When I’m reporting from an inquest I try to just share the testimony that’s given. Which is much easier with live tweeting because you don’t select any, I just splurge as much out there as possible and readers can make their own minds up. For Gaia’s inquest I’ve decided not to live tweet because I can’t possibly cover all of it, so instead I’m taking notes and blogging what we’ve heard. By nature of that it’s selective.
This post will cover the evidence of Dinesh Kannan, given on days 4 and 5 of Gaia’s inquest. Dr Kannan is currently working as a locum consultant psychiatrist in North London, but at the time of Gaia’s life and death was working in Dorset. He told the court that initially he worked as a ward consultant, but then moved to the crisis team. He’s been a doctor since 2001, worked in mental health since 2003 and was made a consultant in February 2017.
Senior Coroner for Dorset, Rachael Griffin, explained to the jury that there are four levels of care a person can have in relation to their mental health. These increase in intensity of care, she described as:
- the first being treatment from their GP
- next, care in the community from a mental health team with reviews at certain stages by a psychiatrist, nurses or doctors
- next, home based treatment care with a more intense level of contact assessed by needs, as an alternative to hospital admission
- final, a last resort, is inpatient admission to hospital, either as a voluntary patient or detained against your will for a period of assessment under Section 2 of the Mental Health Act, or treatment under Section 3.
The coroner commented that she is often told that there is a fifth step to treatment, psycho-social care and assessment.
Dr Kannan agreed with the coroner. He agreed with her a lot. He also appeared to be very much in agreement with Professor Walker’s evidence from the morning of Day 4. So what did we learn from Dr Kannan?
He first met Gaia on 15 December 2016 where he assessed her at an outpatient clinic at Wareham Hospital. Gaia attended with her mum, and had been referred by her GP.
Counsel for the inquest, Sarah Clarke, took Dr Kannan through the GP’s referral letter, dated 29 November 2016, and he agreed that it was very clear. The GP was concerned about Gaia’s depression and anxiety symptoms, and the impact epilepsy was having on her. Gaia’s sexual assault, a year previously, was also considered to be a background factor. Police and other agencies had been involved and Gaia had been followed up by CAMHS, seen a number of times but discharged by them in August 2016. Gaia had received counselling from Dorset Rape Crisis.
Dr Kannan recorded that she’d “made steady progress with minimal CAMHS involvement”, on questioning by Ms Clarke he said he’d got that information from the notes.
Dr Kannan said his practice was to go through all electronic notes before meeting a patient and be prepared. He also talked about how important it was to listen to patients and validate their experiences:
Focus was particularly epilepsy impact on mental health… Gaia was due to have an assessment from Prof Walker in London… could indicate epileptic treatment for specialist.
As went through the assessment it became clear Gaia was presenting with symptoms of PTSD.
Key thing discussed was Gaia didn’t feel listened to through the course of her epilepsy treatment… key thing is acknowledgment of impact having on her life.
I could not provide specific advice around epileptic care and safety.
Summary of the assessment, once I’d validated Gaia’s presentation, went through PTSD symptoms and diagnosis, discussion about treatment strategies could be employed, discussed pharmacological treatment on backdrop of counselling already received. Gaia asked for contact to Steps to Wellbeing…. that would be appropriate option”.
It appeared that Dr Kannan was of the view that Gaia’s primary issue was her epilepsy, and he considered her responses in terms of mental health and mood were proportionate to the situation:
DK: Gaia was very candid, she had good insight into her symptoms… new flashbacks and onset of symptoms, she was avoiding specific places, avoiding public transport… impact that had on her ability to attend college…. but epileptic seizures disabling her from doing so.
Miss Clarke suggested there were two issues at play for Gaia, post-traumatic stress disorder and uncontrolled seizures and epilepsy. Dr Kannan was keen to stress that the primary concern was epilepsy, although he agreed when questioned by Ms Clarke that Gaia was able to link the two, for example, the fact her seizure activity had both increased in frequency and intensity since the PTSD had developed.
The conclusion of Dr Kannan’s assessment in December 2016 was that Gaia’s symptoms were consistent with post-traumatic stress disorder, from previous trauma incident, a sexual assault in 2014 and associated anxiety and depressive symptoms.
His evidence on his plan seemed to be a little contradictory, at first he said it was to advise Gaia to self-refer herself to Steps to Wellbeing. Later on questioning from counsel to the inquest he said that Gaia was receptive and agreed on the action plan but that he was due to make a referral but he admitted that referral wasn’t ever made.
It was unclear why that referral wasn’t made:
“unfortunately that wasn’t sent through…. very unfortunate that didn’t happen”.
Sophy Miles, for Gaia’s maternal family, later confirmed with Dr Kannan that his letter to Gaia’s GP ended by saying that he would make a referral to Steps to Wellbeing:
SM: that letter says you’ll make the referral, so when Gaia got the letter she’d have understood she didn’t need to make a self-referral wouldn’t she?
DK: it’s very unfortunate this wasn’t sent.
SM: If you make a referral yourself the letter has gone…. We heard this morning Gaia had memory difficulties, it’s the sort of thing she might not have followed through wasn’t it? That’s a missed opportunity isn’t it to get Gaia the care she needed?
DK: it is, when followed up with continuum in February, Gaia was more focused on what was happening immediately around her than trauma focused work… that’s the impression I got.
This wasn’t the only error or apology that Dr Kannan gave. Asked why he didn’t send a copy of his consultation letter with Professor Walker and his team:
SC: did you consider contacting Prof Walker yourself?
DK: I was fairly assured because this referral came from GP, that this information would be given to the epileptic team
SC: you say fairly sure, one way to be absolutely sure would be to send letter yourself to Prof Walker which you could have done?
DK: I could have done… if had started treatment would have…
SC: Gaia and her family were clearly of the view that PTSD and seizure activity were inextricably linked; you were of the view was a link, would you consider that useful information for Prof Walker to have?
SC: why not send it then?
DK: I could have done it in hindsight, but was fairly sure as this appointment was sought to address these symptoms, this letter would make its way to Prof Walker.
Dr Kannan conceded he thought at that time Dr Page had responsibility for Gaia’s epilepsy and he could have sent his letter to him, and/or Professor Walker. When asked why he didn’t he responded that common practice was to send letters to the GP to act as a “central hub to distribute information” but good practice would be to send it direct to the specialist.
Asked if he’d do anything different now he reassured the court he has “increasingly learnt to communicate as much as can and make sure all professionals aware of what others are doing”.
I can’t help feel that this is a very apathetic and indifferent approach to take to someone’s care.
Dr Kannan then came across Gaia the following year, in February when she was sectioned and admitted to hospital in Poole for short term assessment, where he was working as the ward consultant.
Gaia had a grand mal seizure in London on 18 February 2017 while staying with her cousin. The next day she decided to return to Bournemouth and the court heard that onset of confusion symptoms started on the 19th which is why she felt she needed to go straight to hospital. When admitted on 20th she was very distressed and upset, expressing delusional ideas that she had a dead baby inside her. The AMHP (Approved Mental Health Professional) considered that she was possibly experiencing psychosis.
When Dr Kannan saw Gaia on the 21st he felt she’d undergone a “remarkable” recovery. He considered that Gaia had a lot of insight and perspective into what caused her difficulties:
“continuum of symptoms, Gaia was clear lots of other life stresses going on for her, fact this perpetrator had tried to make contact, financial restraints with PIP being declined… fact she couldn’t continue on with college, multiple stressors. I got the impression PTSD symptoms were not at the front, could be proportionate response… re-experiencing phenomena was not at forefront, was more emotional difficulties related to life events”.
His working diagnosis was that Gaia was suffering from postictal confusion, compounded by cannabis misuse. Plan recorded in the notes on 21 Feb said would not make any changes to Gaia’s epileptic treatment but will liaise with neurology and seek advice for ongoing treatment. Asked whether this happened, yet another apology from Dr Kannan:
“Unfortunately not, we had the plan, but factors such as Gaia not having any seizures on ward during the 8 day period, responding to diazepam for anxiety, no psychiatric interventions in terms of treatment would expedite our contact with neurologist… we should have sought it but there was no urgency to that contact”.
No urgency is right.
Again the court were told it would have been good practice to contact the epilepsy team but “we were basing it purely on the mental health side of things”.
Asked whether you could divorce one from the other a resounding “absolutely not” was the reply, but that was exactly what happened.
After 8 days there was a discharge planning meeting for Gaia, when asked how Gaia had progressed on the ward Dr Kannan responded:
“We had working diagnosis at hand, were pleased diazepam had benefited seizures. Gaia was on observations every 15mins, for seizures and to give nursing staff insight into her symptoms…. Observed she was well in mood, sleeping well… Gaia was interacting with her peers and staff members, participated in activities, going to gym, art groups, self-care and polishing her nails. She was also able to candidly talk about her experiences, especially the sexual assault with other patients. She was seen mostly in communal areas rather than in her room.
All point to stable mental state. PTSD was not at the forefront.. overall impression ward team had, including myself, was Gaia being 19 at that time, had several life events, stressors, what she was struggling with at that time was managing all these difficulties coming together at same time and trying to manage her emotions.
We thought we could offer practical help, a PIP letter was provided and information on recovery centre, a peer led charity”.
Asked whether any thought was given to Gaia being referred to a psychologist:
DK: I had the benefit of continuum of seeing Gaia in December and then again in February, we were very clear PTSD symptoms were not at the forefront. Any trauma work requires someone to be in safe place… with perpetrator looming large in the community we didn’t think she was in a safe place to undertake trauma treatment.
SC: what about early intervention in psychosis team, was there such a team?
DK: that a specialist service for adult age group for people with early symptoms of psychotic illness, there wasn’t a service available at that point, and at the time we didn’t think Gaia met criteria for an early intervention service
SC: of any sort?
DK: of any sort
SC: so you decided she’d have 7 day follow up with the Purbeck Community Mental Health Team
DK: that’s correct.
The Coroner recapped some of the evidence that Dr Kannan gave for the jury, he again agreed Gaia’s epilepsy was central and asked why he, or his team, didn’t communicate with the neurologist he responded again with what was increasingly sounding like a well rehearsed, but pretty hollow apathetic apology:
“That was a missed opportunity, triangulation of care would have been essential, passing on information we had with neurology team.
I can’t say or state something I don’t recollect, but I’m sure we had it in our minds to liaise with the epilepsy team.
She had an appointment with Prof Walker in two weeks time, therefore was input with neurology team.
Shouldn’t have prevented us liaising with neurologists, should have done, but we knew that appointment was happening”
Then he claimed that the reason might have been linked to the post and there not being enough time. When asked by the coroner whether he had access to emails in 2017, Dr Kannan claimed not, stating they were communicating by fax. The coroner gave short shrift to that suggestion:
Coroner: I’m sure a phone number could have been found, or a fax sent, or an email …its nothing to do with the post is it?
In questioning for Gaia’s maternal family, Ms Miles checked with Dr Kannan that further traumas or upsets can have a cumulative impact on someone with post-traumatic stress disorder, to which he agreed. She then took Dr Kannan to a letter written by Gaia’s mother, and Gaia, complaining about the impact and distress caused to Gaia by a letter he had written.
SM: ‘You refer to the man who assaulted my daughter as her ex-boyfriend’, term you used in your letter, this was not case, she says Gaia was very distressed by that reference.
DK: I was horrified that was the case, that I misconstrued what was being said in the assessment, my understanding of what was said to me was what I narrated in my original letter.
Paul Spencer, counsel for the hospital trust: Ma’am as you know there was a full apology written and sent to the family on 10 March
Ms Miles took to a later point in the letter where Gaia had expressed concerns about the use of the term ‘apparently’ in the letter, suggesting it indicated that her concerns were not based in reality, which in turn led to Gaia feeling that she was not listened to or believed:
DK: Apparently is only used for information gained from other sources, not from narrative gathered from Gaia herself… I was sensitive to point Gaia made that she didn’t feel listened to by professionals, and therefore horrified about [my] inadequacy around perpetrator
SM: so you’d accept that’s of particular importance to someone who has suffered sexual violence?
Ms Miles then took Dr Kannan to the bundle where it was indicated by a colleague of his that Gaia’s PTSD and epilepsy were interacting and impacting her on admission in February 2017:
SM: Gaia had grandmal seizure on 18 February, two days before admission, at time of the admission she was described as ‘distressed having had a psychological revelation over weekend when she realised her rapist was at large in Bournemouth, crying and wailing’ your colleague took the view both Gaia’s symptomatology were at play, that both the post traumatic symptoms, and the post epileptic symptoms were at play at that point?
DK: documentation from Dr Stallard was Gaia was going through behavioural disturbance since the seizure episode, during that was also emotional disturbance, manifesting as fixation or talking about the sexual assault.
SM: his wording is that ‘she has a history of experiencing a sexual assault, described as having post traumatic symptoms’ and goes on to say these two issues are manifesting currently. Do you disagree the post traumatic symptoms were manifesting at that point?
Dr Kannan held fast to his view that Gaia was suffering from postictal confusion, even though the court heard evidence from Professor Walker that postictal confusion was usually resolved in 20 minutes. Dr Kannan felt Gaia’s symptoms were confusion, exacerbated by cannabis use, not postictal psychosis. Yesterday Professor Walker suggested that Gaia was most likely suffering from a postictal psychosis.
Dr Kannan also again reiterated that from his perspective Gaia was not showing florid symptoms of PTSD during her admission. When asked if that might have been as a result of her being prescribed diazepam, and that perhaps Gaia was trying to give staff as much reassurance as possible because she wanted to leave hospital, Dr Kannan agreed that the medication might have reduced her anxiety levels and stated that the staff would make objective assessments of Gaia during her admission.
There was one final apology from Dr Kannan, when it emerged that Gaia had been subjected to inappropriate behaviour and sexual harassment by a fellow patient while on the ward.
This patient, who’d been discharged when Gaia told staff, had spoken about the size of his penis, asked questions about the size of her vagina, asked her to go to the gym so he could look at her breasts, asked her to come into his room to watch Netlfix, asked to set her up with his friend and tried to hug her.
Dr Kannan referred to the “peril of the mixed ward that the assessment unit was at the time”. The court heard how Gaia tried to make light of it, saying she’d been through a lot worse. She joked and said she felt sorry for the person’s girlfriend, and told staff that she felt safe because she knew self defence.
Dr Kannan agreed that this was not behaviour you would want someone to experience when in a place of safety and also apologised saying he was “deeply sorry for what Gaia had to endure in that experience”. He also acknowledged that this event should have prompted consideration of a safeguarding referral, but it didn’t and none was made
I can’t imagine how hard this experience must have been for Gaia. The court have heard how she was sexually assaulted after her drink was spiked in 2014, when she was just 16. The police investigated but hadn’t pressed charges, although her perpetrator was charged with other unrelated offences and given a custodial sentence.
Gaia was left with post-traumatic stress disorder, which in turn was exacerbating her epilepsy and having an immense impact on her health and independence. Gaia did what she could, she engaged with services and counselling from Dorset Rape Crisis centre.
Dr Kannan repeatedly referenced Gaia’s own insight and willingness to engage with treatment, yet she was repeatedly let down by the very same services, to the extent that she suffered sexual harassment in the very place where she was supposed to be safe.
I cant help thinking this apathy, and indifference, this very carelessness, must in turn have caused yet further harm to Gaia.