At the third day of Rachel Johnston’s inquest we heard evidence from Gill Bennett, a registered nurse who was working at Pirton Grange, Rachel’s care home that she was discharged to following dental surgery to extract all her teeth.

We also heard evidence from Dr Monica Nuvoloni, Deputy National Medical Director for Practice Plus Group, formerly known as CareUK. At the time of Rachel’s death they were, and still are, delivering the Out of Hours Primary Care Service for the Worcester area. In October 2018, when Rachel was taken ill, they were also providing the 111 service, but they no longer do so.

Once Nurse Bennett was sworn in to give her evidence the Coroner asked her the usual questions, full name, position, whether that was the same position held at the time in question. This is how the conversation developed:

Coroner: In what capacity were you working at Pirton Grange? Were you employed by Pirton Grange?

I was agency and then they requested me

Coroner: OK, so did you have a formal employment arrangement with Pirton Grange or were you always employed through the agency?

Always the agency

Coroner: I’m going to pause there for a moment because I’m going to ask the parties this, both this witness and Sheeba George in their statements give the impression they’ve a closer relationship with Pirton Grange… I’m concerned about Interested Person status.

Mr Ley-Morgan it is unfortunate to say in the least that the impression given in these nurses’ statements is that they’re employed by Pirton Grange and at no point have Pirton Grange said to us we think these nurses should be separately represented. But they’re not your employees are they?

Mr Ley-Morgan: No sir, they are through agencies

A discussion ensued about whether the solicitors for the care home, who are not actually the nurse’s employer could and should be representing them. Ms Gumbel expressed her concern that it was only as a result of her questioning that it had become apparent that the nurses were not in fact employed by the care home but were in fact agency workers. Ms Ollivere, legal representative for the NHS Trusts involved fed back that she regularly represents agency staff who work on their wards because the view taken is that they should be following the Trusts policies and procedures, although she acknowledged it was a matter for the Coroner and Mr Ley Morgan.

Another couple questions and some further discussion, including this witness confirming that Mr Ley-Morgan had been providing her with advice with regards to this inquest, and Mr Ley-Morgan confirming that both nurses still work at Pirton Grange now (via the agency) and the coroner was ‘satisfied that Ms Bennett and Ms George’s interests are properly covered by representation and there is no need to consider separate interested person status’.

It seems somewhat surprising that we’re on the third day of an inquest, following several pre-inquest review hearings, before this was ascertained. It does appear that some of the statements in this evidence have a number of discrepancies, confusions and omissions.

Yesterday in court we heard from another agency nurse working at Pirton Grange, Sheeba George. She appeared to have a number of revelations while talking to the Coroner and being questioned by counsel, suddenly clearly remembering things that she had not recalled in the previous two years. I think it is fair to say the picture that emerged from Gill Bennett’s evidence today was similarly confused in terms of what she did or didn’t remember although her evidence appeared to be characterised by amnesia.

Nurse Bennett was giving evidence for approximately two hours and in that time she answered that she could not remember on at least 45 occasions. I say at least 45 because I know my notes will not capture everything she said. Rachel had her surgery the last week of October 2018, just 2 years and 3 months ago.

Nurse Bennett did remember that she hadn’t been given any induction when she started working at Pirton Grange. She remembered she had no training, and hadn’t seen any policies or procedures. Nurse Bennett could not remember when she’d last worked in an acute hospital but it was before she’d had children, which she worked out to be approximately thirty years ago.

She found it hard to remember how Rachel’s breathing was when she went to see her after coming on shift on Saturday morning, but she did remember noticing there was ‘watery blood’ on some wipes under Rachel’s chin. She claimed that she’d ‘probably take notes and write them down later in the day’ but she had not done this in this case and didn’t know why.

Coroner: Was there a policy in place at Pirton Grange that required you to take notes?

<shakes head> I hadn’t seen any policies. Generally as a nurse I should have done it without a policy to tell me what to do, but I didn’t do it.

Coroner: OK, regardless of whether there’s a policy there or not, as a nurse looking after a patient who’s just had significant surgery in hospital…

I should have

Coroner: Yes. How are you and other people going to be able to take a view of how Rachel is progressing if none of those notes were made?

It’s not an excuse but the carers were making good notes.

Much shuffling of paperwork and confirming which bundle was being referred to resulted in the Coroner confirming:

OK, those are observations by Amy [care worker] and on the following page. Without fail, they’re regular observations recorded but every time it’s ‘asleep and settled’ apart from earlier on the previous evening when Rachel is noted to still be bleeding.

Nurse Bennett was not concerned about Rachel bleeding the night before, or when it restarted the following morning. She also gave evidence that she was not concerned that Rachel was still not awake. Neither was she concerned that Rachel was at risk of aspiration because she was sat upright.

We heard how Rachel’s breathing had been wheezy (which Nurse Bennett felt was the wrong word, she meant that Rachel was a heavy breather when she was asleep not wheezy). We heard in her statement Nurse Bennett had said ‘I noticed her wheeziness had developed into gurgling noises’.

When asked by the Coroner what she thought about the gurgling noise she responded:

That she might have some fluid trapped in her throat, that she was struggling to swallow her secretions

Coroner: Why was that a concern?

Why?

Coroner: From a nursing point of view why was that a concern, that she was struggling to swallow secretions and there was fluid trapped in her throat?

Her breathing

Coroner: That she wasn’t able to breath sufficiently?

Yes

Coroner: I take it if someone isn’t breathing sufficiently there’s a risk she didn’t get enough oxygen?

Yes

Nurse Bennett described getting a suction machine, pulling Rachel’s lip down and suctioning around her mouth which she felt led to Rachel breathing a lot easier. She accepted that suctioning would not stop the secretions, so it was a short term solution.

Nurse Bennett could not remember how often she asked the care staff to check on Rachel, whether she asked them to note down any observations they made, or indeed how often she checked on her:

Coroner: When did you yourself next see Rachel?

After the suctioning, I was up and down quite a few times during the day, I couldn’t tell you how often or what times, but I went down quite a lot to see her.

The Coroner pointed out to Nurse Bennett she’d made a statement in July 2019, 9 months after the event and made no mention of visiting Rachel during the day. Asked why she was remembering now, she responded:

It’s not that I didn’t remember, it’s that I didn’t write it in my statement

Coroner: Alright, why didn’t you write it in your statement?

I don’t know, I should have done

Coroner: The purpose of writing your statement is so everyone can work out who’d been checking on Rachel, and how she was progressing during that period, so you might think if you’d made several visits to Rachel during that day it would be important to put in your statement?

Yes

Coroner: So, is the reason because you didn’t actually visit Rachel during the day?

I actually did

Coroner: Did you note down anywhere you’d been to visit Rachel?

No. The carers asked me when they were giving personal care if I was happy to be in the room, which obviously I was, and I didn’t mention that either.

I’ve obviously not seen the bundle, or the investigation that Pirton Grange conducted following Rachel’s death, but it seems quite astonishing that so much new evidence is emerging this week.

We heard how Rachel had been gurgling throughout the day and by Saturday evening she had still not woken up since returning from hospital.

Coroner: So sometime around half 4, 5o’clock that evening Rachel was still gurgling, she was still quiet, she hadn’t been awake?

No, no

Coroner: You must have been quiet concerned by that stage?

Yes, ummm, I was concerned she hadn’t woken up and I thought could it be the anaesthetic still in her system. I’d not, I’m not, I don’t know how an anaesthetic would affect somebody with a learning disability, I’m not experienced in that at all.

Nurse Bennett confirmed that despite her concern she didn’t ring the hospital. On Monday we heard from Rachel’s mother, Diana, that she’d been concerned early afternoon and had asked the staff to call the doctor.

We know:

• Rachel had not recovered from the anaesthetic after falling asleep on the journey home
• Rachel had not woken since her return to Pirton Grange
• Rachel was gurgling and unable to swallow secretions
• Rachel was still bleeding but the staff couldn’t open her mouth to see how much
• Rachel had a swollen mouth and tongue, and
• Rachel’s mother had concerns and requested the staff contact the doctor early afternoon.

We heard that no action was taken until after 7pm that evening when Nurse Bennett rang 111 (an hour before she went off shift). She recalled she rang 111 after doing observations on Rachel that recorded a blood pressure of 103/62 and a pulse rate of 81.

The observations were recorded at 19:05 but Nurse Bennett couldn’t tell the Coroner the exact time they were taken, sometime after half past 4 and before 7pm.

We heard that the note added to the 111 system by the call handler who took Nurse Bennett’s call was:

Patient’s reported condition: had all teeth removed, still bleeding from mouth, learning difficulties, may have swallowed blood.

Coroner: I’m not suggesting word for word that’s what you said in that phone call, that’s the note the call handler made. Do you think there’d be any other information you gave the call handler beside the information I read out there?

I can’t remember the conversation sorry

Coroner: If you told the call handler you were concerned Rachel might have swallowed blood, do I take it from that you might have thought Rachel had aspirated?

I can’t remember what I thought

Nurse Bennett couldn’t remember if she checked Rachel’s oxygen saturations, or whether the 111 call handler had asked her for them. She also couldn’t remember what she wrote on her handover, and when probed further, she couldn’t remember whether she wrote a handover.

Nurse Bennett had gone off shift by the time the Out of Hours Service called back. She returned to work the next day, the Sunday morning and couldn’t remember whether she’d asked if Rachel had been awake at all the previous night.

Coroner: At that time, Sunday morning, Rachel had been back from hospital, many hours after her anaesthetic, certainly beyond the 24hour limit, it didn’t look like Rachel had been awake at all did it?

No

Coroner: Were you not concerned about Rachel’s condition that morning?

At that time no, because she did look better

Coroner: Did you do any physiological observations

No I didn’t

Coroner: Do you remember one member of support staff, Helen, coming to speak to you about Rachel at about 10 o’clock that morning?

I can’t remember, no, sorry

Coroner: Asking you to review Rachel because she was still bleeding?

I don’t remember that no

Coroner: When did you next see Rachel yourself after the handover visit?

I can’t remember, I can’t remember the exact time

Coroner: When’s the next time you remember seeing Rachel?

Ohh blimey <sighs> I can’t, I’m sorry, I can’t remember

Nurse Bennett doesn’t recall when she next saw Rachel, but there’s an entry in the notes written at 14:05 on the Sunday saying:

Rachel struggling to catch her breath, MEWS score 8, BP 91/54, pulse 87, temperature 37.3, oxygen saturations 65%

Coroner: What did you think when you took those observations?

We need help and quick, we dialled 999 almost straight away and that’s why I didn’t write this straight away

Coroner: Were you surprised when you took those observations?

Yes

Coroner: She was clearly extremely unwell wasn’t she?

Yes

Later on the Coroner read onto the record a statement from one of the paramedics who responded to the call placed that afternoon. The paramedics arrived in less than ten minutes and transferred Rachel to hospital.

We also heard evidence today from Dr Monica Nuvoloni who works for Practice Plus Group, formerly known as CareUK. CareUK had conducted their own review into the performance of 111 and the Out of Hours Service once the CCG had informed them of Rachel’s death. She explained that they have a ‘set process we follow internally when a patient has serious outcomes, a serious incident process’.

For the internal investigation they had the recordings of the calls made and the notes recorded. They found that some aspects of the call and information provided were not fully captured by the call handler, for example the information that Rachel had a rattly chest and staff were using suction, was not captured in the summary note passed to the Out of Hours Service. However, Dr Nuvoloni did not feel that this impacted on the outcome because the nurse who called back, Alison Truman, who’s evidence we heard on Monday, had asked twice about Rachel’s breathing and had given advice not to use suction for fear of disturbing clots in Rachel’s mouth and worsening the bleeding.

The investigation highlighted two areas of the call that could have been improved, one in relation to red flags that were not fully explored, and one in relation to the safety netting advice given. For example:

Specifically around drowsiness, comments were around patients being sleepy, the nurse from the home comments that’s related to the anaesthetic, but there was no further probing around that. That I’d suggest should have occurred at that point, to ask more about that symptom.

She continued

There was no direct questioning for observations. If a clinician had documented abnormal observations you would assume the person would mention it, but, nevertheless we’d expect our clinicians to ask.

Dr Nuvoloni did also acknowledge the weight that should have been provided to Rachel’s mother’s concerns:

In the transcript it was also mentioned Rachel’s mother had concerns at that point. We felt that was a valuable opportunity to understand what the concerns were and why.

Often family members have important insights and know the patient best, so them saying something particularly was worrying them is useful. So we felt that was a missed opportunity to ask more questions around that concern as well.

On questioning from the Coroner whether Dr Nuvoloni felt there should, or could, have been different outcomes she replied:

Certainly from listening today my judgement is coloured by what I’ve heard today. If concerns had been conveyed in Rachel not waking for meals and not rousing at all, yes that would trigger concerns. You’d certainly inquire if that was normal for Rachel and if it is not, that’s a concern.

Coroner: Lets assume it’s not normal for Rachel. She’d be awake first thing in the morning, she’d be singing… if we take she wasn’t her usual self, she wasn’t rousing at all and at various times continuing to bleed form her mouth

From what I heard today, that ongoing bleeding, that blood pressure reading being the only one we have. If that was only observations that wasn’t normal, all other observations were fine, that would only trigger a MEWS score of 1 which would trigger enhanced monitoring, but it would be somebody we’d want to see, examine and review.

We’d give advice to continue monitoring, it would need very specific questioning and a plan around that. I would expect she’d be reviewed at that point. The non-rousing that’s concerning.

Coroner: Reviewed in what context, a visit from the Out of Hours doctor or goto A&E?

In terms of arousal, if someone is sleeping but you talk to them and they’re able to rouse them and they wake, that would probably fall into primary care review, sleepy and will engage.

If someone is not rousing and they weren’t their normal self I’d be questioning whether they were unconscious and that would be an emergency situation if they were entirely unrousable, a 999 situation.

The inquest continues tomorrow morning.