Day 6 Gaia Pope Sutherland’s inquest: an exercise in futility

Day 6 of Gaia’s inquest started with the evidence of mental health nurse Louise Emeny Senior, who at the time of Gaia’s October 2017 admission was a liaison psychiatry practitioner working at Poole General Hospital.

Throughout the questioning of Mrs Emeny Senior by Ms Clarke, counsel to the inquest, the Coroner, and by Ms Miles for Gaia’s maternal family, a chronology became apparent for the weekend of 21 and 22 October 2017.

Gaia and her mother were travelling back home together on the evening of Friday 20 October and we heard a note of a call that Gaia’s elder sister, Clara, had made to the crisis home treatment telephone support line at 21:05, and again later at 21:44. She explained that she was worried about Gaia who appeared to be having an episode, said her brain was not stopping and she had threatened to kill her mother, who was driving. On the first occasion the advice was for her mother to pull over and go for a drink in Brokenhurst and attempt to deescalate Gaia, and to call the police for assistance if required, contact out of hours GP if required, and think whether there is anyone who could come out to assist with the situation.

On the second occasion Clara requested the crisis home treatment team to come out to see Gaia but she was advised as Gaia was not under mental health services a home visit could not be facilitated.

Then at 22:14 Gaia’s mother contacted the crisis home treatment telephone support line as she was concerned Gaia was having a seizure due to her strange behaviour, and she was advised to call 999 or 111 as emergency services would be able to determine whether or not Gaia was in need of a mental health referral.

Towards the close of evidence today, Caoilfhionn Gallagher for Gaia’s maternal family took Dr Peter Jeffery, a consultant psychiatrist, one of two doctors who conducted the Mental Health Act Assessment on Gaia later that weekend, to records of police contact.

From that we learned that as instructed Gaia’s family called 999 to ask for medical assistance, because at 22:24 a police log recorded that the ambulance service had requested police assistance with a violent female. Gaia’s mother had told the ambulance service that they did not want the police to attend however they felt it was appropriate that the police were in attendance.

The police records then show that they arrived on scene with Gaia and her mother, with no ambulance available. They waited over an hour for the ambulance to arrive, before eventually cancelling the ambulance and relaying Gaia and her mother to Poole General Hospital themselves. In their records they stated:

“No crime, clearly not well and needs medical assistance… this was a medical episode… girl under care of NHS… as no ambulance available taken to hospital by police, no crime committed, service failure by ambulance service”.

Gaia was brought to the Emergency Department at Poole Hospital by the Police in the early hours of Saturday 21 October 2017, and she was clerked into the hospital at 00:22.

She was seen by Dr Taylor at 02:10, and again at 03:15 and then at some stage between 03:15 and 03:25 she leaves the hospital, but returns of her own volition, and is seen again by Dr Taylor at 03:25. A referral to the liaison psychiatry team was made at 04:10, and Gaia was admitted to Ansty Ward, the Acute Medical Unit, so that she were safe, pending the psychiatry day shift starting the following day.

At 07:30am Mrs Emeny Senior, and a colleague Simon Robinson, start work for a long day shift. Mrs Emeny Senior had been on the team for longer and when they divided the work Simon was due to assess Gaia, as it was felt her presentation was less severe than another patient.

Ms Clarke took Mrs Emeny Senior through the paperwork passed to their team following Gaia’s assessment in the Emergency Department. A number of omissions were noted in the records, the risk assessment matrix appeared to be particularly incomplete. Asked whether referring clinicians in the Emergency Department were aware that they should complete every box, Mrs Emeny Senior responded that they were, asked whether it was unusual to receive these sorts of forms on Ansty Ward when boxes weren’t completed, she confirmed that it was not.

In Gaia’s case the box for referral to psychiatry liaison team was ticked, and in response to a question from the coroner Mrs Emeny Senior confirmed that in 2017 it would have been the case that whoever completed the form would be expected to ring and have a clinical discussion with her team. She confirmed that the form itself may come later if making a call was faster. She agreed with the coroner who stated that it had not been completed, that it should have been and we didn’t know when the record we had was made.

Simon Robinson was due to assess Gaia on the Saturday morning and Mrs Emery Senior was reading notes before seeing her patient and had a clear line of sight of Gaia and Simon in an adjacent room, about 10 yards away:

SC: Alright, you didn’t conduct assessment, your colleague Simon did, were you able to observe how that was going?

LES: Yes

SC: How was it going?

LES: It wasn’t really. Gaia didn’t want to engage with Simon at all, she was still elevated in mood and she was loudly expressing her displeasure at him

SC: at one point she was stood on a chair talking loudly on the ward, did they manage to get her down?

LES: I had to intervene, she wouldn’t engage with Simon and the ward team weren’t experienced in managing people presenting in that way. I wasn’t with my patient at the time so I assisted with that.

Mrs Emery Senior confirmed that she managed eventually to de-escalate the situation and it was clear that Gaia lacked capacity to make decisions for herself around her healthcare and she was unable to express herself in a coherent manner, so Simon called for a Mental Health Act Assessment. This request was put in at around about 10:30am on Saturday 21 October.

Taken to entries in the nursing notes from the Saturday the court were told that Gaia was worried about going back to St Ann’s as she was sexually assaulted by a patient there.

A later entry at 17:30 on Saturday 21 October, 7 hours after the request for assessment had been made, recorded that nursing staff had chased the doctors coming to review Gaia as she was very upset, crying and wanting to self-discharge. The nurse said that she’d explained to Gaia she would have to be sectioned if she tried to leave the ward, as she was still distressed and manic at present.

Mrs Emery Senior was asked if she would speak to Gaia, which she did. She went to see Gaia at approximately 17:30 and was with her for well over an hour. Her note at 18:50 recorded that she’d attempted to get Gaia to take medication and get some sleep. Gaia herself recognised that she was elated, not sleeping and that she was ‘as bad as she was when she was detained at St Ann’s in February’. Mrs Emery Senior felt that Gaia was more amenable to talking to her because she was female, rather than for any other reason. She recounted her conversation with Gaia, and that she was changeable throughout, and that Gaia had refused to take extra medication to bring down her mood and help her sleep, and that she refused to consent to an admission to St Ann’s.

That was the only contact that Mrs Emery Senior had with Gaia. At 19:15 that evening there is a nursing note saying that Gaia had taken 2mg diazepam after her conversation Mrs Nurse Emery Senior. The nurse recorded in the notes “She isn’t happy about taking it at all, but feels its better than going to St Ann’s”.

By the time Mrs Emery Senior finished her shift at 9pm on Saturday night Gaia had still not been seen for a Mental Health Act Assessment. The Coroner requested that she talk us through the remaining nursing notes before she returned on shift at 07:30 the following day.

At 19:15 Gaia had taken the diazepam and staff reported she had calmed down a lot, was rational and joking with staff.

23:30 she had become agitated and tearful that she was being kept in hospital overnight; wanted to go home to her own bed to get a good night’s sleep. Gaia had rung her uncle requesting he pick her up, the nurse had advised him that he could not do that. Gaia could not go home without a psychiatric assessment.

00:05 Sunday morning there’s a nursing note saying they’d spoken to the psychiatry team who were currently in Weymouth. Explained that Gaia was currently worse, not settled, shouting and screaming on the ward. Agreed that if the tried to leave police or security would have to be called and she’d be put on a Section 5(2). Doctors were aware.

When the Coroner asked Mrs Emery Smith if she was surprised that Gaia had been discharged overnight she responded:

“Not especially, things can change so much with people and their presentations, so no, I wasn’t overly surprised”.

She confirmed that she also wasn’t surprised that Gaia had been discharged back to her GP, commenting that a large portion of patients that they see are. In response to the coroner asking whether there was anything she could do when she came back in she replied:

“No not really, it would be really professionally rude to interfere in others decisions; Mental Health Act assessment people is two psychiatrists and an approved social worker, they’re more qualified to do that than I am”.

On questioning from Ms Miles, for Gaia’s maternal family, Mrs Emeny Senior confirmed that she felt able to establish a rapport with Gaia:

SM: you describe how you’re able to establish a rapport with her

LES: Yes

SM: Says Gaia taken 2mg of diazepam after her talk with Lou, that’s you, says she isn’t happy about taking it at all but feels it is better than going to St Ann’s

LES: Yes

SM: does that demonstrate just how anxious she was about not wanting to go to St Ann’s?

LES: Yes

SM: At the time when she was disturbed would she be safe to leave hospital?

LES: No, not in that condition

SM: she’s admitted to Ansty ward, that’s a medical ward, admitted because of her mental health condition, she didn’t need physical care?

LES: No.

The Coroner clarified with Mrs Emery Senior what records she would have had access. Ms Miles then tried to establish who was responsible for Gaia’s care while she was at Poole General Hospital:

SM: just one final follow up, I appreciate Simon was the lead clinician, but at the end you substantively really took over the case?

LES: No, the case had been passed to the Mental Health Act Assessment Team. What I did was assist my colleagues in the acute hospital to manage Gaia’s presentation, which is an expected part of my role

SM: Absolutely, as matters turned out you ended up having more involvement than Simon did because you were better able establish rapport.

LES: Yes, but I didn’t take over her case, was just assisting, my aim was to get Gaia to take some medication to rest

SM: I understand the distinction but that leads to a situation doesn’t it, where the person leading, whos’ expected to gather all this information, doesn’t really have much to do with Gaia. The person assisting, who does have interaction with Gaia and her mother doesn’t have access, that’s where we ended up isn’t it?

LES: No, where we ended up is she wouldn’t engage with Simon because she was too aggressive towards him, she was elated and possibly psychotic. So we passed asst to MHA Assessment Team. In order for me to assist with Gaia’s behaviour on the ward, I didn’t need to assume responsibility for her case.

Ms Miles clarified that Gaia was uncomfortable with Simon and when asked if Gaia’s behaviour was a manifestation of her distress, Mrs Emery Senior responded that she felt Gaia’s behaviour was a “manifestation of possible postictal psychosis” but that wasn’t for her to diagnose.

Ms Miles reassured her that she wasn’t suggesting that she had any control over the eventual outcome:

“I’m not suggesting you had any more control over eventual outcome than you did, but is reality isn’t it, that Simon would have had the responsibility of gathering up this information, but there wasn’t much he could do with it because he wasn’t able to engage with Gaia”

I’ll finish with Mrs Emery Senior’s response, which seems to perfectly sum up Gaia’s time on the Ansty Ward:

“Yes, it then becomes almost an exercise in futility because you’ve passed the assessment over to three other people to complete… we wouldn’t come back unless there was a management problem with the patient”.

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