Rachel Johnston Inquest – Day 2

We heard evidence today from an agency nurse working at Pirton Grange, on Day 2 of Rachel Johnston’s inquest. On Friday 26 October 2018 Rachel returned to her care home, Pirton Grange, following a full dental clearance (removing 19 teeth or tooth fragments). Around about the time she arrived back, approximately 8pm, registered nurse Sheeba George, who was the nurse on duty overnight was in a handover meeting.

Yesterday the court heard how Rachel’s mother, Diana, had been concerned about her following the journey back to the home. The support worker who was driving told the Coroner she had no concerns because Rachel was just sleepy after the anaesthetic. She handed Rachel over to another support worker and passed the paperwork she’d received to the nurse in charge.  

Sheeba George was on duty for the first 12 hours after Rachel returned, and then worked the same shift the following night. She told the Coroner how as well as agency nursing at Pirton Grange, she also works in a hospital and she would normally expect a discharge summary to be sent back with the patient. On asking what it would contain she responded:

When patient has had surgery, post operatively it would always mention what surgery, what anaesthesia and normally we would have a sheet with post-operative care as well.

In the absence of this information when asked by the Coroner why she had not called the hospital for more information she responded that she ‘could have called them and asked for more information’ however, she continued stating she had not done so because Rachel was ‘still bleeding out [her mouth], so my first priority was to make her comfortable and stop the bleeding’.

The Coroner persevered, asking once she’d stopped the bleeding why she had not called the hospital. After a long silence Nurse George stated:

That time I made Rachel more comfortable, she was in a stable condition. By a few hours after that the bleeding was stopped…. She was drowsy due to anaesthesia staying in her system for 24hours, I was making the clinical judgement on that.

Nurse George reported Rachel’s bleeding had stopped by approximately 10 or 11 o’clock, she couldn’t say what time for sure and it emerged that she had made no records at all on shift that weekend. She later conceded her record keeping was ‘poor’.

Asked why she hadn’t got a colleague to call the hospital for the information she said should have been provided she said in her ‘clinical judgement’ Rachel ‘was not showing any deterioration at that time’. Again, the Coroner persisted:

Ms George, you’ve told us you’d always expect to have this information, there were many things you didn’t know, you didn’t know how many teeth were extracted, you didn’t know the post-operative care recommended, you’ve told us you didn’t know what anaesthetic she’d had…. so why didn’t you, or someone else, make that phone call to the hospital and get that information?

This was met with silence from Nurse George. The Coroner asked ‘was it because you forgot?’ and she replied she wasn’t thinking about it at the time, this continued for a few more exchanges until eventually ending as follows:

Coroner: Did you remember any time before you went off shift at 8am the following morning? Did you think at any time I must get that information from the hospital?


Coroner: So, can we take it from that that you did forget?

Yes, you can.

Nurse George claimed she had done physiological observations of Rachel after making her comfortable some time between 8:30 and 9pm. She repeated them again before she went off shift, between 6 and 7am the following morning. She recalled also checking Rachel’s temperature on two other occasions but made no recording of any of these checks.

We heard how normally Rachel was an early riser and would be heard singing in the early morning, before the night staff finished their shift. When asked whether she was concerned Rachel wasn’t awake on the Saturday morning she reported she had no concerns because ‘anaesthesia stays in her body for 24hours, so I’m thinking she’s still sleepy’.

For the first time the Coroner reminded Nurse George she was under oath and checked ‘are you quite certain that you conducted those physiological observations at 6 o’clock that morning’. She was certain.

Nurse George was also on duty the following night, Saturday. By the time she arrived a colleague, Nurse Gill Bennett (who’s evidence we’ve yet to hear) had called 111 because of concerns that Rachel had been ‘gurgling and seemed chesty’. We heard yesterday that Rachel’s mother had asked the staff to contact the doctor early afternoon, they’d not done so, the first contact being a call to 111 at 7pm that evening.

Nurse George admitted that she didn’t check if there was any record of observations, or whether anyone else had done any before she came on duty. The Coroner seemed somewhat incredulous:

‘This is a patient at risk Ms George, she’s at risk of aspiration, she’s just had dental surgery with a general anaesthetic. You’ve already told us you were concerned she’s at risk of aspirating, the obvious thing would be to check on her oxygen levels; did you not ask anybody what her observations were?’

Ms George couldn’t remember but didn’t think she did check, apparently at this point it ‘wasn’t normal practice that they wrote it [observations] down’.

Ms George’s evidence was that she did a full set of physiological observations when she came on shift on Saturday because she expected the 111 clinician to ask her for them. She recalled writing them on ‘a scrap of paper’.

The Coroner was at pains to ask her again whether she was ‘quite sure’ that she took those observations as ‘at no point in your statement do you say you recorded those observations’.

Ms George didn’t tell the 111 nurse the observations when she called, because ‘she didn’t ask for them’ and she failed to tell her that Rachel was gurgling, or sounding chesty, despite being asked about her breathing twice. This was explained as her focusing on how Rachel was at that moment, and she wasn’t making any gurgling noises ‘I only went with the present situation after we made her more comfortable’.

We heard that Ms George didn’t conduct any further physiological observations of Rachel until 6am the next morning, but throughout the night she visually checked she was ok.

The Coroner asked again:

Coroner: You’re quite sure you did those observations on the Sunday morning are you Ms George?

Yes I am. I’m pretty sure I did them to make sure she’s ok.

Coroner: There’s no mention in your statement at all about doing observations on the Sunday morning is there?

<She reads> No, it isn’t mentioned.

Coroner: We know by the early afternoon of that day Rachel’s oxygen saturations were down to 63%, are you quite certain you did those observations on Sunday morning?

In the morning, yes, I can’t remember what time, its only for my clinical reasons I do those observations to make sure she’s ok before I do handover.

Visual observations, not recorded. Physiological observations at an unknown time, not recorded. No information to monitor whether Rachel’s condition is improving or deteriorating.

Asked whether Rachel was awake and singing before she finished her shift on Sunday morning, Nurse George was ‘pretty sure she was not awake’.

When questioned whether that was a cause for concern by Sunday morning she responded that she was thinking ‘she’s more sleepy and drowsy due to anaesthetic’. Ms George admitted she’d failed to ask at handover whether Rachel had been awake during the day, she’d failed to check the carers notes and had no idea whether Rachel had been awake since returning from hospital:

Coroner: When it came to handing over on Sunday morning you had no idea at all whether Rachel had been awake since she came back from hospital

< Silence >

Coroner: Because you hadn’t checked, is that right?

I hadn’t checked the carers notes no

Coroner: That’s quite an important observation isn’t it? If Rachel had been awake, her usual self, singing during Saturday, that would indicate things were heading in the right direction might it; on other hand if Rachel hadn’t been awake, had been drowsy, that would be more cause for concern wouldn’t it?


Coroner: You’ve talked about general anaesthetic lasting 24hours hadn’t you? That would have taken you to Saturday afternoon, so it should have worn off by Saturday afternoon?

Yes, in normal… but might be different

Coroner: This is all important information

It is

Coroner: And you don’t seem to have tried to find out whether she was awake or not, do you?

I can’t remember it either

Coroner: There is nothing Ms George in any of Rachel’s records on which you have recorded your own observations about her is there?


Coroner: There’s nothing to say she looks ok, she’s sleeping well, she’s breathing well, my physiological observations they’re all fine, there is absolutely nothing in the records that you have written down about Rachel is there?

I didn’t record observations yes

Coroner: Not just physiological observations, You’ve written nothing at all. There’s no way of anyone wanting to look back at how Rachel was when you were on duty. There’s no information you’ve provided any body is there.

When questioned by Ms Gumbel QC, for Rachel’s family it became clear that Nurse George, in addition to her agency working, is working at Worcester Royal Hospital as a surgical nurse, caring for patients post operatively. She felt what was expected when caring for someone post operatively in hospital is different to in a nursing home.

On questioning Nurse George admitted that she hadn’t rung the hospital for more information that she felt was needed when Rachel was returned to Pirton Grange, she didn’t note down observations, she didn’t ask the nurse she took over from on Saturday what Rachel’s observations had been that day, or whether she’d been awake during the day.

Nurse George had not remembered she took observations on the Saturday or Sunday (they weren’t in her statement given less than two weeks after the event) at the time, but she had recalled them this morning while talking with the Coroner.

Questioned about her lack of concern that Rachel had not come around from the anaesthetic since returning to Pirton Grange, she was asked by Ms Gumbel:

Wasn’t that something you knew as a nurse was very unlikely that anaesthetic was still having an affect Friday night, all day Saturday, Saturday night and Sunday. By Sunday morning she was still not rousable?

Nurse George responded that Rachel was just sleepy and again insisted her observations were in a ‘normal range’ at 6am on Sunday.

After Ms Gumbel’s questions the Coroner sought clarification as to why Nurse George hadn’t recorded Rachel’s observations in her notes:

My mistake I accept it

Coroner: I understand you say it’s a mistake but I’m asking why you didn’t do it?

I don’t know

Coroner: I think there are two possibilities – one that you forgot to put them into her notes, the second you didn’t take observations?

I did I’m pretty sure

It’s a matter for the Coroner of course but Nurse George’s evidence appeared confused, and it took a remarkable turn shortly after when Ms Ollivere, legal representative for the two NHS Trusts asked her questions.

Ms Ollivere asked whether Nurse George had been told that Rachel came around well from anaesthetic and that Rachel was awake and singing in the hospital? Nurse George responded:

I, yes, I think so. She was awake and given yoghurt. Can I tell you another thing as well, when I was coming to Pirton, the car was in front of me as I arrived. So I can hear the sound of Rachel, so I can hear she was singing at that time, when she got out from the car.

[Yesterday we’d heard evidence from two witnesses that Rachel was asleep when she arrived back at the home]

Coroner: are you saying you heard Rachel singing when she got out of the car at Pirton Grange?

When I was coming to Pirton Grange the car was outside. I heard Rachel’s sound inside the jeep yes.

Coroner: Was it singing you heard?

I can’t remember, Rachel sometimes made some noises.

Coroner: We’ve heard evidence Rachel was asleep when she got to Pirton Grange. Sheila Taylor, a witness said she’d been alert for the first part of the journey but after 10mins she fell asleep and remained asleep, are you quite sure you heard that?

Maybe, ummm confusion. Sir I’m confused now,

Coroner: You’ve just told us, you’ve suddenly come up with evidence that you heard Rachel making sound when you arrived at Pirton Grange and she was getting out the car

I’m confused now sir. Rachel was alert and they’d given yoghurt, so when we physically, I only checked Rachel after my handover, physically I saw her at that time only.

Coroner: Ms George I want to ask you, have you just made up that piece of evidence about hearing Rachel?

I didn’t make up that evidence, the car was in front of me, so I heard the sound, I think it was from Rachel.

Coroner: There’s nothing in your statement about that is there?

< She checks > no sir

Coroner: There’s nothing in your statement to say on that evening when you first saw Rachel that she was awake and alert is there?

No, it was not in my statement sir

Coroner: So why have you suddenly remembered this piece of evidence?

I remembered the car was pulling up when I was parking my car

Coroner: Did you hear a sound or not?

Sorry sir I’m confused I can’t say, I don’t know.

As I said, a matter for the Coroner to decide on the quality of the evidence before him.

After Nurse George’s evidence, and a few technical difficulties, we heard evidence from Dr Steven Haynes, an intensive care and anaesthetics consultant at Worcester Royal Hospital. He’d submitted a report to the court based on his dealings with Rachel subsequent to her admission back into hospital, some of which was compiled based on her notes. We heard how a 999 call had been placed by Pirton Grange just before 2pm on the Sunday, and the crew were on scene just before 14:08.

He considered that the paramedics had ‘done completely standard and appropriate emergency management of the situation’. Rachel was reported as:

‘making gurgling noises so you can say airway was at least partially obstructed, manoeuvres were undertaken to physically hold her airway open, deeply unconscious patient can snore badly and obstruct airway as the tongue falls back’.

He reported that his understanding was Rachel was deeply unconscious, and they were able to provide adequate amounts of oxygen so that her oxygen levels could recover but that required ‘the maximum levels of oxygen we could give without ventilation’.

What struck me was what Dr Haynes said next:

I suspect on other occasions a girl with Rachel’s co-morbidities would not normally be offered ventilation on ICU.

I think that because this was in a relative short period of time of the procedure, it was deemed suitable to have. She was given the benefit of the doubt and put to sleep, intubated, so we could fully control her breathing…. remove clots from her airways…  

At the same time, having taken that decision that we’d go that far, a limitation was put in place ,so if full multi-organ failure developed we’d not pursue all efforts to keep her alive

Coroner: The reason being what?

The nature of ICU is we have a huge amount of technology whereby we can sustain life, but sustaining life without hope of recovery is absolutely not the right thing to do.

Given the state of her normal life, her normal ability to function, the fact the more you put a patient through significant trials and tribulations… in many ways you could say we put our patients through hell to get them to survive… it requires strength of character and strength of own physiology to bring them through… reasonable to say she wouldn’t have had the reasoning of understanding and communication with her to import these things were in her best interests… the more treatment we have to give to hope to reverse the situation, the more distress we’re likely causing..

As a general rule I’d say I’m quite happy to admit someone with 5-10% chance of survival, as long as it’s a good chance of survival, but when take into account what quality of life was before, their understanding, that affects the decision we make… the decision was not made by me at the time, but I fully support it.

The questions and discussion that followed mostly centred around Rachel’s swollen tongue and whether it was likely to have impaired her airway, and whether she was likely to have suddenly aspirated or it would be something that built up over time.

Dr Haynes felt ‘on the balance of probability as blood and mucus was suctioned from her airway its likely to have happened over a period of time, it wasn’t a sudden bleed that she’d inhaled at some point, must have been there for a while’.

The inquest continues tomorrow morning.

3 comments on “Rachel Johnston Inquest – Day 2”

David Abbott says:

“…but when take into account what quality of life was before…” – no attempt to hide or disguise the underlying assumptions about who is entitled to life.

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