Day 7 Gaia Pope Sutherland’s inquest: regrets, I’ve had a few

Thursday afternoon and Friday morning of Gaia’s inquest were spent hearing the evidence of Dr Peter Jeffery, a Consultant Psychiatrist at Dorset Healthcare. At the time of his involvement with Gaia, in October 2017, he was a ST5 trainee psychiatrist, which he described as a “higher trainee, approximately a year off completing training to become a consultant psychiatrist”. He qualified as a doctor in 2008 and had worked in psychiatry since 2012.

Dr Jeffery gave evidence for an entire day, Thursday afternoon and Friday morning. I have 102 pages of notes, over 25k words, yet I’m not entirely sure what to share with you. I’ll try to provide an overview of what we learnt from his testimony.

Dr Jeffery was the on-call psychiatry liaison consultant working a 24 hour shift from 9am Saturday 21 to 9am Sunday 22 October 2017. In that role he had two interactions relating to Gaia’s care, the first a phonecall from Simon Robinson, from the psychiatry liaison team on Saturday morning. The second, later in the early hours of Sunday morning where Dr Jeffery was one of two Section 12 doctors, the other being Dr Chamath Rampathirana, who alongside AMHP Ian Loomes, performed the Mental Health Act Assessment.

Simon Robinson phoned Dr Jeffery at 11:27 to advise him that he’d called for a Mental Health Act Assessment for Gaia, and to seek advice on how to manage her. Dr Jeffery described taking the call in his living room and logging onto his computer in real time and flicking through the relevant parts of Gaia’s history. He didn’t recall Mr Robinson saying that he’d had difficulty establishing a rapport with Gaia, but he did give him advice on “contextual management and the medicolegal framework” and the powers he could use under the Mental Capacity Act to consider administering intramuscular lorazepam as a rapid tranquiliser to settle Gaia if required.

Counsel for the inquest, Ms Clarke, took Dr Jeffery through what records he’d reviewed relating to Gaia (the Rio notes prior to his arrival on Ansty Ward, and then a pack of notes on the ward). He recapped Gaia’s history as he understood it and when asked why there was such a delay in the Mental Health Act Assessment taking place, we heard Mr Robinson requested at 11:27 but it wasn’t until the early hours of the following morning that it took place, he responded:

“my recollection was delay in sourcing the AMHP [Approved Mental Health Professional]… common reasons is availability of the second Section 12 doctor, or workload of any member of the team”.

The working diagnosis was postictal confusion, when asked by Ms Clarke, counsel for the inquest whether he considered Gaia was in fact presenting with postictal psychosis his response was:

PJ: absolutely, postictal symptoms any…. manifestation of behaviour could imagine, that was certainly a very high differential for me, supported by presentation before [in Feb 2017] which spontaneously resolved, around about 24hrs of marked behavioural change, leading to admission, after one or two doses of medications and period of sleep got almost complete resolution, sustained for remaining 8 days of that admission, more consistent with postictal psychosis and confusion than serious mental illness.

SC: Do you use postictal confusion and psychosis interchangeably?

PJ: I’d say catch all postictal syndrome… all.

When pressed by Ms Clarke to pick one or the other he said even though when he met Gaia there was no evidence of psychosis, from the description given he’d have chosen postictal psychosis.

He told the jury his overarching impression was:

“undeniably there had been an episode where Gaia was distressed and distraught coming into hospital. She decompensated in a car in Brockenhurst, changed in presentation, become erratic in the car… something happened”.

He cautioned against terminology used by his colleagues in the Emergency Department stating:

“terminology is often used loosely and inappropriately by non-trained psychiatric professionals… misuse of precise language”.

There is something a little ironic here. Dr Jeffery is complaining about colleagues in general medicine inappropriately using terms such as mania and psychotic, misappropriately using specific psychiatric terms; while seemingly himself misappropriating terms relating to epilepsy.

Dr Jeffery referred to postictal syndrome, and he later referenced’ postictal phenomena’, when Professor Walker, the neurologist the court heard from earlier in the week, was very explicit that there is a difference between postictal confusion which usually resolves in about 20mins, and postictal psychosis which is a different state.

Leaves me wondering if the psychiatrists are using terminology loosely and inappropriately.

Dr Jeffery impression of Gaia from reading the notes was that she was a:

“young girl traumatised… having her liberty thwarted… even before having seen Gaia I was compelled towards believing it was something that had happened, that had maybe abated”

He continued to say that he was looking forward to the assessment:

“Went thinking a very, very interesting case, wonder what is going on, this is what we come to work for, to help people and bring understanding to complexity”.

He recalled being quite surprised when he then met Gaia as she was able to have a “very coherent and cogent conversation” with him. The court were told in Mrs Emeny Senior’s evidence that following her conversation with Gaia early on the Saturday evening, Gaia agreed to take diazepam, she hadn’t wanted to but felt it was a better alternative than admission to St Ann’s. Dr Jeffery considered Gaia was quite settled after that, which he felt was in keeping with her admission earlier in the year.

Ms Clarke did suggest that it didn’t look quite as one way as suggested, highlighting a number of later entries in the nursing records where Gaia was aggressive towards nurses, very distressed and wanting to go home. Dr Jeffery responded that this “piqued his interest” but he felt that there was always cause and effect, such as being given medication that you didn’t want to take, or not being able to leave.

Dr Jeffery was asked again to explain the 15 hour delay between the request for a Mental Health Act Assessment and one taking place, and he again described “rate limiting factors” such as staff availability and he conceded it was “not ideal” to conduct an assessment in the middle of the night, continuing:

“Any assessments that don’t get done when there is availability get pushed through to the next day and then succumb to demands, so there is a culture to get done as soon as possible, despite being disadvantage of doing at 3am”.

I’m honestly not sure how this can be in keeping with one of the guiding principles of the act ‘respect and dignity’ when acknowledged that this is about staff availability and not for the best interest of the person. Similarly the assessment team were aware that Gaia suffered from PTSD due to a sexual assault, but they still felt it was appropriate for three men to assess her at 02:42 because they lowered their voices, tried to appear non-threatening and asked a female nurse to chaperone. Not sure how comfortably that fits with respect and dignity either.

In fact when his evidence was recapped by the Senior Coroner, Dr Jeffery went further and said:

Coroner: you’ve already confirmed you didn’t know if she’d had sleep. Were you aware there was concern she needed sleep and a period of rest?

PJ: Yes, she looked tired and the nursing notes said she’d had a busy 24h hours

Coroner: did you consider a deferral?

PJ: No

Coroner: did you not consider it at all, or did you consider it and decide not to defer?

PJ: No, I considered we needed to do it, it’s part of clearing the decks… had an opportunity to do the assessment and took it.

The following day Dr Jeffery did acknowledge the “flippancy of his language” and stated he regretted that. He had a number of other regrets, two in the first instance, and a third identified on questioning.

When Ms Clarke was discussing his discharge plan with him, after it was agreed that Gaia did not warrant detention under the Mental Health Act, he stated that he had an opportunity to signpost Gaia to the recovery centre. When she pointed out that did not happen he responded:

“No, I’ve two regrets, one I didn’t discuss with her Uncle insights through day, would have been incredibly valuable for me to have that conversation. Think there was also opportunity to refer back to Steps to Wellbeing, that didn’t happen, that was an omission”.

Incidentally the court also heard from Dr Kannan earlier in the week, who also failed to make a promised referral to Steps to Wellbeing for Gaia in December 2016, despite his letter to her GP (that was copied to her) stating he would do so.

Here we had confirmation that again an opportunity was missed to refer her to the service in October 2017. Although Mr Spencer, representing the healthcare trusts asked Dr Jeffery about waiting lists for that service at the time and established:

Had you properly referred Gaia to Steps to Wellbeing, she wouldn’t have received the treatment sadly before she was found.

This is such a distasteful line or argument when colleagues of his failed to make the earlier referral too, which would have allowed Gaia to be assessed almost a year earlier.

When Ms Clarke asked Dr Jeffery what the missed opportunities in Gaia’s care were from his involvement he responded:

“I could have established a link to Steps to Wellbeing to engage in trauma focused work, could have contacted neurologist and could have added real value from talking to the Uncle and contextualising”.

That third regret is key, Dr Jeffery concluded that Gaia’s presentation was as a result of postictal symptoms/syndrome/phenomena, meaning that they were a symptom as a result of her epilepsy, and therefore was an issue for neurology.

However, Dr Jeffery made no contact with neurology. He also confirmed to the Coroner that he’d made no contact with Gaia’s GP and there was no system in place for psychiatric teams to provide information to GPs:

Coroner: another missed opportunity to inform the GP then.

PJ: yes, the global ambition to improve communication but logistically it’s very, very challenging to do so.

Later the court heard evidence from Dr Chamath Rampathirana, the other Section 12 doctor and Ian Lummes, the AMHP, who were both also involved in Gaia’s Mental Health Act Assessment.

Mr Lummes, who now works for Oldham MBC, had given two statements to the court. When he gave his first statement in February 2021, he didn’t have access to any of the Dorset records.

He recalled at that time:

IL: I genuinely believed we all felt Gaia had capacity. Dr Jeffery said he was going to write to the epilepsy service as part of the process of him being duty psychiatrist.

SC: That’s what you thought happened when you wrote your fist statement, when you didn’t have any access to this report?

IL: Yes

SC: When you did have access to this report did that cause you to revise your view of what was said?

IL: I cast doubt on my view of February 2021 because I hadn’t written it down. In my mind I thought we’d discussed it but it’s an odd one. She was capacitous but appeared to be engaging in a behaviour where she was slipping through the net.

SC: So you wrote what you thought you remembered when you wrote your first statement. Then you saw your AMHP report and couldn’t see any reference to you having written that down?

IL: That’s right

SC: Is your position you can’t remember what was said or not?

IL: In my second statement I made reference to it by saying I hope I haven’t fudged it, it wasn’t to protect anyone, I wrote about referral to GP…

SC: You can’t guarantee what was actually said, was that the position?

IL: Yes.

On questioning from Sophy Miles for Gaia’s maternal family Mr Lummes conceded there were a number of errors in the record keeping he did conduct.

Mr Lummes had recorded that Gaia’s epilepsy was controlled by medication but accepted that was incorrect. He also made reference to historic self-harm but the court had no evidence from any witnesses of that elsewhere and Ms Miles suggested it was inaccurate.

Finally, Ms Miles pointed out that Mr Lummes had recorded Gaia didn’t take her anti-epileptic medication but she suggested that was a discussion about Gaia not wanting to take diazepam. Mr Lummes responded that he was “quite strong on this point” because he wrote it down. He conceded if no other witness had said it, and there was no record of Gaia saying it, it may have been erroneous.

At the end of Day 7 I can’t help feeling many of the witnesses didn’t really see Gaia as fully human. So many assumptions, omissions and regrets, and so much apathy.  

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