Thread by @ChrisNInquest

Day 11 of Christopher Nota's Article 2 inquest will shortly be starting.

Area Coroner for Essex Mr Sean Horstead sits without a jury.

This inquest discusses suicide and self-harm.

I report contemporaneously, as accurately as I am able. This is not a transcript.

1/

5 Interested Persons represented by counsel

Chris's family by @TomStoate of @DoughtyStreet

@EPUTNHS by Briony Ballard of @serjeantsinn

Hart House by Laura Nash of @SJBnews

@SouthendCityC by Alex Denton of @ropewalklaw

Southend CCG, now @MSEssex_ICS by Nageena Khalique KC

2/

I attend court remotely

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

My tweets are rarely exactly in real time as I try to capture as much as I can, and tweet them once a thread is full/ time permits

3/

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

This inquest discusses suicide and self harm.

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

4/

My #OpenJustice work is crowdfunded chuffed.org/project/openju… and I'm grateful to those who fund, and follow it.

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

5/

I'm assuming that we'll start today with the remainder of Ms Kirsty Lister's evidence, she was Chris's care coordinator, and then we'll hear from Mr Richard Weidner, CPN.

Not sure who is up after him.

I'll stop numbering tweets from here.

Day 11 will begin shortly.

6/

Coroner confirms all three Niche witnesses will be heard tomorrow, today will be hearing the remaining evidence from Kirsty Lister and Richard Weidner.

Coroner discusses his intention for rest of week, he needs time to consider matters. Has in mind a narrative verdict.

Grateful for indication from counsel if they intend to make submissions, albeit on caveat will not have heard from all witnesses yet [my paraphrase].

Coroner makes Julia and Nyarumba aware that he'd like to return his conclusion on Friday but there's a lot to consider and may not be possible.

He's due to start another 2-3wk inquest next week.

Coroner calls Ms Kirsty Lister back, she re-swears an oath.

C: over to Mr Stoate

TS introduces himself, says he won't go through everything

TS: looking at capacity assessments are you familiar with the @NICEComms on decision making in capacity? Published on 3 Oct 2018 nice.org.uk/guidance/ng108

KL confirms all NICE guidance is important and she was aware of it

TS: 1.4.8 Assessors should have sufficient knowledge of the person being assessed

KL confirms that's important and why

TS: you heard Ms Salici's evidence?

KL: I did

TS repeats Sam S response to his question about whether she felt she had enough knowledge to assess Chris's mental capacity at the time she was involved - she said as decision maker she didn't feel was appropriate for her as she didn't know him well enough or his complex history

KL: that's what I believe she said

TS: did she raise that with you at the time?

KL: no

TS: if she had, what would you have done?

KL: are you asking me to look back and say what I would have done?

TS confirms that he is

KL: we'd explore that, look at what they felt they were lacking in knowledge in and see whether they needed to know more. We meet before an assessment to discuss the case, we had met, Ms Salici knew enough...

KL: that's what happened at the time, that's why I disagree with what she said

C: in fairness to Ms Salici, and this witness, she was referring to what she knows now...

C: I think Ms Salici agreed there was a discussion before hand, they did speak, at the time she felt she was appropriate to provide what she did, the Easy Read material and rephrase questions.

C: As I understand it Ms Lister that was her role, you don't suggest she was providing clinical oversight or contribution to decision making?

KL: no she was there to make sure we understood his learning disability and autism needs.... rephrasing questions and so on

C: in terms of process

KL: yes

TS: and yesterday you said she was responsible for writing it up?

KL: yes, she was aiding me. As we heard I spent a lot of man hours in my own time, she would write up for me, then I'd go over it and complete it as lead decision maker

TS: had you read the GOSh report?

KL: yes I read on 5 May

TS: so you'd read [Chris is good at remembering info, but not applying it, may mask some of Chris's difficulties - my paraphrase]

KL: I was aware of that, and I'd had the conversation with Ms Margaret Wall before then and was aware of his over privileged upbringing before that assessment

TS: Over privileged that's a term you're sticking to is it?

KL: Because he had a very supportive family he was able to behave in a different way so we were very mindful he could present well because he came from an upstanding family

C: there's a difference between privileged and over privileged, what do you understand that to mean?

KL: Lots of support, Christopher hadn't come to the awareness of services because the family were doing a good job with him

TS: NICE Guidance talks about role of family doesn't it? [reads]

KL: yes

TS: information gathered from support workers, carers, family, friends and advocate should be used to create complete picture of person's capacity and act on it.

You say Chris's over privileged upbringing meant he had a supportive family?

KL: partly yes

TS: had you had a conversation before the 10th with respect to capacity?

KL: I certainly spoke to mum regularly, we had weekly slots where we spoke about what mum felt should be happening.

KL: Her thoughts were listened to which is why we followed the disagreement policy, and brought extra people in because mum didn't agree with what we found

TS: Julia's statement, he was a gentle boy and often said yes to lots of things...

TS: I pleaded he didn't have capacity but I felt over ruled by professionals. I wanted him to have a capacity assessment by a consultant in autism. Did you understand that strength of feeling before the assessment on the 10th

KL: I dont think before, I think I became aware after we found he had capacity on two counts... difficult to keep your bias in check, we've read an awful lot. Not sure if consultant was suggested after 10th or 18th

TS checks that KL knew that Julia had huge expertise in autism

KL: are you telling me what I knew?

TS: Yes, in a way, having Christopher all her life and two other autistic boys at home, I'm assuming you'd have known that?

KL: I know she knew her children well yes

[missed chunk where KL said she didn't think that her and Julia always agreed but she hoped she felt listened to by her]

TS takes to capacity assessment on use of cannabis

TS reads: "when Kirsty asked questions about overdose he gave different responses each time. Suggesting he struggled to understand how an overdose could impact on him"

Is this an example of masking?

KL: we were aware, considered masking, but also asked questions in different ways to avoid him repeating answers

TS: he struggled, but he gave different answers each time

C [missed]

KL: He struggled in terms of understanding that, but didnt give a repeat answer... it demonstrated he didn't just give learned answers we were able to explore that in depth with him

C: slightly different things, may have demonstrated wasn't given parrot fashion learned answers, but you've recorded he struggled to understand how an overdose impacted on him. He's struggling to understand.

KL: he did struggle, it's a difficult conversation to have. Many people find it [suicide] an uncomfortable subject... that's reflected in my meaning, he'll avoid difficult conversations

TS: hmmm

C: this is the cannabis assessment

KL: yes [missed]

C: the specific questions: can Chris understand the impact that cannabis is having on him, that's the specific decision

KL: yes

C: your para 1.6 doesn't address that specifically... rest of that para what's recorded seems to focus on the overdose issue, doesn't seem to address cannabis

KL: I agree

C: should it?

KL: yes, I think we were trying to demonstrate his capacity to respond, to demonstrate he wasn't just masking, he was giving different answers each time, not just rote learning

C: in that box you should describe your concern., what is your concern there in respect of cannabis use?

KL: understand impact cannabis is having on him

C: does that feature beyond there's a query about keeping himself safe

KL missed

C: that seems to be focused on overdose, not cannabis

KL: yes

C; and it should focus on cannabis, that's the decision being discussed, do you agree?

KL: yes

C: so its deficient to that respect

TS: then you say he's agreed to give up the cannabis for a few months, seemed to give you confidence

C asks for para reference

TS: you said yesterday it gave you some comfort he'd agreed to give up for a few months

KL: I dont think I used those words

TS: i'm paraphrasing. What did you mean?

KL: he identified that he had future plans and future goals

TS: do you think he's telling you what you want to hear there?

KL: no we'd had lots of discussion around it, we;'d explored with him, given him easy read material, went through whole process. Our understanding was at that time giving up cannabis was important to Chris for moving forward

TS: did you have any evidence he would at that point?

KL: he was an inpatient so he'd been made to give up

TS: how long had he been on your caseload at that point how long?

KL: a month

TS: what did you know at that stage

KL: I'd read all the reports and had lots of conversations with mum

[missed chunk]

TS: I think Julia would quite literally have laughed at that answer, that he'd agreed to give up cannabis for a few months, and it gave you comfort

KL: comfort is a word you've used, it didn't give me comfort, but allowed me to follow the law of the Act

TS: well unfortunately not... NICE says identify people, you've said over privileged meant he was well supportive... you haven't got a complete picture, because Julia who you've identified wasn't asked.

KL: I didn't ask that specific question

TS: why not

KL: because I'd had lots of conversations with mum about who Chris was and how he was

TS: Ok, if you'd asked Julia do you think Chris would have understood a tenancy agreement, what do you think she'd have said to that?

KL: I had lots of conversations with mum. You're asking me to imagine something.

TS: I am, because you don't know, you didn't ask

BB interjects

C: I'm taking a note, a little slower please, not being critical but I have impression you're trying to rush through, we're under pressure of time but that does have impact of maybe not being as fair to the witness. Let's take a step back.

C: Contractual arrangements you haven't discussed with Julia. Did you consider Chris would be able to comprehend the tenancy agreements and like?

KL: with our discussions with Chris we went through that with Chris... he understood there would be rules to follow, he recognised

KL: there are rules in the world that have to be followed, he felt he could do that, with support, therefore he demonstrated capacity in that moment

TS: yes Ms Lister, I'm sorry I was going rather fast, Capacity is specific to particular decisions isnt it?

KL: yes, until proven otherwise

TS; yes, specific to particular question

KL: yes

TS: you'd need specific information about that person's ability to make that decision wouldn’t you?

KL: yes

TS: so with greatest respect saying you'd had lots of conversations is not the same as seeking Chris's view about entering into a tenancy agreement, then test it with his mum, who'd have been able to provide a view to take a complete picture

KL: You're asking me a specific question and the answer you're looking for I'm not going to be able to give. Mum had her voice, Chris had his voice and its different. So I hear mum and Chris, they come from different places

TS: yes and the concern is Chris had a recognised ability to mask

KL: and we looked at that

TS: and we know not only his mum was concerned about that, but also Niche found that you gave insufficient consideration to his ability to mask

KL: I disagree with that, I consider we took that into consideration

TS takes to Niche report and reads extracts, only one I could catch is

"documentation on the form and in progress notes does not enable readers to see clarity in the process and approach to the capacity assessments"

TS reads: There is also a lack of detail in relation to the specific responses given by Chris, and the consideration and analysis of information in arriving at the professional's decision on capacity or lack of capacity"

TS: that's the view of the Niche author's?

KL: yes

TS: do you say anything about that?

KL: I agree in part, I agree the paperwork could have been clearer but dont agree we didn't approach in correct manner, have conversations with Chris, take into account his autism, learning disabilities and over privileged upbringing

TS: I was struck yesterday that you said to the coroner you wanted him not to have capacity because you'd have had whole other options available to you

KL: yes

TS asks what they were

KL says DOLS could have been explored

KL: can't say would have been put into place but could have been explored

TS: have you been involved in a Court of Protection DOLS application before?

KL: no

BB: excuse me sir, Court of Protection wouldn't have been involved

NK [didn't catch]

C: excuse me, there's someone here that would like to hear what you say rather than have a conversation between yourselves please. Is there an objection to Mr Stoate's question?

TS: I'll rephrase sir, foreshorten things. Have you been involved in DOLS procedures generally?

KL: no

TS: are you aware of the level of scrutiny applied to capacity assessments in DOLS procedures?

KL: I've just explained I've not been involved in DOLS before which is why I spoke to David Fisher Hope before second assessment

TS: as far as you're aware were your assessments checked?

KL: as far as I'm aware no

TS asks if she'd have expected them to be

KL: we audit regularly, not sure who’d have checked that, possibly safeguarding team

TS: so no one came back to you and said this box isn't filled in, or anything?

KL: no

TS: NICE guidance deal with specialist input... specialists decision specific knowledge ...

TS: eg clinical psychologists or SALTs for example. Front and centre here is Chris's autism and learning disabilities, just so we're clear who is it you say you sought advice from with decision specific knowledge about autism and LD?

KL: I had discussions with psychologist on our team

TS: Dr Allison?

KL: No Dr Ball. Also I had a SALT complete the assessment with me. On second assessment we brought in more expertise, I believe Ms Cay is, well expert is strong word, but bread and butter I believe she said

TS: so Dr Ball, Sam Salici and Melike Cay

KL: and wider MDT... Dr Allison we'd have sought her expertise, not specifically on capacity assessments but more widely on autism

TS: thank you, that's helpful.

TS takes to EPUT records of her conversation with Julia

"Mrs Hopper shared the speed of the move without any real planning would not be helpful for Christopher. I empathised with her and explained normally this process is slower and managed in staged manner but due to urgency

TS reads: of situation it was expedited which meant precautions and planning were not as thorough as we would have liked them to be. We also reflected Covid 19 pandemic has interfered with processes that would usually be in place"

TS asks what meant by urgency and being expedited

KL: due to covid couldn't visit, spent time there, mum felt couldn't have him at home [my bad paraphrase]

TS: covid is a part of it

KL: huge part of it

TS: you say Covid has also interfered... but due to urgency, urgency being what?

KL: he needed to be moved off the ward, couldn't go home

TS: and he was due to be made homeless?

KL: I knew very well that Mum would take him back every time. We didn't believe he'd been on the street coroner at any point, Mum's intention wasn't to make him homeless but she didn't feel could keep him safe at home.

TS asks what precautions missing

KL: to visit, spend time there, give him time to adjust, and for mum to visit, get to know staff, share more thoroughly what she wanted. Those are standard practices for us

C: standard practices for Hart House normally

KL: yes. Again the rules change in a pandemic unfortunately

TS takes to another note 17 June: couple days later, here we can see Chris remains an inpatient, want to look at section entitled risks please.

TS reads: "Christopher is at risk of an unsafe discharge, his discharge to home and Hart House both failed and resulted in Chris

TS reads: needing intervention from emergency services and hospital admissions. Although capacity was assessed and he was deemed to have capacity in regards to supported accommodation and his drug use, this is now being questioned"

TS: You're saying he did have capacity there? Is that what you're saying?

KL: yes we'd already determined previously he had capacity

C: on the 10th

KL: yes this was the note before we carried out capacity assessments again

TS; you write LD to support with capacity assessment tomorrow. Escalate this matter to a higher level as safeguarding needs will not be met if he returns home. Seek advice from legal as to how to proceed. If found not to have capacity then explore DOLS

TS: what legal advice were you seeking?

KL: in relation to DOLs

TS: if he didn't have capacity

KL: yes

TS: this was your note around 19:30

KL: yes

TS takes to note of Ms Jeavons email to Ms Range

TS: I acknowledge here you were not in email, just want to know whether content reached you. 3pm, "Dear Sarah, feels like we're back to square one with this young man and at risk of him being discharged from Southend hospital

TS reads: today or tomorrow. He has nowhere safe to go which is a huge concern" Yes?

KL: that's what it says

TS: was that a shared view?

KL: we had a shared view about keeping him safe

TS: Miss Jeavons is very crystal clear there. He has nowhere safe to go, which is a huge concern. More than a risk. Did you share that view?

KL: I shared the view he had risks

TS: did you share the view he had nowhere safe to go, what your manager is saying?

KL: at that point I believe Chris didn't want to return to Hart House which is why he had nowhere safe to go... he wouldn’t have anywhere safe to go if he didn't want to go back to Hart House no

TS: later on in email says "he needs an appropriate LD placement that can keep him safe, he lasted less than 12 hours at Hart House"

KL: we were exploring Byron Court at that point, in discussions with LD teams at that point

TS: the next day you conducted further capacity assessment yes?

KL: yes

TS takes to Niche report and apologises for it being document heavy

TS reads: "it's difficult to discern from documentation how the conclusion that Chris lacked capacity to decide about prescribed

TS reads: medication could be balanced against having capacity for the more complex or equally complex decisions of community accommodation, care and support as well as the decision about non -prescribed drug use.

TS reads: The assessing clinicians did not document the evidence underpinning their conclusions"

TS: Anything to say about that?

KL: just that I disagree with it [fuller answer - missed]

TS: next day he was discharged from hospital back to Hart House. On arrival evidence suggests he refused to engage with support staff and left the building

KL: yes

TS: did you become aware of that?

KL: yes, I became aware he left because my evidence says I called him to see how he was settling in

TS takes to another record

[missed chunk]

TS: You've recorded "It was explained to Ms Hopper that it had become apparent that no matter what we did it would not appear to be good enough for her regardless of the outcome" what did you mean by that?

KL: that was in relation to the law

TS: that's what follows "it was also explained that we cannot operate outside of the law and as Christopher has demonstrated capacity we needed to respect his wishes and choices, even if they are poor"

KL says was Dave Fisher Hope brought in to discuss law and limitations

TS asks whether the law is contingent on the quality of their capacity assessments

KL: [missed bit] we demonstrated how we came to our conclusions of how Chris had capacity

There were times we didn't agree, but we heard mum’s voice

TS: she says to you that this capacity assessment is insufficient and she wanted someone with consultant specialist in autism being involved

KL: Melike Cay was involved, she shared with you it was her bread and butter... we thought at the time we brought in the expertise required, we went a step up every time to try to support mum.

Discussion about Niche conclusion - can't catch it - TS reads it out

C: the point there is with appropriate expertise is available to staff when dealing with patients where capacity is complex, doesn't specifically suggest capacity assessments themselves should be conducted by consultant level

TS: no, it then says [can't catch] they will then before its acted upon, the consultant will say hang on, let’s have a look

KL: I think we heard from Dr Villa's evidence that did happen, I had a lengthy conversation with her after the capacity assessment

C: did Dr Villa read the paperwork?

KL: I don't know

C: I think her evidence was she didn't

BB: yes, I think she said after the assessment, via the phone, would make sense if she wasn't looking at documentation because that wouldn't have been completed

C: at that point, that's a good point. Did you discuss with Dr Villa before writing up?

KL: the central point where we describe the assessment, on the 18th, was written up by the three of us at the time, but conclusions weren't written up until I'd discussed with Dr Villa

KL: which happened from my car in the car park

C: what about the 10th

KL: wasn't written up until had discussed with MDT

C: so body itself and conclusions weren’t written up until after MDT discussion which included Dr Villa

KL: yes

C: Mr Weidner?

KL: most likely, our entire MDT

C: and on 18th, body was written up but conclusions weren't written up until you'd had discussion with Dr Villa

KL: yes

C: that's the evidence

TS: it would appear to be. You've seen and no doubt read since Dr Villa's email of 29 June, he cant keep himself safe, we can't keep him safe, god forbid we're off the coroner's court, that email?

KL: yes

TS: you heard Ms Jeavons yesterday in her evidence, tertiary panel, that would be care coordinator role to take that action. Did you take any steps to progress to tertiary panel?

KL: yes

TS: what were they?

KL: to explore options as presented by mum... mum made a recommendation, Great Aunt Ruth had recommended Ruskin Mill so I was exploring that. You've also heard Ms Jeavons was also looking for places based on her previous experience

C: sorry who was?

KL: Miss Jeavons

TS: by now Dr Villa is talking about 'god forbid the coroners court'

KL: yes

TS: I'm going to suggest Ms Lister it couldn't be more urgent, she's talking about this young man's death

KL: yes

TS: what steps, urgency, did you take?

KL: I called the Priory, following that email, I also called a meeting as well. I'd contacted the Priory and we attempted to call a meeting to support Chris where he was until we could potentially identify a further placement. In all of this we were following mum.

TS: hang on you said you called a meeting, then you attempted to call a meeting

KL: the meeting didn't happen because Helen Clark was off sick

TS: when did she come back?

KL: I don't know. She'd sent me effectively a care plan for Hart House, so I asked her for a log of what they intended to do with Chris at the same time. more detailed.

C: when it's clear Helen Clark is sick, was there any attempt to get the manager to attend?

KL: I asked if there was anyone would help, part of meeting was to help mum... we knew Dr Allison had been involved in suggesting how might help Chris. Hart House when I asked if anyone had access to the plan I'd suggested said they didn't have anyone at that time.

KL: Which was why we chose to move that meeting to a later date which hadn't been set at that time because Helen wasn't back. I know mum was upset about that

C asks when was due to happen

KL: the meeting was due to happen 1 July

C; and date was yet to be fixed for follow up

KL: we were waiting for Helen to return, she was a pivotal point at that stage

BB: does it assist to see the entry sir?

C: yes thank you, I'll make a note of it

BB provides reference

C: I recounted to you Helen Clark being upset, tearful, when she realised the nature of the ESTEP internal email on 29th, that feeling wasn't shared with her from a team she believed was supporting her

KL: yes

C: I think your answer to that was she was aware he'd been discharged so she'd be able to make up her own mind about those things

KL: yes and she knew [withheld]

C: yes that's the other part, she knew that aspect, knew she'd been discharged.

KL: yes

C: so the expressed sense of the team wasn't expressly communicated to her. I'm wondering given she was off sick, whether that would explain she wasn't aware of that detail?

KL: I don't know, I don't know when she went off sick

C: but she wasn't available for the 1st. Ms Ballard?

BB: I think there's some email around 1st when first learnt, then subsequently learnt was expected to be longer

C: if we can all look for that, I'll look for that myself as well. It's part of the emails I wanted confirmation we had all emails from that period yesterday?

BB: I've tasked that with a huge degree of urgency

C: so you've had this conversation on 29th, was it on 29th you were sending email to Hart House saying thank you for log but I need a more detailed plan?

KL: I'd have to check my statement to establish when that was

C: well have a look, I suppose this sense of urgency, later on 29th he's back at Hart House

KL: it was on 3rd I believe

C: Carla Villa's email lunchtime 29th, at that point the team believe he's staying on assessment unit

KL: yes on 1st was to discuss with Helen and mum and also Dr Sharon Allison was attending that to discuss how we put a robust package in place. Helen was off sick, from my memory I asked if anyone else was available

BB provides reference

C: ok, let's look at that, I appreciate your chronology is a summary, let's look at the bundle itself

MDT meeting cancelled due to not receiving support plan for discussion from Hart House... manager was off work...

C: agreed to reconvene meeting once plan was in circulation and YPDAT had completed their assessment. That's some time off.

Contact with Priory... Chris would have needed to complete rehab before referral to them.

Because of cannabis or cocaine?

KL: full stop any illicit drug use

C: called Julia she was very unhappy at meeting being cancelled. I explained purpose of meeting was to collaborate on support plan, however without that plan the meeting would have no purpose.

C: I shared professionals involved are happy to come back to table again once have the plan and once YPDAT assessment completed. Ms Hopper stated Hart House were useless.

[missed chunk]

C: Ms Hopper expressed how amazing she thought Dr Villa, ESTEP consultant, was and that she is the only on of the consultants to listen to her and give her some time to discuss her thoughts and feelings in regards the matter.

C: She also expressed surprise at how much the ESTEP team were trying to put in place to support Christopher. I shared was in Christopher’s best interests and only way to keep him safe....

C: Julia wasn't aware you as team had come to conclusions you had, he cant keep himself safe, we cant. Any reason, I ask directly, that view wasn't shared with Julia.

C: Appears, inference I'm driven to reading that note, is he could be kept safe in community and just question over time of building up picture but more when team knew couldn't be

KL: we've already shared we’d struggled, we couldn't keep him safe in the community. That email he'd just come out of the assessment unit at that time, we wanted him to stay a little longer but he'd taken his own discharge.

KL: I'm sure we'll hear from my colleague Mr Weidner, he did seem to settle a little bit in Hart House, he was doing his washing, spending time with mum... we were still putting a lot of man hours as whole team into this

C: I understand, the effort would be hard to dispute, yours personally, the whole team, Ms Jeavons, Mr Weidner, and express concern documented by Dr Villa.

C: My concern is what had changed from 26th where as team unanimously thought he can't keep himself safe, and we can't keep himself safe, to this note and discussion with Julia where clear implication is you could keep him safe?

KL: he'd settled a little into Hart house following his discharge. He'd been seen by my colleague, was no deterioration in his mental health following discharge at that point. We were mindful he'd not been able to stay in the community for long in any period.

KL: We know from records we only had him for 16 days in the community. Certainly for me I wanted him somewhere locked up, where he could be safe, but obviously we had to work within the law.

KL: I hadn't had that conversation with Chris about whether he would be willing to go elsewhere, was just on mum's opinions. Chris wasn't aware we were exploring other options.

C: last question on that. What had led you on 29th to team having unanimous view Chris can't keep safe in community, and we cant keep him safe?

KL: because he'd taken his own discharge from hospital, he wouldn't stay, we’d asked for extra help from home treatment team and that wasn't coming. We asked the ward but they couldn't keep him.

C: and the nature of what he'd been doing on 26th [withheld] on background of history of behaviours exhibited

KL: have to take in context, first [withheld] he was clearly psychotic at time.

KL: He'd stopped taking medication but now he's back on medication, wider context to consider, but our preference would have been to have stayed in hospital longer and have support from home treatment team

C: and no capacity for medication... that was example of a dangerous impetus act

KL: yes he could be impulsive if not supported in right play. We had a plan of care, and way of helping him to manage his own behaviours

C: Mr Stoate?

TS: I'm almost done

C: if you dont mind, then we'll take a break

TS: did you ever receive a care plan from Hart House?

KL: I received a care plan, I just wanted more

TS: did you ever receive a risk assessment?

KL: its part of their plan

[missed chunk]

TS: Ms Clarke gave her evidence that its wholly inappropriate

BB: I think we need to be careful that we're referring to the same documentation

KL: if you could show it to me

LN provides reference

TS: did you ever see this, the pre assessment from Hart House?

KL: no

TS: looking down that page for what it's worth, Richard made aware of my thoughts, does not want to return home. Can you see note there mood changes quickly

KL: can see that yes

TS: Ms Clark told her that's what Chris told her

KL: I can't answer to that. I wasn’t there

TS: more on that, did you recognise his mood could change quickly, you've just been asked about the impulsive act of [withheld] is that something you recognise?

KL: when was this document written?

TS: 11 June

KL: post 11 June we had a lot more evidence around that

TS: looking down assessment stage 2 is blank, stage 3 is blank, then we get to Service User Risk Assessment, you said you saw one. Is this the one you saw?

KL: no this is not the one I saw. I saw I believe is entitled care plan with risk built into it. I didn't see any of these documents.

TS: if we look at Personal Support Plan, this is the one you received is it?

KL: yes I believe I've seen that, you'd have to scroll further.

TS: Support needs "I've made numerous serious attempts at suicide. I have no awareness of how my death may impact others or concept of age or death" That was your phrasing wasn't it?

KL: no, I didn't write this

C: when you made reference to care plan is this what you received?

KL: yes

C: and in light of 26th you wanted more?

KL: yes

C: there's another plan dated 24 June, did you have more than one?

KL: I was only sent one, not sure if I documented when I received that

C: 19 we've just seen

KL: I wouldn't have received anything until after 24 June then because I didn't see it separately

C asks her to look at two support plans.

C: 19th do you recall seeing this?

KL: yes, I got this as one document, would have been after 24th

C: so when you got 24th you didnt see 19th?

KL: no it was included, but I didn't see 19th until 24th

C: understood. When did you receive the support plans?

KL: I"ll check my statement, I'm not sure if I've said when

C: before or after 26th?

KL: I believe after but can't recall exactly, will have to go through my statement

C: well have a look, you've said you saw care plan but wanted more, in team meeting on 1st. When did you first see care plans?

KL: I believe it was sent on 3rd, I hadn't received it from Helen, I'm trying to go by note I recall. After 1st when we were meant to hold meeting, was sent to me, and I said I want a better version, there needs to be more

C: and you never did receive better version?

KL: not to my knowledge no

C: if you didn't receive these until 3rd, why hadn't team requested these, a risk management plan. Why wouldn't you have wanted to see that from as soon as he moved in?

KL: we'd had discussions, were conversations around it, but no we hadn't seen it

C: when did you first ask for it then please, I assume its documented

KL: I believe it would have been asked for, so, it would have been a discussion that would have taken place potentially on the 22 June when Chris was seen at Hart House with Helen

C: ok. Potentially

KL: Potentially was Mr W that did that visit

C: Potentially. Julia has expressed continuing scepticism about Hart House being adequate place to keep him safe.

C: Would like confirmation of when ESTEP team first asked details of personal support plan being provided to Chris at Hart House.

That's hard evidence I need, when did you or team first request that information, given you don't receive it until 3 July.

C: You understand why I ask that question?

KL: I completely understand, it’s not documented in my statement, will need to go through

C: dont know if Ms Nash is able to assist?

LN: Is meeting on 22 and documented in EPUT notes on 24th that Helen is completing the plan today... so even on 22 or 24th discussion and Helen says I'll do them

C: but there's one dated 19th

LN: yes, as far as I can see I can't see date was sent

KL: thank you

C: you can't see date sent

LN: No see note would be discussed with mum, then suggestion would be shared

C: I might be being a bit slow. Between Hart House and ESTEP, important document. Hart House viewed by mother as not being safe place.

C: Has responsibility to create support plan including risk management... one dated 19 June. on other side you've got ESTEP obviously aware of Julia's concern, and as Ms Lister understands why I'm interested in this point, I’m probably not going to let it go

C: would want to know what steps Hart House are taking to support and risk manage. To know that, leaving aside meetings and discussions and all the covid context, they need to see the document. So I'm after confirmations as to when it was they were drafted, as far as we can.

C: When they were sent and at moment evidence I have from Ms Lister was they were sent on 3 July. And importantly from my perspective when they were first requested because I'm struggling to make sense of the Villa email on 29th, if at that point personal support plans

C: hadn't been requested, never mind provided. I hope that's clear. I'd like as far as we can. If there is no answer to it, there is no answer and I'll draw conclusions about it in due course. It. maybe sitting there in myriad of papers we have. [Lists again what he needs].

C: I think, hoping that's fairly clear as to what I'm after. Ms Lister to best of your knowledge as care coordinator, can you help me with any of those dates and times, you've helpfully told me were sent on 3 July

KL: that's what I recall from my statement. 19th was Friday, so would make sense he was discharged from general hospital on the Friday. I do know on Sat 20th when we looked to do our follow up visit, Chris was with his mum, that was rescheduled for following day, so Chris

KL: wouldn't have spent much time at Hart House on the Saturday. He was seen by us on Sunday at Hart House. I don't know if Helen was there at weekends, but it is Chris's personal support plan, so may be delay for her to discuss his own plan with him, given weekend in middle.

KL: I don't know for sure, its speculation

C: yes, ESTEP requested these documents, I'd like confirmation of when they were first requested. If its not until some time after his discharge.

C: Did you indicate when you first requested, in light of Dr Villa's email or later than that?

KL: believe would have been discussion Mr Weidner had when he visited Hart House on the Monday because he met with Helen Clark then

C: I'm content if there is a note of you requesting plan will be matter of objective documentary evidence, so not proposing detain you on that point at moment. Its 5 to 12, we definitely need a break. Ms Nash you look like you can share something with me?

LN: In Hart House bundle is email from Helen Clark to Dr Villa on 19 June. Staff are going to collect CN, I'll contact ward to check... my plan is set up strong directed support plan and behaviour contract, will put to CN...l will send to you to add.

LN: I asked Dr Villa about any communication she had with Hart House, said she couldn't remember. Looks like there were conversations as early as 19 June, which is consistent with first one being dated 19 June

C: ok I think the evidence of Ms Lister is she received the whole lot in one go on the 3rd

KL: I can't say exactly it was 3rd but did receive in one go and might be able to establish when

LN: I've also asked for enquiries to be made in respect of Helen Clark’s sick leave

C: so looks at moment Ms Clark has volunteered she will do document and will send it on

BB: yes and if you look at next email up, in response, Dr Villa's response to Helen Clark, p124, I've noticed you replied to me only so I'm copying in my ESTEP colleagues, Sam and Mel

BB: from LD services... [missed chunk] you can cross reference that with some of the entries in records

C: there's nothing specifically in relation to what I'm focused on at the moment the support plan

BB: if can't do it direct its whether we can do it by inference around what people were doing at the time sir. I think if we then look at EPUT notes you have contact between Sam Salici and Hart House, asking do you want support with creating these plans and that's said no thanks

BB: we'll get back in touch if we feel we do, I paraphrase

LN: which fits with evidence in Dr Allisons' statement that she had conversation with Helen Clark about how to support Chris... and its same day its produced

C: and sent when?

LN: we have everything from Hart House, will ask that enquiry be made but not sure will be ascertainable at our end

C: very helpful, can see work going into preparation of them. What I’d like to know is when it was sent. if it wasn't sent and received, was it chased. [missed chunk] if is case Hart House didn't send this document until into July then that's the case.

Discussion re timetabling. Will continue to finish Mr Stoate's questions

TS: this is Chris's personal support plan in Hart House documents [reads quote] do you recognise that phrasing?

KL: I believe there's similar phrasing potentially in the capacity assessment, however this is Chris's personal support plan so my assumption is that's something they've discussed with him, it’s his support plan

TS takes to records: Assessment of Safety and Risk 15 June on first day, completed 27 June Linda Donlan

KL: my colleague

TS: if we go down through this document to page 1721, under protective factors and contingency planning

TS reads: "Christopher's autism has left him with limited emotions., He has no concept of age or death. His family are important to him but he has no awareness of how his death may impact on them" very similar phrasing isnt it

KL: similar

TS asks how this document first into document just seen?

KL: it doesn't, this is 27 June

TS asks what timestamp says

KL: she's added, our system is very complex, in order to keep information still in risk assessment, when open comes up blank, so you navigate back to previous document and add to it and then change. Looks like she omitted to change date, 15 June, when she was working 27 June

TS: and box below, Christopher does not believe he has any risks., that's what's recorded by Ms Donlan?

KL: I don't know if Ms Donlan has added that or if this was carried through from earlier document. That might not be Ms Donlan's entry

TS: in Hart House care plans, have no awareness of how my death would impact others, that's recorded in there, 19th. Then almost identical view expressed in Ms Donlan's risk assessment dated 15th, time stamped 27th.

TS: Did you ever come to view Chris had no awareness of how his death would impact others, or concept of age or death

KL: I've already reported in capacity assessments that he struggled with that...

BB: If I can try and help [takes to bundle] I don't know if this is helping, this appears to be the same document, dated 15 June, with time and date of 15 June

TS: Kirsty Lister. This is same document Ms Lister?

KL: yes its a previous version

TS takes to same sections, protective factors/contingency planning: identical

KL: our practice is to build on care plans, so documented was added to by my colleague Lin

TS: do you recall putting into 15th he has no concept of age or death, his family are important to him but he has no awareness of how his death may impact on them. Christopher does not believe he has any risks. Do you recall that?

KL: I dont recall but it is my entry

C: its your opinion

KL: yes my entry on 15 June

C; that appear to inform ongoing expressions in that respect

C asks why she said query capacity in this form

KL: should have applied the borderline principle, he demonstrated more capacity than not

C: this is another document where you've used the wrong wording... you told me yesterday you were ware of borderline, is it same reason?

KL: yes I’ve just put querying instead and I've carried that through in all my documentation

TS takes to another record: 30 June. Telephone call x3 to Hart House by care coordinator - no response

KL: I don't work on a Tuesday so that's a recording error

TS takes to another record: can you see there, that is Richard Weidner

KL: yes I’ve already said I don't work on a Tuesday

TS: so it wasn't you attempting to call Hart House three times. Did you discuss calling three times and getting no response?

KL: Mr Weidner visited the next day, the 1st

TS: it would have been a particularly important time in terms of risk., he's coming out of hospital, to a place that has failed in the past,. Do you agree with regards to his risk to himself?

KL: yes

TS: perhaps I've not understood this but I'll be asked later by Julia when we try to get your understanding right. If Helen Clark isn't there at this stage?

KL: I dont know if she wasn't there on 29th

TS: your phrase, she was a pivotal person in keeping Chris safe. What was your contact with her after?

KL: she was off sick

TS: so from the 1st she wasn't there, so who was in charge of Chris's safety at that time?

KL: whoever was in charge of Hart House

TS: who was that?

KL: I don't know, they'd have had someone

TS: so for level of heightened risk, Chris is there, whole week, you know you're off view he wasn't safe. Who did you think you'd be liaising with?

KL: well my colleague was doing the visits at that time, I was coordinating care, I wasn't doing everything, I was dealing with home treatment team and we'd established they wouldn't have been involved and Mr Weidner was doing follow up visit next day.

KL: Given he took his own discharge there would have been conversation about who meetings him, not sure from that statement was me. I had conversation with mum on that day

TS: Julia has clear memory on 1 July that a suicidality assessment, how she understood it to be, was booked and due to happen in Basildon near Dr Allison's office. Chris was discharged before he could have that.

TS: Did you organise that, have a conversation with Sharon Allison, any undertaking around Chris's risks around suicide at that time?

KL: its not a terminology I've ever heard, suicidality assessment doesn't exist. It must have been a miscommunication, but I do know we were planning on involving lots of professionals to support Christopher

TS says he's just received additional information and really does need to take a break now

[Court was adjourned at 12:15 for 15mins]

C: Ms Ballard

BB: Ms Lister has shared with me some emails, when we had the issue with XXX. The only one I think that is really of relevance, I’ll share them with you, is to confirm on 2 July Emma Bennett, who is of Hart House, sends the Personal Support Plan to Richard Weidner.

BB: He forwards it the same day to Kirsty with a message, this was what I was recalling earlier, saying, I’ll paraphrase looks like Helen isn’t going to be back any time soon. You definitely need that one.

BB: There are 26 emails in total, as far as I can see they’re all additional traffic of passing things on, I can’t get hold of Hart House, here’s the phone number sort of thing

C: thank you, for completeness I think you better send me the whole lot

BB: I’ll try to condense them into one pdf

C: that would be brilliant, thank you

C checks what time they were sent

BB: we have expressed the urgency for the work you’ve asked for, that’s been repeated, is carrying on as well.

C: as far as this tranche of emails any difficulty in cross serving those

BB: no once I condense it

C; that answers questions I suppose I have, only outstanding is confirmation as to as and when they were chased. Thank you very much indeed. Mr Stoate

TS: Sir I’ve not seen those emails either, had brief discussion in break and think I understand the content of them. I have another issue arrive, discussed with my learned friend Ms Ballard, don’t think takes us further.

TS: I wont ask more, thank you, for now I’ll pause there, if stuff does arise I might beg your indulgence, thank you very much

C: really the only outstanding point is were they chased and if so when. Thank you, Ms Ballard

BB: Is it Miss or Mrs?

KL: Mrs

BB: I’ll jump around a little. You were asked questions, I think by Mr Stoate, might have been the coroner, comments made in email correspondence around timeframe of 16 to 17 June saying nowhere safe in the community.

BB: I wont take you back to that, but will take you to [bundle ref] so we understand the context of those comments. That’s not entry by you… its in context of a query about where Chris was wanting to go.

BB: Call made to Manager of Southend General Hospital Social Work Team in response to email Richard Weidner had received from Ashley [reads it] if move to next entry from yourself, to understand context in which those concerns were expressed, a telephone call 17 June, p1736

BB: to F1 Acute Ward Doctor he says Chris is aware he needs to make a decision about where he’s going to live

KL: yes

BB: at that time was question mark about where Chris was going to go to. He’d been at Hart House for less than 12 hours previously, he’d come out of

BB: assessment unit, spent very short period of time at HH, had seizure and gone into Southend

KL: yeh

BB: and also at that point there were emails as I understand, I’m confident they’re there, from Judi Jeavons to LD EPUT Team querying placement in Byron Court

KL: yes

BB: then want to move on to the Care Act Assessment, that was the main focus of your very initial involvement?

KL: correct

BB: you knew mum wanted support for Christopher a few hours a day and a cleaner to enable her to spend more time with the children, bundle 4949 [reads it]

BB: that was finalised on 22 May while Chris was still inpatient on Cedar Ward, you and Sophie Vincent had been onto Cedar Ward to visit him

KL: yes

BB: A meeting about Care Act Asst between you, Sophie Vincent and Melike Cay

KL: yes

[missed chunk where Ms Ballard takes KL through care plans]

BB: you were asking who conducts checking of capacity assessments… yours all appear in safeguarding bundle, is it there you believe there’s an audit function to check on those capacity assessments? [my paraphrase]

KL: that’s my understanding

BB: can you just, briefly please, set out your experience and background in undertaking capacity assessments?

KL: in my previous placements, slightly more relevant, we carried out multiple capacity assessments because of the type of ward I was on

BB: in NHS?

KL: private setting

BB: inpatient environment was it?

KL: it was

BB: what was context of those in main?

KL: people’s understanding and ability to demonstrate capacity of being in a secure environment but not detained under the MHA

BB: what type of ward was it?

KL: a PICU, psychiatric intensive care unit

BB: how frequently were you undertaking those

KL: almost every day at work

BB: over what time period please

KL: PICU I worked there for 2yrs

BB: has frequency been replicated in other jobs

KL: not to that frequency, but over my whole career I’ve been involved

C: to be clear that’s formal assessment with completion of documentation and so on?

KL: yes

BB: there’s no central MCA pro forma is there… each organisation chooses how they record an assessment, they’re not directed how to do so by the Code?

KL: that’s my understanding yes

BB: can I just, I want to be clear please, about the completion of the forms. I want you to have a look please at the 10 June capacity assessments, we’ve got three. Cannabis one please.

BB asks if she’d used form before

KL: No not this particular form no, this was my first experience of this particular form

BB clarifies: so you’re used to the form, pre covid in the office you’d print one out and take to assessment

KL: yes

BB: you would then fill that out in hand

KL: yes

BB: when you get back to the office you give it to someone else to upload on the system?

KL: it would go to the admin team

BB: so distinction is you’d never done it electronically before

KL: no

BB: and you were doing it at home on a work laptop

KL nods

BB: so reason you don’t take hard copy with you, that you used to previously undertake prior to pandemic

BB: reason you didn’t take hard copy form to complete with Christopher is because you didn’t have the capacity to print them out at home

KL: no, or the ability to return it to the office for it to be uploaded

BB: I understand. So in pandemic you’d take notes, take those home, use notes to complete the form and then destroy the notes?

KL: yes

BB: and the wards couldn’t help you print out this documentation to do in hard copy, two different wards

KL: it was asked if they could print but they were too busy trying to maintain a ward with everyone in bedrooms and monitoring

BB: so the errors on the form only relate to the marking and unmarking of boxes, not to the sections, the written sections are all accurate?

KL: yes

BB: at the time you were completing these three assessments electronically you thought you’d marked boxes correctly

KL: I believed so yes

BB: you didn’t detect the error when you read through it but did when you printed it out in preparation for this inquest, is that right?

KL: yes

BB takes to record, to be clear where the errors are

[About 15mins spent discussing which boxes were intended to be checked, and relationship between them and the text recorded]

BB: communications with Hart House, you were asking them for plans and requesting more

KL: yes

BB: and RW was visiting, you weren’t able to visit on this occasion?

KL: no

BB checks why and KL says a member of her household had tested positive for covid

BB: thank you, in Dave Hart’s evidence he doesn’t recall there being a meeting, but we can pick up with Richard W but Kirsty Lister was also present. Was on 3 July is that right?

KL: yes. We had email discussion on 2nd and agreed a call the following day, I believe by MS Teams

C: I’ll just remind myself of his evidence on the point

BB: from recollection I think he said didn’t appear in his diary so from recollection the meeting didn’t take place

KL: I believe we’d placed an entry on Mobius to evidence that meeting

Coroner reads out David Hart’s evidence on point

BB: entry by you, 3 July, describing the meeting you and Richard W both have with David Hart of YPDAT

C: 3 July at 20:17

BB: everyone agrees the 2 July email exchange, this describes a discussion between three people on MS Teams

C: yes

[missed question]

Kirsty Lister is released at 13:30

C: I would like to conclude Mr Weidner’s evidence today. I’m sorry to do this to everybody, 14:05 please, unless anyone would like to require longer?

[didn’t catch, not sure anyone said anything so assume was on facial expressions]

C: 14:10 that’s a mark of Ms Khalique’s advocacy skills. We may have to sit a little later.

Court is adjourned. Back at 14:10

Discussion re place of a document in a bundle

C: Mr Weidner please, thank you

Richard Weidner swears an oath

C: apologies again for mispronouncing for most of the last three weeks

RW: that's fine

C: you've kindly provided a statement for these proceedings which is in the form really of a chronology of events, together with some information you set out at the start. You'll appreciate having heard quite a bit of the evidence, have you heard the evidence of the ESTEP team?

RW: yes

C: as you are the last witness, we've a good understanding of the chronology... as with your colleagues if you need a break at any time just ask, there's no pressure on time in that respect at all

RW's statement is dated 22 Jan 2021. He's a registered mental health nurse qualified in 1996. Worked exclusively in the community.

C: What additional roles does a Clinical Lead Nurse have at Band 7 rather than Band 6?

RW: I preside over MDTs and provide clinicall supervision for rest of team, except psychiatrist [think he said, maybe psychologist]. I hold a small case load, dip in and out of cases. I tend to know about people when things aren't going great.

C: so you can troubleshoot and assist colleagues

RW: yes

C: give us an idea of the size of the team, Dr Villa, Judi Jeavons, Kirsty Lister

RW: about 14 of us in total, about half of that are community MH nurses or social workers, an employment specialist, support worker, then we have psychiatry and psychology team as well. We have someone who leads on physical health monitoring

C: yes, have heard a fair bit about what ESTEP team is, does and is focused on. Anything to add?

RW just repeats some of what we've heard previously. Says assess people over 6 month period

C: your understanding with regards to Chris was it was a cannabis induced psychosis

RW: yes, that resolved very quickly

C: was an emphasis from Dr TW in her evidence that it was a cocaine induced, was that your understanding?

RW: drug induced

C: yes cannabis or cocaine induced? Notes seem to suggest cannabis use

RW: yes that's what I understood

C discusses professionals meeting

C: meeting I think was in agreement was appropriate diagnoses [LD and autism] even if discussion about extent

RW: yes

C: was muted would be reassessment but remind myself was early days of covid pandemic together with this florid psychosis, and his continuing penchant for cannabis would make reassessment a challenging exercise and shouldn't be undertaken unless reliable...

C: broadly consistent with your memory of discussions?

RW: yeh

C: any doubt in your mind at that time that ESTEP was correct team to be leading at discharge?

RW: not at that time

C: you'll confirm no doubt discharge planning is undertaken from day one of admission

RW: yes

C: and clinicians on ward should be looking towards discharge stage from the very beginning

RW: yes

C: anything else like to add about that meeting?

RW: no

C: I've heard about Kirsty's role and the Care Act Assessment, and issues from ESTEP perspective you'd wish to have address in advance of discharge

RW: uh huh

C: we know don't we there was ongoing contact between Kirsty and Julia, Chris's mother. When was your first direct involvement with Chris yourself?

RW: I think I rang Chris when he was in hospital, I'll have to look at chronology

C: ahead of first discharge, when he was on Cedar Ward?

RW: before he went to Hart House

C; how would you summarise your contribution, either in support of Kirsty or rest of team, in advance of your first contact with him

RW: I dip in and out of cases, but with Chris's case, I don't usually dip in to the extent I did with Chris

C asks if that started before he left Cedar Ward

RW: yes because we were aware he was a complex case and mum's anxiety around his future care

C: so early on you were aware of Julia's concerns

RW: yes

C: and in order for him ot be safe at home he needed a robust care package

RW: yes

C: that was consistent with meeting of 7 May. Minutes of which you didn't receive until weeks later. Was that unusual? I asked your colleague about it too

RW: yeh there were a lot of people there, so would need a lot of checking

C: they weren’t circulated for checking, for three weeks. Appreciate a lot going on, covid and so on. Relatively lengthy, robust meeting, with quite few issues discussed, would have thought all clinicians involved would have wanted to see minutes with a degree of urgency?

RW: yes I'd have thought so

C: you make clear that there should have been notice of discharge

RW: uh hum

C: and there wasn't

RW: yes

C: Julia says this was the first failed discharge, would you agree?

RW: any time when there's an incident such as there was with Chris, after a discharge, irrespective of the cause of it, if someone goes out takes drugs and becomes unwell, I'd have to say it's still a failed discharge

C: so even with all participation [lists] someone goes out and gets drunk, falls over, still failed discharge

RW: yes, I suppose so, you cant control someone’s behaviour

C: but in this context where ESETP are saying we need notice of discharge, mum needs warning, not invited to ward round,... this is a different category of failed discharge would you agree?

RW: yes I'd say so

C: you make point in your chronology professionals meeting, some concerns around potential discharge before Care Act Asst completed, prior to discharge date, which would mean Chris would be discharged without appropriate support in place.

C: KL contacted Dr TF to make request his discharge delayed... ESTEP not received invite to ward review, unaware was taking place, Chris decided take discharge against medical advice, return to his mother's home

C: that's bare bones of what took place, I've had evidence from Julia, Chris's mother and indeed Dr TF, and I'll have to take a view on that.

[Lost a chunk. Apologies]

RW confirms he and the team had some experience of working with people with LD and autism, but not a lot, not regularly.

He said they sought professional development when needed but hard retain in team as staff turnover

RW couldn’t recall a client who had LD, autism and illicit drug use

RW: For me his presentation throughout was settled, but he was putting himself in risky positions. It clearly wasn’t from psychosis, so you’re left with what are the other possibilities of why he’d do this.

RW: One is he’s seeking a thrill and doesn’t quite realise the consequences of that. The other thing would be there something in his cognitive functioning that perhaps we don’t quite understand and that has something to do with it.

RW: Was that which was why I thought should this be, and we were aware of the GOSH report. The information back to use from ward was he wasn’t presenting in way that report laid out.

C: were you aware Julia’s view that he was using substances for self medicating, as so often happens, wasn’t cause of problems but wasn’t helping

RW: yes I was aware

C: so clearly wasn’t psychotic at this stage, possibly thrill seeking, maybe doesn’t understand consequences, maybe cognitive function. Entirely reasonable all three of those things?

RW: yes

C: on background of using cannabis

RW: yes you say cannabis wasn’t helpful, I’d take it further, it really wasn’t helpful, that was one of main risk factors I felt

C: so assessment of risk, will turn in due course, of those competing dynamic contributors to his presentation...

C: obviously manifest themselves from a pretty important perspective in terms of risk

RW: yeh

C: if he’s on ward, doesn’t have access to cannabis, his movements and actions are fairly well contained…

Asks RW if he was aware of [withheld] on ward?

RW: no

C: surprised you weren’t given planned discharge into your service?

RW: yes

C: those risks don’t go away, that arise out of those competing dynamics are present

RW: yes

C: and illustrated by the risks he was taking [lists – withheld] potentially opening himself up to risk of seizure, whilst under influence, even if not caused by it.

C: Then unable to assist himself and putting himself in really risky behaviour [withheld] so the challenge is managing that risk

RW: mmmm

C: so you’re identifying didn’t know exactly what cognitive functioning contribution was, whether also thrill seeking, or not understanding risk taking, on background of consistent and persistent cannabis use?

RW: with the cannabis use as a catalyst I suppose

C: Is cannabis a catalyst in that sense? Or a co-determinant of his actions? It’s not chicken and egg, would that be a fairer, more appropriate way to put it?

RW: yes

C: so obviously capacity assessment is going to be a very important element

RW: yes

C: your experience of capacity assessments assume you do conduct them, have done?

RW: yes

C: routinely? Understanding you had more managerial role

RW: not routinely

C: historically had you done them?

RW: some, I wouldn’t claim expertise in them or anything but I have done some.

C: would appear as far as your team were concerned there wasn’t great experience of the tripartite presentation, LD, autism, drug use...

C: then it follows wasn’t a lot of experience of capacity assessments with regards to patients with the three prongs as it were?

RW: yes yes

C: did you have concerns about whether Kirsty had sufficient knowledge and experience to carry out the first capacity assessment?

I’ve heard her evidence, I’d like yours on that please.

RW: from my perspective she did. She’s a very experienced care coordinator.

I’m aware she did preparation for this assessment and that we had help

C: brought in Ms Salici from the SALT team

RW: yes she was my definition the person who knew Chris. I didn’t have any concerns, there has never been any performance issues with Kirsty

C: no, but for your team this tri-presentation is unusual, Kirsty isn’t responsible for the qualifications and experience of the SALT person who comes to assist in that limited role in which they were contributing. Or indeed Melike Cay.

C: You ask for support as team, you’re provided with support, you act on that support

RW: yes yes

C: what was your interpretation then of the outcome of the capacity assessment

RW: understood was lengthy assessment, in terms of outcome he had capacity, excuse the phrasing but it wasn’t a slam dunk

C: found to have capacity around where to live, more concerns about managing medication safely and understanding effects of drug use…

C: after further discussion with social care was confirmed Chris had capacity with regards to his drug use and was making poor choices.

We know he wasn’t considered have capacity with respect to medication at that stage, perhaps not surprisingly given [withheld]

RW: uh hum

C: but also concerns about understanding effect of drug use. Understand presumption of capacity, balance of probabilities, did you understood he had capacity or not, was it an undecided issue?

RW: No I understood he had capacity

C: again how you’ve put it, had capacity around where to live, but more concerns around… but it wasn’t more concerns, he didn’t have capacity … seems to imply same finding related to medication and….

RW: I understood him to have capacity, but wasn’t clear cut. Was lengthy took some time to reach that conclusion and they were going to look to do that again in the future was always to be on the radar

C: you’ve seen Niche report no doubt?

RW: yes

C: do you agree with those conclusions? [takes them to him]

He does partially

C: how do you reach firm conclusion that he had capacity?

RW: through discussions

C: you’ve no reason to doubt what you’re being told but you’re relying on what you’re being told?

RW: yes

C takes him to entry he made 17 June

C reads: I gave background history and concerns that Christopher is unable to keep himself safe, and my view that both his mother and community mental health services face significant challenges in keeping him safe.

C reads: Suggested that he should be seen by mental health professionals before leaving SGH

I gave background information on the case.

C reads: Explained concerns both in regard to Chris and others being able to ensure his safety as well as concerns around his capacity to make informed decisions in regard to areas such as drug use.

C: So help me with that?

RW: I guess I’d say capacity is dynamic and changes

C: so by this stage, 16 or 17th there are concerns

RW: yes its possible

C: you tell me, you’ve written it, what did you have in mind?

RW: yes that’s what I had in mind

C: and specifically around his capacity to make informed decisions around areas such as drug use?

RW: yes

C; so you were aware that, you became aware was going to be another capacity assessment the following day with additional input of Melike Cay

RW: yes

C: you said further capacity assessment was plan, and DOLS if required. Melike Cay was asked to provide independent advocate, believe we heard that never did come to the for

RW: yes I can’t remember the reason why

C: would ensuring he had an independent advocate, or at least assessed for it, did that fall to ESTEP team to sort out?

RW: my. Understanding was Melike Cay was going to provide that, or look at it

C: capacity assessment 18th you say deemed to have capacity around living arrangements, seizures and deemed to have capacity around drug use but felt could do with more education [my paraphrase] and you’re aware there’s some dispute about whether Melike Cay was going to

C: source specialist assessment

RW: yeh, yeh

C: but you’re relying on what you’re told?

RW: yes

C: Ms Ballard has taken me through YPDAT chronology, first opportunity for contact was Monday 21 June, that was the point at which the YPDAT were contacted

RW: yes

C: covid, all of the context, did you chase up, can you recall?

RW: I do recall because the initial issue, I cant remember dates but there was a delay of a week or so while their manager was off

C: yes we’ve got some detail, leave

RW: yes and we recall requesting face to face, whether was myself or Kirsty, think was me who asked them to reconsider. Took other measures, offered to provide PPE.

C: you document that on 22 June you spoke with Sophia YPDAT team manager. They confirmed they weren’t doing face to face but you felt important for Chris

RW: yeh

C: you visited Chris on 24th with the employment specialist [reads detail from notes] email shared to all other agencies Chris’s mother was feeling cautious but hopeful and medication starting to have effect.

This was period preceding [withheld] of relative stability

C: I’ll not take you to emails, Mr Stoate or indeed Ms Ballard may wish to pick up in due course. You say your colleagues was informed [withheld] taken to A&E. Appeared apathetic… said wanted adrenaline rush… admitted to Assessment Unit in Basildon.

C: At that point what did you expect to be the trajectory? Were you taken by surprise?

RW: I was taken by surprise at how quickly the discharge occurred?

C: why was that, may be self evident, but helpful if you can spell it out

RW: the seriousness of the incident itself, where it occurred, the incident itself.

He reported I think sexual problems which was why he’d stopped his treatment.

I was surprised but also I trusted my colleagues’ judgement.

RW: If Chris had reported that as an adrenaline rush they’d have explored that.

I didn’t share their summary, he was low risk for discharge.

I wouldn’t share that view but I do put some trust in the fact he’s been on that unit and seen by Section 12 doctors for a few days.

RW: It’s a factor

C: does your understanding of an assessment of low risk, Dr Carr said as inpatient he’s low risk, in the community you guys regard him as high risk?

RW: I’d say risk is risk, I know that’s vague, when he’s in hospital you’re pertaining to risk once he leaves the ward, after

C: that’s certainly what I understood would be a logical approach. Were you aware he apparently discharged against advice?

RW: yes

C: there’s the email exchange between yourself and Dr Carr on afternoon of 29th… comes back to you as something of a fait accomplit at the end of the afternoon that he has been discharged

RW: yes

C: 29th is a Monday, did you have concerns about the fact he’d gone back to Hart House?

RW: yes I’d say we had some concerns

C; did you consider he was going to be safe?

RW: yes I would say, well

C: would you say this was a safe discharge?

RW: I think we’d have appreciated him being in longer. So from that perspective not an ideal situation.

C: with all due respect to your diplomacy with regards to decision making of your psychiatric consultant colleagues...

C: when you heard he’d been discharged did you consider that was a safe discharge or not?

RW: ummm, sir I think I can only say what I’ve already said. We’d have appreciated him to be in longer really

C: why would that be?

RW: so there was more assessment of his needs

C: by whom?

RW: by the treating team there, by the doctor

C asks how Chris goes from unable to be safe himself, team can’t keep him safe, to being safe in the community

C: You’ve got to, if I put it in these terms, suck it up, you’ve got to get on? You’ve got no choices

RW: yes, if inpatient treatment isn’t an option

[missed]

C: on 29 someone who cant keep himself safe, you cant keep him safe in community, given that universal view of their team explain why you don’t do anything?

RW: idea would be to have as much community services available as possible really, to distract him from drug use, keep him at Hart House, build his feeling of independence and self esteem.

RW: I think at that point was personal support plan from Hart House, know Kirsty had requested a fuller day to day plan. At this point we’re trying to line him up with the YPDAT. He’d have obviously all the access to our service, things like the employment specialist…

RW: someone to find him structured activities although problematic at time because of pandemic.

He’d continue to see his care coordinator.

Chris would always be high on our radar, we’d have home treatment team if we needed them.

RW: And of course drawing in expertise from other services as well if we needed that. That would be our plan.

C: and had you by that stage then come to the view he could be safely managed in the community?

RW: it would be difficult but yes we felt we had to manage him in the community, he’d only just come out of hospital.

C: help me with what you’ve written, were no clinical grounds with which to request an assessment under the MHA

RW: certainly, this would be based on his presentation when I saw him.

His presentation when I saw him was always unchanged.

He wasn’t presenting as distressed, or distracted, preoccupied.

He was telling us he was safe, he was doing some bits and pieces at the home.

RW: So seeing him in person, he was sort of engaging in treatment. You know he was engaging with us.

Those factors, it wouldn’t have been possible for us to call a MHA assessment based on his presentation.

Also the learning disabilities aspect of the Mental Health Act as well

C: what about that?

RW: my understanding of that was to be detained for a learning disability the risk factors have to be directly related to the learning disability. So looking at his drug use.

C: what about his [withheld]

RW: yes yes, I take that on board.

That had been explored in hospital as far as I’m aware.

When I explored it with him he was kind of able to reflect on it.

He denied it as being a suicide attempt or anything.

RW: He said he wanted an adrenaline rush and I couldn’t prove that wasn’t the case.

He had awareness and insight into what could happen doing something like that.

C: you say he couldn’t comment when asked if he’d repeat the event again?

RW: no he couldn’t comment

C: so he wasn’t ruling it out?

RW: no if he’d told me it was a suicide attempt and he intended to do it again, then I could have escalated

C: you look at presentation in moment, but you don’t do it in a vacuum.

It's an ongoing assessment in time.

C: This lad in the first week had been [withheld] you’ve been relatively candid about your experience in learning disability and autism, and very candid about not engaging yourself in capacity assessments.

Did you have, do you think, a significant grasp of his masking?

RW: yes I was aware it came up in reports he could mask.

When I saw him was degree of that at times.

He would use little stock phrases, umm, but he didn’t do that repeatedly.

C: what about the possibility he was just telling you what you wanted to hear, what he thought you wanted to hear?

RW: yes

C: did you consider that?

RW: I did

C: the stakes are very high, I appreciate the clarity of hindsight. The issue I’m looking at here is foresight and management of risk.

Your evidence is robustly no clinical grounds of which to request an assessment under the MHA.

C: Did you consider following the discharge, earlier than you and the team wanted, back to Hart House, whether a fourth capacity assessment was required urgently by someone with expertise in the field.

Something Julia had been asking for for a while?

RW: yes and I think that was being sought

C: I don’t think it had been scheduled

RW: not scheduled but sought

C: well there’s dispute about who was going to organise that.

What I’m looking for is sense of urgency around capacity assessment.

C: We obviously have view of Dr Carr, your team, Dr Villa close monitoring of situation.

Was another assessment required?

Does he understand his risky behaviour?

C: I’ll be corrected if I’m wrong but it doesn’t seem to be something that was prioritised within the plan that was ongoing at that stage, is that fair

RW: I think so yes

C: you attended the meeting, I don’t think it's in your chronology, but you saw him again on the 3rd.

RW: I did yeh

C: he stated he knew he should avoid using drugs… did not feel he’d have difficulty from peer pressure in refraining from drug use if he had to.

Again, did you take him at his word on that?

RW: no I think I explored that with him

C turns to record

RW: he was future planning, looking forward to things in future, he was engaging with us, taking treatment, he was at Hart House. There was almost this little period of stability about it. Felt that way

C: you’ll have in mind after the last period of stability he [withheld]

RW: yeh I know

C: you attended meeting with Kirsty and YPDAT, gentleman didn’t recall meeting but you do?

RW: yeh yeh

C: was agreement Christopher was not acknowledging having issues with drugs and not wanting directly to address his use of drugs.

C: TYPDAT stated there are no inpatient rehabilitation settings for people using mainly cannabis.

RW: yeh I remember the words he used, he said would be a slow burner, they don’t normally deal with people who just use cannabis but they were going to with Chris.

C: thank you

C: You made contact with Street Triage Team to raise their awareness of him in case he came to their attention

RW: yeh, it was a branch we hadn’t considered

Cl; you attended the professionals meeting on the 7th

RW: I did, I have very little recollection of it but I did attend

C: alright, those are my questions for you Mr Weidner, well take a 10 minute break and then come back. You’ve heard me give the instruction but you mustn’t discuss your evidence with anyone until your evidence is concluded.

15:40 please

[Court was adjourned at 15:30]

Ms Denton introduces herself

AD: I think your evidence was Hart House came from Ms Range

RW: I think so yes

AD takes to note in records email from Amy Glover

AD: Ms Glover is within the recovery and wellbeing team in EPUT is that right?

RW: yes

[Looks like suggestion had come from within EPUT Team]

AD: seems like Amy Glover made suggestion. Would you agree with that now?

RW: I’m not sure I just have it in my mind Sarah Range suggested it and this follows up on it.

AD: in fairness if it helps Sarah Range does talk about it in her witness statement, but by the time she contacted Hart House EPUT had already done so, with you agree with that?

RW: yes then

That’s all from Ms Denton

Ms Nash for Hart House

RW thinks he spoke to Paul Jaggs about finance

RW: the contact I had with Helen, which I cant quite recall, was more around Chris and his presenting difficulties

LN: I’ll ask you about that now. We heard from Ms Clark this document was from her. Had you ever seen this document?

RW: I don’t think so

LN: we can see your name and a redaction

RW: yes

LN: we see learning disability question mark, do you see that

RW: yes

LN: she was asked about her understanding of Chris’s learning disability and said she had a conversation with you. Can you remember what you told Helen about his presentation of LD specifically

RW: that he had LD and autism, that was the account of it, he had multiple diagnoses

LN: if we look towards the bottom of the page, age 7 autistic spectrum diagnosis, do you see that?

RW: yes

LN: do you recall telling Helen about a diagnosis aged 7?

RW: I recall telling her about autistic spectrum disorder but I don’t remember if I told her aged 7. I remember her saying they’d had people with ASD at Hart House before.

LN: is your evidence then that you explained the complexity of diagnosis

RW: yes

LN: can you explain why it says learning disability question mark? Its not your document

RW: no I can’t

LN: her evidence was she hadn’t understood the extent of Chris’s learning disability, would you agree with that?

RW: I’d disagree with that. She had a risk assessment.

LN: She said she had a conversation with you… can you remember a conversation where Helen Clark raised concerns with you on or after 26 June about Chris returning to an open unit like Hart House?

RW: no I remember some conversation about Helen asking me whether she could call an ambulance, no sorry that’s not correct, whether she should call the police or emergency services should Chris leave

LN: do you remember the context of that, what prompted her to ask that?

RW: I cant remember exactly but I assume because it was so close to the recent risk incident

LN: perhaps indicates a degree of concern about that incident

RW: yes

No further questions from Ms Nash

C: that’s left rather hanging in the air. So what was your response?

RW: I think I said to her along the lines of if Chris is telling you he’s going to [withheld] or something like that.

RW: If its clear he’s going out to do something risky then you’d need to call emergency services, but you cant call emergency services if he’s just going out. I sort of recall it on those lines

C: do you think its realistic he was going to tell anyone if he was going to [withheld] or do something risky?

RW asks Coroner to repeat the question, he does so

RW: not at that point

C: no

RW: I find that really hard to answer because there was an ongoing risk so you know, I guess, my answer would be if it was clear he was going to do something risky they’d have to take emergency steps, but if he was leaving to say he was going to the shops, they couldn’t keep him

RW: there

C: that was part of the problem wasn’t it, precisely the problem in trying to keep him safe

RW: yes

C [missed]

RW: We were hopeful, not just Hart House, the whole package really

C: Ms Clark was quite distressed when she heard Dr Villa’s email, she was upset it appeared, that the team she thought were supporting her had that level of concern he couldn’t keep himself safe, the team couldn’t keep him safe yet Hart House were expected to.

C: She expressed concern that view of the team hadn’t been shared with her, anything you want to say about that?

RW: only that my feeling was we were always quite open and transparent about the concerns of managing Chris but also hopeful because we did have plans

C: I try to sit that alongside if he doesn’t tell you he’s going to [withheld] there’s nothing you can do. Any particular reasons why you as clinical lead didn’t share the nature and extent of your concerns with Hart House?

RW: I thought we always did

C; had that been shared with Ms Clark, or anyone else in that team, that Chris could not keep himself safe in the community, and you the ESTEP team could not keep him safe in the community?

RW: I don’t recall

C: do you recall anyone saying that, if you’re full of frank disclosure to her

RW: I do see your point, but I recall quite free flowing conversations with Helen

C: might be the reason she was so upset that this wasn’t shared, arguably the most important aspect, that it wasn’t set out

Anything further Ms Nash?

LN: just that I’m officer of court, email from this witness [reads] was sent to Helen Clark

C: what page?

LN: reason didn’t intervene with Helen Clark was because the question was about Dr Villa’s email but if it is any email then that was sent

No further questions from Ms Nash

No questions from Ms Khalique

C: Mr Stoate

TS introduces himself

TS: in your evidence to coroner earlier you posited thrill seeking, drug use, something in his cognitive functioning we don’t understand

RW: learning disability or ASD is what I meant

TS: we’ve got there

TS asks if he read GOSH report

RW says he did and he recalls the reference to masking

RW: it was something I was aware of, I was cautious to take things slow and reframe things

TS: that was to be my question.

You spoke to Chris a couple of times in what we now know to be the last week of his life.

TS: Did you make any reasonable adjustment to the way you worked with Chris?

RW: I’d try to be quite clear about it and leave a little time to respond… Not talk in abstract terms. I’d try and do that

TS: So you’d try to be clear, not talk in abstract terms and leave him time to answer

RW: yes

TS: did you use any visual prompts?

RW: no I didn’t

TS: had you had any training to work with an autistic young person. I don’t want to be rude, or flippant, you did your best but?

RW: no as I said to the Coroner, we had some training in the team but I had no expertise

TS asks if he’s read the Niche report

RW says he’s read all of it

TS turns to it in bundle

TS: There’s a whole section on autism and suicide Mr Weidner?

RW: yes yes

TS reads: statistics for suicidality are stark… 66% of adults with autism self reported suicidal ideation, 35% reported having plans or having made attempts… further study 72% of adults with autism scored above recommended psychiatric cut-off for suicide.

TS reads: Autistic adults are 9 times more likely to die from suicide

Children with autisms 28 times more likely to think about or attempt suicide. An @autistica report.

TS: did you have in mind any of those stark statistics for suicidality?

RW: no I’d say any complexity, the more complex any case is the higher the risks in general involve suicide.

These statistics were new to me when I saw them.

TS: I’m not going to suggest you should have grasp of percentages, but we’re told there’s stark, significantly increased risk.

Here you are, you say it’s nor psychosis, might be thrill seeking, don’t know.

You’re wondering aloud.

TS: Did it ever strike you to get specific advice maybe to do with his autism?

RW: all I can say is we were talking about it all the time, we were trying to get help from our colleagues in LD and autism services

TS: you were asked briefly about your understanding of the MHA as it would relate to learning disability. You said my understanding is risk factors have to be directly linked to the disability

RW: yes that is my understanding

TS: you’re referring to person with seriously irresponsible conduct with nature or degree that warrants detention in hospital… and need to detain person in interest to their own health or safety….

TS: Did you have any expertise either way, to say whether his learning disability might be directly linked to his conduct?

RW: no

TS: no

RW: I’m not an expert in learning disability

TS: so why is it you say you were prevented from requesting an assessment under the Mental Health Act?

RW: circumstances, he was engaging well with us, he was at Hart House, he was accepting treatment, he was denying thoughts of wanting to harm himself

TS: that could have been masking couldn’t it?

RW: well you can’t mask engagement, he’s engaging with us

TS: you could mask you’re not going to do that again

C: same with engagement, he could just have a conversation with you, he could be masking couldn’t it

RW: well yeh if you say so

C: are you precluding the possibility he could be masking?

RW: no I’m not precluding it, what I’m getting at is if you’re making referral for MHA those are the questions you’ll be asked

RW: Is the person seeing you? Are they taking treatment? What are they saying with regards to self harm

TS: Mr Weidner you clearly had lots of experience in psychosis and he wasn’t psychotic

RW: no he definitely wasn’t

TS: you’re experienced in recognising depression and you say you didn’t recognise that in Chris

RW: there was an emotional block, a lack of empathy, that doesn’t sound very nice.

RW: There was a flatness, I didn’t recognise him as depressed or mood instability, his mood was the same every time I saw him

TS: by now there was "god forbid the coroners court", Dr Villa’s email

RW: yes

TS: you’re openly wondering what could it be, you say, in the email my learned friend just referred to, that does seem to be the case.

TS reads email RW sent: “After feeling optimistic around Chris Nota’s case last week we are seemingly back at square one.

TS reads: Chris is currently at Basildon BHAU [withheld] as yet we don’t have an indication of whether this was a planned suicide attempt although notes do seem to detect an attitude of not caring about potential risk. Or whether he was under influence of drugs at time

TS reads: Seems to have been no clear trigger by way of significant event. I saw Chris twice in the week and there was no evidence of any underlying psychotic features.

TS reads: I am confident that we can't keep this young man safe. No amount of expertise and/or intensive monitoring can safeguard someone who will act in this way without any trigger or warning.

Would appreciate any comments that others may have in regard to a way forward”.

TS: That’s what seemed to trigger Dr Villa’s email, god forbid the coroner’s court.

C: that was effectively the form of words sent to Ms Clark

TS: it does appear to be.

TS: Mr Weidner a few questions.

No amount of expertise you say, colleagues you copied in there [lists 10-15 others] were you referring to them in terms of expertise, what did you mean by that?

TS: Not one has claimed to be an expert, they’ve all said I’ve got some knowledge, done some work.

You say no amount of expertise, who are the experts to whom you’re referring?

RW: isn’t it one of those things where very rare for people to claim expertise, these were the people available to me, Sharon [Allison] and Dr Udu.

C: so nothing we, the addressees, or I, can do?

RW: it does read like that, I don’t think I meant it like that

RW: I was talking about the ESTEP service

TS: you’ve written can safeguard someone who will act this way without trigger or warning, this is 29 June, you’ve recognised why that might happen?

RTW: yes

TS: [withheld] are you able to say whether you consider that to be seriously irresponsible conduct?

RW: yes, I don’t think there’s any dispute around that

C: [withheld] or [withheld] either way no doubt seriously irresponsible conduct?

RW: no

TS: you didn’t know if that was linked to his learning disabilities, you’re pre-judging it. What was preventing you even requesting an assessment from someone who might be able to tell you more from an expert perspective about why he’s behaving like this?

RW: I think partly that email is looking form someone else’s understanding of it.

Partly because inpatient wasn’t option available to us, so partially about having best options available to Chris.

RW: I do ask myself could we have discussed it with the AMHP Hub, an Approved Social Worker, could we have discussed it?

C: well you could have couldn’t you?

RW: well of course, there would be nothing stopping us

C: Dr Carr made a decision he’s not detainable. Apparently against her advice he discharged himself. You’ve now got this problem, this issue.

Um, it’s at least possible is it not that Dr Carr has got that wrong? Given the view of the ESTEP team.

C: Really it's returning to the issue of why couldn’t you effectively get a second opinion as to whether he was detainable under the Mental Health Act?

RW: uh hum

C: even Dr Carr accepts it was arguable he could have been further assessed.

C: So I’m, I think it’s the words that you were prevented effectively, why couldn’t you?

RW: well we could have… was based on my 48hr follow up [think he said]

C: you see. Ms Ballard

BB: Thank you. Mr Weidner you know who I ask questions on behalf of?

RW: uh hum

BB: you have experience of requesting MHA assessments?

RW: yes

BB quite regularly within ESTEP team?

RW: yes yes

BB: you’re aware of the questions you’ll be asked

RW: yes

BB: you’ve not conducted them, you’re not an AMHP

RW: no I’ve attended many

BB: the experience you had led you to expect you’d be asked about patients’ current engagement, whether currently accepting treatment, and what their presentation is

RW: uh hum

BB: that’s why you were exploring issues with Chris when you went to see him

RW: yes you’re always assessing risk, so that’s always on your mind

BB: and specifically asking him about thoughts around taking his life because your experience is that’s what you’re asked about

RW: yes our training has always been to ask people directly about that

BB: was it also present in your mind Chris had just been assessed by an inpatient psychiatric consultant

RW: yes

BB: and when you saw him on xx that was less than 24hrs prior

RW: yes

BB: and that assessment would have questioned whether he was detainable under the legislation and it concluded that he wasn’t

RW: yes

BB: moving onto a different topic, can I ask you about cognition.

BB: You’ve been asked a lot, Chris could just be telling you what you want to hear.

If a person tells someone what they want to hear that requires person to have significant understanding and level of cognition to understand what someone wants to hear?

RW: yes

BB: and that may well demonstrate a significant level of cognition

RW: yes

BB: that email you’ve just been taken to was circulated to Sharon Allison, at least 20yrs experience of working with autistic patients

RW: that’s right

BB: she might not class herself as an expert

RW: that’s what she said

BB: di you class Sharon Allison as quite a modest individual

RW: yes

BB: and you also have in that email Dr Udu who’s heading up the LD service

RW: yes

BB: and David Fisher Hope who’s heading up the AMHP service, is that right?

RW: yes

BB: You were including everybody who you think will give you an indication about a detention under the Mental Health Act

RW: yes

BB: that’s all my questions sir

C checks last question she asked.

[Not sure whether was Ms Nash or Ms Denton who provided it. One of them did]

Mr Weidner is thanked and released at 16:23

C: I see the time but I know Ms Denton has been waiting on tenterhooks for the statement of Ms Wall to be read.

Coroner reads partial parts of Mrs Margaret Wall's statement onto the record.

[Very hard to catch at speed, very partial]

C: She’s the Preparing for Adulthood Manager, prior to March 2020 her role was known as Transition Officer, prior to that she was a probation officer

Didn’t manage Chris’s EHCP that was managed by her colleague Ann Igoe

C: Christopher had statement of SEN throughout his schooling, stayed in mainstream schooling throughout his schooling career.

She sets out various aspects [cant catch]

C: He was articulate, polite, did not give appearance of having autism identified in GOSH report I believe his social interaction could mask his underlying autism.

Chris only came to my attention in May 2019…

C: Chris was anxious about taking his GCSEs, his mother was worried his EHCP was going to come to an end. Informed Ann Igoe wasn’t going to take GCSEs at that stage, wanted to know whether could be paused for a year while Christopher took gap for year

[missed chunk]

C: I said to Ann in light of hospitalisation needed to make sure we’d supported all those involved… went back to CCG amongst others to see who should be dealing with and broker service to help him, not in our remit, limited to SEN needs in education.

C: We have no power to control what health or its off branches, ESTEP or social care, do. Our role is in the assistance of transition of young people into adulthood who have SEN needs.

C: 9 June 2020 is heading. Chris has been readmitted to hospital, when informed by Kirsty Lister of ESTEP that Chris would be afforded package of support, the health commissioner was involved and support was put in place for him.

C: unfortunately because Ms Wall wont be giving evidence we’ll never know quite what she meant by her enigmatic use of the phrase overly privileged.

There we are.

Anything further from that statement?

LN: not from that statement sir, but from Hart House’s perspective. I’d indicated I’d asked dates of Helen Clark’s leave. She was off from 29 June until 24 July

You’d asked for updated admission policy [think she said] and updated action plan

LN said both sent to Coroner’s office on Friday, others Monday.

C asks if she can remember when updated action plan was published

LN can’t off top of her head, but this is current policy and policy at time.

LN is securing a signed statement from Emma Bennett overnight. Asked her to clarify who was author of the Service User Risk Assessment. She cant definitively say who but likely to be able to indicate.

LN: I’ve put my learned friend on notice of this, but my understanding, but wont know until I’ve seen the signed version of that statement, is the author is Helen Clark

C: right. We’ll await the signed version.

C: She’s on sick leave, I don’t need to know details obviously, who was person in this complex and challenging case expected to take up the cudgels on behalf of Hart House with ESTEP, Chris and Julia?

LN: the registered manager was back in work on 24 June but whether she was specifically to take on that role I’ll need to seek clarification

C: I’ll leave that with you.

C: Likely to feature in my determination of what arrangement Hart House had made to cover support in absence of Helen Clark

LN: I’ll tread carefully here, but I wasn’t aware that leave was so significant until today

C: no. In fairness to ESTEP if they’re trying to contact someone and there’s no response and they don’t know what is going on. I’ll not take that further now, will check in the morning

C asks Ms Ballard for an update of progress

BB: “Emails should be pulled by the cyber team”, I’ve no idea what that means, which is why I’ve quoted it, by end of the day. So I will go through it and let you know overnight.

BB says she’s still working on the school reports collation.

C: thank you, it might be dogs that don’t bark, but I need to top and tail it before we conclude the evidence.

Tomorrow. All three Niche witnesses are remote. Ms Nibbs [?] is responsible for the report, she’s written a very large part of it.

C: What I was considering, if all three from different locations are available, is possibility of swearing them all in at outset and in new development of hot tubbing, remote virtual hot tubbing, takes to new dimension literally and figuratively...

C: way of making our way through report and speed up process.

Rather than taking them in silos, seems sensible.

Have a think about it, if anyone takes particular objection to that we can proceed in conventional way tomorrow.

C: Nyarumba, good afternoon to you, and Julia, and thanks to everyone else.

Tomorrow morning then, thank you.

Court is adjourned at 16:37

Back tomorrow 10am.