Thread by @ChrisNInquest

Day 9 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/

5 Interested Persons 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 attend court 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 are often not exactly in real time as I try to capture as much as I can, and tweet them once a thread is full/I have time

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… and I'm grateful to those who fund it, and follow it.

I report 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.

5/

We are due to hear today from three witnesses today, Dr Victor Udu and Richard Weidner of @EPUTNHS and Helen Clark from Hart House.

I'll stop numbering tweets from here.

Day 9 will begin shortly.

6/

Back in court.

Coroner warns there's a lot to get through, 3 live witnesses and some reading, he's hoping to get all done by 16:30

Coroner calls Dr Victor Udu

He swears an oath

C checks Dr Udu has his statement dated 4 Nov 2021 with him

Consultant Psychiatrist in Learning Disability since 2008, 23 years experience in NHS... extensive experience of working with people with learning disabilities.

C checks his qualifications with him.

C asks whether he considers himself an expert in autism

VU: I wouldn't say I have expertise but I have patients under my care who have a diagnosis of autism

C: of learning disability and autism?

VU: yes

VU works with community [and inpatient?] learning disabilities teams

C asks what criteria for admission is to Byron Court, what cohort resident for assessment and treatment in the unit

VU: Byron Court is an ATU... patients admitted who can not be admitted to mainstream wards because reasonable adjustments would not be possible given the severity

VU: of their learning disability. Vast majority have moderate to profound learning disability, if mild then predominant presentation is challenging behaviour.

C: in terms of significant behaviour issues... what's the nature of those that might warrant a stay for assessment or treatment at Byron Court?

VU: usually range of behaviours would include quite severe aggressive behaviour posing risk to self and others, makes it very risky to manage them in the community

C: thank you, would it extend to behaviours to cut to the chase, Chris appears to have been exhibiting. Drug overdosing and taking himself to profoundly dangerous places [withheld] is that the kind of behaviour could be considered a basis for admission?

VU: yes that could happen, but thats with significant learning disability associated with those behaviours

C: I assume learning disability and/or autism?

VU: yes and no other co-existing mental illness

C: so if I summarise that if someone has a diagnosis of LD and autism, is exhibiting profoundly risky behaviour, and doesn't have another mental health diagnosis, then they would in principal be part of the cohort of patients who could be admitted to Byron Court?

VU: that depends if reasonable adjustments can not be made to admit someone to adult mainstream ward

C: my mainstream ward do you mean mental health ward?

VU: yes

C: what would be diagnosis that would require admission to mental health ward?

VU: a diagnosis of mental illness in addition to learning disabilities

C: am little confused, might be way I ask questions, seeking to clarify criteria specifically in relation to admission to Byron Court, such as someone with LD and autism, significant risky behaviours...

C: cant be safely managed in community. In principal could be admitted to Byron Court?

VU: in Chris's case he'd been admitted to Cedar Ward, an adult psychiatric ward. With minor reasonable adjustments he coped well there.

VU: In Byron Court we usually have people with moderate to profound LD, some who have no speech and only communicate through their behaviours. Such an environment would not have been in Chris's best interest

C: ok

C checks he'd seen GOSH assessment before attendance at meeting

VU confirms he had, and had had conversations with Sharon Allison, psychologist, and may have emailed with Dr KTF

C: 7 May I don't think SA had had an opportunity to meet with Chris?

VU: no she hadn't

C reads from statement

C: was it discussed at that meeting that he'd [withheld] and attempted suicide whilst he was psychotic

VU: that was not discussed

C: wasn't discussed, ok

VU: I cant recall that being discussed.

C: psychometric testing 12yrs before had identified IQ58 and he met criteria of autism

VU: correct

C: was agreed by everyone at meeting given first episode of psychosis, substance use, lack of consensus about severity and nature of LD and autism, that ESTEP team were best team for him to be led by?

VU: yes ESTEP team normally take on patients, whether have learning disability or not, take on patients with first incidence of psychosis

C: yes, expectation is if someone is allocated to ESTEP team they're likely to remain with them for at least 6 months

VU: yes

C: because of potential fragility of that time period

VU: yes

C: so from the beginning your LD team would be offering support to ESTEP

VU: yes that's correct

C: Dr Allison would attend CPA meetings and act as a link to the LD Team

VU: yes

C: so who would have been responsible for identifying what support ESTEP needed from the LD Team? Would it be something ESTEP through care coordinator would identify, or Sharon Allison?

VU: A combination of both... what ESTEP identifies... and also SA in her discussions with the ESTEP Team.

She was the link between the LD service and ESTEP

C: ok, you go on to say was recommended not have a lot of people working with the patient... important therapeutic trusting relationship with one person would be preferable... care coordinator agreed single point of contact with Julia, Christopher's mother, and an ESTEP...

C: ..Support Worker would take on that role. Who was that? The student?

VU [missed]

C: yes so SA is contact between ESTEP team and LD team was there anyone else who would be involved in that linking?

VU: no, Sharon Allison was the link. Any concerns raised she'd raise with me.

C: you say we agreed an ESTEP support worker take on this role with supervision of someone with expertise in autism. Is that a reference to Kirsty Lister or to someone else?

VU: I think its Kirsty Lister, I can't exactly recall who that was, but SA was to be the link with that person

C: if she was to be the link, was it envisaged that SA would be supervising someone. 'With the supervision of someone with autism'?

VU: yes SA would be available for advice if it was needed, advice, support and guidance

C: supervision seems to have a slightly different meaning in clinical terms. I was confused by your use of the word supervision

VU: might have been wrong word to use, should be support and guidance of someone with expertise in autism, which in Chris's case was Sharon Allison

C: so you're not referring to Sophie Vincent, the student tasked with the Care Act Asst?

VU: no.

C: So SA, given her expertise, was to provide support and guidance to Kirsty Lister

C runs through chronology in his statement and asks VU to highlight anything he wishes to

C: you were aware throughout that was Julia's position [that LD and autism teams should be the main providers for her son]

VU: yes

C: but it wasn't a position with which the clinicians agreed?

VU: no we're working according to guidance for LD services

C: another recommendation was that Julia should be involved in discharge/care planning to ensure a better outcome. That was agreed?

VU: in that meeting, yes

[missed chunk]

C: you didn't have any involvement with capacity assessment, to the framing of questions, asking them or recording them?

VU: no, I had no involvement

C: you then say following conversations with Dr Villa about complexities of case, and difficulties of keeping Chris safe...

C: you agreed to undertake some joint clinic activities on consultancy basis... but none was arranged before tragic event on 8 July.

Dr Villa was reaching out, I hate the phrase, asking for help?

VU: yes

C: and you were willing to provide it?

VU: yes

C: can I ask why there was no urgency to that... to meet Chris?

VU: it was left to Dr Villa to arrange the meeting, and given Chris's short period in the community it was quite difficult I imagine, I'm speculating, for her to arrange.

VU: I made it clear I was available whenever she was ready to meet Chris

C: so you'd have cleared whatever you needed to to make it to a meeting? I imagine your diary is booked in advance but you were willing to rearrange, if and when a meeting was arranged?

VU: yes I was willing to do that providing it didn't clash with colleagues. Expectation was we'd liaise and agree suitable time to carry out reviews.

C: your evidence to me is you were never contacted by her with respect of making that arrangement?

VU: we didn't get to that point unfortunately

C: you weren't contacted

VU: no I wasn't

C: so she acknowledged your offer, she was pleased with that, but then nothing happened by way of contact with you to facilitate your attendance at a clinic meeting

VU: not before the tragic incident

C: and Dr Villa in fact never met Chris, I think I'm correct in saying?

VU: are you asking me?

C: no sorry I'm asking in court

TS: No she didn't, nor did Dr Udu of course

C: yes

C: Chris was admitted to hospital following a seizure. Were you aware that followed consumption of cannabis?

VU: yes I was told that he tested positive for cannabis and cocaine

BB: sorry sir I have to say we had no evidence of that, it was based on what Chris said but they never had confirmation from Southend Hospital

C: yes... cannabis and cocaine reference is I think Dr Udu in relation to a later admission on 26th

VU: yes correct

C: not the issue on the 27th

VU: thank you for correcting me

C: you confirm again he was discharged back to Hart House on 19 June but you had no involvement in the capacity assessment on the 18th that took place

VU: that's correct

C; and you weren't asked to make any contribution, lets be clear on that

VU: I wasn't

C: you had further meetings with Ms Clayton about the case... she wrote a letter to Julia about LD service involvement in Chris's care and why they weren't lead service.

C: You confirm that's in line with national guidance for the provision of LD services

VU: that's correct

C: were you aware at that stage, emails between ESTEP team members were unanimous of view Chris could not keep himself safe in the community by this stage, and they could not keep him safe in the community?

VU: I was aware

C: what if anything did you say or communicate in respect of that concerns that the ESTEP team unanimously held?

VU: what we agreed in our team meeting was that we would support the ESTEP team from learning disability services

C; forgive me, which meeting was this?

VU: learning disability team meetings, weekly meetings. Would have more support from LD service, Sharon Allison was already involved our Head of Psychology. I'd offered Dr Villa to do joint reviews.

VU: SA had met with Hart House to increase their awareness of autism and provided information.

The same as Sam Salici in communication... and leaflets on presenting information to him to aid his understanding due to his learning disabilities.

That was our involvement.

C: that was the plan to assist the ESTEP team in managing a risk they felt Chris presented, and which they unanimously felt they couldn't manage?

VU: that was the plan. The ESTEP team, if they were of the view the risk was that high in the community and he met criteria for detention under the Mental Health Act they'd have requested that

C; requested an assessment?

VU: yes under the MHA

C: so you'd suggest that question is best addressed to members of the ESTEP team?

VU: yes

[missed chunk]

C asks if he's ever been disabused of the view that Chris tested positive for cocaine?

VU: no, my understanding was he tested positive for cocaine and cannabis

C: you were made aware of admission by Dr Villa but had no direct involvement in his discharge planning from hospital?

VU: yes

C; was your understanding there would be a discharge meeting to which you were invited

VU: yes normally they'd be a discharge meeting, but I wasn't incited

C: you were informed ESTEP Team had arranged Chris to be seen by YPDAT as drug use felt to be factor in incident and high risk behaviour

VU: yes correct

C: in your view was correct as heavy use of cannabis likely impacting on his mental health and leading to high risk behaviour

VIU: yes I agreed with that view

C: I know you weren't involved in the design, conduct or recording of MCA assessments, but what was your understanding of the outcome of the assessments on 18 June?

VU: my understanding was he had capacity to make decisions on his care arrangements and place of residence.

VU: He had capacity to keep himself safe, but there were doubts around his capacity around his drug use.

C: yes. How did you come to that view? Who told you view? Can you recall how you came to have that knowledge?

VU: I read the MCA report in the records

C: did you consider there might be a link between doubts about his capacity around drug use and his learning disability and his autism diagnosis?

VU: lots of young people that use drugs are really no different from Chris.

VU: It seemed he'd been using cannabis, some say cannabis is licensed in other countries and they really don't see any harm in its use.

From what I know of Chris I was aware that was a social outlet for him, meeting up with friends and smoking cannabis

C: I suppose it might be said one difference between Chris and more general cohort of young people who smoke cannabis is he'd had a psychotic episode triggered by his use of cannabis. He'd been hospitalised for several weeks.

VU: yes but he did identify his psychosis was caused by high strength cannabis he was using at the time

C: riiight. Were you ware he made it clear to all and sundry that he was not going to stop using cannabis, he might stop using skunk, but he would continue to use cannabis?

VU: I was aware. That was why the plan was made for the YPDAT and I agreed with that

C: thank you. 7 July, whole range of people were present, the day before the tragic events that culminated in Chris's death.

C: In summary, I'll turn to minute shortly, I'll just ask Rob to turn up Bundle 11 p102.

In summary you say those present agreed with current arrangement, ESTEP being lead service with support of LD service

VU: yes, and that was in line with the guidance

C: agreed by everyone present including ESTEP

VU: yes

C: also agreed to arrange family therapy for Chris and his mum, arrange training for ESTEP team and [missed]

VU: yes

C: I'll turn to the minutes, couple points I want to pick up with you please

C: At that stage meeting was on understanding Chris had tested positive for cannabis and cocaine?

VU: that was the understanding

C: you're recorded as saying his LD is very mild or even borderline... IQ58 probably underestimate...

C reads: SA, VU, GR and GW agreed would be queried as CN's schooling, he attended mainstream schools, and academic achievement...

What did you understand his academic achievements were Dr Udu?

Was it simple fact he attended mainstream school or was it more than that?

VU: He went to a mainstream school, he went to a very good school where people achieved. School reports I saw, he had statement of SEN and needed support in school, he was achieving.

C: what was the achievement other than remaining in school with an SEN

VU: he was doing well academically although he didn't do his GCSEs due to anxiety

C: This might be picked up by others.

When you say he was doing well academically what do you mean by that?

VU: he needed support but he was coping and he was achieving. He was achieving his goals.

C: apart from SA 40min meeting with Chris, neither you, Greg Wood or Gemma Robertson had met Chris?

VU: I hadn't met him but there was a plan to meet him

C: at some point when you were asked to by Dr Villa but that hadn't happened.

A little further down.

You confirmed an IQ of 58 is lower end of mild LD but whilst inpatient on Cedar Ward was functioning at much higher level...

C reads: you reiterated his schooling did not evidence someone with this IQ.

You then added its rare to see drug use by someone with a learning disability.

Can you help me with what you meant by that?

VU: there's a low incidence of drug use in ppl w LD, they don't have the sophistication or the skills or contacts to obtain drugs.

It's usually people in higher ranges of LD IQ range that are able to do that, that have the skills and social.

C: I see, you're not suggesting people with LD generically its rare for them to obtain and take illicit drugs, but people with higher functioning LD would.

You're not excluding that category?

VU: no we have learning disabilities who use drugs who we refer to drug and alcohol; service for support, with reasonable adjustments for their needs

C; so someone with mild to moderate LD, would it be rare, really, for them to use drugs?

VU: the incidence, or prevalence is quite low. Consiering my opwn case load, very few of my patients have a history of drug use.

C; you see someone can be in a mainsteam school and still have a bona fide diagnosis of LD do you agree wiht that?

VU: yes I do agree

C: and someone with a bona fide LD diagnosis will still have friendship groups?

VU: yes

C: and socialise, often with people their own age?

VU: I agree

C: and maybe influenced by what people in those groups do?

VU: they may be influenced

C; and if the group is taking cannabis, they may well take cannabis

VU: the point I was making in that meeting is compared to general population, the use of drugs in learning disabilities is rare.

I'm not excluding it doesn't happen, we have cases that use drugs and alcohol

C: riight

VU: but usually we encounter such problems in people who are a lot more able, in the milder end of ppl with learning disabilities

C; ok, the milder end, but you're not excluding people with milder learning disabilities, together with autism.

They may also find themselves in positions where they use drugs?

VU: I'm not excluding them no

C: given it's relatively rare, your evidence is, would that not be more reason to be concerned, someone with mild LD and autism, albeit high functioning level, is able to understand what the risks are when they take drugs?

VU: yes and steps were taken to support Chris with his drug use. A referral was made to YPDAT for education to get him to that stage where he contemplates doing something about his drug use

C:right. Did you feel, I ask you directly, as you set out in your statement.. all agreed main risk for Chris is his suicide attempts.

Was suggested Chris's seizures and attempts are driven by his drug use.

Mr RW added he felt Chris was more at risk from accidental death.

C reads: GR advised Chris was unpredictable.

RW confirmed last time CN made a suicide attempt he advised was due to fact he "wasn't feeling the day" however CN does not present as clinically depressed

C: Did you feel given [withheld] an appropriate sense of urgency was reflected in this meeting.

We'll set up meeting with Young People's Drug and Alcohol Team?

VU: I agreed with the plan.

Was an urgency I could see from emails in getting the YPDAT team involved and carrying out an assessment

C: can you help me with why it seemed to take so long to come onto the radar... to address Chris's relationship with drugs?

Why did it take so long for that idea to come to mind?

VU: as it became increasingly clear.. when he was on the ward he was settled... it was increasingly clear when he used drugs the tendency to engage in high risk behaviours was worse.

When he was on Cedar Ward he had no motivation to address his drug use.

VU: When it became clear was link between drugs and high risk behaviours, was agreed to refer.

People usually taken on by service when they're prepared to address their problems.

There was a sense of urgency in getting them involved with Chris.

C: I'll suggest it doesn't feel that there's a conspicuous sense of urgency

BB: sir that's not right. There was referral to Stars, they said no is YPDAT and were due to meet Chris the next day

C: yes but its previous weeks.

Alright will pause there, will pick up, if I'm wrong about that the records will set me straight.

[Court was adjourned at 11am for 15mins]

C: thank you Dr Udu, I'll hand over now to Mr Stoate who asks questions on behalf of Chris's family

TS checks he can see and hear him - he can

TS asks Rob [Coroner's Officer] to bring up document from the bundle on screen. He does so.

TS: Dr Udu, can you see that on the screen?

VU: yes

TS: Email [18 June] from you to Dr Villa for update on CN, Chris. Do you recall this email exchange with Dr Villa?

VU: I don't recall

TS: I'll take you to it. Dr Villa's response about 40mins later.

TS reads: Matters have deteriorated further since yesterday due to complaints raised by mum at highest level... including to CCG... in bold.. she does not wish for care to be delivered by mainstream MH services (us).

TS reads: Commissioners are very unhappy we've not managed to find a way forward within EPUT (ie us and LD) to find a LD bed

VU reads

TS: your reply email then starts there 18 June 17:05 from you to Melike Cay of the local authority

VU: yes

S: you've copied in Elspeth Clayton, Gemma Robertson, Sharon Allison

VU: yes

TS: You say Dear Mel please see below e-mail.

TS reads: You say, in my view this is mainly a social care issue, could you kindly work with ESTEP on urgently identifying a suitable LD supportive living placement for CN that can manage his risks and vulnerability.

TS reads: As you are aware he is currently at Southend Hospital. We don't have any bed vacancy at Byron Court.

VU: yes I remember now

TS: Ms Cay's response to you at 18:24, we've had read out couple times if you just want to take a minute...

[Email from MC, social worker, includes:

I would agree that there are some ASD traits however the IQ of 58 does not feel to be a true representation of him now. I do not believe LD services are appropriate for his needs and I would be concerned about the impact...

of him living/being supported by those who are functioning far less than he is, this would have a detrimental effect of his development and motivation]

VU reads

TS: Doctor you didn't make reference to this in your evidence or statement to the learned coroner.

TS: Hope this assists.

You say to MC, this is mainly a social care issue and ask her to find a supported living placement for Chris that can manage his risks and vulnerability.

You also say we don't have any bed vacancy on Byron Court

VU: yes

TS: listening carefully to the evidence you gave to the learned coroner.

You didn't write Byron Court isn't appropriate for this young man, or its not for LD services...

You ask MC to identify LD Supported Living placement on basis you don't have bed vacancy at Byron Court.

TS: Can you help me understand that in light of evidence you've given to the learned coroner this morning please?

VU: yes I had discussion with Dr Villa in email exchange about possibility of Byron Court.

I made clear we didn't have any beds and wasn't suitable environment

TS: pausing there, where do you say it wasn't a suitable environment, where do you make that clear

VU: in discussions between our services managers and Trust managements because Dr Villa escalated up to her Medical Director. That discussion would have been had within our team.

VU: It wouldn't be an appropriate environment for him and indeed its not an appropriate environment for Chris given severity of learning disabilities of patients we admit to Byron Court

TS: Byron Court is your suggestion in this email, on face of it, but no bed vacancy.

TS: Chris's mother had never mentioned Byron Court had she, she was urgently seeking a placement at the Priory wasn't she?

VU: yes but what prompted that email from me was discussion with Dr Villa about Byron Court.

TS: yes you say is mainly social care issues... identify LD supported living placement that can address his risks and vulnerability, Why did you ask her to do that?

VU: I was concerned about the suitability of Hart House given number of instances to meet his needs

VU: I was satisfied with Mel's response that Hart House was going to be supported to develop skills in autism.

They were also having support from Sharon Allison and Sam Salici, and he had been referred to Young Person's Drug and Alcohol Service.

TS: You wouldn't say suitable LD placement that can manage his risks and vulnerability, if you weren't very concerned about situation would you?

VU: I was concerned... but that was a request to Mel, it wasn't a direction...

TS: we've heard Ms Cay's evidence, have you been told about Ms Cay's evidence?

VU: I haven't been told

TS: she is a social worker, an experienced one in a different team to you

VU: yes

TS: you are the psychiatrists leading the LD team?

VU: yes

TS: your evidence was you're satisfied with her response to that request.

Ms Cay's response includes, we've all read it, you've read it, includes "he lacks emotional maturity, I hope Hart House can provide environment to help him develop"

TS: being told you can't go out and reason is its 1am is too vague. He needs something more concrete, maybe some training around autism would help?"

Dr Udu I'm not trying to be rude, you've got concerns about placement, you've asked a colleague urgently to source somewhere else.

TS: It can't possibly be that response from Mel Cay reassured you all was ok then.

VU: It wasn't Mel Cay's role to find placement, what I was asking Mel to do was support ESTEP team in finding

TS: somewhere else

VU: yes

TS: when she said no, I'm not going to do that, maybe some training for placement, needs more concrete, maybe behavioural contract.

What was your response to that?

VU: I was satisfied with her response.

I knew Hart House was already having support from Sharon Allison and Sam Salici

TS: so to be clear, that response chained your view, as expressed to Mel Cay an hour and half earlier that was mainly social care, urgent need find suitable place. Mel Cay's response changed your view on that?

VU: I was reassured by her response

TS: riiight.

VU: I dont directly manage Mel Cay, she works with another team, what I was requesting was her support...

TS: doctor we can read the words of your email

C: pause there please [while he takes a note] Doctor you understood by date of this exchange Hart House were being supported by SA and SS?

VU: yes

C: in what respect?

VU: Sharon Allison was providing information on autism

C: can you just expand on that

VU: around autism. She was in contact with Hart House.

She was available to be contacted if they needed her support.

Sam Salici was also providing information in simple Easy Read format to aid his understanding.

C: right, so, finally this.

You sent your email at 17:05 on 18th, you get response 1hr 20mins later.

When you read that were you sort of immediately reassured to the extent you didn't think another placement was necessary any more?

VU: I was reassured especially because Chris has indicated he wanted to go back to Hart House and I was aware additional support would be put in place for HH

C: ok thank you

TS: did you follow up with Mel Cay to check?

VU: I cant remember.

If there's no email from me in that trail then it must have been an oversight on my part to respond to that email

TS: hmm.

TS: If there isn't an email, I can't see one, it might be Ms Ballard or others... when was the last time you thought about Chris might be, given urgency?

BB: we do need to be fair, I don't think we've got every email in existence

TS: yes, if there is one, I'm not saying there is or isn't. If there wasn't one, when did you next think about Chris after that?

VU: I always had Chris in mind all through

TS: hmm.

You mention later in your statement you refer to 26 June, following discussions with Elspeth Clayton Associate Director LD, you mention letter she wrote to Julia Hopper at request of Dr Villa.

TS: She stated, assume you mean Ms Clayton, LD service will continue working closely with ESTEP in meeting aspects of Chris's care that can't be met within the service.

What aspects of care?

VU: Making advice on reasonable adjustments that should be made for his LD and autism.

I would be available for Dr Villa for joint reviews.

VU: Could advise on how we use medication with people with learning disabilities to minimise side effects, and discuss any concerns she may have and offer advice.

TS: doctor what about his safety. At what point did you become aware of unanimous view of ESTEP he couldn't be kept safe in the community?

VU: I was aware of concerns around his safety

TS: yes, at what point did you become aware?

VU: I can't remember but I was aware there were concerns

TS: yes you must have had that in mind when you sent your urgent request to Mel Cay...you reference his risks and vulnerabilities

VU: yes

TS: the rather euphemistic phrase "needs could not be met within the service" at what point did you become aware of unanimous concerns of ESTEP?

VU: I can't recall but I was aware of concerns in the team

TS: yes. Professionals meeting 7 July, by this point Chris had had 4 recent admissions to hospital.

Prior to last he'd spent 13 days in community in previous 4 months, longest of which was 8 days.

That's from the Niche report. You're aware of it?

VU: yes I've read it.

TS: Brief periods in community following discharge characterised by poor medication compliance and high risk behaviours... [missed chunk]

That was context in which we set the professionals meeting isn't it?

VU: that meeting was called to agree a care plan, joint working between the LD team and ESTEP team for Chris

TS: doctor it wasn't a trick question, you were aware of those facts

VU: there were concerns about his safety, there were concerns

TS: I'm not trying to trick you, did you know that when you came to this meeting?

VU: I knew that

TS: in it you discussed his schooling achievements as they've been characterised. What had you looked at?

VU: I'd looked at school reports and reports from his teachers about how he was doing at school

TS: you'd never spoken to Chris at that time had you? Or ever?

VU: no

TS: or his mum, had you spoken to his mum?

VU: I had not, although a meeting was arranged that was cancelled, to explain joint working

TS: Chris's mum could have provided you with really important information about Chris's achievements at school couldn't she?

VU: she could have done but we had objective evidence from the schools

TS: objective evidence?

VU: school reports

TS: have you read Julia's statement?

VU: yes I didn't hear it but I've read it

TS: she says he was bullied, exhausted, he was stressed. She didn't think he was intellectually equipped to cope with his exams. He tried to [withheld x3] and eventually with very significant input was able to achieve some qualifications

TS: All of that would be important context wouldn't it?

VU: yes but there were school reports available. There's a disparity between mum's reports and the school reports

TS: did you know any of that context I've just put to you?

VU: I didn't until I saw her report for this

TS: her statement after Chris had died

C: can I pause to ask do we have school reports in bundles?

TS: there are bits and pieces

C: want to be clear as this appears to be of increasing significance for Dr Udu's views.

Could you help me with which school reports you've considered?

Primary through to secondary? An occasional year report?

VU: I can't remember exactly but several school reports were sent through and we went through them

C: then I'm going to I think Ms Ballard, I need to see those reports Dr Udu was sent so I can get a feeling, a feel for the detail

BB: I think they're those that were submitted to GOSH at relevant time

C: ah right.

Ms Ballard's impression is the reports you're referring to are the ones sent by school to Prof Skuse for his assessment at GOSH is that right?

VU: I can't remember exactly but I saw some school reports

C: ok, but you've quite properly read the Niche report in preparation for today, and a number of other documents quite properly.

C: An important aspect I consider now is the school reports which you've robustly set out your alternative views.

Help me please, are you talking about reports from secondary school, primary school?

VU: I can not be sure

C: I'm going to need you to help me.

Your evidence wont conclude until I have that clarification Dr Udu.

Your evidence at the moment is you can't remember if they involved reports from secondary school, or as Ms Ballard...

C: I'm not holding it to her she's trying to help the court, or whether they're historic documents provided to Prof Skuse when they compiled their report 12 years earlier.

Have a little think for the moment, which school reports do you think you're referring to.

[Counsel try to find the reports - Coroner brings one up]

C: Dr Udu is that what you're referring to as school report? Pre-Secondary Transfer Plan?

VU: yes I saw that report

C: this one suggests Chris has diagnosis of Aspergers Syndrome with symptoms that are moderately severe

VU: yes

C: in what way is this inconsistent with the diagnosis and assessment provided by Dr Skuse?

On the face of it, reading quickly, it looks entirely consistent with it

VU: its not inconsistent, but observations on the ward...

C: no forgive me Dr Udu, we're not talking about observations on the ward.

The evidence you've given today was based in significant part on school reports...

C: with help of Ms Ballard we're trying to identify those documents that might have informed that, this is one you seem to recognise.

As you said its not inconsistent with findings of Prof Skuse report, it says moderately severe Aspergers Syndrome

TS: yes, and vulnerable in unstructured time

C reads extracts

C: that's snapshot of transition from Yr 6 to Yr 7 Aspergers Syndrome with symptoms moderately severe

C takes to another report

C reads:

Annual Review 13 June: challenges Chris faces changes all the time, Chris needs help to face his autism and learn independence, self-discipline and appropriate behaviour in new environments.

This is Julia writing this, as he enters Year 6.

C: We could have quite an extensive task here identifying which reports you've relied upon.

Given its your evidence I think its quite important you assist us with it.

C: I rather hope when someone gives evidence to an inquest they're able to call to mind, and/or evidence the reports they relied upon, the documentation that informed their view.

My current view is that is going to be necessary given the centrality to your evidence

BB: Might help, annual review summary June 11.

C: do we have a year?

BB: same time as those hand written documents you've just taken us to.

C: Dr Udu on basis of school reports, confirmed this person, Chris had mild or borderline learning disability

VU: It was not just based on school report, was also based on observations on the ward in the ADL assessment

C: I have that in mind.

For the moment unless I can see reports for this aspect, that evidences, what you call a significant underestimation of his cognitive abilities, it's going to be difficult for me to move that forward.

VU: It was not just school reports was also observations on Cedar Ward

C: yes I have that in mind.

It's for me to evaluate your evidence, I'm not going to debate it with you with respect...

C: On basis of school reports which you opined on on various occasions including report on 7 July. I'd like to know which reports you relied upon.

I'll not get an answer to that question now, I'm grateful to Ms Ballard for assisting.

C: Would you have made a record at the time Dr Udu of which school reports you're considering?

VU: I don't remember.

C: would it be your normal practice?

VU: it was based on discussions with Sharon Allison

C: pause there, based on discussions with Sharon Allison.

Did you read reports yourself?

VU: I read reports, discussed with Sharon Allison, got feedback from the ward

C: Dr Udu forgive me.

I'm interested in the first category there, the reports you read.

If you're reviewing someone with degree of complexity like case like this, do you have a record of what reports you've considered?

C: I'm not talking about discussions with SA, or feedback, or assessment on Cedar Ward.

I'm talking about documents you read in coming to your view.

Is it your normal practice to make a record of documents you read, or not?

VU: I'd make a record, and based on discussions...

C: i'll stop you there.

If you make a record, where would we find that, that would help me and you and everyone else in this inquest?

VU: what I said was I normally make a record but I don't know if I did in this case

C: why would you depart from your normal practice in this case?

VU: we had lots of discussions, lots of meetings

C: Dr Udu, you've told me under oath you've read school reports, part of the information you considered in arriving at the views you did in respect of Chris...

C: and his, I'll put in inverted commas "abilities".

What I need from you is confirmation of which records you read. Ok?

VU: OK

C asks Mr Stoate if he's any questions not about this issue, he does

TS: Some brief questions please about the professionals meeting.

Actions out of this meeting [lists] checks would be chance to correct minutes if needed, circulation of draft notes. Is that fair?

VU: yes

TS: next two points for Judi Jeavons to have discussion with Chris and his mum about family therapy, yes?

VU: yes

TS: Dr Wood suggested family therapy might address Chris's mothers drive for the LD label... did you hear Dr Woods say there was a drive for the LD label?

VU: we accepted he had learning disabilities, that was not in doubt, that was not disputed. He had LD and autism, we accepted that diagnosis, and we're working to that

TS: but here you hear the Head of Psychology saying there's a drive from his mother for the label.

TS: Did you pipe up and say there's no need for a drive, its' what he has?

VU: I cant remember, but it's basis on which we were working, he had learning disability and autism

TS: so minutes, two bullets were about drive for label. Do you agree with that?

VU: I can't comment on what Greg Wood made by that

TS: Any concerns regarding her son's care raised by Julia to be sent to Judi Jeavons ... coordination of Julia's concerns?

VU: yes it was agreed that Judi should coordinate all emails coming from her, yeh

TS: this is 7 July yes?

VU: yes

TS: next assure any concerns from commissioners are forwarded to LG... reputational concerns? Or what did you understand that to be?

VU: any concerns from commissioners or mum forwarded

TS: Sharon Allison to liaise with Judi J to arrange for LD and autism training by MS Teams for the EsTEP teams.

My question is back on 18 June you'd asked Melike Cay to urgently find placement for Chris that can manage his risks and vulnerabilities to use your phrase.

TS: Here we are, another hospitalisation on from that, we're back at Hart House and concerns seem to be managing Julia's drive for LD label, managing commissioners concerns and training for ESTEP team.

TS: Is your evidence that would be sufficient to address the concerns you'd highlighted back on 18 June in you email to Ms Cay?

[Witness taken unwell. Coroner has halted proceedings to ensure he receives medical attention. We won't return before 13:30 today, if at all]

Dr Udu has been released.

Another witness has also been released because it's unrealistic will get to him today.

Coroner starts by reading statement of Emma Bennett, service manager. Coroner says wont read whole of statement.

Confirms she's a service manager for Hart House

Pre-admission assessment undertaken by Deputy Manager Ms Clarke, who we'll hear from shortly.

CN assessed as suitable to receive support and admitted to Hart House on 15 June 2020 from Basildon MH Unit

Included monitoring of substance use with drug testing, medication administration and compliance. Support with activities of daily living skills.

Risk assessment of Chris on 15 June by Kirsty Lister CPN outlining key risks Mr Nota currently, or previously, presented with.

Reference to incident in London. Note on discharge reported take all his medication following use of cannabis.

Was no date for this, some what surprising given happened on return from a discharge to Hart House.

Was reported Chris lacked capacity to manage his medication.

Reference to previous suicide attempt. Reference to epilepsy.

Chris was assessed as not able to independently manage nutritional needs.

Risks of abuse as vulnerable adult, diagnosed with autism and LD and IQ58 altho described as being more able. Vulnerable to drug dealers and County Lines.

Chris's LD and autism can affect his understanding of xxx

[missing considerable chunks]

Chris regular user of cannabis even though it made him unwell... he had query capacity to understand the impact of drugs on his body.

Recorded here as having limited emotions, that's what's recorded here, due to his autism.

Patient views Chris did not think he had any risks. Two capacity assessments conducted by Kirsty Lister on 10 June 2020, 1) understanding medication and seizures 2) accommodation

Hart House has zero tolerance policy to drug and alcohol use on site, can not prevent use off premises. Encourage people stop behaviour, and seek assistance from relevant services.

If were concerned by service user's drug use would report it to care coordinator.

Supported Living service, encourage independence, Hart House can not enforce take medication... would use prompts to take medication at appropriate times. Record kept whether he self administered medication or refused, if consistently refused then call made to care team.

Hart House can't control the times people come and go... behaviour contract states if he leaves the property he should inform staff and should return by 10pm but by nature of supported living service can not enforce this as policy.

Residents are allowed to stay away from the service if they choose to do so, Chris did choose to stay with his mother over weekend and she was provided with his medication to enable him to do so.

Hart House does not provide therapeutic input... can not enforce attendance at group sessions (arranged by YPDAT) but would encourage and record attendance

Medication xxx consistently refused from 25 June until discontinued on 7 July... Chris explained due to side effects and staff arranged alternative with his GP

Then follows very helpful timeline, I'm not going to go through all of that, is available to those who wish to refer to it. A lot of email exchanges involve Helen Clark, she may be best placed to deal with it.

They say Hart House were not aware of the concerns of Chris's mum with regards to suitability of Chris's placement at Hart House. If had been aware would have arranged meeting and looked to resolve, if unable to would have referred back to Richard Weidner.

7 July daily record, required prompting to take medication, put some washing on, left the unit. Staff contacted him at 8pm, said would return at 9pm. He did.

8 July

10:45 Chris prompted for medication, came down, took, had cigarette, went upstairs

Chris was going out, asked bring washing down which he did

No time for mum was contacted, Chris wasn't with her and she said she had his bank card to stop him buying drugs.

Then Chris's mum Julia contacted unit to tell them what his friend had informed her.

Next statement Essa xxxx Managing Director of Valorum Care Group... nominated individual with CQC. Previously registered manager with CQC. Hart House is in a residential area close to Southend town centre

Originally operated as care home, in 26 May 2020 de-registered and transitioned to Supported Living Service... 22 month transition period

Provides support 24hrs per day. Staff have experience of working with people with dual diagnosis of mental health and drug misuse.

[can't catch this]

When transitioned to SL service, retained all same staff, retraining undertaken by all staff.

Extra training provided regarding supporting independence.

[details what included]

Ms Nash confirms as far as she's aware all updated actions are completed.

Ms Esa Reeman's statement is from 2021

C asks counsel to source the completed paperwork and get to him by end of day.

Risk assessments have been reviewed... also introduced training on autism for staff

C: the other thing I'd like Ms Nash if I may is confirmation of when that final point was achieved, when there was dissemination company wide please.

Statement concludes with their sincerest condolences to Chris's family for their loss.

There are a number of matters there I'll inevitably pick up with Ms Clark, to extent she is able.

Ms Nash draws to coroner's attention that risk assessment was pre-admission, not on discharge back to Hart House.

He thanks her for pointing it out.

Coroner calls Laura Arnold

She swears an oath

C: thank you for attending today, your evidence will be very brief. You've provided a statement 18 July 2021.

C: You tell me you were on early shift, starting 7am on 8 July.

You knocked on Chris's door to prompt for medication around 10am.

You say he appeared tired.

He came down, we administered his medication to him. He appeared settled in mood.

C: Didn't notice him having any breakfast, not out of character for him.

Went for cigarette then returned to his room.

Said he was going out, I said did he want to put his washing away first, he said yes, he did so and left the unit.

C: You didn't notice anything different to the other fairly limited number of days you'd seen him

LA: no, not at all, he seemed fine

C: how long had you been working at Hart House?

LA: at this point about 3yrs

C confirms she was part of team that had transitioned in last statement

C: had you had that transition training?

LA: I believe so

C: you don't see entirely certain

LA: there was a lot going on, but I believe it was shortly after the company was taken over we undertook the training

C: was also happening in the context of the unprecedented pandemic

LA: yes

C: you're doing your job with PPE?

LA: yes masks and gloves if appropriate

C: could you feel that had an impact on how you could get on with people and relate with people?

LA: not necesarily... was large area we could discuss, we could go to separate space and still be distanced to have conversations

C: did it make it more challenging ot integrate a new person like Chris.

LA: yes definitely

C asks what they were

LA: before was Supported Living when was residential we'd usually have a trial period of a couple days... then they could decide and we could decide if that was appropriate.

C: yes

LA: when we were Supported Living and during covid that wasn't the case obviously, so quite a few changes made

C: so no lead in process, or getting to know

LA: no

C: so once arrived, they're assessed as suitable, they arrive and that's fait accompli, where they live

LA: yes

C: I understand you can't enforce medication, have cut off points for leaving and coming back, all you can do is advice and encourage

LA: yes

C: you'd gone to see Chris to administer his medication, that's you hold it and take it to them?

LA: what would happen is staff member would knock on their door and encourage them to come down for medication. I'd go to medication cupboard and get medication. Chris I believe was on Stage 1 so staff would pop it and watch him take it.

C: so he had to come down

LA: yes

C: Stage 1

LA: yes due to his previous overdose, where he was knew, we'd be dealing with it until he was more aware of it. We'd pop it, check it was correct and him take it. Obviously that didn't happen

C: we see in records he was declining medication, had you popped it out?

LA: no, first you'd ask for consent, before popped it. Depending on situation I might ask again, or might be straight refusal

C: did you say that when you went up to room, or does he have to come down

LA: if he said no I'm not having it I might have conversation at his door

C: is there risk someone is tired, so declines the hassle of going downstairs is that a feature? Is that why you repeat the offer later

LA: yes partly

C: I know in prison, other settings, there's check someone hasn't hidden medication under their tongue. Do you check?

LA: not in Chris's case, if there was a concern about concealing medication we'd check but we didnt have that concern

C: with Chris he was saying he wasn't having it, he was clear about it, then you'd document that refusal

LA: yes

C: I know its a long wait to say that information, but I needed to clarify those points.

TS: Just briefly Ms Arnold if I may, I ask questions on behalf of Chris's family. I want to make clear they are not here, neither am I, to criticise you or make you feel uncomfortable.

TS: You'll appreciate in the aftermath of what happened there are some questions we'd like to ask.

You say you'd been there 3 years, had you had any training in relation to autism?

LA: I believe we had a learning disabilities training thing online but I don't know if it was specifically to do with autism

TS: yes. We've heard in this inquest that learning disabilities and autism can be quite different, do you think you had any specific training about autistic people or how to engage them in the activities you offer

LA: not that I recall

TS: do you recall having conversations with Chris's mum Julia, she sits behind me

LA: yes

TS: did you speak to her on the phone

LA: yes

TS checks she's read Julia's statement, she said she has

TS: she said she queried where all the activities had gone, they said was due to covid 19, therefore they weren't set up with what I was led to believe they could offer. Did you have that conversation with Chris's mum?

LA: I dont recall

TS: were they impacted?

LA says they were: we can offer activities but we can't force someone to do them

TS: by July 2020, pandemic had gone on for few months, albeit in early stages, so inevitably activities were reduced. Is that fair?

LA: yes

TS: I asked for detail of therapy, care plan from Hart House and timetable of activities. Did you have that conversation?

LA: I dont believe I did

TS: she said she had a conversation with a young female member of staff who said 'we don't really have autistic people here'.

Do you remember that conversation?

LA: no

TS: did you have autistic people at Hart House?

LA: not autistic but we did have people with other difficulties

TS: had you ever worked with anyone with autism?

LA: not worked

C: can I check you'd been at Hart House 3yrs but you'd never worked with someone with autism

LA: not that I recall

TS takes through timeline from Ms Bennett's statement

On 6th he was in bed all day

On 7th he required prompting to take medication, on this day he put some washing on and went out. Back to bed. Great deal of encouragement to get up.

On 8th you've described it.

Looking at that week we can see periods of time when Christopher is out, when he's in interactions are offering him, or prompting him about medication

LA: yes

TS: there's one conversation about him cooking, and he does a load of laundry

LA: yes

TS: do you think that adequately describes the activities he had during that week

LA: would need to refer to 1-1 notes... but we didn't see Chris for very long in a given day

TS: Ms Arnold I'm not trying to catch you out.

Were you aware one of his mum's concerns was he needed to be kept busy, have activities, a structure, keep his mind of drugs. Were you aware of that?

LA: not to extent I think she'd have liked... when someone first comes to us the focus is on daily living skills and settling in

TS: I'm not criticising, we see a conversation about cooking and one load of washing. Did you partake in any other activities?

LA: I'm sure there would have been discussion but from my recollection Chris didn't seem very enthused to take part in activities

TS: right.

No further questions from Mr Stoate.

No questions from Ms Denton, Ms Ballard or Ms Khalique

Ms Nash takes to 1-1 notes

LN: 7 or 8 lines of text. Have you seen this entry before today?

LA: Yes

LN: Initials LA is that you?

LA: yes

Discussion re bundles

LN: At medication time Chris refused his xx when I asked why he didn't want to talk about it but it had been causing him xxx I said we could ring the doctors about it and see if we can sort it out. He'll be down in a bit.

LN: Do you recall that conversation on 25 June 2020 with Chris.

LA: yes

LN: where did that conversation take place?

LA: I believe the lounge and he was going to go back up and then come down

LN: Did the doctors appointment happen?

LA: yes

LN: same day, or do you remember?

LA thinks appointment was made same day but can't recall when was for

LN asks if appointment resolved the issue and LA confirms the medication was switched.

Coroner thanks her for her attendance and evidence. She is released at 14:25.

[10 min break]

Coroner calls Helen Clark

She swears an oath

C: you've kindly provided a comprehensive statement in relation to this matter. Do you have a copy of that with you?

HC: I do

C: Ms Clark you've been able to hear the evidence from colleagues read out in part.

C: You confirm you were the Deputy Manager for Hart House. Employed by Adjuvo and previously Hart Care from April 2004 to 20 Nov 2020 and Deputy Manager for around 10 years

[lists responsibilities]

C: you've heard the statement read with regards to the transition to a Supported Living set up

HC: yes

C: It would appear unfortunate timing that took place shortly after the start of the pandemic

HC: yes it was very challenging, but we managed to have only one covid positive resident with us and it spread no further.

C: I want to get an impression, sense of it, how many were people who rolled over with you from one set up to next.

Try get feel for how many new people you had coming in around the same time as Chris.

HC: we had 7 residents I think. We had one gentleman who moved on from us due to his age.... so that left us with 6 I believe and Christopher was the 7th

C: So the 6 Chris was joining had been with you from the old set up to the new set up?

HC: yes

C: so you were below the 10 bed capacity at that stage?

HC: At that stage yes

C: which was probably just as well given pandemic and other things going on

HC: yes

C: you conducted pre admission assessment at Basildon Hospital on 11 June

HC: yes

C: you can't recall if anyone else was present other than Chris? Would that be usual set up?

HC: no usually manager would be present, or another member of staff, but given pandemic was only one member of staff allowed in at that time.

HC: Everything I recorded I passed on to management to enable management to have an understanding of what my findings were

C: ok... you say consists care plans, risk assessments, and decides appropriate care package for individual. Two stage test I guess, firstly is he suitable for Hat House and if suitable, what kind of care package?

HC: yeh, we have a meeting with person, get understanding of their abilities, needs and wishes. then that paired with care team of how they feel we could best meet Chris's needs. Then we'd come up with a plan of how we could meet that person's needs.

HC: What we could do, what we could put in place, what other agencies could support us to get best outcome for people who come to us

C: ok, and care team was ESTEP

HC: yes

C: and care coordinator was Kirsty Lister

HC: yes

C: so did you meet Kirsty before you met Chris?

HC: I'd cc her into a lot of the emails but primarily my liaison was with Richard Weidner

C: ok. When you first met Chris were you aware there was a degree of urgency about him being placed somewhere?

HC: yes I was

C: by telephone or email?

HC: I received a call originally and then I asked him to email any documentation he had before I decided whether was appropriate to go and do an assessment

C: so you spoke to him, is this right, he gave you sense of urgency they're looking to get accommodation

HC: yes

C: you then ask for documents for you to consider them before you go to see Chris, meet him and take it from there

HC: yes

C: next question I have for you is can you recall what documentation you received before you went to meet him

HC: as far as I recall I dont know whether documentation is with you.

I remember receiving a 3, maybe 4 sheet, brief history. Brief medical care where mentioned his epilepsy. The medication he was taking. His needs. It was a very short of basic overall view of Christopher

C: ok in your statement you say, Hart House was informed that Chris had a learning disability, however do not recall being provided specific detail as to the extent of this... was not until later we were made aware of detail, particularly in reference to his IQ

HC; yes that's correct

C: you make no reference there of his autism, ASD, were you aware he had autism?

HC: at that time I was told, and it was passed to the rest of the team, that he had mild learning difficulties

C: that's how it was phrased, your clear recollection of it?

HC: yes

C: that's before you see him.

You describe him in your statement as you met with him, appeared engaged in process, enthusiastic about joining Hart House, he was looking forward to learning new skills such as cooking.

C: Your impression was he was upbeat and positive about Hart House?

HC: yes, he was very keen to understand where we were, how he could get to places, how big his room was. I took pictures of his room, he appeared quite, not overly, but quite excited this was going be his room

HC: Because of refurbishments altho in old building, it was a brand new room. He would be first person living in this room and he loved this idea

C; there was an ensuite with it as well

HC: yes its a beautiful room

C: I've not seen pictures, you're describing a spacious room

HC: yes it was a good size, bigger than average double room. Had large shower, wash basin, toilet. Plenty of storage, bedside cabinets and chest of drawers

C: Ok, you understood he had mild LD but didn't know he had a diagnosis of autism

HC: no

C: over the years you've worked have you had much experience of working with people with autism in Hart House

HC: we had two of our service users with autism, one had Aspergers, and I supported them for many years

C: ok. So your knowledge and experience was born of caring for people. Did you have any formal training in that?

HC: at that time no, since yes.

C: I think Ms Arnold said she didn't have any specific training in ASD. I suppose it follows, up to the point of July 2020, since then may be different.

If you haven't had any training is it right for me to assume other staff members hadn't had any training about ASD?

HC: as far as I'm aware no. They may have had contact with people on autism spectrum at other jobs they had, but not to my knowledge

C: I have to remind myself not only of covid context, but also the very short period of time, counted in weeks perhaps, Chris was actually at Hart House.

We know there's the incident with [withheld x2] and then discharge against advice which led him back to Hart House.

C: At any point did you become aware before his death that Chris had been diagnosed with autism?

HC: not that I'm aware of.

LN: Sir I appreciate that this is this witnesses evidence, but it may set a hare running... could we take to pre assessment document

C: [missed] forgive me Ms Nash it's the memory I'm interested in at this stage. You don't have any recollection of his diagnosis of autism?

HC: No I remember the learning disability being aware, but I wasn't made aware of the level of learning disability.

HC: I questioned it but never got any true specifics about his formal diagnosis

C: alright. Ms Nash I think at this stage we will please. What is your reference?

Brings bundle up on screen and reads

Learning disability ? [? in records not my addition]
Psychosis due to cannabis use
Overdose and excessive cannabis use
Ready for discharge does not want to return home
Last year fit and fall
Richard made aware of my thoughts.

C: What thoughts were they do you recall?

HC: I think it was in relation to the question about his level of learning disability

C: OK, both hand writings are yours

HC: yes

C: the slightly larger handwriting was that prior to the assessment?

HC: no it was all on the same day

C: ok

HC: actually no. The section on the left was after the initial assessment.

Second admission discharged after 6wk stay
3 days later admission to Basildon
Mainstream school
Age 7 autistic spectrum diagnosis

C: looks like you've recorded in your own hand he did have an autism diagnosis aged 7?

HC: I didn't know where on the spectrum that diagnosis was, was a very loosely phrased document

C: were you considering autism and LD to be effectively the same thing?

HC: no

C: do you consider them separate?

HC: yes

C: I asked do you recall he had diagnosis of ASD and your memory was you hadn't been told that but looks like you were?

HC: that was an error on my part

C: so you were in fact aware of that, but you weren't aware of where on the spectrum as it were, his presentation sat?

HC: exactly

C: and you had an understanding he had a mild learning disability

HC: yes

C: alongside the ASD

HC: yes

C; that's written in your hand at that stage... looks like that's entered after he's accepted into Hart House by you, is that right?

HC: Um, what was the date of this?

C shows

HC: I'll stick to my initial thoughts, this was all written on the same day

C: just running out of space?

HC: yeh

C: so is your evidence that you did know he had a learning disability, albeit mild, and autistic spectrum diagnosis at the time of your pre-admission with him?

HC: yes

C: rest of document appears blank, is that the same document?

HC: we'd complete that if someone stayed for a day, or couple of days, but because of the rushed admission we didn't get a chance to complete that

C: riiight. Does it follow you didn't go through this section with him?

HC: I went through house rules, substances policy, him making us aware of overnight stays and letting us know where he was. Not just for safety of him and fire policy but because we had to make sure he was in a safe place.

C: did you go through drugs and alcohol policy with him?

HC: yes made it very clear that drugs and alcohol aren't allowed on the premises. I made it clear smoking cannabis wasn't the best way for him going forward.

C: do you remember how he responded to you when you said that to him

HC: he looked quite sternly at me, frowned, looked puzzled and I remember him saying he thought it was safe, taking cannabis

C: he said he thought it was safe?

HC: yes

C: alright, thank you. I'll return to your statement if I may.

HC: uh hum

C: you prepared his support plans and risk assessments, referred to ESTEP for their approval

HC: yes

C: forgive me I should have asked you this, were you aware Chris had had previous suicide attempts in 2016? And issue in London?

HC: I was made aware of [withheld] London but not the previous one.

There was recently I'm talking, I was made aware by reading statements there'd been an event in hospital [withheld]

C: I was going to come onto that. So at time Chris was with you, you were aware of London [withheld] you weren't aware of 2016 at time

HC: no

C: neither were you aware of [withheld] on the ward, you weren't aware of that either?

HC: not as memory serves, no

C: so you were aware he had an ASD diagnosis from when he was 7. You then say, not until later at Chris's time at Hart House we were made aware of the level of his learning disability, particularly in reference to his IQ.

C: Were you aware this relatively low IQ, the clinicians thought was an under-representation of his abilities?

HC: I don't ever recall having a conversation about his IQ with anybody

C: you say wasn't until later in his time at Hart House you became aware... what did you mean when you wrote that?

HC: That we weren't made aware of his level of autism. I wasn't made aware of his IQ level until he'd been with us, I think it was when he was discharged from Rochford that we were made aware of his IQ.

C: his IQ and the nature of his autism?

HC: No I don't think we were ever made aware completely of his level of autism, but at discharge we were made aware of his IQ level. I appreciate was when he was 7 and they obviously did not re-do the IQ test

C: right, Ok. You then say this, I appreciate others will which to clarify some of those points.

BB: She can't mean Rochford, they weren't involved.

C: When you make reference to him being discharged from Rochford, what period of time are you referring to?

C: You say Rochford, do you mean Basildon, the end of June?

HC: yeh

C: do you mean end or middle of June?

HC: after he'd had the seizure so 16 June

C: alright, you're right Ms Ballard.

C: I believe you write, had Hart House been aware of Chris's level of learning disability at the outset it would have raised questions about how we provided support to Christopher, but might not have meant we weren't appropriate.

C: What do you mean by that please, in your own words?

HC: we were predominantly dealing with people with mental health diagnosis.

We had people that had learning difficulties, due to their mental health becoming apparent, and they were diagnosed due to delay in development.

HC: But as a rule, although we had had a gentleman with Aspergers in the past.

It was very rare we did have people on the autism spectrum.

HC: As I was led to believe it was a low level ASD Chris was dealing with, it was felt we could put things in place to give him some sort of routine and focus.

HC: It wasn't until after that, realising his level, on the autistic spectrum, that it may have been an idea to have greater input, maybe more training of the staff, had we known what we were going to be dealing, helping Christopher deal with

C: OK. So did it become clear that the challenges that Chris was facing and would present to Hart House would be greater than what you'd first understood it to be.

Is that a fair summary?

HC: yes

C: You say Chris was encouraged by staff to take part in various difficulties, supported him to clean his room and do laundry but staff did encounter difficulties.

He regularly left unit without informing staff where he was going.

C: You say his mother would regularly collect him, without forewarning, you say that presented difficulties for staff to keep him engaged in the service

HC: yes

C: may be some questions on that in due course. Nature of service is you can't enforce medication, curfews and so on

HC: yeh it was an open unit.

C: you say when you became aware Chris was not engaging you'd inform Richard W and he'd meet with Chris....with a member from the SALT team. You'd often attend or seek feedback when you couldn't attend.

HC: yes

C: you discussed issue on 16 June where he went to hospital, injured face following seizure.

You raised concerns with Richard Weidner about whether Hart House was right place for Chris, especially given were unable to accompany him out of unit unless he agreed.

C: He was assessed as having capacity and he wished to return to Hart House

HC: yes

C: the concerns you raised with Mr Weidner, were they around risks and safety?

HC: yes one was around seizures, if he had seizure outside unit staff had no way of providing emergency first aid to him.

HC: Risk of smoking cannabis, and dangerous impulsive behaviour, we had no ability to support him with that and help him manage that behaviour and prevent any dangerous occurrences happening

C: ok, thank you.

C: You raised concerns, I know he wanted to go back there, but how were you persuaded Hart House was suitable for him?

HC: I recall RW had a meeting with Christopher in the garden. Not entirely sure if a member of the SALT team were there, so many different meetings....

C: dont worry Ms Clark, you've raised concerns on 16th after seizure and hospital with Richard W.

We know from records was capacity assessment on 18 June.

What was it that persuaded you he could safely return to Hart House?

HC: During this conversation with Richard, we three sat down and Chris agreed to do a management plan.

We agreed we'd try with him to get some sort of routine in place which I thought would help him and support him.

C: yes

HC: I remember discussing different strategies to enable Christopher to participate in these routines, by way of reminders, different set ups in calendars in his room, day by day to let him know what was happening on that day.

HC: Each day when member of staff went to give him his medication, staff members would remind him what he'd agreed to participate in

C: all of those things sound like they would have been in place since the start Ms Clark

HC: we'd have had his activities planned with him.

It was having a more visual reminder, and staff actively reminding him daily, the skills and plans that were going to be undertaken that day

C: ok. Just to be clear, at this stage, period after 16 June. Around this time did you become aware of the nature of his autism, alongside his LD. At this stage were you aware of it?

HC: yes it was roughly this time I'd realised the level of his autism

C: ok. Perhaps a week after that discussion, the management plan, was there an improvement in that period, do you recall. Did he settle down a little bit or hard to remember?

HC: I remember on several occasions I'd go into his room if I was on shift, or in the office that particular day, and jolly him on, encourage him to pick up his rubbish. Come on, give us a hand, actively... and he would get up, and he would clear up...

HC: and he would engage in a slightly better way with staff in the morning if you started the day like that

C: right.

How did you find your relationship with him Ms Clark?

I know not over long period of time... how did you feel he responded to you when you were geeing him up

HC: yeh, he was ok. He appeared, I think because I was the first port of call for him, he appeared to react in a positive way when I was there. You know.

HC: He'd take the mickey and be quite jovial to me, and I didn't have any issues with Christopher.

I thought he was a very pleasant young man.

C: thank you 27 June [withheld] eating his cereal, an ambulance arrived and took him to hospital...

C: you've written he was transferred to Basildon for MC assessment and risk assessment. That's what you thought was happening there?

HC: yes

C: you say you had very little communication from hospital, and very little warning of discharge the following day.

C: And very little support with what support Chris needed after the incident.

HC: yes

C: You had concerns around 16 June.

You raised with Richard W. He had chat with Chris, further discussions, plan drafted, extra support put in place.

C: You were reassured sufficiently to welcome him back to Hart House.

This appears to be another quite troubling incident, were you content for him to come back to Hart House?

Tell me about that discharge process, were you involved with it at all?

HC: I think this was the occasion where Christopher just turned up at the door.

Despite numerous calls to the hospital, no-one I or any of the team spoke to, seemed to be able to give us any sense of what was happening, whether any capacity assessment had taken place...

HC: what was happening.

I stand to be corrected but I know on one occasion, it may have been this one, that Christopher turned up at the door without warning.

I don't know if this was the occasion where he discharged himself.

C: yes there's a discharge against medical advice.

Your recollection is he simply turned up at Hart House from what would have been the assessment unit?

HC: yes

C: presumably you did have the information, he'd been taken from ambulance from Hart House that he'd [withheld].

Obviously you were concerned, you were trying to call to get information.

Do you remember calling yourself to try get information about capacity assessments, discharge planing and so on? Can you recall?

HC: yes, yes I can and I think it's about that time I started messaging Dr Villa

C: when you personally called you weren't given any information about discharge, whether capacity assessments undertaken

HC: no, no

C: so next thing. I'll go through your statement, you've given your recollection there.

C: In conversations with Christopher after this incident he assured me he was not experiencing suicidal thoughts, just enjoyed adrenaline [withheld]

HC: I remember that conversation vividly

C: You raised with RW about Christopher's safety in returning to Hart House as an open unit.

You queried whether Hart House should make a call for 999 if he left the unit?

HC: yes, I remember asking him that

C: Richard's reply was you can't really do that

HC: He said there isn't a DOLS. But even if we had a DOLS we couldn't have physically stopped him going out. So I didn't see that as a viable option.

C: was that conversation with Richard before or after Chris turned up at Hart House, can you recall?

HC: I think it was just after Chris came back

[missed chunk]

C: I was advised Hart House should continue trying to engage Chris in activities and contact the MH service if it was believed Chris was leaving towards the dangers of the town or xxx I was advised to call the police

C: however it was not always possible to see where Chris was heading on leaving Hart House.

Who gave you that advice? Looks different to what Richard Weidner said?

HC: I believe that was Dr Villa

C: looks like you're getting conflicting advice from ESTEP members... Richard W said you can't call the police, Dr Villa advised if he was heading out to town or bridge than can call police [my paraphrase]

HC: yes

C: call or email?

HC: I do remember that being a phone call conversation. Usually sent email after for paper trail

C: 1 July you couldn't attend MDT due to illness, can't recall if you were updated.

C: 3 July Chris was due to attend party with his brother, some discussion about access to drugs at party, you discussed with Julia but believe she was content for him to go and his brother keep an eye on him

HC: yes

C: we then turn to 8 July, you weren't working on the tragic day itself

HC: no I wasn't

C: internal investigation undertaken by the area manager at the time.

As we heard from Ms Arnold, echoed by her colleague, that Chris appeared his usual self on the day.

C: You obviously express your sincere condolences to Chris's family for their loss.

You weren't on duty on the 8th, were you working on the 7th can you recall?

HC: I really can't remember. I worked Monday to Friday

C: on 7th was a professionals meeting, were you aware that meeting was taking place on the 7th

HC: I can't recall. I don't remember being invited to it

C: would you expect to be invited to a meeting of that kind?

HC: yes

C: given Chris was placed with you still

HC: in our care, yes

C: Mr Stoate

TS introduces himself

TS: the initial hand written document you did on Chris's admission. Mood changes quickly. Do you recall that?

HC: yes

TS: who told you that?

HC: Christopher

TS: that came from Chris himself did it?

HC: Everything on that document was held from my conversation with Christopher

TS: Did you consider that a risk with Christopher?

HC: When dealing with people with mental health, changes of mood happening quickly can happen... that didn't cause me any real concern at that time

TS: Perhaps not at that time but you recognise it as a potential risk don’t you?

HC: yes but it would be risk assessed and management would have looked at it.

HC: We'd have written a report of how we could manage that, that would be okayed by the ESTEP team and the management levels in the organisation.

C: Sorry you're relying on the ESTEP risk assessment?

HC: yes

C: You don't conduct your own risk assessments?

HC: yes, initially we'd have collected information from ESTEP team, from Christopher, and any other organisations involved. Written up how we'd support Christopher in his needs. from that risks would be highlighted and risk assessments would be formed from that.

C: riight. Do you compile your own Hart House risk assessments, in documents?

HC: yes. Yes.

C: You do that yourself do you?

HC: I have done yes

C: OK. Sorry Mr Stoate

TS: we can see one I think [takes to bundle]

Is that completed by you?

HC: no that's not my writing

TS: assessor name blank, person responsible blank, date and time blank. Who would be doing that assessment?

HC: that would be his key worker, that's all past, do they use recreational drugs.

A lot of that would be done by the paperwork we have.

TS: is that filled in by someone at Hart House

HC: yes

TS: you mention key worker, did he have a key worker?

HC: it’s not a sufficient risk assessment

C: who was his key worker Ms Clarke?

HC: off the top of my head I can't remember

C: key worker, as it says on the tin, would be fairly key. Have a think?

HC: I don't know. I really can't remember.

C: right.

TS: Did he ever have a key worker Ms Clark?

HC: he would have done yes

TS: you've said that's not a sufficient risk assessment, I mean that's a matter for the coroner but fairly obvious

HC: yes

TS: [withheld] on hospital ward

HC: we weren't made aware of that

TS: use recreational drugs

HC: yes

TS: alcohol, yes. Expressing suicidal thoughts, says yes. Any idea where that comes from, I understand its not your document.

HC says would come from ESTEP documentation

TS: its in the present tense isn't it... would this have come from Chris?

HC: no that would have come from paperwork received from ESTEP, along with Chris.

This would have been filled out with Chris present. Or it should have been.

TS: would Chris have been asked these questions directly?

HC: would also be correlated with information we already received from ESTEP

TS: would Chris have been asked these questions directly?

HC: yes. He'd have been fully involved in all areas of his care plan

C: when you compile a risk assessment Ms Clark, do you ask the person in front of you or just transfer over from other documents, what other people have conducted, or with the person in front of you?

HC: with the person in front of me

C: so you do ask the questions, in the boxes, of the person in front of you

HC: yes

C: so that's what you'd expect compiled by person documenting it.

It's woefully inadequate isn't it, no time, date, signature

HC: this wouldn't be the only document. they'd be a number of risk assessments in place, typed, written for all manner of things

C: alright, your barrister will be able to take us to those if there are any.

C: I suspect we've had the Hart House records provided to us, this is only thing that proports to be a risk assessment I can identify, I'll be corrected if I'm wrong. Is that surprising?

HC: when I viewed the bundle sent to me there was a series of risk assessments in there that I saw

C: ok

TS states would be hard to ask the questions of Chris

HC: We don’t word it exactly like this, we try to do it in a more delicate fashion

TS: not knowing who conducted it, it’s reasonable to assume person conducting it didn't have any training around autism and how to communicate such difficult things as this

HC: I cant comment on it

TS: I'm not criticising but its reasonable to assume person conducting hadn't had that training given you told us no staff had had autism training

HC: yes

TS: says no expression of suicidal thoughts, just acts without warning.

HC: yes

TS: linking back to what you wrote, you know his mood can change quickly, someone has written down he could just act without warning.

I am going to suggest that's highly relevant to the type of risk he might present, would you agree?

HC: yes.

That's why I personally was concerned.

I repeatedly emailed Richard and Dr Villa, for some continued support for Christopher and some areas where I felt he needed to be protected from himself

TS: looking at case now, do you think you, or Hart House, ever got to grips with the nature of risks Chris presented?

HC: very difficult to say, no one can ever fully appreciate thoughts of someone... you can't ever predict what somebody else is going to do

TS: that's not Chris though is it. Did you know the extent of his recent history, even in recent months to July 2020

HC: what do you mean?

TS: repeated admissions to hospital, high risk incidents [withheld]

HC: I was only aware of one incident at the time... [withheld] wasn't something I was aware of. Had I known that that would have given me other things to be concerned about, but I wasn’t aware of that

TS: you were raising your concerns, you say repeatedly

HC: yes

TS: we know team were seeking alternative LD placement as we don't feel he can be managed safely in the community

HC: I remember voicing that concern on several occasions at the end of June, beginning of July

TS: did you see that email from Richard W saying we don't feel he can be managed in the community safely

HC: I remember emailing him words to that affect, but I don't recall whether I saw that one

TS: we in this inquest have been privy to emails within ESTEP from 29 June. One of them Dr V says plans have failed too many times in last few wks, he can't keep himself safe, we can't keep him safe either, then mention of this phrase 'god forbid we end up in the coroners court'

[Witness gets upset]

Coroner asks what question is. TS continues.

TS: you were raising concerns with Dr Villa and Mr Weidner you told us, did that level of concern, we can't keep him safe, he can't keep himself safe, ever reach you in response?

HC: no, you saying it today is the first time I’ve heard that

[missed]

HC: If I was aware that was how the team felt I personally would have taken Christopher to Basildon, and I'd have sat there with him until somebody did something with him, without doubt.

HC: I wasn't aware the team I was relying on to help me, weren't in a position to give me support.

That makes me feel incredibly insufficient because I believed I had the back up of a team behind me in order to support this young man, when in fact. I didn't.

HC: They weren't giving feedback to me about how they felt.

No further questions from Mr Stoate.

No questions from Ms Denton, Ms Ballard, Ms Khalique.

C: Ms Nash

LN asks turn to bundle - Support Needs Review Questionnaire

LN: do you recognise this document?

HC: yes

LN: can you tell the learned coroner if you received it and if so, when and why?

HC: this would have been received from the council to us in response to any person that wanted to, my words have gone

C offers her a break, she continues

HC: if someone wants to sort their care plan out, who was going to undertake their care, if they wanted to be in charge of it themselves.

If they wanted to be the one who made decisions about who, where, when what in regards to their care package

LN: did you receive this pre or post Christopher's admission?

HC: definitely post

LN: closer to the time he was admitted or closer to the time he passed away?

HC: with certainty I can't answer that

LN reads:

Christopher has diagnosis of first episode psychosis. Secondary diagnoses include mental and behavioural disorder due to multiple substance abuse, ASD and potentially borderline learning disability.

LN reads:

Last two diagnoses are based on historical evidence and they might need updating when his acute psychosis is in remission.

Additionally Christopher has an ASD diagnosis.

LN reads:

An OT assessment from Rochford Hospital dated 7 May 2020 states that "he had presented with some social deficits seen in people with mild ASD and also some sensitivity to noise when the ward is unsettled....

LN reads:

Since admission he has not been observed to present with moderate to severe characteristics of ASD"

Do they fit with what you understood about Chris before he came to Hart House, or different?

HC: very different. If I'd seen sensitivity to noise, social deficits, if I'd seen those it would have given me a different view of his ASD

[missed chunk]

LN asks why she raised safeguarding after Chris returned to Hart House and ended up straight back in hospital within days

HC says was because she was concerned that Chris was readmitted so close to discharge, it wasn't a safe discharge so she raised a safeguarding alert

LN: You said you wished him to have a capacity assessment because you were concerned about his risk

HC: yes that's feasible

LN: we now know on 18th after his readmission he did have a capacity assessment, looks like Hart House received copies of 2 of the 3 assessments, do you remember that?

HC: no, we may have done and I've forgotten, I don't know

LN: than you sir, I've nothing further

HC: can I just ask a question?

C: you can ask it whether you get an answer is a different matter

HC: when you said we received 2 of the 3 documents, why would we not have received all 3 of them?

C: that’s for you Ms Nash

LN: all I can say is we have the complete record from Hart House, we have 2 of 3

C: which one don’t they have?

LN: we had consent to accommodation, medication, but we have no record of understanding seizures and poor choices [think she said]

LN: but in any event it doesn’t matter because they're all exactly the same

C: all of these documents you've been taken to were from Hart House records [referencing earlier statement where she said if she'd known she'd have felt differently], so they were with Hart House.

C: Is it a question you just didn't read them for some reason?

HC: no, I'd have read everything, it depends on when we received them

C: good point. Alright thank you.

C: What I'll need Ms Nash from those instructing you is confirmation as to when Hart House received these documents. Ms Clark tells me she read everything, this would include the document you've put to her, in fairness to all IPs if it was sent.

C: Your evidence to me is you hadn't seen this document when you were looking after Chris at Hart House [Support Needs Questionnaire]

HC: yes I don't remember seeing it at all

C: Where would this document normally be sent Ms Clark? How would it reach you?

HC: normally by email but that doesn't look like email, looks like it’s been scanned

BB [cant hear]

C asks Ms Ballard to identify when it was compiled, if and when was sent to Hart House. It's in Hart House records.

LN: It is dealt with in Ms Bennett's statement [reads]

C: Not dated and signed

LN: my understanding was received as part of pre admission documentation

C: yes but the witness doesn't have any recollection of it

LN: not now

C: we can take it off Ms Ballard's to do list, we'll clarify the position through Hart House, Ms Bennett

Coroner: Thank you Ms Clark.

HC: Can I just say to Christopher's mother my deepest deepest condolences to you, my prayers go out to you

C: thank you Ms Clark I'm sure that is heard

She is released at 16:15

C: alright everybody thanks again. That concludes matters for today and thankfully this long week.

Discussion re timetabling

Court was adjourned at 16:25.

Back Monday 10am for the final week.

Thank you for all funding and following my reporting chuffed.org/project/openju…