Thread by @ChrisNInquest

Day 10 of Christopher Nota's Article 2 inquest is due to 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 am attending 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 rarely 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 if it's [my paraphrase] or if 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'm grateful to those who fund it, and those who follow it.

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

5/

We are due to hear from three live witnesses today.

All from the @EPUTNHS ESTEP (Essex Support and Treatment for Early Psychosis) Team: Kirsty Lister, Judi Jeavons and Richard Weidner.

I'll stop numbering tweets from here.

Day 10 will begin in 10 or 15mins.

6/

Back in court. Coroner apologises for delay in starting.

C: I've received what on the face of it looks like a considerable amount of further disclosure... haven't had opportunity to read in any detail... appears to be care plans and don't appear to be cross served to other IPs

C: Ms Ballard can you help us with what they are?

BB: Some of them have already been disclosed, I haven't been able to locate all of them yet but suspect they're already there.

BB: When we went through discharge care planning on Cedar Ward and you asked me to see whether there was any additional care plans so I asked to collate all care plans into one easy place and then what I've done is individually collate them into location.

BB: Those that relate to Cedar Ward, two stays on assessment unit, those that relate to the community.

What I'm hoping you have is information you already have had just in an easier to read and understand version.

Hoping hasn't complicated matters, in order to assist you.

BB: Haven't cross circulated it sir because wanted you to see it first.

C: I simply haven't got time to review all of them.... could they be cross served please

BB: to assist sir the most relevant for you today would be the clip in the community documents to ask Kirsty Lister about if you'd like to

C: right. Well its not my practice to keep any other IPs in the dark. Thank you Ms Ballard for the provision...

C: do we have anyone in court assisting you or is all of your team online?

BB: there's someone in court but I can cross serve them now.

C: OK.... we'll recommence at 11am. May be sensible to start with the community bundle. It's relatively concise from what I can see.

C: It's secured documents that have been provided so not sure they're amenable to annotation in pdf form. Ms Ballard don't know whether there's another version that can be circulated.

BB: in first instance I'll circulate then I'll make enquiries whether can edit to version that can be annotated

Coroner thanks her. Outlines his plan for the day (didn't catch the witness running order, apologies).

Court is adjourned at 10:37.

Back at 11am.

C: Has anybody had an opportunity to have a quick look, the Community CP document provided.

Mr Stoate anything to say at this stage?

TS: no thank you sir

C: Grateful to the @EPUTNHS colleague who provided the update, and happy to hear Dr Udu is receiving treatment.

C: Not anticipating him being in a position to conclude any evidence or follow up questions this week. Is that how you understand it?

BB: as far as I understand it that's an accurate assessment indeed.

BB: Because of school reports we can not seek confirmation from Dr Udu, so we're trying to access by Sharon Allison checking emails exchanged between them at the time.

With regards care plans am confident they're all in the bundle, shouldn't be anything new for you at all.

C: thank you very much indeed then.

Coroner calls Judi Jeavons. She swears an oath.

C asks her to keep her voice up and speak into the microphone as well.

C: you've kindly provided a statement dated 25 Oct 2021 with respect to your involvement in Chris's care

JJ: yes

C: you've heard some of the evidence, not sure if you've heard all of it?

JJ: I've heard quite a lot

C: you'll appreciate, as will your colleagues in court, that the sequencing has been deduced.

C: Understand the chronology in some detail, your chronology is very helpful and covers a lot of detail... wont ask a lot about it [but tells her to bring things to his attention if she wishes].

C: I've seen email exchanges in ESTEP group, and your prompting and various concerns throughout the chronology about a number of things.

You've expressed on more than one occasion concerns about @JuliaCa20602661 being heard, and listened to and included.

C: You'd identified that as an important aspect of hte care management and treatment of Chris since the very beginning.

JJ: yes

C explains he wants it recorded on the record.

C: the other detail we'll go into is the management of Chris with regards to risk management in the community.

Both of those matters raised not only within ESTEP team but across a number of different teams?

JJ: yes

C: you were also as it were passing on the concerns you'd heard from Julia herself and trying to action matters to address those concerns to the extent that can be done?

JJ: yes

C: you're really quietly spoken, you're not a foghorn like some of us, its really important that those listening online including Nyarumba and your counsel Ms Ballard can hear. It's all affirmations to date.

If need break at any time just ask.

C: You've been a registered MH nurse since March 88, worked for EPUT and its predecessor since Jan 2004 as Early Intervention in Psychosis Manager until you returned in March 2021.

JJ: yes

C: you'd been manager of the service for a couple of decades, a decade and a half at least

JJ: yes

C outlines service

C: supports around 300 ppl, a fairly reliable indicator of the caseload?

JJ: yes across, now, three teams

C: Did you have a focus this was primarily in relation to cannabis use, or combination of different drugs?

JJ: at time understanding was cannabis and psychosis, but complex situation.

JJ: Very beginning of covid, we always assess people before making diagnosis but we weren't able to do that as we couldn't go onto the wards

C outlines reminder to himself re covid and timings

C: even you as clinicians weren't getting access?

JJ: no we couldn't go onto wards, we were mostly working remotely.

Were trying to keep one or two staff in the office to protect staff. At that time didn't know what was to come in terms of covid.

C; so any assessment carried out you're relying on clinical assessments of Dr Thies Flechtner and colleagues

JJ: yes

C: you didn't have, from a clinical perspective, the chance to reassess?

JJ: no

C: were you aware of the self-harming incident [withheld] on the ward?

JJ: I was only aware of that last week

C: that's the first you've heard of it

JJ: yes

C: and the self harm incident that Mr Stoate took the witness through?

JJ: I can't recall that, but as manager of service i'm generally on the periphery, was only because my colleagues were concerned that I ended up becoming more involved.

C: understood. We'll hear from Ms Lister next.

C: If it were something you'd not heard of, given your close involvement... are you surprised you weren't alerted to a suicide attempt, would ESTEP team expect to know that?

JJ: I would expect that we'd know about [withheld], have had opportunity to look through notes. We'd had video calls with Julia so was aware of incident several years prior

C: 2016, you were aware of that, but that was from Julia?

JJ: yes

[missed chunk]

C: have you seen anything in the records that indicates ESTEP were made aware of it?

JJ: no

C: you didn't meet Chris at any point?

JJ: no

C: but you were involved in supporting the teams.

C: you particpated in two or three video calls with the team and Julia... you attended three multi-professional meetings and escalated concerns on behalf of the team and linked into other agencies and professional groups.

JJ: yes

C: did you have any concerns about the earlier allocation of Chris to the ESTEP team?

Understand you and your team didn't get to assess him yourself... but robust discussion on 20 May 2020.

C: Did it seem to you ESTEP were appropriate team, or did you have any reservations at that time?

JJ: can't recall that at time, but normal practice and standards is if anyone presents with first incidence of psychosis, it's like cancer, early treatment is best.

JJ: We're always proactive in taking on cases if we can. We work very much as team, care coordinator coordinates team, became clear was wider complexity and Julia had concerns we needed to make sure we were addressing his needs in terms of the autism, so I escalated that to

JJ: ask for additional support from colleagues

C: colleagues in the EPUT LD team?

JJ: the @eputnhs LD team and social care [@SouthendCityC] via Sarah Range

C: so initially ESTEP felt to be right team at time... appreciate you were one step back at that stage.

C: I heard evidence once allocated to ESTEP general position is someone will remain with that team for 6 months?

JJ: yes we do an extended assessment for 6 months.

With drug induced psychosis may not have further episodes if don't continue to take drugs.

JJ: We offer service for up to 3 years for people with psychosis because there's various causes of psychosis

C paraphrases to check understanding

JJ confirms

C: did you become aware of how fixated Chris appeared to be about cannabis use.

C: Intended to keep using it, didn't see any link to his mental health issues. Something you're aware of or difficult to say?

JJ: can't recall I became aware of that, but was in some team discussions where that was discussed...

JJ: think second capacity assessment discussion I was present and he'd made it clear he didn't want to stop using cannabis

C: yes. It appears to be common ground, you'll correct me if I'm wrong from your understanding, that after initial treatment on Cedar Ward, 6wks or so...

C: the psychosis receded, was dealt with?

JJ: yes

C: not withstanding his erratic or non compliance with medication subsequently, he didn't appear to ever experience another incidence of psychosis?

JJ: that's my understanding... but we were under the understanding he was...

JJ: taking his medication, which would obviously help that

C: yes

C: you were very aware from earliest opportunity that Julia had concerns about keeping Chris safe in community [my paraphrase]

JJ: Yes I think I was aware at the point he was discharged she had concerns

C: you weren't aware prior to discharge she was saying she wasn't able to keep him safe?

JJ: I can't recall being aware of that

C: family may pick up in due course. 5 May email to Richard W asking him to allocate the case while xx is off?

JJ: yes another care coordinator initially but he had covid so it was reallocated to Kirsty Lister

C: and we know from sequence of events altho request to attend discharge planning meeting, that didn't in fact happen in end.

C: The ESTEP team weren't invited to, and didn't attend discharge meeting, because Chris discharged against advice as I understand the evidence

J: that's correct

C: although the meeting that led to that is subject to different accounts from different witnesses and the minutes recorded.

You attended MDT to discuss Chris on 3 June... so could look at how best support her

5 June multi professionals meeting.

C: By this time Kirsty Lister was in post as care coordinator?

JJ: yes

C: on 8 June discussions about how best support him post discharge and concerns. Email trail between 8 and 12 June you asked Dr Carr to keep Chris in hospital to try prevent failed discharge, to get...

C: care plan in place, to minimise risk to family and distress to Chris

JJ: that's right

C: at this stage you'd made requests for support, not only from LD team but also Sarah Range. Had they been made at this stage?

JJ: yes

C asks what response to requests was

JJ: from what I recall the LD team said didn't meet their threshold because they deal with moderate to severe LD but we did have some contact and calls with colleagues.

Sarah Range directed me to the Southend General Community Team, you've already heard about S75 agreement.

JJ: ESTEP don't have any social care staff allocated specifically to them. So we had to link with community team for someone to support Kirsty with assessment... we want to make sure we follow process and do to the best of our ability.

JJ: Better to have multiple people working together on that.

C: so did you make the approach to community team to secure and what was upshot of there?

JJ: yes in my statement 30 April. Sent email to team manager and he agreed someone the next day.

C: yes. Then a copy of the Care Act Asst was sent to you 9 June?

JJ: correct

C: 9 June there's Teams meeting with yourself and [lists] to discuss safe and robust discharge plan and support for Chris to Hart House. By this stage had already been the initial discharge

JJ: yes

C: quickly followed by the [withheld]

JJ: yes

C: what was the feedback or concerns if any expressed to you at that stage. What were you as team leader concerned about?

JJ: I think the team were concerned this could happen again.

JJ: Julia had expressed concern she couldn't manage him at home.

He'd obviously [withheld] which we were very concerned about.

We were looking for alternatives... was very difficult because people weren't accepting referrals because of covid...

JJ: transfer of care was very difficult so we were looking at what options we could have to best support Chris and family

C: were you reliant on the decision making of clinicians at the assessment unit as to whether Chris was detainable?

JJ: yes

C: when I look at the care plan that was provided, I may come back to it. Were you aware that [withheld] was, on the basis Chris had attempted suicide, that's how he expressed it?

JJ: that's not my understanding

C: what was your understanding?

JJ: my understanding is that he took the tablets I believe because he wanted to sleep; not sure if this is where that phrase was used "he didn't feel the day" might have been later

C reads from record

C: [missed bit] he claimed his intentions were to end his life, did not tell anyone and slept for remainder of day. Next day appeared quite twitchy and when mum asked he said he'd taken all his tablets the day before.

You weren't aware of suicidal intentions expressed by Chris?

JJ: no, if you look at the notes, in the days around that when we found out the account was different

C: yes. Did you have experience of working with people with autism and learning disability?

JJ: not per se, worked in early intervention for 25yrs. In job before that, was expected to work with social care to find appropriate placements and visited placements run by @autism

C: ok. Decades before, a couple of clients, that as the limit of your direct experience of people with autism and/or learning difficulties?

JJ: yes

C asks about team's experience of working with autistic people and ppl w LD

JJ: its not our bread and butter, we're used to psychosis, but Ms Lister and Mr Weidner are very experienced, so had some awareness, but it's not our day to day which is why we liaised with Sharon Allison because she's more experienced than our team.

C: would you agree it was a failed discharge? I guess self evidently given he ended up back in hospital having [withheld]?

JJ: if you look in those terms it's a failed discharge. But Chris wanted to leave hospitals, we didn't have the completed Care Act Asst at time...

JJ: but those were his wishes and maybe it needed to be tried. It wasn't successful, and listening to what Mum was saying as well, we decided to look at other options.

C: yes, he was discharged into your team, assume the watch word is to keep him safe.

C: 24hrs later he's [withheld] and found himself in hospital

JJ: I don't think that was the reason why he was readmitted though. He'd [withheld] but went out with friends, possible smoked more cannabis, was found on sea wall couldn't move his arms and legs.

JJ: My understanding he wasn't directly readmitted because of an overdose

C: right, what did you understand was reason then if hadn't taken overdose?

JJ: because he was found on sea wall and couldn't move his arms and legs, he'd gone to A&E and obviously needed checked out for any side effects of medication

C: Ok, later confirmation, "he didn't feel the day and thought fuck it" and [withheld]? Where would you locate that?

JJ: personally would look at ESTEP community notes but can't be sure was in there as relayed in assessment unit, but I wasn't involved day to day

C: ok, we've got first failed discharge, team weren't aware was happening, back to his mother's address where she'd...

C: explicitly expressed she didn't feel equipped to keep him safe. He [withheld] and smokes cannabis, found on sea wall unable to move.

You've agreed that's uncontroversially a failed discharge.

Team are expressing concern about how can we manages this

JJ: yes

C: mum is unsurprisingly going up a gear in her concerns... she's had him back, out the door, detained in London, back in hospital, discharged again, back in hospital.

At this stage what was available to you to escalate to try avoid a further failed discharge, did you feel?

JJ: think that was when we tried to embrace working more collaboratively with our LD colleagues to provide more rounded care plan and plan for future support, and to look at options for suitable accommodation, which we knew was going to be a difficulty because no one was

JJ: accepting admissions at that point

C: and you rely on clinical view about whether he was detainable under the Act?

JJ: yes we had multiple conversations as team about that, and contact with the AMHPs locally about that, during this whole period

C; there never was an assessment in this period was there from what I can see?

JJ: I dont believe so in the community... but in hospital when Chris requested discharge, the clinicians would be assessing that

C; yes, they were putting risk in hospital as low, your team came to view the risk Chris presented to himself was a high risk?

JJ: that's correct, when people are in hospital its a fairly secure environment, when out of hospital its more complicated [my paraphrase]

C: so its a different measure of risk... so you as part of team leadership, why not consider if at this stage, post first failed discharge, why not consider MHA assessment given high risk in the community?

JJ: I wasn't present at all meetings but I guess that was probably discussed at every meeting.

This was early covid, we were having daily meetings so was probably discussed daily

C: ok, will pick up with KL and RW but wasn't on your radar as do we need a formal assessment of Chris at this stage, mid June and prior to 8 June assessment?

JJ: on X June I'd asked Dr Carr to keep Chris in hospital, she'd have looked at that point whether she can detain him and obviously that wasn't an option

C; you cant go behind that?

JJ: no I'm not a Section 12 approved doctor, its not in my gift, but certainly we'd ask those questions

C: yes. The email exchange between Dr Thies Flechtner and Dr Carr about forced homelessness, were you aware at the time?

C: Ms Range has said it felt like there was significant pressure to find him somewhere otherwise he'd be homeless?

JJ: I can't honestly recall, I'm under oath and I can't remember if I was aware of that at the time

C: you weren't copied into the emails

JJ: no, I've seen them whilst we've been in court. Dr Villa responded, Dr Villa would have shared that information if I was present at team meetings, can't say whether was at all

C: in any event, urgency from your opinion to find somewhere in a context that was covid challenging?

JJ: yes

C; can I ask, as we move to Hart House, had you over all your years had working relationship with HH in past?

JJ: I didnt know it well, some years earlier when I held small caseload I'd had patient go there, was very complex case and was very successful, but understand since then the management had changed

C: were you aware Hart House was transitioning from one set up to another?

JJ: I wasn't aware

C: which ironically coincided with covid onset, but you weren't aware at time

JJ: I wasn't

C: are you actively searching for a placement, or Kirsty or Mr Weidner?

JJ: I think the team were doing that, but I looked up placements from @autism as I'd had previous success with them

C: we've heard evidence from Ms Clark, about the assessment process and what information she did or didn't have.

C: Who would have been providing her with information to inform her assessment of Chris, would that be ESTEP or inpatient wards?

JJ: probably ESTEP but that would have been informed by information from the ward as well

C: again I'll be corrected if I'm wrong, but one of aspect Ms Clark said she wasn't aware of was the nature and extent of autism Chris suffered from.

Seen documents that indicate was mentioned but not clear to me at moment when she saw those documents, may become clear in due

C: course. At this point as her was accepted by Hart House, funding in place, done pretty swiftly is that fair?

JJ: way more swiftly than is usually manageable

C: you and the team were aware of Julia's ongoing concerns about hart House?

JJ: dont think at that stage were concerns. She had concerns about wherever he'd go, understandably, I believe she went with Chris and had a look and recording in our notes was she quite liked the look of it

C; that may be taken up by Mr Stoate

JJ: the opinion did change, understandably

C: I think, Mr Stoate will correct me, she understood Hart House was short term measure, not medium to long term but your understanding was, if it worked, a medium to long term option?

JJ: that would be my understanding

C: I'll leave to others to develop further. In your statement, the chronology, there's no mention of the capacity assessment, I'll take up with Kirsty L, were you aware that was going to take place? Had already been one on 10th. Any reason why you didn't include them?

JJ: I put at top I'd only included my involvement rather than put in what everyone else had already said. But I was aware because I'd escalated that we'd like support with the MC assessments. There had been a meeting with Lyn Prendergast, maybe Sarah Range as well, maybe not.

JJ: We were looking at having someone from LD involved with more experience with learning disability and autism... had been meeting, I'd been instructed we needed to do it that day to facilitate discharge

C: that was 9th, it was put back to 10th.

C: You weren't impressed with that, I've seen email exchange. Did you know Ms Salici and SALT team? Did you know her and level of experience?

JJ: no but what was explained to me was her experience was she'd be able to rephrase questions to ensure understanding

C: and Easy Read material as well

JJ: yes

C; and there was the ambiguity around illicit drug use that emerged from that. Were you aware of that?

JJ: I dont think I was aware at that time

C: 16 to 18 June email trail, you asked LD to take lead on case, CCG requested same.

Have had evidence from Sam Ball on that. Could you reiterate what those concerns were please?

JJ: I think that we had concerns altho we were knowledgable about psychosis...

JJ: we had other things to consider in this case.

We'd like to either share the case more robustly, or ask LD to take on case and we'd support them with elements of psychosis.

The psychosis had remitted at that point, that's not to say it would stay that way.

JJ: But the picture with autism, we wanted to ensure Chris had the best treatment possible, rather than take on all the responsibility without all the knowledge

C: was your understanding @EPUTNHS LD Team were best placed to take lead with you as support, rather than ESTEP...

C: continuing to take lead, with LD on margins or peripherally with them offering support. You thought should be other way round?

JJ: not quite, I actually thought Social Care LD Team... they were aware of specialist placements.

JJ: Was their team, had forwarded to Sarah Range to ask the team to look at option.

Dont know exact timelines, but we'd had discussions.. ESTEP do take people when mild LD, had discussed with colleagues at Byron Court and LD Health Service and Chris was functioning at level

JJ: that wasn't moderate, severe. So we linked with social care.

C: and the view of Social Care was this remains, four square an EPUTNHS issue, either EPUT LD or EPUT ESTEP but it's not to do with social care?

JJ: that was her point of view, but Melike Cay did work with Kirsty and was very supportive. We had a bit of a battle at start to ensure appropriate people were involved but MC was involved and supportive and worked alongside us

C: I heard from her, her's was an informal role as advisor and support but she wasn't formally seconded. She was social care team, Sarah Range was very clear remained outside EPUT umbrella, any LD input had to come from @EPUTNHS LD, Sharon [he called her Sarah] Allison route.

C: Not withstanding MC came to assessment and was fairly proactive in sending emails. Was that fair summary?

JJ: that's a fair summary

C: you describe once battle to get someone, you got over that hump, my words not yours, it was a useful contribution she made

JJ: it was

C: and the team felt so?

JJ: I believe so

C: Ok, I'll ask them. Video call with Julia, she raised concerns capacity assessment was done by someone who didn't have autism specialism.

C: One of features of case, the MC assessment, however they're interpreted, they appear to have had significant impact on trajectory and nature of care management and treatment that followed, why wasn't the consultant involved in those? Why wouldn't Dr Villa be involved?

JJ: it's not a routine thing, she'd not met Chris, one of principles is it should be by person who knows them best.

So we had Kirsty doing it with SS initially, were aware mum wasn't entirely happy with that, so we involved Melike Cay who was much more experienced in capacity

JJ: assessments, LD and autism. So we had reviewed those decisions to make sure was robust.

C: so on first occasion Ms Salici was introduced for first time, second occasion Ms Cay for first time, why not have clinical specialist involved.

C: I'm not sure I'm too persuaded by idea can't have new people... why not have consultant involvement?

JJ: I think at first assessment Kirsty had only met Chris once, we were listening to mum... assume capacity unless proven otherwise.

JJ: As manager would look at policy and follow that... I believe team did follow policy, Kirsty was subsequently looking for other support to test out the view on the drug use.

C: you're aware of the Niche report criticism, despite recognising efforts made by Kirsty, that she lacked expertise in this field?

JJ: in drug and alcohol?

C: no in learning disability and autism.

C: They were of view someone more experienced in LD and autism should have been involved?

JJ: Melike Cay was more experienced, by her evidence here last week it was her bread and butter, she was informing that process with Sam and Kirsty

C: that might be something Ms Denton picks up. She wasn't there in a clinical role was she?

JJ: depends whether you call social workers clinical, for us she's part of our clinical team because it’s a team approach

C: ok.

C: Skipping forward a little bit [withheld] that led to admission to assessment unit. What's identified is emails between yr colleagues made it very clear, Dr Villa's contribution in particular spells out, the end point being tragically where we find ourselves in a coroners court

C: In stern terms the team was united from everyone so far, and unanimous, in that last week of June, he can't keep himself safe in the community, we can't keep him safe in the community.

JJ nods

C; I'll hear from Mr W about his engagement at this time. if that was the case what was the plan? He can't keep himself safe, you cant keep him safe?

JJ: Kirsty was working with Hart House and had asked them for a more enhanced care plan and was looking at other options

C: Hart House Deputy Manager informed us last friday, don’t know if you heard her evidence?

JJ: no

C: Mr Stoate summarised email exchange and Dr Villa's very clear expression of concern, you’ll tell me if it wasn't shared by all of you.

C: Ms Clark was very upset when she heard that, her evidence to me is she did not realise that was how the ESTEP team themselves were viewing the position. He couldn’t keep himself safe, you as team couldn't keep him safe, and Hart House not knowing, on Helen Clark’s evidence...

C: that's how community team felt. Hart House were asked to do something you as a team didn't feel was possible.

JJ: our concerns were escalated after [withheld] and Helen as Deputy Manager would have been aware of that incident.

JJ: I don't see that our concerns should have been any different at that point from that incident happening.

C: I see. So for that reason, because Helen Clark would have known about [withheld] did you and your team know expressly about how much detail she knew about [withheld?]

JJ: I cant answer that personally

C: It is important if you're saying its contingent, she could have formed her own view...

JJ: my understanding is from the notes an ambulance went to Hart House and picked him up because a passer by had rung an ambulance.

JJ: Cant say what was said there but believe our team became aware of it from Hart House, but you'd have to look at notes from ESTEP and Hart House to know what was communicated then

C: Her evidence was had she known how your team felt she herself would have taken Chris to hospital and remained there until something was done about it. She was very heartfelt in that evidence...

C: If your evidence is, whatever view you and your team took about whether he could keep himself safe, or your team could keep him safe, that was irrelevant because she knew enough to make her own decision with effect to Hart House?

JJ: yes but I'd also expect there to have been some communication at some point between ESTEP and Hart House

C: yes, and you aware now, he was discharged, apparently against medical advice by Dr Carr, allowed to have his discharge on the 29th

C: so what was anticipated to be the plan didn't come into fruition. He just ended up turning up back at hart House

JJ: I was here when Dr Carr gave that evidence

C: your evidence is your team were or weren’t aware of the discharge taking place on that day

JJ: I can't remember, I'd have to refer back to the notes

C: central issue, did you as ESTEP team, did you as manager know he was going to be discharged on that day?

JJ: we didn't know he'd be discharged that day, plan was for later date, but as manager wouldn't normally know everything day to day, although I knew more than I would normally in a clinical case

C: because that would be a concern wouldn't it. If Dr Carr has taken the decision someone is not sectionable, can't be detained, takes decision not to formally assess under the MH Act.

C: Decides they have capacity, this chap who cpl days before [withheld], he's now back in your care. Would be important for your team to know that wouldn't it?

JJ: would be imperative to know that. We'd arrange to see him within 24-48hrs and we'd liaise with Hart House as well

C: yes. If someone discharges against advice, what’s technically the time for you to see them? 24 to 48 hours?

JJ: would need to check policy, when discharged against advice used to be wasn't that but we always follow people up within 48hrs, try to do within 24

C: but formality part comes from if someone is discharged routinely

JJ: yes if its planned discharge

C: but in case of informal discharge, certainly in Chris's case you'd seek to see him asap

JJ: yeh and I think due to the concerns, its not that I necessarily knew this at the time, but the team had referred Chris to the crisis team because they provide 24hr day, 7 day support we'd requested they take on this case, but they didn't

C: what was reason, was it cannabis use?

JJ: I can't recall

C: Kirsty may be able to help, I can see her nodding, thank you

C: You conclude [reads] involvement from ESTEP team was extensive

JJ: yes people were working out of hours, I remember emailing Kirsty late one evening and telling her you need to stop working now. Certainly KL, RW and Dr Villa were working beyond and above what we'd normally expect, but it's nothing less than I'd expect

JJ: , I work with good people, we recruit good people

C: and has to be put in context of impact on other cases

JJ: yes, and we had to ask others to take on Kirsty's cases so she could continue in this way

[missed]

JJ: yes and because of Julia's concerns because we could hear her concerns

C: and recognise them

JJ: yes

C: was it your view Julia's strong sense she was being excluded had some basis in fact, appears to support your contributions on 7th?

JJ: I don't think she was being excluded by ESTEP, we were speaking to her very regularly. We accept parents are experts in their children, and always want the best for them. We needed to hear her voice, and Chris's voice.

C: yes do you feel others were hearing her to the extent ESTEP were?

JJ: I think other people were aware

C: they could not not be aware of Julia, and her fighting, if I use those terms, for her son.

C: But did you have any concern about the extent that others were recognising and dealing with those concerns or not?

JJ: I think we agreed we needed to contain things within our Trust, so agreement was made emails would come to me so we could support Julia and Chris

C: I’ll leave that there. We'll take a break. Back at 12:30

C gives JJ a warning about not discussing evidence.

Court is adjourned. Back at 12:30

[This is all out of time, its almost 2pm and I'm still catching up. Apologies]

C: to coin a phrase, come on down Ms Jeavons. Thank you Rob, Mr Stoate

TS: before I start there is evidence from this witness that you'll know, is not agreed from the perspective of Julia and the family, I could certainly ask some questions and put bits to this witness...

TS: but suspect some of it might be at risk of repetition... you have in mind the concerns of the family, the chronology and the email correspondence

C: Mr Stoate as tempting as it is to foreshorten matters, I think any particular points of disagreement would be useful to put to give witness opportunity to put her position. Rather than us repeating email traffic I've deliberately stepped back from that...

C: if there are elements of that particularly important its probably best if you, albeit concisely take Ms Jeavons to them

TS: thank you. Chris was referred to team on 15 April 2020

JJ: yes

TS: have you read or did you hear Julia's evidence?

JJ: I read her statement

TS: when I called ward on 16 April she called ward and was told no plans to be discharged... she told Dr TF they needed to work together on plans... she said she knew they needed robust package of care because she knew she couldn't do enough to keep safe.

TS: Dr TF couldn't exactly recall but agreed it sounded like what Julia would say

JJ: yes

TS: you agreed with the learned coroner that it was a failed discharge, takes to bundle... email from you 10:29 8 June, your response to Dr Carr...you say

TS reads: "my concern is that it will fail again if we do not have a robust care package in place its probably quicker to find him an appropriate placement than a support worker and if and when it fails if he is discharged home, then this then adds to the mums arguments...

TS reads: and complaints and is probably more distressing for Chris too"

TS: You're saying fail again?

JJ says wanted him kept in hospital to check whether safer alternative placement

TS: yes key bits appropriateness of placement and robustness of care plans for him. Crucial aren't they?

JJ: absolutely

TS: language is almost identical to that of Julia in April, whatever happens the care plan has to be robust

JJ: yes

TS: I'm doing this as briefly as possible. You were asked some questions about Julia's view on Hart House, I’ll refer you to her statement, para 82... [reads] her view is placement felt very last minute, I'd complained by this point

TS: I was disappointed in the management of this discharge, the speed and lack of planning

JJ: ok

TS: she says she had a conversation with Kirsty L and said was unsafe for him to come and go as he wished, felt ignored on this... was told he'd have fun there...

TS: Kirsty told me there were specially trained staff working 24hrs a day and Chris would receive support for developing his life skills, which he desperately needed

JJ: uh hum

TS: she was concerned about lack of planning, Chris's ability to come and go, she felt her expectations were managed significantly upwardly about what was available at Hart House. Does that accord with your memory of what Julia was saying at the time?

JJ: I probably wouldn't have been party to those conversations at that time

TS takes to bundle [her email to Sarah Range 17 June]: he has nowhere safe to go which is a huge concern, your words, Hart House presumably because that's where he went back to.

TS: So you didn't feel it was safe at that time?

JJ: yes those were our concerns at that time

TS: you say he needs an appropriate LD placement that can keep him safe; you're clear in your view there?

JJ: yes

TS: view of the team?

JJ: yes

TS: He lasted less than 12 hours at Hart House. Mum is saying it's LD that need to take a lead and we are getting to the point where we agree with her. There needs to be some direct action and increased input from the LD service.

JJ: yes

TS: response from Sarah Range, asks what's happening for Dr Villa's request for Byron Court, says LA can't do that because it's a hospital. You recall?

JJ: yes

TS: your response, health LD team don't feel it's required, they feel it is a social care responsibility

JJ: yes

TS: another email from Sarah Range, including Dr Udu, saying mainstream mental health need to manage his care yet Trust are suggesting LD care need to assess, she says not clear how this work

JJ: yes

TS: you reply... LD services generally work with people with an IQ score under 60 and Chris's last assessment was 58 which suggests specialist support not mainstream

JJ confirms she thought that was case from policy

TS asks JJ whether she ever felt Chris's IQ score was being debated to avoid providing services

JJ: No Dr Villa was really clear that's the information we have to go on so that's what we worked with as a team

TS reads another email 17 June: Dear Sarah, are you saying there is no role for social care LD service? And the Trust should manage his LD issues and accommodation. In our view his mental health is not the issue here at all.

TS reads: That doesn't really seem to be in the spirit of collaborative working. Judi.

JJ: we didn't have the knowledge and resources in ESTEP of what social care facilities were available for people with LD and autism, that was what I was asking for collaboration on.

TD: did you feel you ever got it?

JJ: not from that response, but certainly from the input of Melike Cay we were getting some support which was very helpful

TS asks why Chris wasn't appropriate for the @EPUTNHS LD Team

JJ: because they provide healthcare for moderate to severe learning disabilities and have a very very small community service for people with high intensity needs which weren't in same way Chris was presenting, because Chris's presenting needs were around his mental health.

JJ: My previous experience of people being placed in NAS many years before was it had been through social care. Social care deals with social care placements, and health placements dealt with by NHS and EPUT team.

JJ: Felt more appropriate if looking for suitable placement around LD and autism to look for placement from people with experience in that area.

C: what about his mental health isnt issue here at all?

JJ: wasn't priority at that time, he'd received from initial episode of psychosis and was taking treatment as far as we knew. The things not covered in that time were more autism specific, we heard what Julia said and wanted to do best option for Chris

JJ: which is why we were looking for support for Chris

C: did you feel that support you had in mind would deal with risk appropriately?

JJ: difficult to determine something like that because you have to assess risk on every visit, but being in autism focused placement where we'd provide support for mental health, felt like a safer option to us at that time.

C: thank you

TS: thank you, finally email from Dr Villa to you 29 June 2020. You know email?

JJ: not without seeing it

TS takes to bundle. Dr Villa's 29 June email saying "plans have failed too many times in the last few weeks, he can't keep himself safe, we are not able to help him remain safe either" in bold

JJ says she doesn't recall it

C: You dont?

JJ: I dont have the brain capacity for all emails... I receive around 500 a week

C: but given the date, time, severity... you don't have any recollection of receiving this at time?

JJ: at time I would have

C: its for me to make judgements in due course... your evidence to Mr Stoate, repeating to me, is you don't have any particular memory of this email because you receive around 500 emails a week?

JJ nods

TS: its more than striking isn't it

C: subject CN drugs, so we know what the safety focus is

TS: a few sentences down, will be the two of us, Dr Villa and Ms Lister I think

JJ: yes

TS: going to the coroners court

JJ: yes

TS: coroners court dealing with death, no question of level of risk here?

JJ: no

TS: so end will need to go to tertiary panel

JJ: probably wouldn’t go to tertiary panel, that's the healthcare team...

TS: did you take any steps after 29th to go to tertiary panel to ask for specialist unit?

JJ: I didn't personally take any steps

TS: whose role is it? Consultant in your team is using language like failed plans, he cant keep safe, we cant keep safe, coroners court, tertiary panel. Presumably urgency is high?

JJ: yes

TS: who's going to start preparing that for panel?

JJ: care coordinator and we'd ask social care to help with us

TS: with your oversight?

JJ: probably in this case... generally I wouldn't be aware of level of detail of what's going to panel but in this case probably more aware than other cases in our service

TS: can you recall did you take any active steps towards advancing this to tertiary panel?

JJ: I can't recall... is there a response from me in this email chain?

TS: part of the problem we have is chains aren't always easy to follow... [scrolls up bundle] forwarded correspondence but I can't see any response from you. Do you recall a response?

JJ: I cant recall what I did at that time 2 years ago. that isn't to say I wouldn't take any action, would be unlike me if I was at work on that day not to respond to Dr Villa.

JJ: We work closely together, would be unusual for me not to have a response to that or a Teams call with them. In my statement from my diary it says I spent time liaising with team on that day but can't remember detail of that

TS: does your statement touch on any detail

JJ: No I can't recall, there were over a thousand emails sent about Chris

C: at that time?

JJ: yes

C: a week before his death, where the leading consultant psychiatrist is setting out her concerns. What Mr Stoate, and I am interested in, is what you personally did?

JJ: looks like I had some conversation with team, but I can't recall then or now what that was. I'd have to go through archive of emails

C: we've had, I'm hoping, disclosed all the relevant emails and isn't one in response from you to Dr Villa

Missed JJ's response

C: I'm reliant on the disclosure I receive from @EPUTNHS, they've not disclosed anything further, I'll be corrected if I'm wrong. In preparation for your statement you'd have looked at your emails?

C: This is the last engagement you have prior to Chris's death, apart from the meeting on the 7th

JJ: there was a lot of emails, I looked at my dairy and calendar for day, I do make notes in my diary, it was very difficult going through all the email chains to find the

JJ: relevant information

C: I'll not labour point, but would be about looking at what emails you sent in that time period wouldn't it?

JJ: they're all in archive by then can be difficult to get information

C: would seem a little convenient almost, it's a coroner's inquest, all we're looking is whether there was a response from you?

TS: Sir Ms Ballard appears on screen

C: Ms Ballard can you help?

BB: no sir, but what I'm not confident to say is that every single email in existence has been delivered to court... I wouldn't be able to seek that assurance to you sir

C: right, well what I’ll seek before I close evidence in this case is all emails from xx June, the last admission to his death, have been provided by EPUT. I don't think it's an unreasonable request, I've relied on hitherto. Consistent with Duty of Candour, all relevant emails.

C: I'm not talking of every email sent and received, although that would be gold standard, but what I am clear about is this last admission through to death, all emails have been provided.

C: I understand why you say what you do Ms Ballard, those instructing you have legal responsibility. Thank you Ms Ballard

C then asks Judi Jeavons about the professionals meeting on 7 July [day before Chris died] and asks if her memory accords with what is recorded in minutes

JJ: I'm relying on minutes of that meeting to be accurate, so yes

C: we do need to try with current care plan and provisions in place at the moment,. That was your feeling on the 7 July?

JJ: yes Chris had wanted to go back to Hart House, with capacity assessment deeming he had capacity to make decision about his accommodation, with reservation he went back there but as I said Kirsty was looking at other accommodation options throughout.

C: so that, appears to be objective record, of what you said at that meeting. 8 or 9 days after the email from Dr Villa

JJ: uh hum

C; can you assist me with how you reconcile those two if you shared the view of Dr Villa?

JJ: I'd had conversation with Dr Villa on that day because she was unable to attend the meeting. Was called by the Deputy Director at the time because she wanted assurance we were all working together, we still had concerns as team so were looking at what a support other

JJ: colleagues felt they could input into this to keep Chris safe while Kirsty was looking at other options

C; and you felt you could?

JJ: that's what Chris wanted at the time

C: but 8 days earlier you'd all agreed he couldn't and you couldn't keep him safe, whatever he wanted. Trying to reconcile

JJ: I was aware Ms Lister had been communicating with Hart House to try to get a more robust plan in place to make sure his time was filled.

JJ: If he was active and busy we felt would help with risk, not having activities to do felt increased risk, so we were working with them at that time

C: thank you. Mr Stoate

TS: I'll leave it there thank you

No questions from Ms Nash

Ms Denton: I ask questions for Southend Borough Council as it then weas @southendcityc you were asked about Melike Cay and your answer was it depends whether or not you call social workers clinical.

AD: Ms Cay was clear in her evidence she doesn’t' have a clinical role, Ms Allison confirmed that was not case... do you disagree with Ms Cay and Ms Allison or do you ultimately accept Melike Cay had no clinical role at all in assessing Chris?

JJ: I don't accept she had no clinical role at all in assessing Chris

It’s a shared assessment [my paraphrse]

Ms Denton says she wont take that point further but SBC disagree

AD checks her answer about LD Health; she confirms they provide care for people with moderate to severe learning disabilities

[missed question]

AD: to clarify, the evidence generally from SBC witnesses is that social care have no input with NHS colleagues in preparing for tertiary panel... is it case you're mistaken about social care's involvement?

JJ: no I don't think social care are involved in tertiary panel, that's the health panel

AD: so you're happy to accept social care wouldn't have any involvement in escalation of matter to tertiary panel

JJ: yes that's correct

No further questions from Ms Denton

Ms Khalique: I represent the ICB, formerly CCG.... do you remember Mr Sam Ball?

JJ: yes I communicated with him and one of his colleagues

NK: yes. Mr Ball sees his role as trying to support collaborative working, is that your understanding of his role?

JJ: yes, he was very helpful... he was very supportive of what we were trying to do

NK: I'd just like to ask about a couple of emails appended to your statement if I may. 3 June 15:56. That email is from you Ms Jeavons, included in chain is Sam Ball and his

NK: colleague Jo Tyler from CCG, do you remember that?

JJ: yes

NK: sentence towards bottom, you're talking about the difficulty of mental health services not necessarily being right place; you say

NK reads: "my previous experience might suggest a specialist placement might be safer for both him and mum but we may need help getting through that process. As his MH is not an issue the ward wont keep him there unnecessarily"

What were you meaning there?

JJ: many years ago I had two people I was working with in hospital, was working with social care to try to find placements for them... that was what was in my head at that time

NK: so was this a broad description about specialist placement rather than a specific inpatient NHS setting you meant?

JJ: yes this was a community placement suitable for someone with autism, LD, and we'd support with mental health input

NK: understood. So you were talking about Supported Living focused on autism, migh tbe best option for Chris at time?

JJ: that is why I raised the question because that's what I was hoping for

NK: that was an email chain with Sarah Range, the local authority. At no time, correct me if i'm wrong, at no point was request made to the CCG for a bespoke inpatient setting for Chris. Is that right?

JJ: I can't recall whether were discussions with CCG or not, but certainly there were discussions about that very thing which may be touched on this afternoon

NK: were you here on Friday when Dr Udu gave some evidence?

JJ: yes

NK: he said Byron Court wasn't suitable because Chris didn't meet the threshold, there was also talk about there not being an available bed, but he felt mainstream services were most appropriate for Chris. Do you remember that?

JJ: yes

NK: and he felt Byron Court wasn't suitable for Chris

JJ: yes

NK: so was mention of Byron Court, but was never any application as far as you're aware for a bespoke inpatient setting for Chris?

JJ: no as far as I'm aware wasn't, although Mum had asked whether he could go to the Priory, which we pursued as line of enquiry but they weren't prepared to take Chris at the time, which is probably why it wasn't taken further.

NK: So clinically led, an approach made by ESTEP or EPUT to see whether they were willing to take on a patient before you'd take it next step up, is that correct?

JJ: yes

C checks timing, we're continuing

BB: first of all Ms Jeavons you realise who I ask questions on behalf of dont you?

She nods

BB: you said EPUT LD services generally work with people with IQ under 60, would like you to have sight of a letter from Elspeth Clayton [bundle]

JJ reads it

BB: can I ask you to focus on hte paragraph that starts The National Service framework

JJ: yes

BB: you know Elspeth Clayton's role at time?

JJ: I do

BB: So she was Associate Director of Learning Disabilities. In terms of who the team worked with would she be better placed to know or you?

JJ: absolutely Elspeth would be better placed than me

BB: she describes LD services in EPUT focuses on those with moderate to profound learning disabilities ... she says numerical value attributed to Chris was 58 and that equated to a mild learning disability range, yes?

JJ: yes

BB: and therefore fell outside of the LD team

JJ: yes, the health team

BB: yes, I’m talking about EPUT LD team.

BB: She is describing there the national approach, even if taking score given to Chris at age 7 would deem he would be cared for within mainstream mental health services, is that right?

JJ: yes that's correct

BB: do you think you've possibly got the cut off points for IQs wrong in your evidence to coroner if that's what Elspeth Clayton says?

JJ: entirely possible, it's not my field of expertise

BB: I'll; move on.

BB: The reason you were asking for social care LD team to be involved, is as I understand it, because the national approach did not cover Chris with IQ score he was given at age 7 to be covered by EPUT LD services.

BB: You as EPUT team did not have sufficient knowledge about all options available, to put in paraphrased way? Yes?

JJ: yes

BB: so you were reaching out to the local authority who'd have a greater understanding of what was available is that right?

JJ: that's correct

BB; because the difficulties faced by you as team, if we focus on latter end, because Chris had been deemed as non-detainable under MHA

JJ: yes

BB: he'd been deemed as having capacity

JJ: yes

BB: so his views of where to go were of central importance

JJ: yes

BB: they had to be respected above all else because he waws deemed to have capacity, that's a legal requirement isn’t it?

JJ: yes, not me personally but as team, had been through capacity in MHA and discussed with Dave Fisher Hope to check we'd been through what we shd have been

BB: so you were seeking top support Chris at Hart House as you tried to find an alternative as a team, is that right?

JJ: that's right

BB: in part because that's what the law limited you to do if you can't detain under MHA and cant take decisions contrary to what he wanted because he had capacity

JJ: yes that's correct

C: thank you very much Ms Ballard, the issue of assessment post discharge will be something for this afternoon.

Thank you Ms Jeavons, that concludes your evidence you're released from your oath and free to go.

Court is adjourned at 13:28. Back in at 14:10

[Still catching up]

Back in court, Kirsty Lister is called and swears an oath.

Confirms she has her statement with her.

C summarises her details, she’s a registered mental health nurse with over 30yrs experience in inpatient and community settings.

C: Was studying for CBT in Psychosis qualification, was in final year at that point

KL: that’s correct

C; so were you working part time at that point?

KL: yes

C: you’re in the penultimate term of your degree, covid hit, and a case as complex as Chris’s fell into your lap as it were?

KL: yes

C asks how much she was working at time, she confirms 4 days per week, one of which was training.

C asks if impacted on her ability to do her care coordination role. She says they work as team.

C: who would take over on days you weren’t in if something significant happens, would it be Mr Weidner?

KL: possibly, we work closely as team… might be any number of clinicians that stepped in, primarily I’d say Mr W supported me

KL has worked with ESTEP since 2017

C: you’ll appreciate how much of the evidence, the chronology has already been provided to me over course of last 2wks, I have a good idea of where you slot into things chronologically and your role, what you were doing and emails.

C: Rather than speaking about you, we’re speaking to you now, so really important in my questioning to you, or evidence you’ve heard, if there are things you want to straighten out… we know there are points of disagreement on some aspects of the evidence

C: when you’re allocated a case do you have any say as to which you take or receive or not, with experience you’ve got assume you take whatever comes in your path?

KL: as a team we discuss referrals, due to covid process was slightly different.

KL: Normally we’d assess, discuss, think who would be most appropriate, who had space. IN this case we didn’t carry out that assessment took word of Dr Thies Flechtner that Chris was suitable for us. Don’t recall being there when he was first allocated, might have been on leave

KL: When reallocation came up was asked if I’d take him given complexity of case

C: yes. Your experience in learning disability and autism, or cohort of those suffering from both, if that’s the right word, increasingly I’m thinking its not suffering

KL: I have experience of working with people with LD and autism in past, I wouldn’t say I’m an expert but I do have knowledge

C; additional layer, LD, autism and drug use, was that something you’d worked with before?

KL: if I’m honest I cant recall, worked with a lot of people with substance use, some with LD and autism but cant recall if both at same time. Cant recall [missed bit]

C: we’ll return to that. You had I imagine extensive experience of conducting MCAs?

KL nods

C: have there been occasions when you’ve identified someone as requiring a MHA assessment, but you wouldn’t be the person who conducted that?

KL: that’s correct

C asks circumstances that would request

KL: significant deterioration in mental health based on them being settled in community. Aware having a LD also has impact in the MHA and how applied in different way... I have knowledge of that

C; what specifically would LD autism presentation be in MHA

KL: Seriously irresponsible behaviour enacted on repeated occasion, because of their learning disability, that’s my understanding, however I’m not Section 12 doctor so I’d seek opinions on that

C: seriously irresponsible behaviour on repeated basis, that’s your understanding?

KL: that’s my understanding but it has to be because of their learning disability

C: you don’t conduct, but can trigger, make clear one is necessary.

C: Not something you did in Chris’s situation, because you didn’t think he met that test seriously irresponsible behaviour as result of his LD and autism?

KL: this was discussed by the team very regularly,,, we were meeting in the morning and afternoon… this was discussed in those meetings. As MDT team felt wasn’t grounds to call for that assessment. He’d been in community for very short period of time.

KL: Having been discharged on a couple of occasions against medical advice, so my understanding from my colleagues is if he were felt to be detainable they would have detained him on the wards.

C: Dr Carr gave risk as low, you as a team seemed to unanimously agree the risk was high

KL: yes that’s correct

C: I’ll come on to latter point of how reconcile views of team and view expressed subsequently that he could be managed in the community.

C asks if multi disciplinary meetings were recorded

KL: potentially in xx document, might be there

C: can you point to any, imagine you’ve looked at documents in some detail

KL: I believe it is recorded in there that we’ve had that discussion and it wasn’t felt that a MHA assessment would be appropriate at that time.

C: ok I’m conscious, I think I have sufficient grasp on Care Act Asst and Carers Asst being undertaken…

C: you and ESTEP didn’t have any concern 7 May professionals meeting concluding you were the appropriate team to lead at that stage?

KL: at that stage we were appropriate

C: and generally ESTEP would be lead for next 6 months?

KL: that is our operational policy sir

[missed chunk[

KL: ESTEP were initially right team.,.. I worked very closely with mum, hope its ok to call her mum, she’s been mum throughout for me

C: I’m seeing nods, yes

KL: ESTEP had been lead, I know switch to LD services was mum’s wishes. What was clear was he needed to be under a service, it wouldn’t have been appropriate for us to discharge him at all

C: yes. So under a service, if he was under the lead of LD team contributions from your team, if he was under the ESTEP team, contributions from LD

KL: yes a team around me approach

C: what Mr Ball described as a wraparound support

KL: yes

C: I’ll need to consider the contributions from teams other than ESTEP. Do you consider was sufficient contribution to the wraparound from other services. Do you feel?

KL: As heard from my colleague earlier at beginning that was tricky… but over period of time I felt people were hearing our voice, and mum’s voice. We tried to advocate for mum and Chris. People became more involved, services would be a better choice of word

C: do you agree as Ms Jeavon’s put that the contribution of Melike Cay was valuable and supportive?

KL: incredibly

C: we heard from Melike Cay her team technically didn’t need to be involved, it was an add on she was providing from the social care LD side.

KL: that’s certainly how social care have described it to us, from my point of view I thought it was an invaluable MDT approach

C: so social care were saying they were going extra step, you prefer to describe as multidisciplinary or collaborative approach

KL: both, multidisciplinary and collaborative

C: beyond the valuable and supportive contribution of Melike Cay, who else would you say contributed,..,. practitioners or clinicians, to use my phrase, that stepped up

KL: from my own personal point of view as care coordinator, not sure if this is right time to state, were a lot of discussions above my pay grade. From my perspective I found the contribution of Mr Sam Ball incredibly useful.

KL: At time of Capacity Assessments Ms Salici incredibly helpful. Also had lots of email exchanges offering advice, with Sharon Allison

C: I’m leaving your team to your side

KL: I couldn’t do that sir [laughs] and I’d also like to add while not a team member, mum, was an incredibly useful contributor to this. I’m sure there might be others

C; those are who come to mind. I’m scrolling through, coming to first discharge

KL asks date

C: we’ll start 22 May. You emailed Dr Thies Flechtner, saying you’d like to attend discharge meeting, but you don’t work Tuesdays. You were spelling that out because you wanted to be there and couldn’t be on a Tuesday, crystal clear

KL: yes

C: no planned discharge meeting… I’ve heard from Dr TF, you were well aware by this stage of Julia’s concerns about support in place prior to discharge.

KL: yes I was very clear

C: not least because of her experience of 7/8 April where Chris had come back from London having been detained in London on S136, had returned in taxi, grabbed his ipad and was out, leading to the Section xx detention.

C: I want to ask about this discharge, against medical advice, and returned to his mother’s address without any appropriate support in place.

What did you think about it at the time and did you consider it safe in all the circumstances?

KL: I believe I emailed Dr TF to say we felt it would be an unsafe discharge….

C: Explain wouldn’t be any extra support in place by Tuesday, as agreed in professionals meeting 7 May. Absolutely spelt out

KL: yes

C: did you ever get a response to the email you sent?

KL: I had a telephone call with Dr TF

C: what did she say in summary

KL: telephone call wasn’t immediate, it was after

C: after the discharge? Your email was sent on 22nd [?]

KL: yes the Friday, I believe the discussion was held after he discharged to explain Chris had taken his own discharge

We spoke about it. I reiterated Mum needed more support, Chris needed support.

KL: We also spoke about me not being invited to CPA discharge which she agreed I should have been invited to, was an oversight

C: were you surprised, you as care coordinator, liaising on Care Act Asst, with a mother expressing the concerns you’ve spelt out in an email...

C: that you weren’t invited. Were you surprised by that, it seems on the face of it, quite a thing to have an oversight in relation to. Almost first person on invite after mum would be the care coordinator.

KL: It is unusual that we don’t get invites, normally we are invited to participate in CPA discharges. Obviously it was covid, normally we were on the ward

C asks how long Chris was in the community after that discharge

KL: I believe he was discharged on the Tuesday 26th and by the Saturday he was in the assessment unit. Friday was admitted to acute unit, was transferred to Basildon under Level 2 observations by Saturday 30 May

C: so in one view the lack of safety in that discharge was born out by events that manifested themselves and he’s back in the assessment unit, is that a reasonable conclusion?

KL: we’d consider that a failed discharge

C: assume as care coordinator its not entirely unheard of for someone to have discharge review formally, but person comes off as Chris was no longer under section, decides to discharge against advice.

C: What’s contingency plan in that case, generally, must be possibility they’re going to walk out?

KL: its considered, especially if someone has been on a section detained. We’d still as team react to that and create a 48hr assessment anyway and formulate plan from there.

C: so if clinician says no grounds to detain they just walk, and there’s nothing you can do if you’re a) informed about it before b) seeing them within 24-48hrs

KL: yes taking discharge against medical advice, is more experience consultants on team would have considered detention under the MHA, either section 5-2 or 5-4 nurses holding power

[missed chunk]

C asks if 3 weeks for the minutes to be circulated for checking felt excessive and KL agrees that would be excessive. She confirms she’d have received an update from her colleagues.

[missed chunk – discussion about care records]

C: So Chris had told Araba Duah [?] that he’d overdosed. He stated “I woke up in the morning and because I did not feel the day. I thought fuck it, and took the tablets”

He claims his intentions were to end his life. When did you find out about that?

KL: Given that was Saturday I’d have been aware the following Monday

C: thank you, was this on your mind, certainly on this account, it says he claims his intentions were to end his life

KL: yes that would have been on my mind

C: and if it was on your mind you’d have shared that with your ESTEP colleagues?

KL: yes

C: at that point Mr Weidner had made contact with Stars and they suggested the YPDAT would be better service…

C: obviously I’ll take that up with Mr W in due course, but few weeks later before YPDAT were approached. Is that your recollection as care coordinator

KL: yes I believe so

C: can you help us with why delay?

KL: I believe because he was an inpatient at time, and because of covid we weren’t allowed on the wards

C: thank you

X described him as victim of his own over privileged upbringing… was masking a particular concept you were familiar with at time you were working with Chris?

KL: yes I had seen the GOSH report as well at that stage

C: so you’d not only seen the GOSH report but you’d read the report

KL: I had read it, but I didn’t understand all of it, the cognitive assessment teams, but have excellent support from psychology who were able to explain them to me

C: including Dr Ball

KL: yes including Dr Ball, and this was the evidence we had

C: you weren’t going behind the diagnosis

KL: sorry I’m not sure what you mean by that sir

C: forgive me, because the tests were when he was 7, the evidence I’ve heard is it wasn’t consistent with his academic achievements...

C: a lot of discussion around what that means, but he was at mainstream school and his experience on ward. Suggestion was his LD and autism perhaps wasn’t as pronounced as Prof Skuse found, but it was maintained by Dr Ball and others that you wouldn’t go behind that report...

C: unless and until could have updated assessments

KL: yes thank you

C; and they couldn’t be done for range of reasons [lists them] can I confirm with you that you weren’t going behind them

KL: no

[missed chunk]

Coroner asks KL whether she felt she had the right skills, experience and training to conduct the mental capacity assessments.

KL: I did but also was mindful, I knew Mum had a disagreement with respect to what was being provided and what she’d like Chris to have which was why we sourced extra support from LD

C: we heard from Ms Allison that with the benefit of hindsight, Mr Stoate put as foresight, for me to consider, would have been better for Ms Allison with her wealth of experience to have supported you through that assessment rather than Sam Salici.

C: Did you know Sam Salici before you worked together?

KL: No

C asks if she was aware she wasn’t very experienced at MCA assessments

KL: I was led to believe that she had far more experience and knowledge than she declared

C: let’s be clear you weren’t led to believe that by her were you?

KL: on the Tuesday when I wasn’t in work I believe this was discussed… that was the day pressure was put on us to complete the assessment then, but it’s a Tuesday which I don’t work.

KL: Also knew when that took place that was where the support was requested, I would have put faith in my colleagues to make sure the appropriate person was selected to do that.

KL: As a Band 6 specialist I’d have expected Ms Salici to have that knowledge and experience and have chosen her for that reason.

C: and you’re aware of what Ms Salici said in her evidence that she didn’t have that knowledge and experience

KL: I did hear that, but we had a long conversation before and I didn’t get any impression she didn’t have experience in that, she was very forthright in what she could bring, what she could do and how she might help me

C: and was there again on 18th with additional support of Melike Cay

KL: yes, reason for bringing in another layer was because of disagreements we had… mum was very unhappy with the results of what we concluded in first assessments.

KL: I was the one wanting to find he didn’t have capacity because we could have applied a whole other level of supports, however I have to abide within the law

C; we’ll come onto those; you’ve read the Niche report

KL: I have

C: and what it says about a lack of clarity. Focusing on 10th, query around capacity

KL: poor choice of words on my behalf

C: might be thought critically important. He wasn’t found to have capacity around medication

KL: that’s what we found

C: you say was found to have capacity around where to live, more concerns around understanding medication and harmful effects of drug use… Easy to Read material provided...

C: after further clarifications with LD team was felt he had capacity around his drug use but he chose to make unwise decisions.

You’ve used phrases there that don’t appear to have particular clarity

KL: In this case when we discussed drug use with Chris he stated he didn’t want to stop using drugs.

We were questioning in various different ways, looked at capacity in aspects suggests, rephrased our questioning, explored with him, gave him literature.

KL: In respect decision around drug use we applied borderline principle… states if there are more yeses than nos to a particular posed questions then have to deem capacity is held.

KL states they had more time because he was inpatient at time

KL: He stated he’d have a break and breaks are useful. As the act states we have to assume capacity

C: yes, there were concerns, so first stage is to have capacity assessment.

He has a learning disability, that triggers the assessment.

C: When was the autism friendly literature given, I thought it was prior to the conduct of the?

KL: It was sent to the ward prior to, can’t recall if Chris had access to it or not but we took another copy anyway and went through it with him

C: is how you express it… there were more concerns around managing medication safely and understanding harmful effects of drug use. You concluded he didn’t have capacity around managing medication safely but in same sentence around drug use

KL: he said he’d take a break from taking drugs

C: not on the 10th, not in your statement, may be in the full document, lets turn to it

[Discussion about the document, can't easily be found in the bundle. Agreed that Rob, the Coroner's Officer, will photocopy the version Ms Lister has.

Court adjourned. Back 15:30]

Coroner confirms Nyarumba won't be able to view the document, and neither does anyone following online.

BB gives bundle reference - Bundle 4 p390

C: I should just say this, its right isnt it, not a criticism, the copy we copied from you has at page 5, is it your hand writing?

KL: yes

C: Its in a highlighter, next to can a decision be made you've written yes, then borderline with asterix, then other boxes highlighted red. Assume added subsequently

KL: because the X doesn't show where it should. I highlighted because those are the boxes I've ticked but doesn't show on form.

C: what about yes borderline

KL: to remind myself this was meant to be ticked, the others weren't but I couldn't take that off

C: I'm struggling a little to understand this

TS: Sir it looks like Ms Ballard has frozen, it might be important

C: Ms Ballard can you hear me?

NK: I've had a text from her saying I can hear him, he can't hear me

C: the him is me is it?

NK: yes, she'll sign off and sign back in

[Taking this chance to hit send on these tweets]

BB: Sir can you hear me?

C: I can hear you

BB: sorry you've got me frozen in court, which is very inconvenient...

C: if you can hear us now we'll turn please to page 5, what you wont see, I suspect on your version is some annotations I was just discussing with the witness

BB: I'm aware of them, I know they're something the witness wishes to bring to your attention during the course of her evidence

C: there's an X next to the decision can be delayed. but seems two options, first not appropriate to delay, second first person not likely to gain...

C: or develop capacity. Can you help me with this form and what's going on. May be I need further evidence about how these malfunction if that's what's being suggested.

KL: working remotely was given as electronic copy which didn't allow me to edit the boxes.

KL: Also I'm not responsible for uploading, I'd give to admin team. Normal process is I complete manually and it would be typed up for me. I was working from home, wasn't aware the boxes had moved around.

C: when did you write yes next to it?

KL: when I printed it off, was first time I'd seen it printed

C: so recently

KL: yes, because with the borderline principle we felt he might gain capacity by understanding more about it [my paraphrase]

C: so you're saying there is an X, you have ticked a box saying this can be delayed.

KL: this cannabis one yes

C: you're asked describe process, is inpatient to persons' mind or brain

KL: that's yes, as I wrote underneath because of his autism

C: here the No box is ticked

KL: it's not, it should be in the yes box. If it's no I wouldn't have written anything, its yes which is why I wrote that

[Autism diagnosis could impact on Christopher's level of understanding and difficulty imagining different circumstances and outcomes]

KL: We were mindful of that [autism] that's part of the capacity assessment.

C: can the person understand the information relevant to their decision, are you telling me on this occasion it is in the right place?

KL: it should be in the yes box. Although we were querying capacity, he said he was going to give up drugs for a while... under the borderline principle there were more yeses than no which was why he concluded he had capacity....

He had agreed to give up for next few months

C: you've written "we queried present capacity in regards cannabis use as Christopher could not make the link between his recent use and how ill it made him, where he required emergency services and hospitalisations...

C: Although he has agreed to give up for the time being so he can access supported accommodation" so that's a utility.

Can they retain information long enough to make the decision, there's no box but it's crossed yes

KL: hmmm

C: describe how assessed, you've written "discussions, using visuals, rephrasing sentences, repetition" there's nothing written there

KL: I think continues on next page

C; I'm looking at that question, there's nothing written

KL: we'd already done that in previous write up what we'd already bought, we'd brought Easy Read, I dont repeat that

C: it's there for reason isn't it, you haven't written see above or anything.

C: Can they weigh up information as part of process of making decision. Nothing is marked. Neither box appears to be ticked. You've highlighted as a yes. It's not a question of X in the wrong place as in 1.8, there's just nothing there. What's the explanation for that?

KL: I ticked the yes box, I have no idea why it suddenly disappeared

C: let me ask you this, I presume you reviewed all these forms when preparing for these inquest proceedings, why didn't you mention any of this before today?

KL: that the forms aren't accurate?

C: yes, we're Day 10 of the inquest, brought to my attention for the first time.

Julia, Mr Stoate are hearing it for the first time.

When were you first aware the form was malfunctioned in this way?

KL: when I printed off for here, when we were going through the bundles, was when I realised the form hadn't translated as it was completed.

C: well we'll complete this form for the moment.

C: Can they weigh up information, nothing marked, you've highlighted yes box.

Query present capacity in regards cannabis use... he did not feel cannabis made him unwell or caused spasms, he believed it was a reaction of his body

C: He struggled to see cons in cannabis use despite discussing this with him. He agreed to give up cannabis for next few months. Did it occur to you he could tell everyone he'd stop to get accommodation, but its the "biggest thing in his life" quote, why would you swallow that?

KL: I don't think we swallowed that

C: discussion with LD team, those present?

KL: we certainly discussed it after and in the moment explored that with him and revisited multiple times various different aspects of what we were posing at that time.

C: Completed on 10th at 1pm, Chris expressed this [cannabis] as most important thing in his life... query his capacity to understand dangers, unable see link between use and spasms, when discussed with him and possibility of him dying he sat with blank expression on his face

C: as if he could not process this... Chris stated he does not care how long he lives, and does not care about getting old, this is in conflict with his future plans... could not express emotion... was no empathy shown when we explored how others might feel if he died...

C: was unclear if he'd be able to keep himself safe but was able to understand what the word vulnerable meant [am missing most of this at speed] in conversation he initially tells you things you want to hear, but on querying for more information he struggles....

C: I'm trying to reconcile the answers you tell me in your evidence you gave, even though it doesnt match what is recorded elsewhere. When you use phrase query capacity in relation to medication, cannabis, keeping himself safe...

C: so no capacity for medication, capacity for cannabis use and keeping himself safe

KL: I've explained the borderline principle. I shouldn't have used the term query

C: were you aware of the borderline principle at the time?

KL: yes it's part of the capacity assessment

C: with respect, are you sure you haven't become aware since

KL says she was aware

C: I'm struggling to see why you wouldn't do it at time?

KL: I dont want to make excuses however Ms Salici was supposed to be writing these up, but at the last minute she wasn't able to.

C: why wasn't she able to?

KL: she had childcare issues... so they came back to me, I was filling them out late at night, not to make excuses

C: did you have the forms with you?

KL: no because I was working from home and didn't have any way of printing them, and the ward couldn't help us in that respect

C: it’s your assessment

KL: we were completing them together

C: were you aware she'd never completed one, hadn't recorded one?

KL: we spoke about it, she agreed to write it up, we'd discuss and then submit it

C: whose name would have gone on the front

KL: was still my name I was still the lead

C; so why would she have completed it?

KL [missed]

C: so had did you know that? Did you have a notebook?

KL: yes

C: do you still have a copy of that?

KL: not from 2yrs ago, I'd have typed them up and destroyed them because they contained personal information

C: so there's no contemporaneous record of what you write on the form

KL: not now no

C: so instead of writing, this is all new evidence to me. Where you've written bottom p5 query capacity with regard to cannabis use. He couldn't understand the causative link.

KL: he couldn't demonstrate it, in that setting, at that time

C: instead of writing query present capacity, what would you have written, what did you intend to write?

KL: what potentially would have been more helpful is we demonstrated he'd agreed to give up cannabis, so we could apply borderline principle was answering more yes than nos, he recognised he'd need to give it up in order to go to a different placement.

KL: We'd keep providing support, but as inpatient could be delayed because he didn't have access, so we would continue to provide support and education involving YPDAT.

C: it was obvious he wasn’t going to give up drugs wasn’t it?

KL: that doesn't make his decision invalid

C: no, it just demonstrates a different motivation

KL: we felt he understood this was something he'd need to do. As I said, I've already said sir, for me if I could go in and say he lacked capacity there would be more routes available but I do have to follow the law...

KL: and we couldn't prove that he definitely didn't but there was definitely more work to be done

C: ok. With some trepidation I'm going to turn to the assessment on the 18th.

C asks BB for reference in the bundle

BB can't locate it

KL: There isn't a formal copy of the cannabis question because we weren't revisiting at that time because we were still following on from previous assessment, he was due to be seen by YPDAT... we discussed with him and all agreed as per write up he had an understanding...

KL: but there isn't a formal write up of an individual question for cannabis on the 18th

C: Ms Ballard you heard what said was no formal assessment with regards to capacity as it was, my words, a work in progress

BB: yes sir, that's what I'd understood from the contemporaneous notes... I've got both in Bundle 4 and 7 [she provides reference]

C: no, no, no, all the way through, the boxes appeared to work on this occasion... 18 June, returned 10pm...

C: left accommodation 1am and consequently suffered seizure [C reads] in the garden, this is the day we heard evidence from Melike Cay in respect of, cannabis and cannabis tolerance. Third paragraph of what you've written, keeping safe in context of cannabis.

C: Attempted to discuss his cannabis use and he replied no comment... was able to share would not give up cannabis but could take a break... he said because of his tolerance.

C: So not here to get into his assisted living, different reason now, 8 days later. Was that cause for concern?

KL: we continued to question him

C: I see that but he's giving a different reason isn't he.

KL: you have to take in context of whole line of questioning, didn't just take one answer...

C reads

KL explains that Chris hadn't had chance yet to work with YPDAT, was still saying he'd give up, so they felt they'd bring in a specialist

KL: that's where the decision came in seeking expertise, someone a specialist in drugs, alongside LD and autism

C: Melike Cay was fairly clear in her evidence that you suggested she'd take lead in doing that

KL: yes she'd had experience of outsourcing, her team paying for an expert

C: I think i'm right in saying Ms Cay didn't accept that, am I right in saying that?

BB: She accepted there was a conversation, she recalled in context as you recall of sexual health, and she didn't accept it was going to be her who was finding that question.

C: was it your understanding it would be?

KL: my understanding was she'd explore the process, not that they'd fund it... but she'd explore and if that person existed we could find someone to help us under the disagreement principle because we were aware that mum felt differently to us

C: right. You've written is 19 year old male, his social aspects of life are solely around his cannabis use and he has no motivation to change this. He does have aspirations to be independent.

This box is in regard to keeping safe isn't it?

KL: yes I couldn't untick it if that makes sense, although on this form we weren't making the decision around drugs, this particular decision was about his seizures

C: and that decision was delayed?

KL: no, it wasn't delayed, I'd ticked the box

C: it does, what does that signify?

KL: on this form that the decision can be delayed but we didn't need to delay....

C: so why has it got a cross next to it then?

KL: I unticked it I don't know... there are areas where this form hasn't translated... I take back to covid, we'd normally have a paper version which someone would type up for me

C: this is 2020 arent these forms being completed electronically routinely?

KL: You would hope so

C: I would. They're important medical records in an Article 2 inquest. These MCA assessment forms were designed as you understand it to be completed electronically or in paper copy

KL: yes

C: have you ever come across difficulties completing them electronically before?

KL: I'm not aware of colleagues completing electronically, generally we'd have paper copy we'd mark and someone else would do it for us

C: did you not have a printed out copy for this one, on the 18th?

KL: no

C: why not, this was 7 or 8 days later

KL: we weren't in the office sir, I was working from home. This assessment was decided to do the day before, whilst I had my laptop with me, the three of us sat together and wrote up the body of text and then I transferred when I had wifi at home and continued to fill in the box.

C: OK. Conclusion that Christopher had capacity and could keep himself safe. In relation to cannabis?

KL: no this was in relation to seizures only

C: any relationship between cannabis and his seizures?

KL: his evidence was he hadn't taken cannabis at that point. For us, this was around his seizures and having a seizure in the middle of the night, in the street.

C discusses timetabling. Mr W won't be heard today. We will sit until 5pm.

C checks Melike Cay's evidence re specialist

BB confirms she did not agree that she was the one who was going to be looking into it.

C: different to your memory, your memory is she did

KL: and my memory is based on my entry that day on the mobius notes we hold

C: did you ever chase her up on that between 18 June and his death?

KL: no because the agreement was he'd have input from YPDAT

C: so his capacity would only be assessed if he'd engaged with YPDAT?

KL: no, if he hadn't engaged with YPDAT then we might have explored again, but that didn't happen

C: discharged to Hart House, over course of that week was relatively positive news, then incident of [withheld] on 26th, is that right?

KL: yes sir

C: that was ironically the same day you explained to Christopher he had a signed contract for Hart House... you've written there Christopher had no intention of stopping his drug use and felt was not linked to his physical health.

C: That seems to go completely against what he was telling you on the 10 and 18th June would you agree?

Is what he'd said to other clinicians, on the ward and elsewhere, I aint stopping the cannabis

KL: at that point we'd be pushing for YPDAT involvement and we were still going to be doing another assessment with a specialist

C: You say he was a gentle and kind man, I'm in no doubt about that.

C: You said you'd said to Chris would need to revisit capacity assessment [think he said] and he replied it's all good.... Julia's view was as helpful as you were trying to be, your lack of experience in the field was inhibiting, ditto the 18th, her ongoing concerns about his...

C: embedded intention of not stopping his drug use, is it, you weren't surprised she's asking for a specialist drug and autism placement

KL: I wasn't surprised at all, wasn't first time we'd discussed

C: and in that context he [withheld] you say was seeking adrenaline rush, you say was unclear if was suicide attempt... back in the assessment unit.

By this stage, I don't think we need to go to the very clear email exchange with Dr Villa of 29th...

C: you as a team knew Chris couldn't keep himself safe. You knew as a team we can't keep him safe.

KL nods

C: what did you have in mind at that stage, what was the way forward going to be?

KL: for me, mum suggested somewhere she'd like him to go so I started contacting various placements.... a discussion we had with mum was she felt might be helpful to get him out of Southend, we were looking at places, keeping in mind this had to be a place Chris agreed to go to

C: he wasn't felt to be detainable at this point

So at this stage he's in Basildon Assessment Unit, under the care of Dr Carr, on 29th couple days later accedes to his request to discharge himself, apparently against her advice, having assessed him as at low risk...

C: or self harm or suicide. So did it come as a surprise to you that he was discharged on the 29th?

KL: it would have, but I didn't know until the 29th that he was an inpatient, because we don't all work weekends.

KL: I only knew then he'd been admitted, and that he was being discharged, on the same day.

C; when you found that out was that a surprise?

KL: yes and I believe I had a conversation with the ward to ask them to try and get him to stay

C: was there any discussion about an assessment given the capacity borderline position you'd identified?

KL: at that stage he was an inpatient, Dr Carr had decided he was capacitous. The first assessments had been on her ward, so she was aware.

KL: She deemed him to have capacity and not be detainable.

C: right, home treatment team were asked to be involved, they felt was not appropriate.

They were asked again. What reason did they give for not being involved?

KL: The reason given was due to his autism it had been identified we needed to keep the amount of personnel engaging with Chris to a minimum so he had a consistent team.

KL: The home treatment team work on multiple staff doing visits, so they didn't think would be appropriate to send multiple people at all time so was felt he should remain with us.

KL: Although due to covid I wasn't able to do face to face at that point so Mr Weidner took over the face to face and I did remotely

C: did they give the same reason on both occasions?

KL: yes

C: so the first time they came back and said no, and you went back again....

KL: yes this was happening on the same day as the email that we'd identified we'd struggle

C: so even though on balance it would involve new faces that was worth it, something in your view was important?

KL: that's why we asked twice

C: yes. Richard agreed to do the 48hr follow up.

We've got the email exchange. Were you ever disabused of the notion he'd tested positive with cannabis and cocaine?

KL: no I wasn't aware he had tested positive for cocaine... cannabis was his go to drug. Also I'd seen the recording.

C: so you had the suspicion right from the start. Quite a bit was made by Dr TF that cocaine might have led to the psychosis. Did you have experience of that?

KL: in all my dealings with Chris he felt cannabis wasn't contributing, having used other drugs previously he felt that was what had contributed to his psychosis

C: you made enquiries with the Priory... and they said they wouldn't take anyone with drug use

KL: well actually they weren't taking any NHS patients, and weren't working with drug use

C: so they were ruled out completely.

So Julia felt Hart House, in her words were useless, but commended Dr Villa and the ESTEP team for efforts they made to support Chris.

C: I'll hear from Mr Weidner tomorrow, but post the discharge on the 29th I’m trying to understand given unanimous view he couldn't keep himself safe, you couldn't keep him safe, mum is saying Hart House is useless and can't keep him safe...

C: whether team considered MHA assessment, notwithstanding he'd just come out of the assessment unit.

Was that something you discussed at any point up to the tragic events on the 8th?

KL: my recollection is hazy, was an awful lot going on there. I'm mindful of not being biased having read a lot of stuff. It would normally have been a discussion we would have had, however I'm also mindful that Dr Carr didn't think he was detainable at that point

C: yes but she's got the perspective of an inpatient low risk

KL: that was her belief at the time

C: yes, but she's got him as an inpatient, you guys have him on the street, in the community. Level of risk you all considered to be high risk, it hasn't gone down?

KL: we did. I cant say under oath that we definitely had that discussion but I most likely had

C: so you should have had a discussion about someone returned to the community when at and about the time he's gone into care you've all agreed he can't, and you can't, keep him safe

C: other than Dr Carr says he’s safe for discharge?

KL: we would have discussed, certainly in light of RAG. Would have been what's package of care in place. But it wouldn't just be about that

C: would it have been part of it?

KL: you're asking me to remember that, but....

C: yes it’s days before this young man's death.

You're put in a position where you're being asked to keep someone safe, who you don't believe you can keep safe.

Put in an incredibly invidious position, I understand that, in all circumstances, including Julia's representations

C: Can you help me whether there was a documented discussion with the team, beyond the email spelling out concerns from Dr Villa, that documented discussion with you collectively, that spelt out whether a MHA assessment was needed?

KL: I can only make an assumption on that, I'm really sorry

C: no, that's fair enough.

Coroner asks what placement options were explored

KL: That was Ruskin Mill and there administrator said she’d sent through information but I never did receive that

C: even after the tragic events

KL: No I didn’t ever receive that

C: you sent over a thousand emails, worked late nights, extra hours to try to support this young man and his family. I remind myself in the context of the covid pandemic.

C: You were the care coordinator, you’re not solely responsible. You sought to draw together other aspects.

NK: sir forgive me I wonder if the witness wants a moment

C: I can see the witness

KL: I’m fine, thank you

C: it was a frustrating aspect of what you were doing. My last question Ms Lister was in relation to the professionals meeting on 7 July.

You weren’t present at that, were you aware of the outcomes of it before the tragic events the next day?

C: Did you know the clinical plan would continue?

KL: No, I was just following the plan that was already in place

That’s all Coroner’s questions for now.

Discussion re timetabling. Switching of order of questions being asked

Ms Denton introduces herself

AD: Was it the case that you looked back at contemporaneous notes or just relying on your memory?

KL: both

AD: There’s no mention of any steps to be taken by Melike Cay in sourcing an expert and equally there’s mention in there of Sam Salici and Melike Cay of helping with reframing questions and so on.

AD: Is it the case you may be mistaken in plan for MC in sourcing an expert or is there a document you can take us to to show that?

KL: I don’t think there’s a document, but I didn’t have any experience in that so I couldn’t do that. But Melike Cay in her evidence did state she had experience….

[missed some]

AD: we’ve already seen email from Melike Cay saying more work to do in respect of drugs but no formal follow up

KL: my recollection is we were going to do a formal assessment once the YPDAT team had been involved

AD takes to bundle: One of your paragraphs in the written note… piece of work to be done about drugs and alcohol, were of view he’d be more amenable to that if delivered in an informal manner. Does that inform your recollection at all?

KL: Piece of work would be done by YPDAT and they’d do in informal manner, be aware of autism, find locations that would make Chris feel comfortable.

AD: you mention the borderline principle is part of your policy, are you suggesting that’s EPUT’s policy?

KL: that’s from Capacity Act itself, I’ve not checked EPUT’s policy itself

No further questions from AD

C: Ms Khalique

NK introduces herself

NK: When you talk about the borderline principle do you mean a person is not to be deemed to lack capacity unless they’ve had education to do so [my bad paraphrase] so you needed to do work

KL: that’s correct

NK: wanted to look at the document you provided with hard copy now. Para 1.8 two stage capacity assessment, internal page 5 of hard copy document. You told us some errors in populating the fixed boxes, yes and no boxes. Stage 1 is there impairment of person’s mind or brain…

NK: looking at content and ignoring boxes for moment is the impairment or disfunction of the person’s mind or brain autism diagnosis?

KL: I think its both autism and learning disability

NK: in this box

KL: yes autism

NK: so there’s no question from the content that the answer is yes… autism diagnosis, in this box?

KL: yes

NK: that then presumably led you to go onto Stage 2 is that right?

KL: yes

NK: because we know if the person didn’t meet stage 1 then the assessment should be stopped.

So let's look at content.

You’ve gone on to say we query capacity, when you query someone’s capacity, do you then revert to making sure all practicable steps to help them make the...

NK: decision are taken before you come up with the conclusion that they lack capacity?

KL: yes

NK: ok, as I understand it its recorded in box 1.9, p6 of hard copy, where recommendation is for further education and support around cannabis which should be provided.

NK: Is that correct?

KL: yes

NK: so is that practicable step to help Christopher at this stage to make informed decisions around cannabis?

KL: yes

NK: at this stage we know MCA is that someone is deemed to have capacity unless all reasonable steps are taken, is that correct?

KL: yes

NK: ok, finally, you mentioned in your evidence Sam Ball… its become clear that there weren’t any formal applications for an inpatient setting for Christopher because he wasn’t detainable, and as an informal patient he wouldn’t agree to go

KL: well

NK interjects: I’m talking about keeping him in hospital as an informal patient

C: depends on setting doesn’t it

NK: I’m talking about Byron Court and Priory. Is your view he wouldn’t go as he wanted to go to Hart House.

KL: He wanted to go to Hart House, but I didn’t put either option to him as neither would take him so I didn’t want to confuse him

NK: yes. Mr Ball in his evidence talked about wrap around services. If it’s right wasn’t going to be an inpatient setting, what did you understand to be a wraparound service, and who would provide it?

KL: important to say was aware of a lot of discussion above my level about that. My understanding was I’d work with different services in order to support Christopher as best we could

NK: and one of those services was YPDAT

KL: yes

NK: and that’s a service commissioned by the local authority is that your understanding?

KL: I don’t know who commissioned that service I’m afraid

NK: were you aware Mr Ball made an introduction to that service through Dr Villa and the manager of YPDAT

KL: I’m aware of that now, not sure of that at time, but have to push to my colleague Mr Weidner who was taking a lead on YPDAT

NK: which brings me to my final point, your evidence was you found Mr Ball’s input to be helpful

KL: very much so

NK: thank you.

No further questions from Ms Khalique, KC

C: Apologies once again to the ever patient Mr Weidner (he was bumped Friday and today)

BB confirms she’s liaising with Sharon Allison to provide a bundle of emails, and she’ll not be able to check with Dr Udu as he’s not well enough

Coroner reminds her of his request to check he has all emails disclosed to him from last admission to Chris’s death.

Ms Lister is asked not to discuss her evidence with anyone.

Court is adjourned 16:57.

Back 10am tomorrow.