience with learning disability or autism?

GW: I was aware the Learning Disability Team and Sharon could provide that support as needed

C: it’s quite dynamic situation though isn't it.

C: Providing training and so on, longitudinal feel to it, to provide it, give training and apply it... degree of urgency around how risk would be managed in community.

Did you have any concern based on what you heard in the meeting on the 7th?

GW: we heard Chris wasn't significantly depressed; he engaged well in an environment where he could stay aware from drugs and not be, I suppose, tempted.

That he managed well in relatively anxiety provoking environments, on the ward, that he was able to settle.

GW: That he understood the intentions of his treatment and support he was receiving.

That he could form good relationships with is carers.

That he had consistent care coordination.

GW: If I could be absolutely reassured that every single service user I'm involved with would not place themselves in any way at risk, that would be fantastic.

GW: There was obvious concerns that Chris could behave impulsively at some times, but also clear indications he could participate in programmes, could participate in groups.

That he'd managed well at college.

That he could engage.

C: this is in context that 10 days earlier he [withheld] on background of while psychotic [withheld] in London and [withheld] and additional self-harm.

On background of 2016 earlier suicide attempt.

C: So of course wouldn't it be nice if everyone could be kept safe all the time. In the particular circumstance of Chris Nota he was presenting in this way, he'd been [withheld] was that spelt out?

GW: cant recall if detailed discussion, was focus on aftermath of that how he'd described and explained

C: adrenaline rush and how he got there.

Very well. Mr Stoate.

TS introduces himself

TS: Professionals meeting 7 July [takes to record]

TS reads: GW enquired as to why all believe Chris's mother is so keen on labelling her son with LD and whether it’s just because she believes there will be better support for him if he has that label.

GW suggests was error in recording and that the word severe was missing

TS: did all believe?

GW: my understanding of that discussion, if I can finish, is there are facilities for people with learning disabilities that are very severe.

The question there was would Chris be appropriate for that kind of facility

TS: that's the evidence you want to give on that point is it?

GW: that's my recollection of the discussion in that meeting

TS reads: GW added that she, in an attempt to engage him in social contact seemed to be placing her son in harm's way as clearly his judgement isn't great and he needs an element of structure and support but from what GW, you, have heard about the case...

TS reads: Chris's mother is instrumental in enabling him to leave Hart House and spend time with friends who are abusing strong cannabis, and possibly other drugs.

TS: was that your contribution to the meeting?

GW says was discussion in meeting [missed detail]

TS: one page up, CN's mother believes Hart House is a glorified youth hostel.

She'd repeatedly expressed concerns there was no structure, and she's repeatedly raised them.

GW: what I understood is that is what people said

TS: Who was describing her as instrumental in putting him in harms way?

GW: I can't recall

TS: who was telling you that? Who was telling you she was driving for a label?

GW says was discussion in meeting

C: Chris's mother drives for the LD label

GW: again I think they've missed out the issue of severity. What we were discussing was Chris's suitability for specialist placements for severely learning disabled young adults

No more questions from TS

C: Ms Nash?

LN: I think your evidence to the learned coroner was Hart House had experience of managing dual diagnosis, severe mental health and drug use. Was that something you were told?

GW: it's on Hart House's website

C: you didn't have any knowledge of their experience with learning disabilities and autism though?

GW: no

No questions from Ms Denton

Ms Khalique for CCG

NK asks to check date on meeting just looked at - 7 July

NK: when you were talking about the learning disabled label and possibility of what that might bring with it.

Can you remember if there was any discussion about any particular inpatient setting, such as Byron Court or any other name of a place at the time?

GW: it’s quite a long time ago, I imagine there would have.

There had been discussions whether Byron Court or something like that would be suitable.

Also discussions about specialist request to tertiary panel.

And general discussions if would be right environment for him

NK asks if he recalls the conclusion of discussions

GW: If I recall correctly Sharon spoke about how Chris had settled well on general adult inpatient unit and were people at Byron Court who were significantly disabled with significant behavioural issues

NK: was that a bar to making application to panel?

GW: not that I'm aware of but better put to Dr Udu or someone from learning disabilities

C: I'll put this to Dr Udu tomorrow. Its added 'its rare to see drug use by someone with LD' do you remember that being said?

GW: not particularly?

C: does it accord with your knowledge of such things?

GW: accords for someone with a severe learning disability, they're vulnerable to abuse really.

Someone with poor social judgements, a lack of capacity to understand where they're placed at risk

C: someone with a learning disability and autism might, could, fall into that category

GW: when consider the right thing to do is look at context and consider all possibilities.

Not aware of any linear link between ASD, learning disability and drug misuse, not a causal link

C: no, but the vulnerability to exploitation you mentioned with respect to severe learning disabilities.

Someone might not be in position to make judgement whether wise if lack capacity in respect to that decision?

GW: would be important to keep in mind all of the factors that may contribute to making anybody more vulnerable

C: yes.

Ms Ballard

No questions from Ms Ballard

C asks if he remembers Judi Jeavons raising that Julia felt she wasn't being heard

GW: There was a lot of discussion about Chris's mum and various things going on.

C asks what that entailed

GW: There was a lot of discussion about anxieties and tensions between various people trying to help Chris, and I include his mum in that.

GW: I felt it might facilitate a cohesive good environment for Chris if some family systemic therapy could be provided for her and Chris.

They'd both need to agree with it.

C: hmmm.

Coroner thanks and releases Greg Wood at 16:35

Short discussion re timetabling.

Court was adjourned at 16:40.

Back tomorrow at 10am.

Thanks to my crowdfunders who fund my court reporting, and all those engaging with this feed chuffed.org/project/openju…