Thread by @ChrisNInquest

Day 15 of the Article 2 compliant inquest touching on the death of Christopher Nota will begin shortly.

Area Coroner for Essex Mr Sean Horstead sits without a jury

This inquest discusses suicide and self-harm

1/

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

I was pleasantly surprised at how twitter held up yesterday, and hope to finish this inquest by live tweeting.

This is the penultimate day

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

3/

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 relied upon as such.

As far as I'm able I indicate where I [missed chunks] or I've used [paraphrase]

4/

This inquest discusses suicide and self harm.

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

5/

My #OpenJustice work is crowdfunded chuffed.org/project/openju… only possible thanks to those who fund, follow and engage with it

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

6/

I'll stop numbering tweets from here

Day 15 should begin shortly, c 11am if not before

The inquest is expected to conclude tomorrow

7/

C: If everyone is present we'll make a start

Coroner checks recording is on - it is

C: I'm joined by a couple members of press in court, apart from that all interested persons attending remotely

C: Unless there's anything anyone wishes to raise with me I'll start by thanking Mr Stoate for his submissions, I'm sure they've been cross served.

For the moment i'd like to crack on, if I may use that phrase, with the evidence of Dr Otun

Dr Gbola Otun swears an oath

C: Statement is dated back in September, there's been no doubt over the last 2 months some further progress, what I'm proposing to do for completeness is read into the record your statement, then we'll go back over points of clarification I have [missed chunk]

C: you confirm you're a consultant psychiatrist and Deputy Medical Director for @EPUTNHS and you're responsible for inpatient services across the organisation, took up position in July 2022 having previously been an area director [missed chunk]

C: set out qualifications and background.... [missed chunk] set out statement of actions taken by EPUT following Niche report earlier in 2022.

[can't hear coroner very well]

C: Is that now complete? [An update or action plan]

GO: There is some progress on some of the comments I made in my report, I believe some information has been sent to the Coroner's office

C says he'll need to check that was received

C: formal action plan was delayed, has there been an action plan now, yes or no I suppose

GO: actions in my statement are formalised and we're working on them

C: right, you can go through and tell me which have been completed and which are outstanding

C: You say you accept all recommendations in Niche report and will work with partners to address them, recommendations 1-8 have been formally accepted by EPUT

GO: correct

C: obviously and understandingly recommendation 9 in addendum report doesn't feature in this statement, is that accepted as well?

GO: that's accepted

C: turning to Recommendation 1

C: 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.

You've written the Trust actions in relation to this will be led by Medical Director... confident can identify

[missing lots, sorry]

C: focus on repeated admissions and escalation without referring to a specific diagnosis... Trust already collects information about patients re-admitted within 28 days of discharge to ensure failed discharge plans are reviewed.

C: That was already in place was it at the time Christopher was at the Trust?

GO: yes we already had this [missed]

C reads statement from GO
[too fast to catch, apologies]

C: what's update on this recommendation?

GO: the Medical Director went back to medical team, to suggest rather than clinician have this and not have time to do this, made recommendation, we've been expanding medical leadership, so medical director requested funding for additional Director for Flow and Capacity.

GO: Interviews done in December and will be in post from 1 Feb 2023.

C: funding for an extra Clinical Director for Flow and Capacity. That clinical director I assume would have a clinical background?

GO: yes he's got a clinical background, he's a consultant psychiatrist.

By way of background, wanted to mention couple changes since incident with Chris, obviously want to [cant hear] the family.

GO: Had one deputy medical directors, now have 5.... we've expanded that so there will be good clinical leadership for all our services, the same thing with expansion of all clinical directors.

GO: the Clinical Director for Flow and Capacity will work directly with me to look at this specific audit of treatment and review of patients admitted within 28 days.

GO: In my additional review I said we'd look at patients admitted 4 times in a year, but actually I'll ask them to look at everyone re-admitted in 28 days, approximately 5 across the organisation per month

C: I suppose it follows if there is review of those readmitted within 28 days an eye will be kept on them as matters roll forward?

GO: correct, idea is we'll have an idea whether support available post discharge were sufficient or what were the factors for readmission.

GO: We have terrible issues with bed management, and want ensure [didnt hear]

C: so progress made after long inpatient stays whether voluntary or under section, you highlight obvious problem if all work and progress then made is undone after brief period in community

GO: correct

C: safety of the discharge will be reflected no doubt, including risk assessment, when people are readmitted within a month, that 28 day period.

GO: yes

C: thank you, dont want to take up all your time, might be questions from others

C: will move onto recommendation 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 consistent way

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

You've written trust response led by ATG and GW?... responsible for suicide prevention training.

C: Relevant to this that Trust @EPUTNHS has adopted Learning Disability standards published by @NHSEngland to assess quality of care provided to patients with autism, learning disability... [fuller answer, can't catch]

C: You then say the LD standards were published by NHSE in Jan 2019 as part of NHS long term plan.... these standards will be applied to these services from 2023-24.

C: On the face of it that looks like a 5 year delay between standards being published by @NHSEngland and when they'll be applied.

Can you help us why there has been that delay?

GO: it was published document so NHS could strive towards it but then they're measured against standards from 2023-24... document providers and commissioners need to look at to ensure sufficiently satisfied those standards are adopted across organisation

C: long lead time, not withstanding covid, even if one takes date of death in July 2020 were any standards being applied by time of Christopher's death?

GO: some of them would have been....

GO: but also other things introduced by document which would not have been part of standard practice....

[cant catch]

The idea was to ensure commissioners provide funding and work with organisations to ensure services meet standards by that time

C: recommendation arises out of finding from Niche report which identifies shortcomings in this respect, so urgency with which it needs addressed is self evident.

Is that something @EPUTNHS recognises?

GO: 2023-24 is when have to have standards, we're not waiting, we're confident we'll do that

C: well stipulated time is 2023-24 we’re in 2023 albeit only by 5 days... what's best estimate you can give me of when standards will be applied across service as indicated?

GO: I'd just be guessing if I answer that because I don’t work in LD and it’s not under my portfolio. There's a Director for Learning Disability who will be working on that, I can get that information, they'll be working as quickly as possible

C: I'm sure they are, but as quickly as possible is a little bit as long as a piece of string... if haven’t got that update I'd ask an update is provided as to projected time scale for implementation of the 2019 LD Standards published by NHSE

GO: that's fine

C: I'm hoping to conclude these proceedings by the end of tomorrow afternoon, if we can have that update of escalated time scale for full implementation please by end tomorrow I'd be grateful please.

Thank you very much indeed.

C: You continue Trust have updated their autism training from July 2022... touched upon within existing Positive Cultures induction, now contains learning disability and autism

[can’t catch]

C: We've run a Reasonable Adjustments campaign in EPUT, with follow up in Oct 2022.... plan to report audits of case files whether compliant with standards and training.

With respect of training, what’s the position now?

GO: Trust has approved 8 trainers as of September, and an additional 8 trainers, we'll have 16 [I think he said]

Is ??? training, each trainer can only train 8 but 2 trainers can train 12.... prioritising front facing clinicians

C: that’s ongoing since September, alright.

So in fact it appears timeframe for completion of statutory guidance and new autism training is already up and running and will be ongoing?

C: prioritising those with more direct contact in first instance with learning disability and autism patients?

GO: that’s correct

C: I'll turn to recommendation 3

C: The Trust must ensure that leadership and peer review from consultant-level practitioners with appropriate expertise is available to staff when dealing with patients where the matter of capacity is made complex by co-existing mental impairments.

C: This should include who will lead on agreeing points relevant to the decision; the methodology of approach; who should be involved; and reviewing the information and evidence discerned prior to conclusions being made and acted upon

C: You say led by Lead Consultant for Social Work [?] process for contacting consultant via social care manager [really hard to hear at this stage, apologies]

Ms Ballard interjects to raise concerns about sound

[missed chunk]

C: in terms of recommendation, consultant level practitioners with specialism in autism or learning disabilities was identified in summary as shortfall by Niche in provision of care.

C: My words not Niche’s the overloading of responsibilities on the care coordinator, rather than proactive engagement from consultant level practitioners with specific expertise.

C: What's the thinking as to why Lyn Prendergast, AD for Social Care would be the person to really lead this or was it simply that she was chairing the initial stages?

GO: the issue of capacity assessment... social lead consultants...

GO: consultant social workers are under direct line management, specially trained assess capacity linked to complex decisions, have a lot of experience regarding accommodation, treatment, they're not doctors but trained social workers to conduct those assessments in complex cases

C: alright, but in cases where element of learning disability or autism isn't there issue for consultant psychiatrist input?

GO: they'd be working with team but not all consultant psychiatrists would have up to date experience of assessing patients with learning disability and autism... learning disability is 6 months of training in psychiatry and they'd have been in practice for a number of years

C: alright, so its recognised by EPUT for example consultant psychiatrist working in inpatient context don’t necessarily have expertise in autism or learning disabilities to conduct appropriate capacity assessments themselves?

C: This additional area is to address that shortfall of expertise?

GO: I'll reframe that, in vast majority of cases capacity is possible to assess but when dispute, such as this, can draw on other expertise from specialists

C: right, that would be driven by consultant psychiatrist in inpatient setting recognising they don’t in fact have sufficient expertise or experience to conduct capacity assessments for those suffering from learning disability or autism.

C: It would require them to have that insight before calling on assistance?

GO: usually would be discussion in team, safeguarding lead for locality would be involved and working with consultant. This is escalation system to say in this case we need more expertise.

C: alright. Thank you.

Recommendation 4 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.

C: you've written Trust already has Dual Diagnosis policy, you've provided that, generally are no specific services for people with autism and drugs misuse, but services locally are familiar with ppl with learning disability and autism and are aware to make reasonable adjustments

C: Passed responsibility again to Dr Lyn Prendergast and she'll work with local drug misuse services to make sure they're aware... learning disability and autism services will now be represented in monthly dual diagnosis workstream meeting...

[missing lots, apologies]

C asks for an update

GO: this action is completed, learning disabilities and autism are now part of dual diagnosis workstream meetings, they were present in October and November meetings

C: they'll go forward on monthly basis?

GO: yes they're now members of that workstream

C: thank you, in context of Christopher's case I have in mind that it didn’t ever reach stage where he was seen by YPDAT...

C: I'll move onto recommendation 5 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

C: (b) all safeguarding documentation and minutes of safeguarding meetings 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've written responsibility for this sits with Head of Safeguarding, he's written note of timescales for achieving this. You've provided a copy of that, to which I'll now turn.

C: he writes as follows, in respect to the first two areas is target date of 3 months.

C: Can you help me with when this is dated because there's no date on this note. Assuming was note compiled at time or before

GO: sorry I don’t have a date, but around that time

C: are you able to update me as to target dates identified there, have they been achieved or no?

GO: unfortunately I wasn’t able to get an update from them.... but XX is helping us review our records and information around safeguarding but wouldn't be able to tell you how far they've gone with that.

C: right. Um, ok.

C: There's some aims and ambitions expressed in this document form September but I'm not any closer to knowing whether target for three months [lists] which will have expired by now.

C: I'd quite like if possible pls, together with earlier update, where those three elements identified as 3mth targets in September have been achieved, an update on progress to date on 6mth target to updating safeguarding procedure so explicit on recording safeguarding activity

C: For lay person looking in these don't look like challenging or complex issues, update procedure, struggling to see why takes 6 months?

GO: it’s not process that takes long time, it’s making sure everyone is trained so that timeframe may be put there to ensure practice is embedded within organisation

C: so aim is by end 6mths all staff trained and its rolled out, that's the aim?

GO: that's correct

C: an update on that please

[missed chunk]

C: how long has Duty Safeguarding Service been in place, is that a new development?

GO: no its not new, it’s been in place for years

C: so that would have been available to Kirsty Lister, the care coordinator?

Right, I see

C: service operates single point of access which has streamlined services.... [missed]

All of this if I think I understand you was all available back at the time?

GO: duty system definitely was, single point of entry may have been introduced in 2021 after covid I think

C: right. So point of access was introduced in 2021, because I don't recall, I'll be corrected if I'm wrong, this aspect being a feature in the case or something the care coordinator had access to. Whether that's relevant or not I'm not in my own mind entirely clear at the moment

C: Currently developing safeguarding supervision procedure.... target 12 months.... safeguarding team developing standard template for recording supervision, that's target 6 months.

If we could get update on those that would be helpful please

GO: yes

C: I turn then to recommendation 7, you note 6 is addressed to commissioners, and addressed by ICB

7 is as follows: The Trust must ensure that the suicide prevention strategy and associated work includes consideration of the increased risk of suicide in patients with autism

C: and the different way in which suicide prevention planning for such patients must be considered. As part of this the Trust must review the emerging evidence on suicide and autistic adults from national research organisations such as @Autistica

C: and current thinking on the best ways to support to this population, as it considers the required adjustments to eligibility criteria, risk assessments and standard pathways, incorporating the use of practical and behavioural strategies in addition to cognitive strategies.

C: you write this is an important recommendation, indicates link between suicide and autism risk is not entirely clear.

Respectfully the evidence I heard yesterday, by reference to a number of emerging studies, to be fairly clear, risk is 7 to 9 times.

C: Is it your view the relationship between autism and suicide risk is not entirely clear?

GO: definitely clear suicide more common in people with autism, but drivers of it not entirely clear.

GO: I've been to @Autistica website, they say relationship between autism and suicide is not just based on diagnosis alone, need understand more

C: yes, certainly evidence of specialist yesterday from whom I heard seemed to indicate a number of elements of presentation of autism, for example appreciation of protective factors appeared to be fairly clearly identified

C: and subsequent 2022 document seemed to support autism and autism traits as reflecting an increased suicidality, with reference to aspects of autism that informed that increased risk. In any event, I have received evidence on that. I'll continue with your para 18

C: The Trust has suicide prevention group, of senior clinicians.

You attach copy of strategy and guidelines, both due for review in Jan 2023.... at same time ICS is trying to secure system wide approach to issues like this

C: plan to work with them and others locally to identify whether lessons from this case, and recommendations can be fed into strategy and all areas in ICS.

Specific research largely unpublished, Trust happy to consider emerging evidence and incorporate into policy and strategy.

C: at moment is position that this recommendation hasn't yet been fully actioned?

GO: I think the action is actually to take into account increased risk in patients with autism.

GO: I think what we've said is we're looking at research evidence and will incorporate into policy this month when its due for review.

Also people with learning disability and autism rely on a number of non NHS organisations

GO: you can have suicide prevention strategy at trust but needs be consistent with other organisations and we want to work with them.

Done a lot of work over last two years, this is another we need to build on to ensure we get this right

C: Thank you very much indeed.

C: Before I move off 7 Dr Otun, would it be possible for me please to request an update with respect of the outcome of the January meeting, so I can have an idea of the orientation and future trajectory of the Trust's approach

GO: [couldn't hear]

C: once meeting has taken place, some time in February. following that meeting I'd like to understand please what the orientation is on this particular recommendation that arises from the suicide prevention group, following the review in January...

C: an update that I can share with the family, subject to my view on Regulation 28

C: Recommendation 8 The Trust must ensure that concerns raised by families are responded to and documented appropriately.

C: The Trust must develop guidance to support families and staff when relationships become adversarial, this should include an escalation pathway to enable resolution

C: You write Trust is considering this recommendation and agrees need a shared pathway with single point of contact for family to avoid multiplicity of individuals drawn into matter and inconsistent responses.

C: Current thinking would be in PALS system... concern two parallel systems which would have negative effect of catching all information. Intention look with complaints team in trust and develop pathway.... responsibility sits with Manager of Complaints Team Clare Lawrence

C: as concerns need addressed with family. If not satisfactory addressed will be scoped to escalate. All responses signed off by CEO when escalated to complaints policy. All matters subject to review at Director Level.

[missing much, sorry]

C: in respect to this aspect was certainly my understanding the thrust of what Niche report authors were identifying was need for a senior clinician to be involved at an early stage...

C: front loading an engagement with, in this case Julia, but carer or family member from whom dissatisfaction or a complaint might arise.

So there was available a senior clinician with expertise in the field, who could manage those issues to assist the carer...

C: but also to recognise particularly in autism and learning disability case with significant degree of complexity, the importance of the complainant/carer being utilised as a resource proactively in clinical management and treatment.

C: That's my understanding of thrust Niche were driving at. I'm a little concerned the response of the Trust is to really, don’t mean pejoratively but sounds it, to shoehorn it into a complaints process, which we all know is a slow process at best of times because of due process

C: and evidence gathering.

It’s a very lengthy, laborious and time consuming process but seems to miss the point of front loading that engagement to offset an increasing level of concern being expressed by the carer.

C: Also misses point of senior clinician level engagement, the resource the carer may provide is appropriately exploited. That's my response at the moment

GO: I understand that

GO: Clare Lawrence has made proposal approved by ET, her proposal effective from 1 Jan is actually meant to do opposite of that.

We have complaints liaison officers who receive complaints and concerns, and share that directly with Deputy Medical Director to...

GO: have a clinical look at it and decide what needs to happen.

Don’t want complaints to go on for weeks and months before Medical Directors have any sight of it.

We have care units in each locality, when complaints come, if inpatient complaint or concern

GO: that comes to me to have a quick look, I’m required respond in 48hrs to decide what want do with that.

Whether that's another consultant to look at it, not suggesting everything goes through formal complaints, in order to capture better to have that collected.

GO: Don’t want situation where multiple systems, concerns directly with team, then we hear about it 4mths later. That's just to capture it.

C: that's very helpful, thank you, I suppose the emphasis you place back in September is its best placed by building on PALS service.

C: To do something different, to streamline with officers particularly escalating to you or relevant clinical director swiftly I'm assuming.

What timescale from complaint to making to clinical directors desk, we're not talking days?

GO: I’ll give you a live example, I received one yesterday, someone made concern on 31 December, sent to me yesterday, I immediately asked consultant to look at it.

C: so over bank holiday weekend it’s on your desk, within a week. Thank you very much.

C: Will now turn to recommendation 9 Trust must ensure all clinical information present in email communication is reflected in entry in the clinical record [think he said]

Appreciate you were only aware on 22 December.

GO: we were already doing work around our record management policy and how we keep records.

Although this is recommendation from Niche, this had occurred before, so we were already looking at how we manage our records, including telephone calls and emails.

GO: I believe you have statement from Lynbritt Gale. We'll let that work finish but idea would not be to record every email but where clinical information exists it should form part of clinical records.

That work is ongoing and will be reflected in our record management policy

C: thank you, I believe in the view of the Niche authors they looked at, were about 8 or so in 40 they reviewed. So it’s not all but significant proportion.

So that's ongoing, not relevant in this particular case but technological challenges and new ways contact is made...

C: including by text messages, which I understand from other cases is user friendly, but again one faces challenge of how that information is then uploaded and recorded in clinical records. I have that additional layer in mind, consider it ongoing and under review.

C: Assume you accept recommendation therefore, for completeness?

GO: yes we do accept the recommendation.

C: Dr Otun that includes my questions for you. We'll take short comfort break and then return. I know you have to leave by 1pm for clinical commitments.

Court adjourned 12:10 for 5min break

[I’m obviously almost an hour behind]

C: I’ll turn to Mr Stoate, if you’re there?

TS: good afternoon Dr I ask questions on behalf of the family.

TS: I just want to clarify something you said, Sir. I don’t think its position that Niche identified only 8 emails

Coroner acknowledges and reads

[too fast, so consider this a paraphrase]

We’ve reviewed 76 pages of communication containing in excess of 60 emails.

C: Just 8 of emails contain information present in Chris’s records, while majority might not be relevant…. Is some would have expected to be contemporaneous entry or risk assessment…. Absence would have led staff to misunderstand seriousness

C: right, of the 60, 8 contain information present in Chris’s clinical records, so 8 of them did reflect, 52 didn’t by my simple mathematics.

It could be argued the majority of emails weren’t relevant, but doesn’t go other way to say all others.

C: A significant number but they don’t specify and don’t think they were asked

TS: yes sir, its slightly more nuanced

C: yes important conclusion they reach, in how impacts on potential underestimation of risk. Thank you

TS: thank you.

TS: Dr I’ll just ask about Recommendation 8

Trust must ensure that concerns raised by families are responded to and documented appropriately.

TS: The Trust must develop guidance to support families and staff when relationships become adversarial, this should include an escalation pathway to enable resolution.

Families are most often the individuals who know and understand patient very well…

TS: importance of involving families in decisions about patient care cannot be underestimated. Do you agree with that?

GO: I agree with that

TS: there are plainly situations in which direct contact between treating clinicians and families is going to be required

TS: for example if consultant psychiatrist says I’ll discharge the person back to their family home, in which family have real concerns about their ability to keep that person safe.

Would you agree are situations where direct contact is required?

GO: I agree with that [fuller answer, didn’t catch]

TS: one example, may others, you agree? [missed question]

GO: in principle, am aware of situation where patient wants to go home and family doesn’t want them home for example

C: It would be difficult to argue with the principle given is in @eput Suicide Prevention Strategy….

[Coroner reads from it]

C: will value insights families have about their loved ones and include them in treatment, will ensure changes in care such as S17 leave will be discussed with families when appropriate [reads more]

That’s 2018-20 policy in place at time.

C: Don’t think there’s anything controversial in that respect

TS: [missed] It was establishing a foundation, for how Niche proposal and what set out in Dr Otun’s statement, how they address that in practice

TS: Ms Hutchinson said yesterday “there were very clear and valid concerns coming through from Julia, Chris’s mum, the quicker those concerns were dealt with would mean concerns reduced over time..

TS: if autism specialist had been involved, if care plans were coproduced, that would have reduced concerns’

Picking up on coproduction of care plans, that should involve families wouldn’t it, would you agree?

GO: I’d agree in broad terms yes

TS: you’ll understand Chris’s family considered this very carefully. The suggestion by Trust or Niche there should be third party clinician, between family acting as gatekeeper could have potential to obstruct direct important contact between family and clinician treating patient

[missed]

GO: not sure understand question, sometimes when communication is difficult the presence of third party can help…. In principle if two parties can’t agree, presence of third party can help

TS: am sure you’re right in certain circumstances.

TS: I’ll put a different way.

If Consultant Psychiatrist phones up and says want send him home, family have real concerns that they can’t keep him safe.

That’s not an issue for PALs is it? They're longer term complaints?

GO: yes, PALS don’t get involved with that, that’s a clinical discussion

TS: absolutely, family concern is if there’s a role, with best will in the world, phrase used elsewhere, not phrase the family wish to associate themselves with “to manage a family member”.

TS: A third party however well-meaning or expert, between family member raising, from Ms Hutchinson’s words “very valid concerns”… risk someone becoming gatekeeper, a manager, and not addressing concerns of family about how address patient

GO: if comes to medical director will be clear is medical matter and not something PALS person needs get involved with… if comes to me I’d ring consultant and say what’s problem here, have you had a discussion with the family.

GO: These sorts of instances luckily are not common, but when they do arise, helps have fresh pair of eyes to see

TS: this will sound very simplistic, point raised with me by family.

TS: Imagine entirely different medical scenario, if your child had cancer, was receiving treatment for cancer.

You as concerned parent wouldn’t want third party liaison point, you’d want to speak to the doctor and say what’s best course of action...

TS: you wouldn’t want to be managed by a third party. So how different for someone suffering from constellation of issues Chris was?

GO: I wouldn’t use the word manage. It’s an opportunity for supervision.

GO: Consultant may not be aware they’re not able to communicate with the family.

It may well be I agree with family and say this is situation.

Is part of supervision framework when receive complaint

GO: Ultimate goal for consultants to learn from complaint and change practice, it’s not management issue, a supervision for me.

TS: Niche say Julia’s concerns were frequently documented but little evidence were considered or acted upon.

TS: Family really want to understand how [missed chunk] that with action you’re proposing now with deputy director, how’s that all reconciled please?

GO: I’m convinced new process will address that. Not all concerns like this are captured and documented by organisation.

GO: If aware frequent concerns raised through this new system, we’ll only close when sure addressed by team.

Idea is to hold people to account, say we’re aware of this concern, we’re not getting involved, we’re asking you to ensure this matter is dealt with.

GO: Doesn’t stop concern being raised several times but gives organisation oversight that concern is raised…. I think the problem is not recording the concerns and the Trust not aware of it at all, other than the team members

TS: sir I’m just checking my WhatsApp group, sorry

C: sure

TS: sir for now if I may I’ll stop there.

No questions from Ms Nash, Ms Denton, Ms Khalique or Ms Ballard

C: Back to you Mr Stoate, have you had sufficient time to review with Nyarumba?

TS: I have. I’ll just say through this medium, there’s an issue I’ll discuss with him and family rather than raise with you at this stage. Nothing more for this witness, are other issues.

C thanks and releases Dr Otun at 12:33 asking for updates before he concludes tomorrow afternoon.

C: Alright, Mr Stoate did you want to take a few minutes to liaise with the family or are you content for us to turn to the issue of submissions?

C: Ms Ballard comes on screen, you’ve seen Mr Stoate’s helpful written submissions.

BB: I have sir, very grateful for them, but due to time received, no criticism in any way, but I need to speak to my client about them.

BB: It’s a request for time, 40mins please, that should foreshorten any submissions I have for you.

C: Mr Stoate, if I say we’ll resume at 13:20 that gives you time to deal with any issues with Nyarumba and Julia as well.

C: For my part I’m grateful, assisted if I may say, by the brevity, clarity and focus to which matters are set out.

Particularly helpful to have references to addendum report, with very very limited further matters

C: I consider subject to further submissions that matters identified are those I should properly consider.

I’ll leave that there.

We’ll reconvene then at twenty past one. See you then.

Court was adjourned at 12:35

Back at 13:20 [Just about now]

We're back in court.

C: If I can start by turning to the other IPs Mr Stoate... [missed] in no particular order, in no particular order ask Ms Nash, Ms Denton and Ms Khalique

LN: agree with learned friend these are broad issues [paraphrase] nothing otherwise from me

C: Ms Denton

AD: I have little to add, is one section I'd seek to make some submissions on.... regard the factors I'd urge the court to consider

C: thank you. Ms Khalique?

NK: nothing further to add sir, you're very familiar with the territory.... [missed chunk]

NK: at some point sir I probably ought to just touch on PFD issues, have just a sentence to say about it from clients I represent, the ICB, to confirm, check you've had the statement filed by us from Alfie XXX

C: I'll double check that while I have you there

C confirms he has it and has read it

C: I will return to that topic if I may probably at conclusion of tomorrow's summing up...

Ms Ballard? You next, just trying to get indication of likely length of time?

BB: Three minor points sir, shouldn't be longer than 5 minutes, possibly 7 and something minor to say about PFD matters

C: thank you, Mr Stoate don't know if there's anything you wish to add at this stage?

TS: nothing to add at this stage thank you

C: Ms Denton

AD: Briefly mention of local authority team and extent of which is inadequate, would raise some relevant guidance, case of Watts and United Kingdom [?] has been applied by Court of Appeal in subsequent matters.

AD: Scope any positive obligation has to be considered in way does not present an impossible obligation on local authority [think she said, sorry, cant catch]

4 factors as to limit of local authority control in this case

C: thank you, a little slower please Ms Denton if you'd like me to take a note. You have in mind Mr Stoate's footnote 6 re proactive involvement of someone with expertise in learning disability and autism would have made substantial alteration to Chris's treatment

AD: first is to keep in mind the nature and remit of LA control, scope of their power generally, and in circumstances of Chris's case.

Would refer you to witness evidence of SBC employees [lists]

C: which aspects, there's voluminous contribution from those three, which aspects please?

AD: extent to which clinical role on part of LA, conflation of roles and remits between clinical learning disability services and non-clinical LD services

C: from SBC perspective what you say is aspect in Chris's case?

AD: looking at Niche report recommendations made, extent of dependency LA and all would have had on clinical input, management and care of Chris, and how that affects scope and power of LA members

C: what's your submission specifically on that aspect, was LA learning disability team is limited to non-clinical aspect?

AD: yes won’t make submissions evidentially but may consider clinical role landed squarely in remit of EPUT rather than the local authority

AD: I’ve conflated various factors, can I simply add in terms of Niche report, as far as you draw any conclusions from that, I note referred to in family's submissions to support various findings

AD: think would be inappropriate and unfair to rely on contents of that Trust commissioned Niche report, and aural evidence of the authors, in so far as it relates to Local Authority input.

Original report 5.1.1.4 [?] when not in remit to comment on adequacy and scope of LA

[missed chunk]

AD: Would simply ask keep that in mind in so far as the local authority is mentioned in the conclusions.

Only further minor point I'd add is of causation.

AD: If you're of view has been any inadequacy on part of LA, I'd invite you to consider extent to which that can be said to be more than minimally contributing to the death, when what can be taken from Niche report is an accepted list of findings as regards to EPUT

AD: I don’t have anything further to add sir.

C: thank you very much indeed, bear with me. Help me, the specific witnesses were?

AD: Sarah Range, Margaret Wall, Ann Igoe, and to extent relevant Melika Kay but not in that context

C: Melika Kay of course contributed to the MCA assessment so you don’t include that element in your submissions?

AD: no

C: Thank you very much, over to you Ms Ballard

BB: thank you sir, first point, no doubt you’ll be mindful of conclusion of experts at 3.2.5 of addendum report of Niche when drawing your conclusions regarding the central issue.

BB: That’s paragraph in internal page 11 at top, I don’t think I need to read that out to you if you have it there.

C: no possible to determine what outcome of MHA assessment might have been, in dependent doctor or AHMP may have considered Chris was not detainable [missed bit]

C: will have in mind requisite standard of proof in coroners court and looking at what inferences I might draw from the evidential matrix with respect of that aspect. Thank you for that

BB: not only that, central issues can include possibly contributive matters of course.

BB: Second point identified 7b and c of Mr Stoate’s written document to you. Do you have those in front of you? Can’t see what you’re looking at?

C: I do

BB: whether those matters converge to be one and same thing, on date of 29 June, that’s a matter for you

C: yes part of same point, I agree, thank you

BB: with regards to adjective used for capacity assessments

C: yes

BB: to just be mindful of the evidence given by Kirsty Lister, in the respect of the real challenges faced by her, arising out of the pandemic

BB: which impacted upon the formal recording of those assessments.

If you recall sir, she would ordinarily give the job to the role of administrator who was used to completing those reports and forms online, but she had to print them out

BB: she couldn’t review them before they were then scanned onto the system, please be mindful of those aspects as result of the pandemic

C: two elements, usually administrative staff familiar with layout and formatting of report to input what she had drafted, absence of that

C: and absence of them to be printed out and her, Ms Lister to review them

BB: indeed

C: you urge me to have that in mind when considering nature of adjectival description of any shortfall in that respect

BB: do you wish me to address PFD?

C: [missed]

BB: please may I delay in making a submission, if any at all, I wish to wait for the updates you requested from Mr Otun

C: of course, might be helpful to hear what Mr Stoate wishes to submit

C: together with anything Ms Khalique and you may wish to advance to assist me in whether my statutory duty is triggered.

C: Thank you very much indeed. Ms Khalique?

NK: to be clear statement we provided was supplementary in response to specific questions you made

NK: I don’t anticipate making further submissions just wanted to make sure the court had that.

C: Thank you. Indeed. Mr Stoate if I can return to you please.

Anything you wish to add to Ms Denton’s submissions?

TS: yes thank you, and thank you Ms Denton for clarity of point she makes.

I’m looking at 7a roman 5 in which I’ve suggested safe conclusion would be inadequate liaison with and inputs from the local authority learning disability team

TS: leading to a lack of assertive action to support a partnership approach to Chris’s care

Family submission proposition is sustainable as matter of fact, that is fact you could find.

TS: To assist Ms Denton’s concern, I had read the point, may need better drafting if you wish to address.

The point in Niche was failure by @EPUTNHS to reach out proactively and take that action for partnership support

TS: I’d understood evidence from Ms Hutchinson and Ms Ibbs as @EPUTNHS not reaching out to local authority to be proactive in approach, rather than seeking to impose positive duty on local authority.

I would agree that’s not appropriate.

C: that foreshortens that issue then, probably deals with all your concerns Ms Denton?

AD: yes thank you sir.

C: anything further on Ms Denton?

TS: no thank you sir, not on Ms Denton’s point unless I can assist you further sir?

C: no, bear with me one second, is effectively no criticism extended to the local authority learning disability team in the rest of your submissions?

TS: sir that’s not quite the way I’d put it, but you’ve seen what I’ve put, nothing else Ms Denton needs to deal with I’d suggest

C: do we move to Ms Ballard’s brief submissions?

TS: if I may. Two I think, capacity and the Mental Health Act

Looking first at capacity, what adjectives you use is entirely a matter for you, won’t take you any further than that would be trampling over Rule 27.

TS: In family submission evidence sustains language of that strength because point about capacity goes far wider than the recording of the capacity assessments.

TS: Have in mind particularly the evidence of Ms Hutchinson yesterday, from my note, actually Ms Ali’s note, far more accurate than mine…. [missed]

Specialist input key.

TS: She also said decisions about accommodation, drugs use and keeping himself safe were very important decisions in his life…

and there should have been more senior clinicians directly involved in the MCA process

C: yes, fairly uncontroversial given that was supported by Ms Allison, albeit with caveat of in retrospect, I understand what you say as to at the time and not only with benefit of hindsight, I have that in mind, thank you

TS: significance of capacity decisions, its inconceivable that wouldn’t be understood by clinicians with experience in autism, but you have the point sir

TS: In relation to the Mental Health Act points, I’ll not die on the hill of my drafting of issues.

TS: It might be you think two issues are conflated into one.

I tried to be as precise as I could in that regard, one of key points made actually expressed further up, not just failure on 29th to evidence any adequate consideration of the MHA

TS: or Chris’s capacity to keep himself safe, but also it meant he left, with quotes from Niche, “without all avenues that could have kept him safe on the ward being explored” so wider more nuanced point than saying because don’t know outcome cant be causative….

TS: That involved as total picture, inadequate use of two legal regimes set out by Niche, and failure to explore all avenues to keeping himself safe, I cite Niche directly

Sir unless I can assist you further I think I’ve addressed the points made.

TS: Could I just quickly check the WhatsApp group?

C: of course

TS: Don’t think there’s anything else at this stage I need to add sir

C: at 7g, I have in mind rule 27 and submissions from your colleagues, described as ‘Inappropriate judgements being made about Chris’s mother with little or no understanding of the complexities of the home environment that she was managing, leading to the inappropriate placement

C: of Chris at Hart House’

Which element of the evidence do you rely upon for the, as it were causative link, between the emails you refer to, the homelessness point, and the inappropriate placement?

C: I have recollection of evidence and I just need to place with whom it was the evidence that those emails and/or the threat of imminent homelessness expedited the search for and eventual securing of Hart House.

Can you recall the witness on that?

TS: I can assist directly.

TS: Can refer to Niche appendices where they summarise emails… internal page 8, underlying that, I set out in footnote, para 9.5 where quotes inappropriate judgement comes from, Niche’s words not mine, refers to Dr Thies Fletchner and Dr Carr. Set out in addendum p8

C: do you mean the addendum to the addendum report?

TS: yes the appendices, last email Dr TF 8 June 13:05… mother will have to make a decision, over the page Dr Carr said go to the council as homeless.

TS: There was yours, and my questioning, of both of those witnesses and crucially the evidence of Sarah Range who accepted, I’ll check note, accepted the decision to put Chris at Hart House was “rushed”

C: who was that?

TS: Sarah Range, in her witness statement

TS: and when I suggested rushed she agreed and said was direct result as threat of imminent homelessness, which Niche refer to as flawed decision of those clinicians, due to not understanding situation at home, which you might link back to how Julia was dealt with.

TS: As for Hart House, no one including the manager, felt they could keep Chris safe by the end.

C: yes, gave me some pause for thought about point 8…. I need to consider whether that was an adequate placement in and of itself

TS: absolutely, we say it wasn’t

TS: I think that’s a firm conclusion you can draw from evidence if I’m not trampling on rule 27

And you’ll recall the moving evidence of Ms Clark about what they thought about Chris being there, and you might want to factor in the contact between Mr Weidner and Hart House

TS: and very little contact in last few days of Chris’s life

C: thank you very much indeed, if nothing further, will adjourn for today.

We’ll resume, I’ll aim for 13:30 tomorrow and will proceed through to the conclusion of these proceedings.

C: We may sit slightly later than the usual 16:30 if necessary.

After 12 or 13 days evidence, absent a jury, this is not an occasion I’m proposing to sum up the evidence in any detail.

C: Will go through three stage process suggested by Chief Coroner, will identify those findings and determinations that inform in evidence the conclusions I reach

C: One matter wanted to check with you Mr Stoate, I assume for Box 5 in record of inquest the usual address should be, not Hart House but Julia’s address?

TS: yes please

C: proposing to leave employment blank, don’t think he was a student at time, could include unemployed?

TS: sir can I take instructions on that if don’t receive response immediately

C: yes, matter of clarification tomorrow, I don’t think he was studying at time?

TS: he wasn’t, unemployed isn’t something I’d advise

C: no

TS: Julia makes point that he was disabled by that time, but not sure appropriate in that box?

C: not really appropriate, it’s not an occupation. Will leave that blank, as am allowed to do. Could write former student but that’s pretty much everyone in UK

C: Thank you very much for your assistance

TS: sir before you go, can I raise this issue, want to be upfront, on basis not to cause any difficulty for the inquest at all, but it’s something of concern.

There may be an ability to set the family’s mind at rest going forward.

TS: On Day 13 on 30 Sept I think, you’d requested transcripts of everyone interviewed by Niche on the Worcestershire basis. Escaped us to raise before now but not escaped family as background concern they’ve got.

TS: Want make very clear, not suggesting should detain you at this point but if you could address that at appropriate moment please

C: I don’t think I received those transcripts, wasn’t something at forefront of my mind as necessity

C: reason at that time as frank as can be was any residual concern as to what had actually been said given Niche were aware of the content of the Dr Villa ESTEP email exchange, on basis of information they had from memory at that stage, that the matters hadn’t been

C: didn’t appear in clinical records or hadn’t been raised in course of interviews.

In light of confirmation these matters weren’t raised, was no challenge to that. That was purpose I had in mind at that time, as requesting what was said, to establish what wasn’t said

C: and that these matters hadn’t been raised, deduced in course of questioning yesterday.

In those circumstances that was limited purpose of my request for those. Not something, taking matters proportionately and appropriately, I need to delay matters now to obtain.

C: Something I should say may have fallen even off Julia’s radar which I know is very acute, was issue about chronology of events between EPUT and clinicians post pre inquest review hearings and start of proceedings

C: Georgina Warne has provided a detailed account and I have no concerns arising out of that aspect, I am satisfied on all I’ve read that was an administrative error, oversight, rectified and dealt with expeditiously when I raised concern forthwith

C: Was Mr Moor who raised the issue and was dealt with by EPUT team appropriately. Have no concerns of that aspect either.

TS: one sentence from me Sir on behalf of family, hope understand context of which was made

TS: was me who asked Niche authors yesterday about level of concern expressed in emails versus what was said in interviews with Niche, you’ll have that in mind when determining what evidence you accept and reject in your findings I’m sure

C: it would be remiss if I didn’t consider all aspects of evidence, I have the point, thank you very much. Unless anything further, we’ll adjourn, if everyone is ready for 13:30 tomorrow I’m hoping to start then

BB: there’s one more issue still outstanding and will be addressed sir, you requested back in September a statement regarding disclosure and how handled for inquests and inquiries. That is now finalised and will be with you tomorrow

C thank you it’s part of an ongoing dialogue you’ll appreciate Ms Ballard, at senior levels I’m engaged with at EPUT, that won’t delay matters further.

Do you know who is providing it Ms Ballard?

BB: Lynbritt Gale with caveat she’s drawing information from various people as your inquiry draws on various teams

C: can’t see any difficulties in that being cross served when provided to me

BB: indeed, and that was what you’d previously ordered

C: thank you

C: Thank you all very much indeed. I’ll see you tomorrow. Julia I hope things are ok at home and Nyarumba I hope things remain well where you are as you head into mid morning.

We’ll adjourn matters now.

Back tomorrow for 13:30 hopefully, if not 2pm certainly

Court adjourned at 14:13.

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