Thread by @ChrisNInquest

The resumed inquest into the death of Christopher Nota is due to start shortly. It was adjourned after 3 wks back in September. This is Day 14 of this Article 2 inquest.

Area Coroner for Essex Mr Sean Horstead sits without a jury

This inquest discusses suicide and self-harm

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

I am concerned about recent changes to twitter and its stability. If once I start I find it is not possible to tweet fully and accurately due to technical glitches then I'll stop and blog later

2/

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

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I am attending court remotely

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

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My tweets are rarely posted in real time as I attempt to capture as much as I can, and tweet them once time/pauses permit.

Where possible I indicate where I have [missed] or [...] or if it is [my paraphrase] or if I am uncertain [?]

5/

This inquest discusses suicide and self harm.

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

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My #OpenJustice work is crowdfunded chuffed.org/project/openju… I rely on those who fund, follow and engage with 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

7/

I'll stop numbering tweets from here.

Day 14 should begin shortly, c 10am

If the tweets stop then I'll blog later. You can find my written blog here georgejulian.co.uk/blog/ and any new video blogs here youtube.com/@thegeorgejuli…

For more on Chris see

https://twitter.com/GeorgeJulian/status/1568253022916198402

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Coroner Sean Horstead introduces himself, 4 Jan 2023.

C: Happy New Year to one and all, this is the resumed and final inquest into the death of Christopher Nota.

Purpose of the adjournment will be known to all, I don't repeat it. Will turn shortly to the evidence of the 3 Niche witnesses attending remotely today,

Coroner thanks them for their hard work in preparing an addendum statement and attending today.

All but one counsel is attending remotely.

Coroner checks all can hear him. Ms Nash is in court, others are attending remotely.

Coroner acknowledges travel difficulties and assures everyone they can attend remotely.

Coroner checks counsel and IPs can hear him.

Mr Stoate points out that no-one can see the coroner but can hear him crystal clear.

C: I'd hate to deprive you or anyone else of the unbridled pleasure of seeing me in full January mode

Camera views are adjusted

C: Joking aside, most important is that Ms Ibbs, Dr Potter and Ms Hutchinson [today's witnesses] can be seen and heard

Coroner checks other counsel and IPs are connected and can see/hear

They all can

Coroner reads Chief Coroner's Guidance 28 June 2022 Guidance 42 - criminal offence to record and broadcast proceedings

Gives permission to attendees to have access to video links

Coroner confirms has granted permission to me to attend remotely and joined in court by one member of the press

C: Before return to expert evidence from Niche report, can I indicate direction of travel for resumption and conclusion of this inquest

C confirms will largely read into record the addendum report, stopping as necessary, IPs will then have opportunity to draw out any matters he hasn't

Further evidence to be read onto record from Emma Bennett - says he'll start with that

C: Also statement updating where EPUT have got to in recommendations

C confirms he's intending to hear his evidence tomorrow in 2hr slot from 11am [Dr Otun I think he said]

C: May well be in Article 2 compliant inquest the logical and sensible course is to conclude matters in Box 3... and in Box 4 a narrative conclusion is direction of travel perhaps, uncontroversial sensible course, but opportunity for all counsel to make submissions will be there

C says he's deliberately not sought to draw any conclusions until conclusion of evidence today.

Coroner says he intends to sit at 13:30 on Friday for conclusion but requests counsel don't book anything for Friday morning as that may change.

Coroner calls onto screen Ms Ibbs and her colleagues

He swears them all in. Naomi Ibbs gives an affirmation.

C: you're a senior consultant and you effectively chaired the panel producing the Niche report and addendum report

NI: that's correct sir yes

C: by summary your background is what? I know you've given this evidence before

NI: My background is health and social care management, in a commissioning and provider role. Latterly as an independent reviewer of serious incidents in health and social care setting.

NI confirms she's been conducting investigations for 9 years

Dr Mark Potter gives an affirmation

MP: I'm a consultant psychiatrist, I've almost 30 years experience as adult consultant, mainly community MH team but also inpatient... significant medical management experience...

MP: I was the Medical Director at St George's.... probably 50 or 60 investigations over the years

Christine Hutchinson gives an affirmation

CH: Registered LD nurse... associate [missed chunk] additionally work independently undertaking reviews and other consultancy work

C confirms he'll address most questions to Ms Ibbs, but others can chip in

C confirms he'll read from addendum report

C: Information by way of emails and exchanges you and your colleagues hadn't had sight of.

C: I by way inducing your evidence, became apparent a number of emails hadn't been seen by you, I'll say no more than that other than it became necessary for an adjournment for EPUT and other IPs to put together a bundle of relevant emails....

C: 77 page bundle, which then took rather longer than we hoped but again no criticism.... available time reduced from 42 days to 27 days.

You've managed to provide report, received 22 December, all IPs now seen, together with paginated bundle of those emails.

C: First of all I extend great thanks to all of you three for the efforts you've expended, interrupting no doubt busy other schedules you had. Very grateful for the report you've provided.

C: You didn't re interview anyone, or seek additional information. Based addendum report on review of emails and what was indicated, in respect of the trigger email if I refer to it.... you'd expect content to be reflected in medical notes

C says he'll revisit original recommendations and whether they're changed from addendum, then cover the additional recommendation.

I'm actually going to be reading quite a bit of the document into the record as it were, if I ask you to summarise we may miss out elements.

C: As I'm reading through if there's anything you Ms Ibbs, or Dr Potter or Ms Hutchinson wish to draw out please do....

C confirms he wont read out the emails... if any IPs wish to take issue with any of those they have the opportunity

C turns to internal page 7, para 2

C: you've set out the original recommendations in an earlier passage, I don't propose to go through those in any great detail. You set out the recommendations, then we turn to p8 [missed chunk]

Discussion about ESTEP team being appropriate team for Chris's treatment

MP: think that would be standard practice, someone presents with psychotic illness, early intervention is right way to go.

C: doesn't appear was any return of psychotic episode per se in weeks and months that followed that discharge in May and tragic events in July

NI confirms that's correct

C reads: Education staff reported that at college there was a marked difference between what he believed he could do and what he was actually able to do and that he “often slipped under the radar”.

Coroner summarises that Niche found Trust staff should have placed more weight on information from people who knew Chris, especially his mother, Julia

They agree

C reads: default should be the MHA, and if after robust testing that is not applicable, then the MCA should be used

Altho Chris was detained under S2 of MHA, and capacity assessments had been completed, it was Niche's view that the Trust did not use either framework effectively.

C reads: By the time of his fourth hospital admission on 27 June Chris had spent just 13 days in the community during the previous 11 weeks.

The longest period of time that Chris had been in the community was just eight days.

C: Chris’s mental state appeared to settle rapidly following admission to hospital. However, his brief periods in the community following discharge were characterised by poor compliance with medication and high-risk behaviours (particularly being found on bridges or overpasses)

C: exacerbated by illicit drug use. He appears to have exhibited little if any interest in addressing these behaviours during his periods of in-patient care and therefore such behaviours were likely to be repeated each time he was discharged.

C: At the point of his fourth admission to hospital more consideration should have been given for detention under Section 3 of the MHA.

C: The need for rapid re-admission following his of his previous hospital discharges and his high-risk behaviour in the community might be considered evidence that his mental disorder was of a nature (and possibly degree) that required treatment in hospital and

C: was necessary for his health and safety. Also, that less restrictive options were not sufficient to maintain his safety (i.e. community treatment).

C: Anything wish to draw out or emphasise or findings speak for themselves?

NI nothing to emphasise

MP: when come on to what additional emails added, picked up was evidence and feeling amongst teams looking after him was risk that wasn't containable in community setting. Doesn't change findings but strengthens basis on which they're made.

MP: If can't keep someone safe in community, leads to more restrictive options, consideration of MHA or MCA.

C: thank you

C reads: This would have resulted in an opportunity for a longer assessment and the potential to work with him on trying to mitigate some of his

C: high-risk behaviours, for example by engagement with drug and alcohol services. A shorter period of leave to his new accommodation using Section 17 of the Mental Health Act could also have been utilised to try to facilitate a safe transition to community support.

C reads: We found Trust staff did not give sufficient consideration to the impact of Chris’s autism and learning disability on his presentation and communication. The effect of this was that inappropriate decisions were made about his mental health care and treatment.

C: It is our view that Chris’s autism impacted on the explanations he gave to staff about actions he took.

C asks if any additional comment

CH checks whether wishes to address masking at this point - they'll address later

C: 2 recommendations arose: The Trust must ensure that in cases where a patient has frequent admissions to hospital over a short period of time and their clinical presentation is not clear (staff did not understand why Chris was exhibiting high-risk behaviours)

C: a more sustained assessment and treatment period is fully considered and 2. The Trust must ensure that staff document care plans, risk assessments and risk management plans (including relapse prevention and crisis contingency planning) in a structured, personalised and

C: consistent way, ensuring that reasonable adjustments are made for patients with a learning disability or autism.

C: that is obviously contingent on availability of relevant specialisms to facilitate...

C: You say is our view emails do not change focus of original recommendations, however do consider they strengthen basis on which they're drawn.

Emails in early June show Trust recognised Chris's case was complex....

C: evidence much debate about which service should take lead in managing Chris's case but ultimately no change to team left with repsonsibility for Chris, namely ESTEP, I've added that in.

C: Email from Judi Jeavons... 3 potential placements... unclear what action taken following this suggestion

You say subsequent emails show MH services were aware Chris's case was complex, was need for careful planning and would be unwise to discharge home

C: There was evidence of awareness of diagnostic uncertainty.... and questions of impact of Chris's learning disability and autism.... aware Chris's risk was present at home and in Hart House [June email] also clear Chris did not have capacity around drug use...

C: 16 June Dr Villa confirmed Hart House could not contain risk, 17 June confirmation hospital admission required. Dr Victor Udu email confirmed Chris was not for them [learning disability service] and that Chris should be dealt with by mainstream services

[missed chunk]

C: By 20 June was clear view Chris could not be kept safe in community, reference Richard Weidner, due to unpredictability and level of risk. Little understanding of what was driving Chris's behaviours.

C: Email Dr Villa confirmed view specialist placement was required to keep Chris safe, highlighted previous plans had failed.

Chris had been voluntary patient under Dr Blaga Carr for 2 days after [withheld].

C: Summary of Chris's risk set out in Dr Villa and Mr Weidner's emails were not reflected in his clinical records on 29 June or subsequent entries. Would expect to see this level of concern reflected by way of contemporaneous entry or updated risk assessment.

C: Original evidence we reviewed documented Mr Weidner's assessment on 1 July as 'no evidence of imminent risk' and no grounds to request MH assessment.

We've not seen any evidence of formal assessment, Chris's capacity in response to this request.

C: By end June clear evidence in emails, view of some Trust staff, specifically ESTEP team who had lead responsibility for his care in the community, correct?

NI: that's correct sir, yes

C: that Chris could not be safely managed in community, either at home or Hart House given he wouldn't stay and insisted going out.... little evidence of anyone taking charge and acting decisively

C: You then say if patient can not be kept safe in community are options to explore as alternatives.... appears no evidence of consideration around use of MHA and rationale for possible detention under S3 remains.

[Missed chunk - given didn't know what was causing Chris's behaviour]

C: Was our view mental disorder could not have been completely excluded, consequently consideration of MHA would have been appropriate

C: Difficult for us to understand why specialist placements were being considered without consideration of MHA or DOLS... impossible to determine what outcome may have been...

C: you weren't able to predict outcome of MHA assessment but you were clearly of view should have been considered and undertaken?

NI: that's correct sir yes

C: I was struggling to reconcile having heard evidence of Mr Weidner... July 1 email with 29 June email traffic

C: Were you able to reconcile the two in any significant way or not really?

NI: umm, no, we weren't able to reconcile them. Our view was that the narrative in the clinical entry of 1 July was quite different from the concern being expressed in the email communication

MP says clinicians can get drawn into imminent risk... but if you look at overview of case, helicopter view, can see is risk.

Cant answer for Richard but imagine what's drawn out is distinction of immediate risk and longer term risk

C: would I be right in thinking the email of Dr Villa 29 June, does appear to be taking something of a helicopter view, overview, of nature and extent of risk because of failed discharges if put it in short hand?

MP: yes

C: we can't keep him safe, he can't keep himself safe, we need to do something else... which coincides with period where he's voluntarily at assessment unit under care of Dr Carr

MP: yes

C: we'll turn to exchanges of Dr Carr, aware of what you say about lack of formal assessment of capacity by Dr Carr, you made point she was asked to assess his capacity to keep himself safe, you haven't seen any evidence in response to that request....

C: I think Dr Carr's evidence wasn't formal assessment but ongoing assessment, we'll turn to that shortly

NI: thank you

C: last thing wanted to ask in respect to this first element we've just been through, is impact on big meeting on 7 July, or later meeting in July...

C: Impact of absence of clinical documentation of concerns reflected in 29 June discourse narrative.

What's the effect of that not being available in clinical notes on trajectory of that meeting?

NI: I think our view wld be if you have a set of clinical records that range of clinicians are relying on to present an accurate picture of a patient's presentation, it is that information that is relied upon to inform discussions and therefore decisions about care and treatment

NI: If the clinical records are not reflecting the full picture of a patient's presentation then that by its very nature will lead to discussions and decisions being taken that don't have the full picture.

I don't know if Chris or Mark want to add anything?

MP: no I think that's a fair summary

C: is there an additional element, not only of the recording of a range of clinicians consideration of the presentation, but also their express concerns it appears with respect to care management and dealing with the risk

C: that presentation is identifying?

Another element, rather than simply accurate clinical picture... including we don't know what's driving it for example, but range of clinicians from Ms Jeavons, Ms Lister, Dr Villa, Mr Weidner, if can use term clinicians...

C: shared view of unmanageability of risk. Is that something that should appear in records?

MP: yes I think so. Obviously covid played a part, but the complexity, so much going on, people worried about what diagnosis was, was he psychotic, how much level of ASD did he have

MP: how much of intellectual impairments, illicit drug use, where should he be.

There was so much going on, so many involved, some of the more simple, basic stuff got lost.

MP: People were very aware of complexity, very concerned about it, everyone was working very hard to manage what was going on but simple things of risk management got lost, that was my feeling.

C: yes, an element I'm understanding of basic risk management would be sharing clinical view of nature and extent of risk?

MP: yes

C: that was not transposed from email exchanges into clinical record, if it had been that visceral level of concern, my words, would have been apparent in the big meeting in July. Is that fair?

NI: yes I think that's a fair summary

C: Mental capacity assessments did not adequately set out the salient information for each decision separately and did not consider ‘masking’ or executive functioning explicitly.

C: We acknowledge that the mental capacity assessments completed by Chris’s care coordinator Ms Lister tried to consider the impact of autism, but she was not experienced in understanding the impact of autism on a patient’s presentation

C: We do not say that the outcome of the capacity assessment is wrong. However, there were differing views of his capacity (between clinicians and Chris’s mother).

Some of the MCA documentation is confusing as to the accepted conclusion of the assessors.

C: Therefore, the clarity on what statutory framework should have been used for next steps is unclear.

[missed chunk]

C: recommendation that arises is The Trust must ensure that leadership and peer review from consultant-level practitioners with appropriate expertise...

C: is available to staff when dealing with patients where the matter of capacity is made complex by co-existing mental impairments.

This should include who will lead on agreeing points relevant to the decision; the methodology of approach; who should be involved; and...

C: reviewing the information and evidence discerned prior to conclusions being made and acted upon.

Pausing there, my note of Mr Stoate's questioning of Sam Salici's evidence, her evidence she didn't feel she was equipped to contribute to assessment per se....

C: she was there with specific role to provide easy access tools as required

Point was made, Melika Kay, as social worker, would have no clinical input, although she was part of team with views expressed, albeit as you identify Ms Ibbs was confusing...

[missed chunk]

C: follows I think by process of elimination that Kirsty Lister, care coordinator, became sole determiner of the MCA assessment.... hope that's fair...

C invites counsel to clarify his summary if necessary

BB: with regards to Melika Kay, she I think held herself out as having more of a role than you've indicated in your summary.

BB: She described these assessments as part of her bread and butter... that phrase springs to mind, but haven't got her evidence up in front of me to review it, it’s a memory job rather than anything else

Ms Denton says she can clarify her note with Ms Ballard's and get back to Coroner over lunch if helpful

C: I want to be clear, my impression, that burden fell on, I did have I thought fairly clear as non-clinician she didn't feel she had that decision making role with respect

C: to mental capacity assessment but if I'm wrong about that, I stand to be corrected.

We'll proceed Ms Ibbs on basis you've identified matters, I think I'm on safe ground with respect of Ms Salici's contribution.

C asks Ms Hutchinson if like draw out anything about masking

CH: few things, capacity assessments, often people jump in without thinking through salient points of methodology, often jump straight in rather than thinking what's best way of doing this and who should be involved.

CH: Ms Hopper was available, and staff at college were available who'd passed comments on level of understanding versus what he says, possibility of masking, or executive functioning issue, or both present.

CH: Should have caused more weight to think about methodology in how approach mental capacity assessment itself.

CH: We weren’t able to speak to Sam Salici or Melika Kay, we saw evidence in notes, and what Kirsty told us in her interview, there were indicators of masking and executive functioning issues, but weren't understanding of those, breadth of their impact or how contributed to how

CH: he presented, from mental health view and his explanations for his actions, but also comments and phrases he was making in assessment.

CH: Unfortunately led to them placing a lot of weight on his verbal interactions with them, potentially skewed their understanding and outcomes of assessment.

CH: We can’t say assessments were wrong, no opportunity to view video footage of Chris during those sessions, records don't contain sound bites of what he said...

CH: too limited for us to say outcomes were wrong but clearly number of indicators there that required more work on assessment methodology

C: given critical importance of these capacity assessments, seems to be view of all those involved, these were important.

C: Should someone, an experienced clinician, with specialist knowledge been involved in such a complex case, in those mental capacity assessments, preparation, conduct of and recording of.

Is that a view you hold?

CH: I think so, difficult to say clinicians’ should be involved in every assessment, but when sliding scale, decisions more complex, involvement becomes more key.... very important, significant decisions in his life...

CH: and we've got complexity around executive functioning and masking, and risks in relation to his behaviours and impact on his mental state and personal safety, suggests should have been more experienced clinicians with more experience directly involved in assessment process.

CH: there were consultants engaged in conversations but weren’t directly involved in assessing capacity and supporting Kirsty as care coordinator in these assessments she undertook

C: evidence of Sharon Allison was with hindsight might have been better for her not Sam to be involved

CH: yes, I consider myself quite experienced, but where its particularly tricky, I myself might still go to consultant with experience for support....

CH: is understanding who are right people to engage in processes.... care coordinator made attempts to engage that expertise, but unfortunately you highlighted from information we didn't have, the people afforded to her possibly weren't the best people to assist her

C: thank you, bear with me one second. Dr Allison had one 40min meeting with Chris, that was known to you?

CH: yes, that wasn't to assess capacity, that was to explore discrepancy they felt between GOSH report and his presentation...

CH: was that difference between previous professional reports and current presentation she focused on

C: that's correct, she confirmed she didn't discuss cannabis and wasn't there to conduct risk assessment or formal assessment.

C: I have to reconcile with fact she did seem to come to settled view an autism unit wasn't required at that time.

You say your view emails don't change focus of original recommendations...

[missed chunk]

C: missed opportunity to engage Julia, Chris's mother, in supporting capacity assessment, as person who knew Chris best.

C: You've seen there have been tensions, and challenges, as neutrally as I can, from Julia's perspective working with Trust, and other IPs perspective working with Julia, but your collective view is this was a missed opportunity to get Julia involved in supporting this assessment

C: whatever the difficulties?

CH: that's correct, and also why we rely on college staff, if those tensions were insurmountable there were others who knew Chris very well who could have been identified as well

C: thank you

C: if was issues and problems, a formal process to deal with those, is something you identify

NI: that's correct, yes, although we've not touched on in this summary.

NI: The guidance in the MCA Code of Practice does set out a process for assessors to deal with disagreements about capacity, and we didn't see any evidence that was followed.

C: thank you

[missed chunk]

C: area of concern, capacity queried, consider further supports our original finding some of capacity recording is confusing.... email stated Chris had capacity with respect to drug use on 18 June, conclusion was they were unable to discuss with Chris

C: no form was completed for assessment.

Dr Carr asked assess capacity 29 June, seen no evidence was conducted.

Her email to Mr Weidner on 29 June said was 'absence of reasons to keep Chris in hospital’

C: was no evidence, you write, at this point that Dr Carr had referenced her colleagues’ conclusions in relation to using drugs, which at best queried his capacity, at worse found his capacity lacking. Our original conclusions stand.

C: that conclusion seems a striking one, no evidence Dr Carr had referenced her colleagues’ conclusions.... seems to be quite an important element of the assessment process, and indeed the decision not to detain further at that period of time?

C: Would you agree my emphasis is correct?

NI: I would agree that your emphasis is correct. I do think it is a very important point.

NI: It links back to the issues we were discussing earlier about longitudinal risk assessment versus risk assessments of what is happening at the moment right in front of a clinician

CH: If I might add, the reason the emphasis is important is because duty of care changes when someone lacks capacity... as such their actions may have been different if they'd revisited a capacity assessment around drug use...

CH: or progressed earlier statement he lacked capacity, duty of care would be different, actions may well have been different. Whether or not would feature as part of detention decision and Section 3 could be separate matter.... Mark might want to comment?

C: Dr Potter, would it be potentially relevant?

MP: yes I think it would be relevant, with Christopher was no real understanding of what was driving his behaviours, he'd been stable in community, not completely stable, but in education, going out etc.

MP: Something happened and he's not able to function in community, may well be illicit drug use was contributing to that.... [missed chunk] whether Christopher had capacity, impact on his risk and drug behaviours, is obviously relevant.

C: Thank you very much, bear with me.

C: An attempt was made to engage the young people’s drug and alcohol team in working with Chris. However, this proved challenging because they were not offering face-to-face assessments due to the Covid-19 pandemic. A meeting did not take place prior to Chris’s death.

[missed chunk]

C: ties back into points made re capacity assessment, specifically with regards to drug use, re-testing it, or relying on way conducted

C: You say, it is our opinion that Chris’s drug use would not have met the threshold for most substance misuse services, and that disproportionate weight was placed on the involvement of the young people’s drug and alcohol team.

C: The Trust must ensure that when addressing substance misuse, care plans are appropriately tailored to meet the needs of people with a learning disability and autism.

Not first case I've heard where drug use and autism have featured....

[missed chunk]

C: anything about drug services for young people with learning disability that would be different to services for people with EUPD for example?

CH: statutory duties are no different, duty to make reasonable adjustment to take account of person's protected characteristics.

CH: In Chris's case protected characteristics are threefold, learning disability, autism and mental health needs.

Should have been reasonable adjustments... not just by drug and alcohol or specialist teams, but by any teams.

CH: A number of reasonable adjustments through the GOSH report, although the language of reasonable adjustments wasn’t used then, but they talked about what strategies that would assist...

CH: does details things like using social stories, planning ahead, providing info in small chunks, and various ways.

Should have been reasonable adjustment of mental health services consideration of his drug use, and consideration in terms of drug and alcohol teams approach.

CH: What should have been offered and how was a little beyond what we looked at but certainly were reasonable adjustments that should have been made.

[missed chunk]

NI: fact Dr Villa was expressing concern about intention for telephone assessment, that in her view wouldn't offer appropriate picture to YPDAT given Chris's autism

C: Dr Villa recognising positively a reasonable adjustment that needed to be made in the circumstances. Thank you

??: We set that within context of covid, YPDAT weren’t undertaking at that stage face to face appointments. The plan was in fact to have a face to face, that was being set up on basis of what Dr Villa had identified. Thank you.

C: insufficient documentation regarding safeguarding referrals, planning and supervision....

Trust staff did not always correctly reference safeguarding issues within patient records.

C: There is no indication of the status adult safeguarding enquiries undertaken, and we have seen no documentation or minutes of safeguarding meetings.

Recommendation 5 that arose

C: The Trust must ensure that clinical staff reference adult safeguarding issues correctly within patient records, in particular

a) reference must be made to the status of the adult safeguarding enquiry

b) all safeguarding documentation and minutes of safeguarding meetings

C: must be accessible and

c) if clinical teams are seeking support and advice from the Trust safeguarding teams then this needs to be clearly recorded as safeguarding supervision

C: You say your view emails didn't change original recommendations....

C: Judi Jeavons email did identify would become safeguarding issue, Julia had indicated she could not keep him safe without a full care package

Email 16 June documented Hart House staff would raise safeguarding alert due to concerns Chris was being exploited in community.

C: Was no outcome documented in Chris's records.

Richard Weidner documented ESTEP team were not confident they could keep Chris safe [quote from email] ...

C: email later same day from Judi Jeavons indicated colleague on safeguarding team should be made aware of teams’ concerns about keeping Chris safe.

Not clear whether escalation happened... nor outcome

C: again another route to really highlight concerns ESTEP team had, all of them shared on 29 June, but you couldn't identify whether that was ever escalated or followed up

NI: that's correct, when we completed original report the concerns in Mr Weidner's email wasn't available to us, so we didn't seek to establish more information outside what was available to us.

NI: In saying not clear from email whether was escalated as suggested, we're simply saying that, from bundle of emails we received it isn’t clear, not inference it didn't happen, simply we don't know whether it did.

C: ok, Ms Ballard, if there is evidence of that being escalated, by way of safeguarding referral or colleague informed, if documented anywhere am sure those instructing you will be able to find it.

BB: yes sir, as you know were a number of safeguarding concerns raised, but not at this point in the chronology, may be matter for you sir given what subsequently transpired. I can see if anything done prior to Chris's death.

C: yes we have a separate bundle of safeguarding records, but I don't think there was

BB: no I don't think there was, not caveated on basis can provide to you, but understanding why was case if case, don't think was expressly raised with Mr Weidner when he gave evidence

C: that's right, doesn’t appear to be raised by email, don’t think we have any evidence safeguarding team were contacted with respect 29 June

BB: thus far no, I'll correct myself if I'm wrong

C: Ms Ibbs, you say, 6.5 is contingent, is limited to fact is no email you've seen, that has led to colleague in safeguarding team being informed... on working assumption was no further safeguarding raised at that point

C: in light of what transpired on bridge on that occasion, what if any comment would you make? How significant would it be?

NI: comment would be same whether had or had not been further incident on bridge.

NI: Were significant concerns being expressed by staff and it was an opportunity to escalate those concerns to safeguarding experts, who at the very least, may have been able to provide some advice, consultation and guidance about how to respond...

NI: and at best could have instigated a safeguarding referral and inquiry.

C: would that potentially have fed into in any way the decision to discharge rather than detain, don’t know if Dr Potter can assist with that. If safeguarding had been raised on 29th?

MP: I suppose hypothetically if a formal safeguarding meeting had concluded Hart House was not a safe place for Christopher to be, that then lends itself to more discussion of what are alternatives, should it be to remain on ward, it’s a hypothetical...

MP: just another mechanism to formally identify concerns current arrangements in community weren't working and resulting in too much risk

CH: if I might add sir it could have prompted a shared discussion buy a broader number of people to discuss situation, might have led to development of a shared strategy, approach, action plan to supporting Chris during that time.

CH: May or may not have impacted on detention decision but could have impacted on how teams were working together in deciding what needed to happen

C: including discussion at big meeting at the beginning of July?

CH: yes

C: which I have to say Richard Weidner was present for, there is that as well, I have that in mind.

Thank you.

C: deal next with links to local authority learning disability team.

Chris’s records have few references to staff from the local authority learning disability team.

C: We heard from senior management that Trust staff felt “under pressure” from the local authority learning disability team to provide the necessary support to Chris.

C: It was reported to us that they (the local authority learning disability team) stated that the threshold for entry to their service was for an individual to have an IQ of less than 80.

C: It was also reported to us by Trust staff that the view of the local authority was that Chris’s IQ was above 80 and therefore he did not meet the criteria for support from the local authority learning disability team.

C: The Trust has integrated teams, health and social care staff, or adult mental health services but that for learning disability services, the teams are not integrated, and social care support is provided by the local authority.

C: There have been a small number of referrals that have escalated to the attention of Trust directors where there has been disagreement between the Trust and the local authority about which organisation should be involved in providing support to a patient.

C: This has predominantly been where a patient with autism was presenting without a comorbid mental health problem.

C: It is our view that there needs to be urgent discussion and resolution between NHS and social care commissioners about what services are provided by which organisations to this increasing patient group.

C checks what means

NI: Increasing number of patients with a diagnosis of autism

C: not necessarily comorbidity but just autism

NI: yes

C: your recommendation 6, NHS and social care commissioners must work together to identify the gaps in provision of services for patients with autism, and commission appropriate services from relevant providers to meet those needs.

C: It is our view emails do not change focus of original recommendations.... clear some of these emails from LA learning disability team and senior staff copied in, however seen no evidence taken supportive action to partnership approach...

C: final two areas, three including service restriction due to covid pandemic. Will take a break now. Resume at midday.

[I'm a couple hours behind, apologies, I'm going for sharing as much as possible rather than immediate tweets]

C: At no time did staff document that they were aware of the increased risk of suicide for Chris because of his autism. This factor did not feature in any of his risk assessments

It is our opinion that Chris may have benefitted greatly from an appropriately targeted safety plan

C: This could have included provision of structured activities linked to his other interests that might have engaged his time and reduced the likelihood of drug use, provision of an outreach support worker, provision of a peer support worker and online psychological therapy, CBT.

C: From our research it is clear that although studies have identified a significantly increased risk of suicide in autistic people, there are currently no validated suicidality assessment tools available for autistic adults, and no validated suicide prevention activities.

C: It is therefore important that staff make all attempts possible to create plans tailored to individuals, this could include a person-centred approach to risk assessment and mitigation using their own documentation with some adaptation, social stories that are widely

C: acknowledged in learning disability and autistic spectrum disorder practice as helpful, these could have been suggested and developed by the speech and language therapist with Chris and the Care Coordinator, and using or adapting specific tools from the Safewards Initiative

[Safewards website is here safewards.net ]

C: such as mutual expectations as part of developing contracts and boundary setting with Chris as a co-producer.

C: The Trust must ensure that the suicide prevention strategy and associated work includes consideration of the increased risk of suicide in patients with autism, and the different way in which suicide prevention planning for such patients must be considered.

C: As part of this The Trust must review the emerging evidence on suicide and autistic adults from national research organisations such as @Autistica and current thinking on the best ways to support this population as it considers the required adjustments to eligibility criteria

C: risk assessments and standard pathways incorporating the use of practical and behavioural strategies in addition to cognitive strategies.

C: What impact did bundle of emails have.... did not change, many emails identifying risk to Chris's safety but no formulation of what would be contributing or continuing [think he said]

[missed chunk]

C: Ms Ibbs, and or rest of team, to help me... help me if you can with the statistics as best they are available to you with respect to increased risk of suicide in autistic people, what can you help me with in that regard?

NI: I'll turn to my colleague Chris to take initial response on this one

CH: is limited research with regard to suicide risk, in first report we included summary of research available at time.

CH: 7 to 9 times more likely in autistic people, suicide risk, depends on what study look at what data get.

C: so in that range 7 to 9 times more likely in autistic people?

CH: yes, suicidality.

CH: The research in summary believes this is due to added stress burden that comes from diagnosis of autism. Fact autistic people often experience victimisation, bullying discrimination, they're often rejected by society, feel isolated, have some level of internal stigma

CH: recognise themselves as different to norm, neurotypicals. They have a level of unmet support needs and dissatisfaction with life, leads to lack of social engagement and leads to increased suicide risk [think she said]

CH: also research shows autistic people have difficulty accessing help, some of that due to masking... but also due to communication and interaction difficulties.

CH: Difficulty in communicating feelings, experiences and understanding what communicated from people offering support around them.

Also there's a reduction in usual protective factors.

CH: When talk about suicide risk and mental wellbeing talk about protective factors, support network, people around you that you can talk to, and trust. For autistic people, reduced protective factors, particularly around social skills, planning for future and social networks.

CH: Comes together in a perfect storm for autistic people, in that suicide risk is raised.

The other thing raised in some studies, not all, is that standard approaches to suicide prevention are not effective.

CH: Individuals need to take a personalised approach. Often practitioners will say if someone is planning for future would suggest suicide risk is lower because they have future state....

CH: that's not necessarily case for autistic people, may talk about future event but still act impulsively and act to take their own life.

Some of measures may not be as accurate or valid when assessing autistic people

C: thank you very much, that's very helpful.

C: Pardon the pun, but how niche is the knowledge that there is an increased risk of suicidality for those suffering ASD?

Is it a niche, discreet area or would you expect those clinical practitioners to be aware of that fact?

CH: I think it probably is niche, if you're interested in autism or suicide, you’re more likely to find information.

CH: But the information about increased risk has been out now for 4 or 5years, would expect strategic suicide prevention strategies to be referencing some of the data coming through.

CH: It is based on small studies, so extent to which individuals taking into suicide prevention strategies, staff training, will vary across the country, but its certainly a message we need to get out there.

MP: from psychiatrist on the Clapham Omnibus, you'd expect from general psychiatrist to know some increased risk, not necessarily the detailed analysis Christine has just given, I think that would be fair

C: from professional curiosity point of view, my first question is if there's an increased risk, what's the nature of that increased risk, first thing as non clinician I’d think to ask.

C: If got general psychiatrist on omnibus, I particularly have in mind here those working in mental health units, on wards, where there are inpatients.

Is your knowledge and experience that those clinicians are, and should be aware of increased suicidality for those with ASD?

MP: yes, I think you'd be aware there would be some increased risk, but might not know the exact…. I think the issue with Christopher’s case is in some ways his behaviour gave a clue really.

People didn't really understand what was driving the behaviours, what was going on.

MP: I think most people with even a slight curiosity would probably think perhaps his other needs, his autism or learning disability, would be one of the drivers that might help us understand what's going on with him.

C: on the face of it, the view he can manage his own risk, doesn’t seem to appreciate the nuanced effect the ASD may be making, if that's coming from a consultant psychiatrist responsible for inpatient wards that strikes me as being something of a lacuna in the knowledge base

C: would you agree?

MP: possibly, the other point I'd make is as far as I'm aware Christopher was using illicit drugs before these incidents started occurring, suspect may have made things worse but suspect it probably wasn't the only driver

C: right, sorry to dwell on it, if as clinicians you're aware is increased risk of suicidality for those patients of yours in inpatient setting for example, if they have ASD, why wouldn't you seek out, what's the reason, what's the nature of the increased risk.

C: Isn't it the first thing you'd do as a curious, dare I say, responsible, clinician?

MP: I'm not sure really, I think again in context of what was going on. Covid was going on. There's lots of noise around Christopher and his care. Lots of complexity, lots of people involved

C: Dr Potter forgive me, I'm not really asking specifically here about Christopher, I'm asking more general point, from clinical curiosity, interest, point of view.

C: If your evidence appears to be well you'd expect most consultant psychiatrist should know increased risk due to autism, but not how much.

The increased risk is not double, but 7 to 9 times, that's an important thing to know I’d have thought?

MP: possibly, but as Christine said the studies are small. Personally I wouldn't want to say more than I'd expect a reasonable clinician to be aware of some risk.

MP: Wouldn't necessarily state they'd go out and find... would generally come up in CPD things, come across huge range of complexity and conditions.

C: Ms Ibbs can you help on this?

NI: I think what we're grappling with here is a combination of as Chris has said some niche, non-mainstream research, that perhaps is more likely to be accessed by clinicians from specialist background, or having specialist interest.

NI: This isn't the first investigation the three of us have done for a patient with autism who has subsequently taken their own life.

NI: I think what your recommendation is trying to lift up the responsibility in a more strategic way, so that there is increased awareness and understanding within suicide prevention strategies and discussions amongst clinical teams

NI: rather than placing the expectation on an individual clinician, who is probably incredibly busy and certainly in a case as complex as this one as we've referred to earlier, there was a lot of focus on the firefighting aspect, rather than thinking about getting the basics done

NI: I'm not sure I've articulated that in perhaps the best way

C: no, I follow. It might be thought getting the basics done, involves an understanding of the particular level of risk for any particular cohort of patients, be it bipolar disorder, EUPD, but autism...

C: ASD appears on what Ms Hutchinson has said, and the research indicates, relied upon by your report, 7 to 9 times that ballpark area increased suicidality. I mean that's marked.

NI: It is marked

C: I think what you're saying to me is the point of your recommendation, which reflects your finding in your investigation, is that at a strategic level there needs to be a reassessment of the ways in which ASD suicidality is approached

C: which will then promulgate information necessary, rather than, for example, I give their names because they're the consultants we’ve heard from, Dr Thies Fletchner or Dr Blaga Carr having at their fingertips this sort of knowledge.

C: but you'll understand from coronial perspective and families perspective, its incredibly important that the people deciding someone isn’t sectionable, can’t be detained under MHA, have a grasp of that research, albeit small scale and niche.

C: If you rely upon it, I'm confident I can rely upon it, would you agree?

NI: yes absolutely

C: so target for recommendation is strategic, corporate, Trust level rather than individual practitioner level. It may be that's something I need to reflect upon quite carefully

C: having in mind what Dr Potter has emphasised that there was particular complexity, as there always is, you can’t just lump everyone in, particularly with ASD, it’s about disentangling the myriads factors that feed in to better understand, care manage and treat

NI: yes

C: which takes us back full circle to the facts that Julia, as a challenging witness, I don’t use that pejoratively, as a challenging witness to what was going on.

Her concerns were very much geared to that suicidality issue as I understand it

C: and it was something she’d raised herself.

Nothing to add from others

C: got to get it out there, that's your key point?

CH: yes

C: recommendation 9 communication with family

The frequency and length of communication from Miss Hopper was difficult for staff to manage.

C: We can see and have heard Kirsty Lister was allocated as the clinician to conduct most of the liaison with Julia and be Chris’s care coordinator.

Miss Hopper’s concerns were frequently documented, but there is little evidence that they were fully considered and acted upon.

C: It is our view that the Trust should have identified a clinician with expertise in autism to work jointly with Chris’s care coordinator and that another senior member of staff should have been identified to work with Julia.

C: you've emphasised Ms Lister was doing her level best, doing everything she could, was undoubtedly committed it would seem to me, in her close relationships with Chris, her team and Julia, but the limits of her experience inhibited what she could do.

C: That’s context I think you're suggesting should have been clinician with expertise in autism to work jointly with her

NI: that's right

C: and that another senior member of staff should have been identified to work with Julia

C: two elements, so clinician with expertise in autism to work jointly with care coordinator, and another member of staff to work directly with Julia.... to address her concerns and myriad challenges

C: she'd be first to admit she wasn’t going to let up, and she did not, the number of her interventions born from concern were clear.

Is that what you had in mind, two separate elements?

NI: yes it is, I think what was driving that view was actually it would have been potentially more effective to take that approach.

So that rather than what appears to us, the approach being taken was managing Julia,

NI: that actually the approach we've suggested may have resulted in her information and her input being more effectively used in Chris's care and treatment

C: right, so utilising her as a resource rather than doing best to manage her concerns and reactively address those

C: obviously do that, but look to utilise her as a resource in the care management, planning and treatment of Chris

CH: can I add sir a senior clinician having that contact would be analysing, summarising, picking out themes from the regular communications with Ms Hopper

CH: and therefore they'd be able to transfer that in way that was more effective, influence care coordinator and others in what they were doing and planning.

Our analysis was care coordinator was expected to take everything in from all the people involved...

CH: as well as all communications from Ms Hopper and make sense of everything at once.

That was clearly completely overwhelming. She shared in interview with us.

That's where the recommendation comes from.

CH: Something I've seen done with other families when similar challenges, idea from practice used elsewhere

C: that would be my next question, some would say if we had a significantly robust team this is something we could do, but heard evidence ASD team was small one,

C: but your evidence Ms Hutchinson is this has been done elsewhere and tried and trusted approach

CH: yes no validated evidence, but from experience. Wouldn’t use in every case but in cases where high level of concern, significant communication...

CH: need to free up clinicians to work directly with person, while someone else is synthesising the information coming through, it’s not about closing the door, it’s about pulling out important themes from that communication

C: thank you.

C: the other thing mentioned is this is relatively short period of time, from issue in London in April to tragic death in early July.

The particular efficacy of suggested route here, clinician with expertise in autism working alongside care coordinator, together with separate

C: clinician with overview of concerns of family and others.

If that is front loaded into care management and treatment of patient, and also of in this case Julia, would have been beneficial in shorter, medium and longer term?

CH: you'd anticipate sir, there were very valid and clear concerns coming through from Ms Hopper, the concerns would reduce over time then.

If there is an autism specialist working in partnership, would have reduced a number of concerns we heard from Ms Hopper.

CH: If the care plans were coproduced that would have reduced concerns raised... short term investment for long term gain putting it briefly

C: yes self evident potential to reap benefits at earlier stage.

C: Leads me back to, certain circularity to this, what appeared to be a collective view, not shared by Julia, regarding the mild nature of the learning disability and milder end of ASD presentation.

C: There's no clinician saying wasn't a learning disability or no autism, but nature and level of extent of those two features of presentation that was as you've highlighted debated quite considerably over period of time.

C: You indicate to detriment of focusing on nuts and bolts, the basics.

The fact it appears there was a narrative that in fact he's got more ability than GOSH test indicated, his autism is at milder end of spectrum.

C: Dr Thies Fletchner clearly saying she's not expert and would welcome view of others, would that have any impact Ms Hutchinson on nature of further support provided to care coordinator and separate clinician to work with Julia as resource.

C: Fact was perceived as mild autism, has that impacted do you think?

CH: difficulty we've got across services in England is level of investment has predominantly been around diagnostic services, not services that support and intervene.

CH: There's a dearth of services to support MH services, to support others in making those adjustments, in understanding how autism impacts.

The other thing, that view of this autism being mild is in context of not understanding the level of masking going on.

CH: Without that interrogation or assessment of to what extent was Chris masking and camouflaging the impact of that, it’s difficult to say mild autism was accurate view, further assessment would have been needed.

CH: Options at the time of querying GOSH assessment should have been, either, we're in acute state here need to get beyond crisis so we accept and review later, or, they do an immediate review and determine extent to which it impacts.

CH: In my view the view he had mild autism shouldn't have changed need for autism practitioner involvement at that time, in high risk, crisis, in pandemic limiting how we could work.

C: yes one of common these in myriad exchanges Julia had was to emphasise the ability of Chris's…. his ability to mask, something time and again was emphasised.

C: Which takes us back to not approaching Julia as someone to manage, but also to deploy and utilise as a resource to inform the care management and treatment. It’s that circularity

CH: it is, yes, and the college tutors the care coordinator spoke to also described that Chris would mask his autism

C: Families are most often the individuals who know and understand the patient very well. The importance of including families in discussions and decision about patients’ care cannot be underestimated.

C: There is evidence that Trust staff were in contact with Julia, but that contact was often fractious and sometimes documented in a pejorative manner. Julia often felt that her concerns were not listened to by staff.

C: Emails made frequent reference to views held by staff about Chris’s mother, and to extent to which views differed… evidence of judgement being made about Julia, with little understanding of the home environment Julia was managing.

C: I wont ask you further about that, Mr Stoate, might want to draw it out. But am I right professionally, it would never be appropriate to refer in records or emails in pejorative manner to any carer or patient?

All witnesses confirm

C: service restrictions due to covid pandemic.

Chris was under the care of Trust services for a short period of time, just three months, at a time when the Covid-19 pandemic had resulted in a national lockdown.

C: There is no doubt that this impacted on the ability of staff to work with Chris as they would normally have done, for example, through face-to face assessments.

C: Our view emails don’t change original recommendation.

Much debate about accuracy of diagnostics conducted by GOSH when Chris was child…. Staff challenged these and need for re assessment but these were not undertaken due to covid pandemic.

C: Pausing there, perhaps Dr Potter, was also suggestion given first episode of psychosis was need to wait period of time before effective reassessment could take place. Any view on that?

C: Or do you share Ms Hutchinson’s view, either you rely on GOSH or you crack on with a reassessment, particularly with regards to autism?

MP: it clearly was covid was very challenging for staff, clearly had impact

C: yeh sure, was really whether the updated assessments.

C: I see issue with covid for face to face but was additional element referred to, to wait a period of time after first instance of psychosis, don’t know if you had any comment on that or do you think covid was the principal concern here?

MP: I understand what Christine is saying about need act on assessment, staff didn’t really believe that assessment, so clearly they’re in a difficult position about then.

MP: It’s hard for clinical staff if you’ve got a report you don’t believe in and think patients abilities are better than that.

Hard to sign up to that if you don’t have confidence in that.

MP: Again feeds into narrative of how short period of time it was really, wasn’t enough time to do more detailed assessments

CH: if I might add sir, I think you’re accurate in saying the presence of psychosis can invalidate an assessment, can affect how person is presenting

CH: so you wouldn’t normally reassess when people are acutely mentally ill.

You either accept what’s already there until get beyond crisis and then check everything out and reassess, or if it’s so significant you need to reassess, you reassess in knowledge a psychosis will be

CH: affecting what you’re seeing

C: yes, at point of discharge in May doesn’t appear to be any re-emergence of initial illness, we can see with hindsight

NI: yes that was recognised by ESTEP staff at time, not just with hindsight

C: yes, so that wouldn’t be impediment for re-assessment if was thought was necessary. Given scepticism not of GOSH diagnoses but extent of autism. I think I’m right in thinking Dr Thies Flechtner expressed not expert but gave her impression, agreed with assessment of the

C: one specific clinical autism expert who did meet with Chris on one occasion for conversation over 40mins. Her impression from that meeting was one Dr Thies Flechtner and Dr Carr not being experts, coincided with what they felt.

C: Is that fair summary as to how that part of the narrative emerged?

CH: yes I’d say so

MP: not withstanding that GOSH assessment Christopher had coped in the community, with a lot of support from his mother, he had been attending college, he had been going out

MP: so change in course of his admissions and risky behaviour, clearly something, his ASD and intellectual impairment were consistent so something had changed

C: yes and I suppose was inability as Mr Weidner said to nail down what was driving that change in behaviour

MP: absolutely

C: it’s that that I understand it informs your view a period of hospitalisation for further assessment was necessary and appropriate, do I understand that correctly?

MP: yes absolutely

C: Ms Ibbs?

NI: yes nothing further

C: is that correct?

NI: yes

C: alright. Email from Sam Ball…. You’re recognising that unless and until GOSH is overturned it has to be recognised and worked with, is that your view?

All agree it is

[missed chunk]

C: turning to final section, further recommendation, you write, to complete this addendum report we’ve reviewed 76 pages of communication, 60 emails.

Just 8 emails contain information in Chris’s records…

C: some notable information we’d expect to see reported as contemporaneous entry or in updated risk assessment.

Absence would have led staff to underestimate the level of risk.

C: I think your instinctive and immediate reaction when I read to you Dr Villa’s email was it should have been in clinical records, that was your view and remains your review? Some other emails should also be included in clinical record, in addition to one just mentioned.

Authors confirm it is

C: Trust must ensure all clinical information presence in email communication must be reflected in entry in clinical record….

C: Appears reluctance from LD services to be proactively involved in Chris’s case…. Highlighted in email from Sam Ball…. Said expected to see proactivity from LD services, but little change in LD services involvement over following 3 weeks.

C: I suppose point might be made Dr Udu was in email exchange, offered his support and spelt out why he didn’t think Chris was suitable for LD lead. The offer of being a sounding board, my words not his.

NI: I think the key word in our first sentence is proactively.

NI: We recognise there were offers of being available for telephone discussion or contributing to MDT meeting, but as we mentioned earlier in our evidence, actually having proactive involvement from somebody with expertise in learning disability and autism

NI: in our view would have made a substantial difference to Chris’s care and treatment

C: and risk management obviously falls within that?

NI: indeed

C: Ms Hutchinson assume you agree?

CH: agree...

CH: and I agree general policy is where people should access mainstream mental health services they should do, but that doesn’t preclude partnership working.

CH: Could have been mental health services leading the care at that time, but it doesn’t preclude partnership working.

CH: It was a little more passive, if asked I’ll come to meeting, if asked I’ll do phonecall, give support, rather than proper partnership working, where you’re in as proper partners, in there trying to understand what’s going on

C: right, thank you. There appears to have been, 11.3, remains our view was too much focus on debating degree to which Chris’s learning disability and autism was reflected in assessment from GOSH.

C: Team had clinical assessment which they should have either used as basis for assessing and treating Chris, or undertaken an up-to-date assessment. Neither was used and we consider was missed opportunity

C: Decision for staff to allow Chris to discharge himself from hospital was flawed…. No evidence of assessment of capacity from Dr Carr…. [missed chunk]

Consequently allowed to leave hospital without all avenues that could have kept him safe being explored.

[Paraphrase]

Timetabling discussion

Court adjourned for 30mins. Back at 13:30

[Obviously I’m hours behind now]

C: over break was emailed report dated 2022 by Mr Moor, are authors aware of that document?

NI: I have seen it, yes

C: it is, is this one of the documents, one of the research pieces you and your colleagues were considering at the time?

NI: no its not, but it is referred to loosely as being a piece of further research information that was due to be forthcoming. One of the authors of the document was authors of the research we’ve reviewed, Sarah Cassidy

C: I’ve circulated the research, it seems on my swift reading of it, Ms Hutchinson are you familiar with this report?

CH: I am aware but please don’t ask me any exam questions

C: but you have read it, you’re familiar with the content, seems to reflect a number of the elements you’ve referred to including increasing risk of suicide amongst autistic people….

XXx et al…. Kirby et al Autism Res 2019

C: Given hasn’t directly informed your report won’t ask about it, wanted to indicate to all IPs they’ll have opportunity to read and consider overnight.

It’s helpful in my view, as current autism research, in relation to suicide

C: and it is something I’ll hear any IPs wishing to make submissions in respect of it tomorrow.

Will consider any PFD matters [missed chunk]

I’ll leave that there for moment

[I'll double check overnight but believe the Coroner is referring to @Sarah_NottsUni @sbaroncohen et al 2022 article in @TheBJPsych

Autism and autistic traits in those who died by suicide in England docs.autismresearchcentre.com/papers/2022_Ca… ]

C: With no further ado I’ll turn to Mr Stoate on behalf of the family, thank you

TS checks everyone can see and hear him, they can

TS: Ms Ibbs I might do same and direct my questions primarily to you but of course if you wish to refer onwards your colleagues will be well able to jump in….

TS: Wanted to start by picking up with that exact issue, with respect to article, not about the article. Julia’s own evidence to the inquest, I’m looking at her witness statement, Bundle 1 p 26 para 40, will read couple sentences of it if I may.

TS: On 8 April says Julia: Chris was sectioned under S2 of MHA… he was transferred to Cedar Wood, at this time myself and his Great Aunt stressed to professionals we believed Chris’s difficulties were routed in his learning disability and autism and couldn’t be explained

TS: just with regards to his cannabis use… also explained my background with regards to my brother, Julia’s brother who was autistic, took his own life

Julia asked that Chris be referred to an autism specialist. There are repeated occasions in her evidence about her saying that

TS: She has raised risk of suicidality, in her opinion, routed in his learning disability and autism, does that prompt the need to engage, and not just manage, Julia and people like those in Julia’s situation?

NI: will turn to colleague Chris in moment, but as evidence set out earlier, when have someone with complex needs, front loading additional support and intervention has been shown to be of benefit.

CH: I think there’s two points to your question really, to what extent should there be arrangements to assist with management, but you’re asking about engagement of. What we’ve suggested senior person working with Ms Hopper enables those things

CH: manages amount of communication but also engages her in care planning and assessment and so on.

Autism policy stresses engagement of families, its essential, there’s co production, co-development, co-delivery.

CH: Those aren’t policies our mental health colleagues are used to intrinsically working with.

That’s where engagement with learning disability and autism colleagues would have assisted them, with need for that level for engagement.

CH: So yes, she should have been engaged.

We aren’t party to evidence provided before us being in court, but your reading from that evidence would have triggered a need for partnership working rather than occasional consultation with autism or learning disability services

MP: can I add, I’d caveat though, I have to be fair, I know Julia was concerned, but I think the sheer volume of her correspondence overwhelmed the service.

That did make it difficult for them to manage, difficult to take input because there was so much of it.

MP: I do understand Julia was a concerned mother, but looking from consultant psychiatrist perspective if I’d been on other side I’d have found it difficult.

MP: To be fair some of the things Julia wanted, she was very keen for learning disability services to take the lead, we’ve already seen the LD services didn’t want to do that, was in keeping with mainstream national policy.

MP: Were some tensions between what concerned relative wanted and what was in keeping with national policy

C: Dr Potter before Mr Stoate comes back in.

To clarify on that point, as I’d understood your colleagues, Ms Ibbs and Ms Hutchinson were indicating in clear terms,

C: is the very issue of volume overwhelming services was precisely the reason they were suggesting it would have been helpful and beneficial to have a senior consultant working with Julia, in this case Julia, from the start

C: to facilitate the management of her in those blunt terms, and to utilise and deploy her as a resource.

Trying to reconcile your view given what your colleagues have given.

MP: yes, I totally agree with what should have happened, because that didn’t happen

MP: what was actually happening. Clearly the volume of emails, that’s what should have happened, but it didn’t. That was partly explained as what was going on, didn’t mean to add confusion.

C: I understand you want to be balanced and fair and that’s very important.

C: Some of the things you indicate Julia was after weren’t going to be practically possible… all of those things can be explained and ameliorated and dealt with if you have someone with some seniority and experience in autism to facilitate that explanation.

C: It was the absence of that which would have led to what felt like a tsunami of communication, because Julia in her evidence, didn’t feel listened to.

MP: yes

C: Mr Stoate, apologies

TS: the other point I was making, will seek Ms Hutchinson’s view on this if I may

TS: in terms of joint working, front loading it, specific concern about suicidality and family concern about Chris, was there from the very beginning.

Julia was saying that from the very start wasn’t she?

CH: yes

CH: certainly in our conversations with Ms Hopper she shared that with us, she said that right at the beginning, and evidence you’ve read she gave to coroner, she said that, on the day of his admission under Section 2.

It’s before the volume of emails had started to arise.

TS: indeed

CH: that’s policy for autism and learning disability services, to engage with families, that’s where specialism with those services and partnership working is helpful in sharing what policies there are

[missed chunk]

CH: for me that’s why the partnership working between mental health, learning disability and autism services should have been more proactive rather than on request.

You don’t know what you don’t know.

CH: Mental health services didn’t know what they didn’t know, they didn’t know about best practice, so how would they know to know….

That’s where partnership working comes in, albeit with mental health services taking lead

TS: presumably you’d agree one important way to trigger that is to listen to someone like Chris’s mum, who said her concern was that problems were routed in Chris’s learning disability and autism, and she was worried he would go like my brother….

TS: there was a family history of actual suicide, not just suicidality….

CH: yes that should be key feature in formulation

TS: just to say, I and the family, fundamentally don’t accept characterisation of communication as tsunami, or avalanche or any sort.

TS: This is right at the beginning, two important pieces of information being put there, front and centre

CH: yes absolutely

TS: prevention of suicide strategy…. Learned coroner was asking about professional curiosity, you’d want to know the risk wouldn’t you?

TS: Non clinicians we can all accept different ways studies rate [?] people, but if that level of concern is being expressed then, that should trigger joint working then and there wouldn’t it?

CH: you’d expect it to be start of formulation, to understand what’s driving behaviour, what’s causing. Ms Hopper saying that should have started drafting of formulation…

CH: in fairness they did engage learning disability and autism services, but focused more on evidence underpinning diagnoses and whether valid or not, than presenting issues at time, suicide risk, mental health issues, risky behaviours

TS: yes. I’d like to turn to different issue, emails and information contained within them.
There must, I’m sure you’ll all agree, be proper space for clinicians to have discussions about patients, I can see you all nodding.

TS: But the exercise you’ve had to undertake, and the break we’ve all had, is that not an expression of the level of concern expressed in those emails must be expressed in proper and formal way?

NI: yes and that’s what led us to make our recommendation 9

TS: you talk about Dr Villa and Mr Weidner’s emails not reflected in Chris’s clinical records…. Expect by way of contemporaneous entry or updated risk assessment…. In your addendum bundle, p25 and 26, email of Richard Weidner 11:05 you’ve summarised he was not confident ESTEP

TS: could keep Chris safe, no amount of expertise could keep someone safe that could act without warning [not sure if that’s accurate, consider as paraphrase] and Dr Villa’s email ‘god forbid the coroner’s court’.

TS: These indicate a really high degree of concern about Chris don’t they?

NI: yes they do

TS: you say their absence would have led staff to underestimate risk [missed chunk] Emails evidence serious and genuine concerns about Chris’s ability to keep himself safe.

TS: Family would like to know whether that level of concern was raised by ESTEP staff when you interviewed them originally as part of your process?

NI: it’s not my recollection that the degree of concern reflected in the emails was reflected by anyone that we interviewed.

NI: Chris and Mark interviewed staff with me, I’d welcome your comments as well?

MP: Obviously we don’t have records in front of us but don’t recollect anything of that nature

CH: me neither, the degree of concern around risk wasn’t reflected in interview with Dr Villa, and the email wasn’t shared with us during that interview or subsequently

No further questions from Mr Stoate

No questions from Ms Nash or Ms Khalique

C: Ms Denton please

AD introduces herself and checks can hear

AD: only just one matter of clarification in relation to recommendation 6 of your report and section 7 links with local authority learning disability team.

AD: I should have said I ask questions on behalf of the local authority.

In your original report you said at para 5.114:

It is not within the remit of this investigation to comment on the adequacy of the response from the local authority.

AD: Although input from the local authority was included in the original terms of reference, this was at the request of Miss H, and it is beyond the scope of a Trust-wide investigation.

AD: However, it is our view that there needs to be urgent discussion and resolution between NHS and social care commissioners about what services are provided by which organisations to this increasing patient group.

AD: steps took putting draft reports to Trust for those individuals to comment, is that right?

NI: yes

AD: and none of those individuals were employed by the local authority is that right?

NI: my understanding, unless anyone employed by local authority and seconded to Trust

AD: Thank you appreciate that, 7.7 of addendum: clear some emails from local authority learning disabilities team and senior staff copied in however seen no evidence they’ve taken a partnership approach to addressing Chris’s needs.

AD: to what extent do you consider that’s commenting on adequacy of response from local authority?

NI: it is commenting on the emails we received, we understood that you agreed between you which emails we’d be sent…

NI: there was nothing to help us determine what response was present from council

AD: If I put it in this way, in as far as you indicate that bundle didn’t assist you in finding response from council, to what extent do you accept that falls outside your remit of investigation?

NI: yes absolutely, it was a level 2 serious incident investigation and level 2 only covers the organisations which is commissioning the investigation

AD: thank you, no further questions

C: thank you, bear with me

BB introduces herself

BB: I think you agree Chris presented as a complex diagnostic picture, is that right?

Authors all agree

BB: complex moving case, an element of psychosis, whether present or about and to what degree, autism spectrum disorder what extent was present...

BB: and impact, learning disabilities also the degree and impact, overlayed with drugs misuse, issues of risk, and what had triggered the change in his presentation [missed chunk]

Mr Potter best direct that summary to you, taken mostly from your answers

BB: does that summarise moving aspects to a complex diagnostic picture?

MP: yes it does, other consideration I think is up until that episode Christopher seemed to be relatively settled in the community

MP: I know there had been some incidents of self harm but was a distinct change to his presentation

BB: does that distinct change add another issue in team suddenly presented with complex picture, rather than this is complex picture developed over a period of time

BB: with a patient they’re familiar?

MP agrees

BB: therefore not just complex diagnostic picture, but one that is highly complex, is that correct?

MP: think it’s fair to say this is a highly complex case, yes

BB: learning disability and autism draws in different teams, that’s right isn’t it? That’s to all of you

NI: it should do yes

BB: learning disability services within mental health services, within local authority, and oversight of CCG as well.

BB: That can present a challenging picture to manage, involving many different services is that right?

NI: I’m not sure I’d describe it as challenging picture by presence of different services...

NI: the reason many services needed to be involved was because of Chris’s presentation was complex rather than other way around

BB asks if they agree number of teams involved adds layer of complexity

NI: yes I suppose it does add a layer of complexity. Chris don’t know if anything further to add?

CH: I think in health services we’re well used to working across teams and services, even with simplest of presentations you’ve got 2 or 3 services involved with an individual….

CH: There was clarity around which service was expected to lead, that came across in information we saw and when we spoke to people, and level of understanding about what each individual services contribution was.

CH: I’m a bit with Naomi here, I wouldn’t express that as adding complexity but they’d need to consider how to communicate, and what

MP: to add complexity for me was hardly any of the diagnoses were certain.

MP: Had there been a definitive LD diagnosis, definitive autism diagnosis, definitive psychosis diagnosis…. My take is services were trying to work together but struggling a bit with who should lead….

MP: That’s what seemed to play out a bit in meetings, who should be ultimately responsible I think

C: can I just intervene there.

C: Dr Potter there was a definitive diagnosis of ASD, there was a definitive diagnosis of learning disability, and was for period definitive diagnosis of psychosis. Was nature and extent that was issue, not diagnosis itself.

MP: yes you’re right, it was the degree and whether that degree was enough for Christopher to sit within LD services or mainstream services

C: no and your report concludes in first section in addendum that ESTEP was the appropriate team to lead? Yes?

MP: yes to start

C: so any complexity is about the nature of the input of LD services and others.

On that topic, given Ms Ballard has raised issue of complexity, this elevates significance, important and burden upon the care coordinator, doesn’t it?

NI: yes it does

C: the care coordinator has enormous burden on his or her services when you have level of highly complex case, and multiplicity of services contributing, is that important consideration and...

C: does that take us back to whether there was sufficient support for Kirsty Lister in the role she was energetically attempting to fulfil?

NI: yes very much so. A care coordinator’s role is exactly that, to coordinate care, not to deliver everything

C: Sorry Ms Ballard, I just wanted to clarify that for my own note.

BB: thank you sir. Is it also relevant to factor in specialist units that exist where they do for autism or learning disability, have varying admission criteria which are usually quite restrictive and limited

BB: to the severe end of the spectrum? Is that relevant consideration for teams working here?

NI: I’m not entirely sure I understand your question, I’m sorry, are you saying specialist units only take the severe end of presenting diagnosis?

BB: that specialist units have varying admission criteria which can limit them to severe end, and some, we heard Priory would not have accepted Christopher, because of drug use issue overlaying diagnoses.

BB: Is that relevant to bear in mind when reviewing your decisions of presentations and how managed by team

CH: inpatient units for LD and autism units, they have same admission criteria as any other mental health wards

CH: described by @CareQualityComm as mental health wards for people with autism, or learning disability.

National policy is driving those units to avoid admissions where clinically appropriate, so much more stringent dialogue before agreeing admission to those units.

CH: Wouldn’t describe as people at severe end of range, but those who’s needs can not be met in community, can’t have risks managed in community, who warrant a specialist mental health setting rather than a mainstream mental health setting,

C checks her answer for his note

BB: In addition, I think you agree, were in the thick of a fast paced changing situation, Ms Ibbs you’ve described it as the team were fire fighting in what to do and how to manage risks presented to Christopher

NI: when you say team are you referring to ESTEP team?

BB: yes

NI: yes

BB: would you accept its easier to accept things could do differently when have luxury and time to do so

NI: are you asking from a historic perspective or in moment?

BB: comparison from review in historic perspective versus decisions taken in moment?

MP: I think I tried to address this in September, when we do inquiries we try to base our opinion on evidence available to team at time and what they did, rather than what we know now.

MP: From mental health perspective, it isn’t with benefit of hindsight, from email trails there is clear evidence the team were worried about whether Christopher could be safely managed in the community, given those should have led on to discussion about

MP: if he isn’t safe in community, where should he be….

That is challenge not to be drawn into narrative because know where its going to end but I don’t think that’s the case in this case honestly

NI: thank you Mark, I’d agree with that.

NI: As indicated earlier in our evidence, the email bundle we received has given further evidence to that position

BB: indeed, those realisation s were becoming present to team at end of period of time, rather than being present at outset, that is fair isn’t it?

NI: yes

MP: yes

BB: based on evidence they had of how Chris was reacting to various steps put into place to try and manage his presentation

NI: yes

BB: so while it might be apparent to Chris’s family his risk was present from outset, for team it was towards end of that timeframe these issues became apparent, is that right?

MP: one of drivers for mental health care is principle of least restrictive option.

MP: Generally when patient comes in, particularly when been living in community, initial process of thinking is they could be managed in community, perhaps supported accommodation might be seen as reasonable option.

MP: As get to know someone try to engage in less restrictive option than more restrictive, so wouldn’t immediately think of Section 3 and secure placement, normally.

That’s part of general sequence of events in a mental health setting

NI: the thing I’d add to that is we’re aware Chris presented to adult mental health services for the first time in April.

When working with a new patient we’d normally expect to see a family history, a family narrative about how that person is presenting,

NI: being included in the formulation which leads to risk assessment and risk management strategies

C: did you see that?

NI: to some degree

BB: because its important isn’t it, not just to manage, it’s a fairly obvious question, not to manage a patient based on what their relatives state at the outset…. Have to base on evidence [missed chunk]

MP: you’d triangulate all the information wouldn’t you, what you know, what’s said by patient, what’s said by family

CH: that’s important, you don’t have to gather information directly from observations...

CH: you accept information from people who know person well and accept that and set that within context of clinical formulation

C: so for example the college tutors

CH: yes, college tutors, the family, if he had friends visiting although at that time covid he wouldn’t have had visitors.

You take all information available to you, together with anything might be in records, local authority records, team records.

CH: His first presentation with mental health services but had they looked at any other service involved previously, think at that time they were informed of GOSH assessment, referral to CAMHS etc, they’d done some of that

BB: I also think you accept, and have referred on number of occasions, was extraordinary amount of work being undertaken to try and manage risks Chris presented with, by ESTEP team and most particularly by his care coordinator, is that right?

NI: yes there was a great deal of activity that we saw

BB: can I then ask from paras 5.5 and 5.6 in your addendum report, you say decision to allow Chris to discharge himself from hospital on 29 June was flawed… I think rationale follows from rest set out.. is that correct?

They confirm it is

BB: I think you understand Dr Carr was asked to assess Chris’s ability to keep himself safe before leaving hospital, was email at 16:30 sent by Mr Weidner on 29 June. Is that right?

NI: yes

BB: sir matter for you, if that email was received by Dr Carr after she’d assessed Chris for his self discharge it follows she wouldn’t have been able to take that into account?

NI: yes, if he’d already been discharged then opportunity would have been lost

BB: indeed, you go on to say not seen any evidence an assessment was completed at that time, may be because the request for one post dated the decision to allow Chris to self-discharge

NI: yes although in email trail it appears Dr Carr replied to Mr Weidner at 15:56 in which she said Chris wasn’t willing to wait until the following day for discharge and she had no valid reasons to keep him in hospital.

NI: No mention in that email about the capacity assessment request.

BB: indeed, if I can just follow through what I understand was chronology. Dr Carr initial email timed 15:48…. Says she’d try persuade him to stay until tomorrow, he was first on her list on the 30th anyhow.

BB: That was her normal practice to see patients for review within 72hrs of arrival, however Chris had requested to leave, so she’d had to bring her review forward to 29 June and alerted Mr Weidner to that possibility.

BB: He then replies at 16:21, her response at 16:56 was she saw Chris and he wasn’t willing to wait until tomorrow and she had to allow him to discharge himself.

BB: That would suggest, would it not, probably matter for coroner to review, was no evidence given by Mr Weidner or Dr Carr that she’d understood she’d been asked to assess Chris’s capacity to keep himself safe in formal sense

BB: prior to point she’d discharged him for self-discharge, were you aware of that?

C: sorry, I’m not sure…. If we can look at what evidence was…. [cant hear] I think you’re suggesting… I don’t recall Dr Carr saying she hadn’t seen Richard Weidner’s email

BB: It wasn’t put to her sir

C: in those circumstances it would be a matter to me, wanted to check she didn’t say she didn’t see it…. Reasonable inference might be was ongoing email exchange between them, 15:58 response from Blaga, 16:21 further email from Richard

C: response at 16:56 from Dr Carr, if not missing evidential element I can draw evidence from that chain then

BB takes to electronic record of ward round. Start time 16:20 and finish is 16:50.

BB: Appears email received shortly after start of it and she responds shortly after Chris made his decision and had taken his leave

NI: I’d want to add something at that point

C: yes

NI: accepting email communications possibly occurred whilst Dr Carr was reviewing Chris, also of concern to us was the fact that Dr Carr had determined that she had no reason to keep him in hospital.

NI: And it was our view there was an opportunity there to have used Section 3 potentially, at least to have considered an assessment for detention at that point given everything else that had taken place at that point. Mark don’t know if anything you want to add there?

MP: yes in context of our inquiry we’re very keen not to identify and scapegoat individual clinicians, so point is within the system was evidence of what was happening with Christopher and therefore why detention should be considered.

MP: Wouldn’t want focus just on Dr Carr at 4pm, but in wider system was that information that wasn’t being shared and coordinated, we’re not trying to identify individual clinician errors so to speak

BB: indeed, which is why I sought to clarify your conclusion for Chris being allowed to discharge himself was XX and matters more generally

CH: if I might just add capacity isn’t an issue if you’re looking at detention under the MHA…

CH: by the 29 June there is sufficient information in the system there to evidence a rationale for detention under Section 3

C: Ms Ballard I think final email sent 17:04 by Richard Weidner… [reads] was there a further email response to that, I don’t see it in the bundle?

BB: not that I’m aware of, not that has fallen out of the investigation we’ve seen

C: whichever way it falls, it would appear Mr Weidner’s 16:21 request doesn’t appear to have been undertaken and his follow up email seeking clarification wasn’t responded to

C: that’s how evidence stands

BB: yes but to be fair sir the 16:21 email was responded to

C: that was responded to, what’s the evidence about that, was he literally out the door as soon as that ward meeting finished.

BB: sir I don’t think the evidence addressed with that specificity

C: yes but I asked about the discharge note

BB details the discharge notes

C: can I ask panel, you see email, having come out of that ward review with outcome as documented by Dr Carr

C: if you received that request for capacity review, is it in your powers to say hang on, let’s look at that, and speak to Christopher and conduct that review. Could you do that?

MP: Obviously you could do that.

C: yes

MP: for me, if someone was so concerned, they wanted me to do something immediately, I’d want them to give me a call actually, not sure email is right way of conveying urgent requests.

Don’t know what you think Chris?

CH: to add to that, in response would have been helpful to have clarity that had not been completed and if thought was necessary to arrange subsequently.

CH: Unusual for inpatient consultant to follow up once someone discharged but clarity on fact was still outstanding might have been helpful.

C: thank you. Thank you Ms Ballard?

BB: those are all my questions sir

C: thank you, just bear with me. Alright, thank you very much, Mr Stoate, you wanted to keep a little portion of powder dry, not inviting you but did you want to come back on any specific point or not?

TS: sir the few points I’d have wished to have raised you’ve already done so, thank you

Nothing further from other IPs

C: Ms Ibbs, Dr Potter and Ms Hutchinson, thank you very much indeed for all of your efforts in assisting this inquest. I’m very grateful indeed.

C: Let me check with you whether anything further you’d wish to add?

There isn’t

They’re all released and free to go at 14:42.

C: alright, short break. We’ll return at 14:55…. Please take instruction of nature of any submissions you’re likely to wish to advance and we’ll have that discussion in ten minutes time

We returned at 3pm

Coroner reads onto record the addendum statement of Emma Bennett from care provider that runs Hart House about pre admission discussions and paperwork [I won’t attempt to catch it]

Discussion about records relating to discharge and where they’re found in the bundle

BB: My understanding of Ms Kay’s evidence, having looked at my notes, she says she was very experienced in undertaking mental capacity assessments at the start of her evidence… also had experience of undertaking such assessments in autism and learning disabilities, however,

BB: she says in terms of the actual assessment although she fed into it extensively, Kirsty Lister was decision maker although she fed in to that decision, reviewed that decision and agreed with that decision.

C: very helpful, so KL is effectively the decision maker but she fed into it, reviewed it and agreed it. I think it was one of your colleagues that put she was not a clinician. I might get this wrong? Ms Denton?

AD: no that’s right sir, my note, if anyone disagrees please say, You say you’re not a clinician but you do conduct in your capacity as a social worker to which the answer was yes.

AD: Generally I don’t take issue with the evidence renewed by Ms Ballard, in so far as its relevant later in questioning it was put to Melika Kay, I believe by yourself, you ask [missed it] she says she wasn’t sure [how her involvement was required]

AD: decision was made she’d attend as secondary advisor to Kirsty…she said she’d give generic advice…. You asked was that on basis of you were helping out or did Matt Harding now consider service was formally engaged?

AD: She said no, was secondary role to provide advice to Kirsty [think that was].

C: so she was there in secondary supportive role, although Kirsty Lister was decision maker she’d reviewed document and agreed it, and we know there’s criticism of the document.

AD: yes I don’t think we’re miles apart, just the overall content of her role has to be kept in mind.

C: yes, she’s there in secondary role, support to Kirsty, but she reviewed document and agreed it

[further discussion about what evidence was]

C: we have issued subsumed in any event in the context of the critique from Niche

BB: to be clear Mel Kay says she read the write up in the clinical records, not the formal assessment, but the write up was the same as was put into formal documentation

C: so she read the write up not formal documentation

BB: yes and then you’ve got the issue of printing and not printing out

C: I think its accepted by all that the documentation could be clearer. Thank you both very much.

Discussion re submissions

TS: I am in position at this stage to say, usually question to ask of me, the question of neglect, subject to your views if you take different view will be guided by your view on it, doesn’t strike me, or us, as appropriate for this case.

C: Mr Stoate, my preliminary indication is I don’t think it is, on any view.

There is a complexity of presentation, a complexity of management, and treatment, a complexity of engagement, not unusually multi agency and multi team involvement.

C: The critique offered by the independent Niche researchers is very clear and accepted in large parts, certainly the recommendations are accepted, but I think it falls short of that which is the objective legal test for gross failures in a strictly legal sense of that.

TS: Sir can I for the benefit of the family, flip the telescope as it were. It really is because of the complexity of Chris’s case that he required so much more than he got, which is what Niche set out in clear terms.

TS: I wouldn’t want to frame it for @JuliaCa20602661 of any evidence falling short of a particular thing, just don’t think it neatly fits the circumstances and complexities of this case, better encapsulated by a narrative conclusion which I think you’re heading towards anyway

TS: It’s not aiming for something and falling short, clearly Chris’s was a complex case, was known to be a complex case, required X, Y and Z which we’ll submit requires a narrative conclusion in these circumstances.

TS: Before I move on, what I was going to say, if it would assist you to provide written submissions on what we say the narrative should contain I was anticipating and can certainly do that

TS: subject to some time for Julia to consider it given how long she’s waited for these proceedings. Nyarumba too of course.

TS: Anticipating brief submissions, wont address neglect as I say, but not stray beyond justifiably critical narrative given evidence you’ve heard and that of the Niche authors.

C: thank you that’s very helpful, obviously consistent with Chief Coroners Guidance 17, nature and content of any narrative.

[It's here if you're super interested judiciary.uk/wp-content/upl…]

C: Findings as expressed in open court, wont all make way into narrative, you and family and all IPs will understanding think most recent of Smith cases, findings expressed in open court constitute part of public record of findings of hearing.

[I believe that this is the case he's referring to
judiciary.uk/wp-content/upl…]

C: Conclusions that make themselves into record of inquest are that, but don’t exhaust findings made to inform conclusion themselves.

TS: thank you sir that’s understood will endeavour, should it be needed, to make clearer to family as well.

C: we don’t need huge tranches of recitation of evidence, but very difficult to make submissions in Article 2 narrative conclusion without touching on evidence

C: no doubt you’ll do it in concise way

C: Ms Ballard, I presume the orientation of Mr Stoate and the court as indicated with respect to neglect as an adjunct or part of conclusion is something you’d agree. Anything further you wish to address me on at this stage?

BB: not in relation to conclusions sir, just want to touch on issue of PFD evidence, will do in just a moment. Imagine I’ll have something to say orally in response to what Mr Stoate will put in writing but don’t need to address you on general concepts of

BB: what you can and can’t include. Total agreement narrative is appropriate way to conclude your inquest and what you say on public record, as in case of Carol Smith, is part of public record.

C: thank you very much indeed Ms Ballard, we’ll come back to PFD point.

C: Ms Nash?

LN: wouldn’t seek to dissuade from narrative, and nothing coming from me in writing

C: Ms Khalique?

NK: agree entirely with Ms Ballard’s comments and your conclusion with regards to a narrative with critical comments within it, but wish to reserve right of oral submissions in response to Mr Stoate’s position

C: Ms Denton?

AD: I adopt the position of Ms Khalique and Ms Nash, wont expect anything from me in writing, maybe in oral submissions.

C: just to say this Mr Stoate, you’ve heard what other advocates have said, you will have an opportunity to respond to any responses

C: you will have opportunity to respond, if there is anything…..

With respect of PFD evidence, will hear submissions at end of conclusions session on Friday

TS: that’s not something I’ve had chance to discuss in any detail with the family, I know they’ll wish to. Likely to be oral submissions given the timings, won’t have anything useful to add now, but when you invite submissions will ensure have spoken to family then

C: thank you

C: Ms Ballard and I, as matter of public record, have had discussions on remit of PFD and she and I would wish to remind of the Chief Coroners Guidance on PFDs. Ms Ballard do you wish to put down a marker?

BB: yes sir there was a witness statement with attachments from Dr Otun [?] on 22 September with attachments

Checks everyone has received it

Further discussion re timetabling and future plans for next two days

Court adjourned at 15:35

[I'll be back tomorrow, possibly at 10:30am but maybe not until 11am, it's not definite what time we're starting.

With thanks, as ever, to those who have crowdfunded my reporting, I couldn't do it without you chuffed.org/project/openju… and those who share the tweets]