HHJ Smith told the jury that there were a number of agreed facts, and that they are what they say on the tin, distilled from documents. He said that similar to the agreed statements from witnesses that were not in dispute between parties, and are just as much evidence as if a witness came along in person, so were read onto the record, this was the same in a slightly different format.

The judge told them that there were some quotes and extracts in the documents, including the various documents that Mr Knox was keen for DC Simms to agree the contents of. He said that there was no requirement for the extracts to be read out word for word because they were referenced on the record. No one disagreed.

HHJ Smith said that Mr Herrmann would read them out, not to insult the jury member’s intelligence but so that they are on the recording of this trial. He also told the jury that this was a dynamic document and by that he meant that later in the trial additional facts may be added.

The facts were organised in three sections, general matters, the defendants and the residents. I have listed all facts but have summarised some of the detail; some of the general matters relate to extracts but I’ve listed where they were sourced from.

General matters

1a the plan drawings of Whorlton Hall were agreed as a true representation of the layout of the hall, except an error on page four which should be labelled 1^st floor and not 2^nd floor

1b photographs of Whorlton Hall were taken on 14 May 2019 at 10:45am by Crime Scene Investigator Woods and agreed as a true representation of Whorlton Hall on that date

1c job descriptions published by Danshell

1d careplans, not entirety of patient careplans, which would also include observation charts and other documents relating to each patient

1e MDT refers to multi disciplinary team

1f Cygnet report on Whorlton Hall dated 25 Sept 2019 following inspection 17-19 May 2019 which gave overall rating inadequate

1g Cygnet report on Whorlton Hall dated 17 June following inspection 3-4 March 2016

1h Cygnet report on Whorlton Hall created December 2015 following inspection 4-6 August 2015

1i CQC report following inspection of Whorlton Hall in September 2017, CQC found Whorlton Hall to be in breach of health regulations and reasons are quoted within the document

1j Durham County Council Minutes – during the course of the investigation minutes obtained from meetings held by Durham County Council in which the operation of Whorlton Hall was discussed, minutes 15 June included in document

1k extract from minutes of Durham County Council meeting 4 September 2018

1l extract from minutes of Durham County Council 5 February 2019

1m Danshell’s policy on observations November 2018 published policy titled ‘Observation, safe and supportive engagement policy in England’ to be applied in all facilities managed in early 2019

The defendants

2 Peter Bennett – born in 1969, interviewed 31 May 2019 12:14-13:08, and as voluntary attender 18 February 2020 19:59–21:58, all with a solicitor present. He has no convictions, cautions, warnings or reprimands recorded against him.

3 Matthew Banner – born in 1979, staff rota provided by Cygnet reported he was on shift on 11 January 2019. Mr Banner was interviewed 24 May 2019 12:33-13:12 and again 11 February 2020 11:17-1256, all with a solicitor present. He has no convictions, cautions, warnings or reprimands recorded against him.

4 Sarah Banner – born in 1990, interviewed 24 May 2019 12:14-12:47 and 13 February 2020 10:56-12:34, all with a solicitor. She has no convictions, cautions, warnings or reprimands recorded against her.

5 Karen McGhee – born in 1968, interviewed 24 May 2019 and 25 June 2020 10:47-12:12 all with the presence of a solicitor. Ms McGhee’s employment at Whorlton Hall commenced as staff nurse on 21 November 2017. She completed probation at Whorlton Hall on 9 August 2018. Her salary was £27,248 pa and her contracted hours were 40 per week. She was promoted to Senior Staff Nurse on 14 February 2019. The court heard her training and employment history, including that between March and November 2017 she worked as a Community Nurse with Tees, Esk and Wear Valleys NHS Trust. She was awarded a BNSC Hons in Nursing Studies in 2017 from Teesside University. Further employment history was provided. Her HR records record that Ms McGhee had a diagnosis of dyslexia, and she has no prior convictions, cautions, warnings or reprimands recorded against her.

6 Ryan Fuller – born in 1995, staff rota provided by Cygnet reported he was on shift on 11 January 2019. Mr Fuller was interviewed on 24 May 2019 and 3 March 2020, and was at all times represented by a solicitor. He is of good character and has no convictions whatsoever.

7 Niall Mellor – born in 1996. He was arrested at 07:25 on 24 May 2019, interviewed that date between 11:56-13:11 and on 11 March 2020 between 10:24-13:23 and at all times he was represented by a solicitor. He has no previous convictions, cautions or reprimands. He notified CQC about a physical assault by Y, witnessed and condoned by X.

8 Darren Lawton – born in 1975. He was arrested at 08:50 on 24 May 2019, interviewed that day, and as a voluntary attendee on 28 July 2020, all times in the presence of a solicitor. For the second interview he also had an appropriate adult present. He has one conviction against him, 11 August 1998 before Grimsby and Cleethorpes Court for a minor road traffic offence, failing to stop after an accident, failure insure… no others recorded against him.

9 John Sanderson – born in 1997. He was interviewed on 6 June 2019 and 23 July 2020 in the presence of a solicitor. He started work at Whorlton Hall as a support worker on 24 June 2018. In July 2018 he was injured by a service user, fracture to right arm, returned to work 31 October 2018. On 7 December 2018, further fracture to right arm, returned to work 11 January 2019. He has no previous convictions, cautions, warnings or reprimands.

10 Sabah Mahmood – born in 1995. She was interviewed on 24 May 2019 and 24 July 2020 in the presence of her solicitor. She was employed by ByKare [sp? ByCare] Healthcare Worker Agency in March 2018 and began as agency staff at Whorlton Hall in March 2018. She was employed by Danshell at Whorlton Hall on 18 October 2018. She was employed to work 40 hours a week for a salary of £16,307. In her HR file is an induction pack and there were no completed entries against training. She has no previous convictions, cautions, warnings or reprimands.

The residents

11 Patient 1 – born in 1998. Moved to Whorlton Hall in February 2018, transferred from a residential home in Nottingham. Her placement was funded by Staffordshire and Shropshire CCG. From records provided by Cygnet she was diagnosed with schizoaffective and autistic spectrum disorder with psychotic symptoms and had a history of being physically aggressive towards others. Patient 1 may assault staff when she perceives her needs are not met. She may also remove her clothes and lift them up to expose her body. Can escalate very quickly. Staff to calm her by directing her to white noise and breathing techniques. Noted by management were increase of incidents when men on observations, was recorded ‘prefer to be supported by female staff although will accept men for short periods of time’. Patient 1 does apologise for her behaviour and has superficial understanding of the impact. Cygnet records show 50 incidents of minor violence, aggressive acts and minor self-harm between October 2017 and February 2018 causing staff to restrain her. Patient 1’s PBS plan said one thing she needs more of was handy options safe to fiddle with. She has a history of challenging behaviour since at least January 2014. She was first detained under the Mental Health Act in 2014 and has been cared for in a number of locations including hospitals, specialist inpatient settings and adolescent units. Prior to Whorlton Hall, and since September 2017, has been an increase in challenging behaviours including psychical and verbal aggression.

12 Patient 2 – born in 1969. Moved to Whorlton Hall in July 2014, funded by Darlington CCG. In records supplied by Cygnet it was recorded that she was diagnosed with autism, preoccupied with collecting magazines and CDs, and she will arrange her personal items neatly. She would often sit with head rocking back and forth, would stand up and straighten her clothes and sit back down. She has difficulties in communicating, often uses her own version of Makaton to communicate with staff. If agitated she assaults staff, causes damage and self harms by biting the back of her own hands.

13 Patient 3 – born in 1998. Moved to Whorlton Hall in April 2017 and funded by Morecambe CCG. Records supplied by Cygnet state he was diagnosed with moderate learning disability and autism. Numerous placements over the years, these had all broken down. As a result has attachment difficulties and high anxiety level on a daily basis, can lead to be violent towards staff and tearful. Moods can fluctuate rapidly, including confusion of memories.

14 Patient 4 – born in 1966. Moved to Whorlton Hall in August 2018, funded by Newcastle CCG. Cygnet records state he has a diagnosis of mild moderate intellectual disabilities and autistic spectrum disorder with OCD type traits. He was admitted to Whorlton Hall due to ongoing challenging behaviour and he has a history of making inappropriate comments towards females. He has a diagnosis of Type 2 diabetes due to his diet, which needed to be managed by the hospital. He doesn’t like to talk about diabetes, will become agitated if staff speak to him about this, all documented in his careplan. A risk screening and assessment tool completed on 5 February 2019 stated Patient 4 has a history of aggressive behaviour towards staff and had previously displayed violence towards others and caused damage to property. He has a history of banging doors, pulling heating panels from wall, throwing items over fences and has smashed several items to point needed replaced. Long standing history of agitation and aggression including assaults on staff and damage to property. One of his coping strategies noted to be low stimulus environment. In summary of presentation in recent weeks to 11 September 2018 risks included kicking, hitting, punching and biting, predominantly risk to staff, risk to property and risk of placement breakdown. In Cygnet records were 14 incidents of items being removed from his room for safety including on 5 October, 28 October and 8 November 2018. There were 14 episodes of violence from Patient 4 that led to restraint between 21 and 25 January 2019; in January there were 40 incidents, 15 of which took place in the corridors. Police examined documents between 15 December 2018 and xx February 2019 were 65 incidents of verbal or physical aggression involving Patient 4.

15 Patient 5 – born in 1985. Moved to Whorlton Hall in February 2016, funded by Durham CCG. Cygnet records recorded he has a moderate learning disability and a history of behaviours and aggression. He committed a criminal offence in 2010 which resulted in him being sectioned under the Mental Health Act. He is also diagnosed with epilepsy. Can be violent to staff and other residents. Communication difficulties and uses Makaton and gestures to communicate.

16 Patient 6 – born in 1980. Moved to Whorlton Hall in June 2016, funded by Morecambe CCG. Extract from Safe use of restrictive intervention policy was provided to police, alongside an extract from Patient 6’s health passport. He has a history of physical injury to self and others. Can be without warning, sometimes square up to staff and say ‘I’m going to get you, I can’t help myself you’re going to get it’. Patient 6 needs routine and structure; it is recognised that he will shout profanities when anxious or agitated. There are no identified triggers for Patient 6, but certain clothing can make him agitated. He is most settled when with familiar staff, when he is not tired or hungry. He often self harms, headbutts corners of walls and opens up wounds. Patient 6 was classed as the most demanding patient in the hospital, and he had his own flat monitored with CCTV 24hrs day. He had a minimum of four staff on during the daytime and two in the evening. He didn’t have free access to the hospital like other patients.

17 Patient 7 – born in 1999. Moved to Whorlton Hall in August 2017. Cygnet records show she has borderline intellectual disabilities and traits of EUPD. On 23 January and 3 February 2020 police examined material of Cygnet healthcare related to Patient 7’s careplans and PBS plans, which are at divider 4.

18 Patient 8 – born in 1963. Funded by Newcastle CCG. Records state he has bipolar disorder, moderate learning disability and frontal lobe damage from a childhood injury. Appears fine in and around the home, but can become agitated very quickly. Careplan does state he can become violent towards staff and patients.

That was the end of the case for the crown. The jury return to court on Wednesday morning.