Sally Lewis Inquest: Day 1

Five and a half years after she died, the final inquest into the death of Sally Lewis got underway today at the Worcestershire Coroner’s Court in Stourport on Severn. David Reid, the Senior Coroner for Worcestershire, was sitting and there were six interested person’s legally represented in court. I was attending remotely via MS Teams.

A family group have their photo taken at a party. A woman with learning disabilities looks off to her left, she has party popper in her hair. Next to her a woman with shoulder length blonde hair smiles at the camera. Two younger people, are also huddled into the photo, a female leans in next to the two women, and a young man stands behind them with his hands resting on the shoulders of the outer women.

Sally’s family, who are still crowdfunding to pay their anticipated £24-30k legal bill, were represented by Mr Stephen Clarke of Garden Court Chambers. Dimensions who were Sally’s care provider were due to be represented by Mr Craig Hassall KC, but due to time slippage and a judge falling ill in another case he is defending he was unable to make it to court today so Mr Matthew Breakell took his place with the expectation that Mr Hassall would make it later in the case. Mr Dominic Kay KC represents the registered manager, Julie Campbell, Mr Cox represented Worcestershire County Council, Ms Wilks the Care Quality Commission and Mr Mumford represented Dr Williamson, Sally’s GP.

Mr Reid started by indicating to the court that he would be calling Susan Wall from the CQC next week, not to give evidence directly in relation to Sally’s death but to “find out a bit more about the timings of the CQC’s investigation” and to “see how much they were aware of the effect that their decisions may have had on the timing of this inquest”. He then checked with Mr Breakell that the bowel records in the bundle were all that was available, asking if there were any more records. Mr Breakell told the court that as far as he was aware everything had been served, and he explained at the time of Sally’s death Dimensions were moving to a system of electronic records.

C: So there would have been entries made electronically and then produced?

MB: Yes

C: So can I take it as far as we know, when the report says created between 1 January and 31 December 2017, these are all entries made in relation to recording of bowel movements over that period?

MB: Electronically, if there were any paper records they would be included in the paperwork

A discussion then followed about the make up of the bundles and the pagination of them. This was followed by discussion of some timetabling matters before the coroner started the evidence by reading the statement of Francesca Finesso onto the record.

Francesca Finesso

Ms Finesso was a Support Worker at Dimensions until May 2017. She told the court that she met Sally before she moved into The Dock as she was based at Stourbridge Road, but she moved to The Dock, with two other people shortly after. She said that during the day there were usually two staff members on shift supporting the three residents, and one to one care was only provided if a resident was taken out, or at mealtimes. One member of staff would stay over in a sleep in role overnight.

Ms Finesso described Sally as having “some behavioural difficulties” and “not able to have a full conversation”, adding that she “would ask for a cup of tea but she was largely non verbal”.

In relation to her constipation Ms Finesso in her statement for the court said that:

Sally could become very agitated if she needed to go to the toilet too and did have some issues with her bowels. If Sally did need to go to the toilet she could start shouting and frantically moving her hands; she would also sometimes grab objects and throw them.

Ms Finesso added that this could also happen at bath time or when Sally was changed into her pyjamas. She went on to tell the court a little about Sally’s toileting habits.

Sally didn’t have regular bowel movements, she preferred to go to the toilet during the night so I would always check with the member of staff who had done the sleep-in whether Sally had been to the toilet overnight or not and if she hadn’t then I would administer her with a Laxido before she went to bed to help her with her bowel movements. As she preferred to go to the toilet during the night it could be difficult to know whether she had had a bowel movement. I don’t believe Sally was prescribed any medication to assist her with her bowel movements, though I have not had sight of the MAR Charts recently, and I recall she was given the Laxido as and when it was required. She was also sometimes given Senna if she needed that as well.

She finished her statement by saying she never had any concerns over Sally’s health and that the colleagues she worked with at Dimensions “genuinely cared about the people they were supporting” so she expected if there had been any concerns someone would have raised them. She wasn’t working at Dimensions at the time of Sally’s death and she told the court she couldn’t comment on Sally’s health in the lead up to her death.

Next the coroner called Callan Glassey. It was at this point it became clear how difficult the sound was to hear on Teams. I’m usually fairly adept at deciphering speech at low volume but I found today incredibly patchy. The first witness was difficult to hear, the second almost impossible at times, the third was very clear and audible. Luckily the coroner was in the habit of checking witnesses answers with them, so I’ll report based a lot on that, and direct quotes will be thin on the ground.

Callan Glassey

Mr Glassey works as a Support Worker at Dimensions and had done for a number of years before Sally Lewis died. He told the court that he’d first worked in a service in Redditch before transferring to Stourbridge Road for a couple of years, before moving to The Dock as part of the support team when Sally and the other residents moved in there. In response to a question from the coroner asking if he was ever Sally’s keyworker, he told the court that “at one point I think I was” but he couldn’t remember precisely, he thought it might be when they moved to The Dock.

When the coroner asked him what he knew about Sally’s issues with constipation and bowel movements, he said that he’d been told that Sally suffered with constipation and was on medication. He said it was hard to know if Sally had had a bowel movement because Sally was someone who was able to goto the toilet by herself. The coroner asked Mr Glassey if there was a plan in place to try and monitor Sally’s bowel movements, he first answered what he tended to do with regards to supporting Sally to use the toilet, when the coroner asked again, he responded with what people recorded. On the third time of asking he responded that he believed there was a management plan and medication.

The coroner asked Mr Glassey about the medication Sally was on for her constipation. He told the court that he thought Laxido was her PRN medication in a powder form. When the coroner asked him if he remembered administering Sally with daily constipation medication he said yes and he thought that it was Senna.

The coroner then asked a number of questions to try to ascertain how staff knew when to give Sally PRN medication for her constipation. Asked by the coroner how long staff would leave it before giving Sally that dose of Laxido, ‘a few hours, a few days, what would it be?’ Mr Glassey said that he believed “it was if she hasn’t been for a day or two, after she’s having the Senna, if that’s not done anything, or nothing’s happened, a day or two”. He gave a fuller answer which I couldn’t hear.

The coroner asked if there was anything about Sally’s behaviour that might make staff think she was constipated and Mr Glassey said he didn’t personally think so. He told the court that Sally “ate and drank fine” and was “still going out on activities”. He said that Sally was non verbal and she couldn’t communicate, but there were “no tell tale signs”. The coroner then asked if there were no tell tale signs that Sally was in discomfort from constipation, what would he look out for and Mr Glassey responded if she was “off her food or really bloated, if she stopped eating or was struggling to walk”.

The coroner then took Mr Glassey to records in the bundle, focusing on Sally’s health action plan document.

C: Is that a document you recognise?

CG: Yes

C: So you’re familiar with that document? Can I ask you then about that particular page, about my health. It says I need help with my bowel function, yes I take Laxido daily, were you aware of that?

CG: Not when I worked there… was the Senna I believe, unless that was changed, I don’t know. When I worked there it was PRN.

The coroner took Mr Glassey to the start of the document where it was dated as updated on 5 June 2015 by Sonia Parchment. He pointed out to the witness that this document, from two years before Sally’s death, said that she required Laxido daily. Mr Glassey said that he only remembered it as PRN.

The coroner then moved to another document, Constipation and Bowel Health Management Plan – A Guide which he said he wouldn’t go through in great detail, but he asked Mr Glassey if he was familiar with it, to which he responded that he’d have read it at the time when he first started working for Dimensions.

C: Last three lines, This guide is to help you to think about all of the things that should be taken into consideration when compiling an effective Bowel Management Plan for someone you support, who is at risk of constipation. Did you ever help compile a bowel management plan for Sally?

CG: No

C: Did you ever read, or see, a bowel management plan for Sally?

CG: If it was in her folder then yes

C: Looking back now do you remember, was there such a plan in place for Sally?

CG: I can’t remember [can’t hear] if it was in there I’d have read it.

C: But you can’t specifically remember whether there was one of those?

CG: If it was in her support plan I’d have read it.

The coroner then took Mr Glassey to a copy of the Bristol Stool Chart and asked him if a person was passing Type 1 stools what he would think about that, and what if anything he’d do? He said that it could mean anything really, that she needed to drink more.

C: This document is prepared for a purpose isn’t it. What I’m wondering is as a Support Worker, were you actively looking to see what type of stools one of the people you were supported was passing?

CG: Yes

C: You were, ok. So if somebody was passing Type 1 stools, hard, lumps described in the document here like nuts and in brackets, (hard to pass) what might you think that means? Would it make you do anything? Take any action?

CG: [can’t hear start of answer] drink more water, change diet, yeh

C: What if anything would you as a Support Worker who noticed that do?

CG: Ensure they’re drinking more water and managing what they’re eating [fuller answer, can’t hear]

The coroner then asked a couple of questions about medication and its role in management of constipation before asking Mr Glassey if he’d note down anywhere that a person he was looking after was passing stools of this type. He responded “not specifically no” before adding that it would be noted in her daily notes that it had been hard for Sally to pass stools today.

The coroner asked more about what would happen if Sally was having continuing difficulty and passing Type 1 stools and Mr Glassey said he’d note that down in the daily notes. Asked what would happen and how he’d escalate things, if it was continuing after a few days, despite Sally being encouraged to take more fluids and eat an appropriate diet, Mr Glassey said that he’d make contact with the GP to get permission to give her more medication. He said he would speak to the manager first.

The coroner then took Mr Glassey to another record and asked if he recognised the monthly charts where the size and nature of stool passed was meant to be recorded. He said he did recognise them, and that there was a new system at the time. In response to a question from the coroner of whether there was anyone at The Dock who required a note taken every time their bowel movement was witnessed Mr Glassey responded that he “wouldn’t say it was a requirement to document it, we just did it anyway, it wasn’t assessed or anything”.

C: There’s a clear difference isn’t there between doing all you can to monitor and make note of a resident’s bowel movement, and sometime if you happen to be around when someone went to the toilet that you’d try and get in there and take a note. What was going on when Sally was at The Dock, was it if you’re around and witness something might make a note? You wouldn’t do your upmost to record every bowel movement a resident like Sally had?

CG: No, you’d support Sally to the toilet, if noted would be documented… [cant hear fuller answer]. Throughout the night, half the time you wouldn’t even notice, you’d get woken up by the flush of the toilet, so hard to know exactly what she did, what size it was.

The coroner then took Mr Glassey to another document, Constipation Screening and Referral Tool, and asked him if he it was something they were using at the time he was looking after Sally. He responded that it was and gave a fuller answer that I couldn’t hear. The coroner checked that if it were in use at the time, Mr Glassey would have read it and been using it, but he couldn’t actually remember whether it was in use or not at the time. Mr Glassey told the court that it would have come from Sally’s health plan.

The coroner checked his understanding that this tool had been introduced after Sally’s death with Mr Breakell.

C: We don’t have one for Sally. Are you able to assist whether this was in place at the time of Sally’s death or since?

MB: It was a system in place at the time

It was then for Mr Clarke, for Sally’s family to ask questions. The sound became even more difficult at this stage. Mr Glassey said he’d had no specific constipation training but had read up on it. There were a number of questions and answers I couldn’t hear and then Mr Clarke asked Mr Glassey if he was aware that someone who was constipated, with an impacted bowel, may still be going to the toilet, he wasn’t. Asked what he understood the risks of constipation to be, and what he was aware of at the time, he told the court “obviously if she’s constipated, risks are can cause death or issues with health”. Mr Clarke asked if he was aware of sepsis, whether his attention had been drawn to that at the time, he said no.

Mr Clarke then took Mr Glassey to records in the bundle and asked him a number of questions which I didn’t catch. In response to Mr Clarke’s question Mr Glassey told the court that he didn’t know the telltale signs of sepsis. The coroner asked him if he was aware that a bowel blockage from constipation could eventually lead to sepsis and he replied “not 100 per cent, no”.

Mr Clarke then asked further questions about sepsis and its relationship to constipation.

SC: Would it be fair to say if you had read this document in detail you would know about the connection between constipation and sepsis?

CG: If she was constipated and was long term effects

SC: I’m asking about your awareness and knowledge

CG: If I was aware she had all the signs of sepsis would be followed up on

SC: Mr Glassey, you said to the learned coroner you didn’t know the connection between constipation and sepsis … at the time of Sally’s death you could not have known?

CG: I probably did, I must have read it. It’s that long ago now I cant think back to what I read or hadn’t read… as stands now I cant remember anything

C: Can I just ask, you told me a moment ago I didn’t know severe constipation could lead to sepsis, is that the case before you read this document today? You didn’t realise severe constipation could lead to sepsis?

CG: At the time

C: No not at the time, before you read this document today, did you know severe constipation could lead to sepsis?

CG: Yes

C: How long have you known that do you think?

[I couldn’t hear his reply]

Mr Clarke then took Mr Glassey to records in the bundle and asked him why of all the risk assessments they’ve been provided Mr Glassey’s signature and date was only on one of them [having checked that all team members should sign and date to say they’ve read it]. Mr Glassey said “what was in her folders at the time I’d have read”. Mr Breakell interjected to say that these documents have been printed off the system, and they were not originals. The coroner asked where the original ones are but I didn’t hear his answer.

In response to a question from Mr Clarke, Mr Glassey said he’d never received any supervision or feedback about his record keeping. He said that he couldn’t tell the court whether there had been any spot checks of quality control while they moved to the new electronic system, that he didn’t believe Ms Campbell or anyone else had ever spoken to him about the quality of his record keeping or documentation.

Mr Clarke’s then asked Mr Glassey whether there had ever been an attempt to note down and identify what Sally’s individual behaviours were and meant. He responded “me personally, I couldn’t really tell you”, he gave a fuller answer which I couldn’t hear before adding “anything could trigger her at the time”.

The coroner then asked Mr Glassey where he’d record that he didn’t know if Sally had passed a stool and he said he wouldn’t. He said in handovers he’d handover and say they didn’t know if Sally had been. Mr Clarke then asked Mr Glassey a series of questions about the administration of Laxido, I couldn’t hear his answers but can report that Mr Clarke asked about a batch number for Laxido that related to July 2017 and that it “appears there was no Laxido administered from this batch”. Mr Clarke asked whether Mr Glassey recalled giving Sally Laxido in the last three months of her life, and whether he recalled administering it.

SC: This batch, 20 August 2017 is only administered very rarely on a handful of occasions, am I right?

CG: Yeh

SC: Would it be right to say the position is Sally was receiving Laxido only very rarely, rather than on a regular basis?

CG: Laxido was as and when required, that must have been bowel movements documented then

Asked if he was aware of any guidance from the GP as to how often Sally should be opening her bowels he said “I’d have thought so yeh, not personally to me”

SC: Were you aware the advice from the GP was Laxido was to be given to achieve one stool per day, soft?

CG: My understanding is if hasn’t been for a certain time, she has that to achieve a stool, yeh.

The coroner then wanted to check his understanding of something with Mr Glassey.

C: Thank you, could I ask you in that folder, just turn to tab 5 please, page 401. Are these what you’ve referred to as the daily notes?

CG: [can’t hear]

C: Yeh, so when you say we would record for example if Sally hadn’t had a bowel movement during the time that I was looking after her, I would record in the daily notes, ‘no bowel movement’ yes?

CG: Yes

C: Just page 401 are those your initials?

CG: Yes

C: Is that your writing?

CG: Yes

C: So we can see at the top, you appear to have taken over 9 in the morning? 19 May, you started 9 in the morning?

CG: Yes

C: Page 401 ends 8 in the evening doesn’t it?

CG: Yes

C: If we look over the page we’ve still got your initials until following morning, you were on overnight as well was it?

CG: Yes

C: So just have a read through all your entries there to yourself for a moment, [paused] there’s nothing there about bowel movement or no bowel movement is there?

Just as another example can we turn forward to page 422, this is 29 May 2016, can see your initials from 3:30 in the afternoon, going through to around 09:30 the following morning, is that right?

CG: Yes

C: Just read through those again if you would. Nothing in there to assist with whether Sally was having a bowel movement or not was there?

CG: Not on that particular day no [fuller answer – couldn’t hear but he says he was recording electronically as well]

C: Let’s take a more recent example, bundle 3 please, page 2394 behind tab N

To put this in context ok, these are the daily notes I think for June 2017, so this is 4 months or so before Sally died. So we can see on the 6 June those are your initials there are they?

CG: Yes

C: So we can see what you’ve written in there. Do you agree that there’s nothing there for that whole day, morning until bedtime, no mention of Sally’s bowel movements there?

CG: Not there no

C: So if was to suggest to you perhaps bowel movements weren’t something you were putting into Sally’s daily notes, bowel movements or lack of bowel movement, was not something you were putting into Sally’s notes, would you agree with that?

CG: No

C: You wouldn’t. So these just happen to be an example where I found you haven’t but you’d say you normally did?

CG: Would be verbal [fuller answer – couldn’t hear]

C: Mr Glassey if we take this example I’ve just shown you, is a whole day isn’t it?

CG: Yes

C: And no mention of whether Sally has passed any bowel movement or not

CG: Yes, on this piece of paper

C: How is anyone going to be able to effectively keep a record of how regularly Sally is passing stools?

CG: Would be verbal

C: Why would you do it verbally and not document it anywhere?

CG: Was the way at the time

C: So would your attitude be, fine to hand it over verbally, they can make a note of it instead?

CG: Would be handover sheets in the morning, today’s tasks, it would be on there

When the coroner checked his understanding and asked Mr Glassey if he’d not thought to document it in Sally’s records, he said that was how he was told it was done “that’s how information was passed to each other”.

There were no questions for Mr Glassey from counsel for Julie Campbell, the County Council, the CQC or Dr Williamson. Mr Breakell for Dimensions confirmed that Mr Glassey was medications trained, and that any ‘medical conditions’ he’d take to the GP.

MB: In terms of MAR charts is it fair to say they’d be your point of reference for medication required at that point in time?

CG: Yes

MB: So when it comes to medication, you weren’t necessarily be looking at support plans, but MAR charts, prepared by a GP surgery?

CG: Yes

Mr Breakell checked Mr Glassey’s understanding of when PRN constipation medication was required for Sally.

MB: When you talk as and when required, understand on your evidence when Sally hadn’t been for two or three days, then it was required?

CG: Yes

MB: You understood she was still having a daily medication for constipation?

CG: Yes

MB: In terms of Sally’s bowel movements, I think it’s right isn’t it from what you’ve said, Sally was able to go to the toilet by herself?

CG: Yes

MB: And if she’d been to the toilet by herself during the night, would you be able to identify what sort of bowel movement she had had if she flushed?

CG: No

MB: How would you have documented if you had?

CG: Literally would have been, Sally been to the toilet, not witnessed, then case of [can’t hear] you’ve not actually witnessed the bowel movement itself

MB: How was Sally in terms of her behaviour when she went to the toilet?

CG: A lot better if she took herself. If she was taken she could get agitated and upset, seemed to be a trigger for her, don’t know about past or whatever used to upset her if took her, but when she took herself was a lot more calmer.

MB: and in terms of her support, your role was to support her to be as independent as possible wasn’t it?

CG: Yes

MB: Balancing that against her safety?

CG: Yes

MB: And being mindful of her dignity and privacy?

CG: Yes

MB: In terms of the documentation, appreciate it’s been some time since this incident took place and Sally sadly passed away. When you say things have changed, haven’t it in terms of documenting?

CG: Yes

MB: And more information available to Support Workers for areas such as bowel movements being documented is that right?

CG: Yes

MB: It may assist the coroner I think that. The organisation things have changed, is it fair to say your memory of time, was generally oral in terms of discussing Sally’s bowel movements, rather than documenting it?

CG: At the time yes

MB: Bit now you’re saying?

CG: Yeh a lot more, paper based

MB: Nothing further for me.

The coroner thanked Mr Glassey and told him he was free to stay or leave as he wished, it was a matter for him. The coroner then said he’d read or summarise three more statements.

Anne Venn

She told the court in her statement that she was previously employed by Dimensions for approximately 12 years, leaving in September 2018. She had the equivalent to an NVQ Level 3 and was given training when she first started working at Dimensions, including medication administration training. She had worked at Stourbridge Road and The Dock supporting Sally and the two other residents and she told the court that she got to know all three of them very well.

She usually worked 28 hours a week but reduced her hours to 21 a week at some point, she couldn’t remember when. She would usually work day shift and once a week she’d do a sleep in, usually on a Friday night.

She told the court that Sally “had quite complex needs and could, on occasion, be challenging to support. She had autistic tendencies and could become very frustrated at times. It could be difficult to know what she had become frustrated about as although Sally could talk, it was usually only certain words or phrases she would use rather than full sentences”.

She said she had no concerns over Sally’s physical health and she was generally quite active.

I know that Sally struggled with constipation and that this had been ongoing for a number of years, certainly since I had known her Sally didn’t always like to sit on the toilet and could get quite distressed about it, which would cause her to be unable to have a bowel movement. In order to assist with her bowel movements Sally was prescribed a number of medications for various issues but for her bowels she was prescribed Bisacodyl, Senna and Laxido. Bisacodyl was given to Sally every night and the Laxido had been prescribed to be given as and when it was needed. Laxido would usually be given to her if she hadn’t had a bowel movement for a couple of days. Senna was introduced later although I can’t remember when but I believe it was due to the Laxido causing her bowel movements to become very loose however Laxido would still be used if she became or appeared to become very constipated.

She said that Sally’s medications were administered in keeping with the MAR charts kept in a folder in her bedroom. She said that Sally usually had a bowel movement twice a week “which was normal for her”. She said they were consequently quite large, or could be a significant amount.

If there was anything unusual about her bowel movements then this would have been recorded in her daily notes. Sally was able, and did, take herself to the toilet when she needed to, sometimes she would require support but usually she would stand up and say ‘toilet’ when she needed to go. We would wait outside the toilet for her to finish to make sure that she had washed her hands and was clean afterwards. She would also go to the toilet in the night so it could be hard at times to know whether she had had a bowel movement. If I had had any concerns over her bowel movements or lack thereof I would always mention it to the next staff member coming on shift and ask them to monitor Sally.

Anne Venn finished her statement by saying that she was on annual leave the week Sally passed away and she had seen her when she was in the park with her children. She also said she did remember she had seen Sally the week before she died “and I do remember that she had been quite agitated when sitting on the toilet, which is something I had mentioned to one of the other staff members but there was nothing unusual about her behaviour or how she was presenting“.

Susan Allen

She told the court in her statement, read by the coroner, that she was previously employed by Dimensions as a Support Worker. She was off due to ill health during her pregnancy from October 2017 and resigned in April 2019. She had worked with Sally at The Dock for just under a year. She said during her time at The Dock she “got to know Sally quite well”. Adding that she had “communication issues and was largely non verbal” and that she “also had certain mental health conditions, along with some bowel issues”.

Sally could sometimes struggle to go to the toilet and wasn’t always very regular in her bowel movements. It was also sometimes difficult to know whether Sally had had a bowel movement because she was capable of going to the toilet herself. She would stand up and say ‘toilet’ and take herself, and would go during the night. I personally never had any concerns over Sally’s abilities to go to the toilet. I knew that she could sometimes have trouble going to the toilet and in order to help with her bowel movements Sally would take Senokot two or three times a week and also had a sachet, which I think was Laxido but I believe that was only administered as and when it was required.

Ms Allen ends her statement by saying that:

Sally could be difficult at times but she was such a nice lady to have supported. Sally never appeared to be unwell during the time I worked at The Dock.

She said that she was off sick when Sally died and she was “very shocked” to hear that she’d passed away.

Elaine Robinson

She told the court in her statement that she’d previously worked for Dimensions for around 13 years supporting a gentleman as ‘enabler support’. She also did some bank work for them at Stourbridge Road and The Dock. She had an NVQ Level 3 in Health and Social Care. She told the court that although her hours showed she worked at The Dock for over 100 hours she “probably only supported Sally Lewis once, maybe in the bath”. She said due to Sally’s “erratic behaviours” it was felt those more familiar with Sally should support her and she supported the other two residents, whilst still interacting with Sally. She told the court she’d make her cups of tea and toast.

She’d witness Sally being given her medication and countersign the charts. She told the court she’d read Sally’s support plan in the past, and she was aware that she was on laxative medication but she couldn’t recall the name of it now.

I was also aware that Sally could become constipated and have very large bowel movements, some of which could block the toilet. I did not support Sally in the toilet but I would ask her if she needed to go. I was aware Sally wore pads.

Ms Robinson ends her statement by saying the last time she’d seen Sally was the weekend before her death. She said she hadn’t observed Sally’s behaviour change in any way prior to her death.

Sally’s behaviour could be erratic and aggressive. I was never sure what would set Sally off, but her behaviour included screaming, shouting and smashing and throwing things in the house.

Victoria Howe

The coroner then called Ms Howe to give evidence. I couldn’t hear any of her answers in full, just occasional snippets. I’ll report based on what I could decipher from the coroner’s questioning.

Ms Howe no longer works for Dimensions but worked for them previously. The coroner said he really wanted to focus on Sally’s particular issues with constipation. Ms Howe said that she was aware that Sally suffered from constipation and that it was discussed amongst staff. Asked by the coroner when she started working at The Dock, whether she received a briefing about Sally’s bowel issues she said she’d read her whole support plan and had to sign it.

When the coroner asked if she was aware of Sally’s bowel issues through conversation with other staff or reading documentation, Ms Howe responded through conversation.

C: Through conversation. Did you actually read anything in any documentation about Sally’s bowel issues?

VH: She had bowel movement charts [fuller answer – can’t hear]

C: Now just so I’m clear about this. Do you think that the reason you hadn’t read anything in Sally’s support plan was because you didn’t read it in full, or you did but there was nothing in there about Sally’s bowel issues?

VH: Possibly that I didn’t read it in full

The coroner then asked Ms Howe if she was aware at the time that constipation in general could be a serious issue for a resident, she shook her head but I couldn’t hear her answer. The coroner asked if she was aware it could pose a risk to someone’s health, I couldn’t hear her answer. The coroner then asked if she’d received any training from Dimensions about bowel safety and bowel issues? She said no.

The coroner then asked further questions and took Ms Howe to the bundle.

C: This is a MAR chart, a medication administration record, do you recognise the chart?

VH: Yes

C: Half way down, Laxido orange, one sachet daily when required to try and get at least one soft daily motion, ok?

VH: Yes

C: Can see Sally’s name at the top. Looks like what’s on there is that should be used to get Sally to pass one motion every day doesn’t it. Were you aware of that?

VH: [cant hear]

C: I don’t mean prescribing obviously, administering, alright. Look along from that entry there, can see there are boxes to be filled in to indicate someone has been given dose of that medication, is that right?

VH: Yes

C: We can see between 6 June 2016 and 3 July it looks like Sally may have been given Laxido on 4 different occasions. Is that how you’d interpret that chart?

VH: Yes

The coroner then took her to another record in the bundle, of the daily notes from June 2016 and asked her where she’d record bowel movements in those notes. He asked whether it was on a document specifically intended to record bowel movements or just somewhere she found was a good place to record it. She flicked through the bundle and there was some discussion before she found a document called ‘additional support records completed’ and there was a column for a bowel chart.

Ms Howe told the coroner that at the time some people were using paper records still and some were using the electronic record system.

C: Have you got Page 2684? Reason I ask is these are the daily notes on the electronic system for the last few months of Sally’s life. Did I hear you say a few moments ago bowel movements wouldn’t be recorded on here?

VH: I don’t personally remember being able to enter bowel movements on the tablet [fuller answer – can’t hear]

C: was there a reason why you wouldn’t record bowel movements on the electronic notes?

VH: [cant hear]

C: p2684, half way down and at the bottom are couple entries by you aren’t there? And backwards to 2683 another entry by you isn’t there?

VH: Yes

C: In fact if we go to 2681, back couple pages if you wouldn’t mind, entry by you near bottom page, 10 August, you’ve recorded Sally seems constipated

VH: Yes

C: Are you quite sure you weren’t recording things regularly on this system?

VH: [cant hear]

Ms Howe said that both the paper and electronic systems were used. The coroner checked that in June 2017, even though the electronic system was up and working, Ms Howe would record in the paper booklets. She said she would at the time.

Asked if she’d have taken any action on 10 August, other than recording Sally seemed constipated she told the coroner she’d have had PRN medication but only the shift leader could make a decision about giving medication.

The coroner took Ms Howe back to the MAR chart for 10 August and said that it didn’t look like anyone has administered Laxido to Sally. Ms Howe agreed.

C: Are you surprised at that? If you look at that MAR chart no one has given any Laxido at all during August. You’ve realised the issue on 10 August, Sally seems constipated, are you surprised to see that?

I couldn’t hear Ms Howe’s answer.

She said when asked by the coroner she didn’t know what had given her the impression that Sally seemed constipated, but generally if someone’s stomach was quite hard to touch at times it could be an indicator. She also told the court that Sally would sit on the toilet for a period of time, with no movement.

C: So can I take it when you entered in the notes, seems constipated, this wasn’t simply a question of Sally not having a bowel movement during your shift, went a bit further than that, her behaviour suggested to you?

VH: Was possibility, but then Sally at times did display behaviours

C: Can we put it like this, in a normal shift, if Sally hadn’t had a bowel movement, hang on, in a normal shift, if Sally hadn’t had a bowel movement, would you be recording ‘seems constipated’?

VH: No

C: So I can take it there was something else about her behaviour that led you to make that note?

VH: Yes

C: There must have been mustn’t there?

VH: Yes

C: Having noted from Sally’s behaviour she seemed constipated in your view, you’re surprised to see no one had administered any Laxido?

VH: Yes

Ms Howe confirmed that she was the person looking after Sally on 10 August, that she was able to administer Laxido to Sally and asked if there was anything stopping her giving Sally Laxido she said that she didn’t remember, possibly the timeframe.

C: You didn’t need permission from anyone else?

VH: No, but you do need two people to administer medication

C: including Laxido?

VH: Yes, that would be the only reason I can think why I didn’t administer it myself.

C: one second, last three questions before lunch. Tab number 17, you may need to go back, lots of tabs earlier on in the bundle, if you can just find tab 17. Page 2753 there have you got that?

VH: [Can’t hear]

C: Am I right in thinking this is a sheet for those occasions when somebody was working on their own at The Dock, needed to give medication and therefore couldn’t be two people to give medication? This is a way of recording that so there’s a record, is that right?

VH: Yes

C: turn page we’re interested in 10 August, page 2756, no that takes us to September, see at the top

VH: Yes

C: if you go back, entry before that is 21 June isn’t it? So, it doesn’t look like anyone has noted down they were on their own that day does it? Can I take it if you’d been on your own that day and given Laxido to Sally you’d have noted down on here you’d be on your own that day?

VH: That’s correct

C: And you’d expect anyone else on their own that day to do the same?

VH: Yes

C: So you can’t help us why Sally wasn’t given Laxido that day even though you’ve recorded she seemed constipated?

VH: No

C: You cant, OK.

At this point the coroner said court would adjourn for lunch. He gave Ms Howe a warning, asked her not to discuss the case with anyone and asked her not to have lunch with Ms Rumble, this afternoon’s witness.

After lunch the coroner said he had a few further questions for Ms Howe. He took her to a page in the bundle.

C: This I believe is a print out of the electronic bowel charts that were completed between January and the date of Sally’s death. It relates only to Sally, on this page and following page two further entries. These appear to be all the entries made in 2017 for Sally. Now we can see about 6 or 7 lines from bottom is an entry by you, is that right?

VH: [can’t hear]

C: Can I take it from the fact you’ve made an entry there that you were used, by this stage, 2 August 2017, you were used to making entries on the electronic care notes, particularly in relation to bowel movements?

VH: [Can’t hear]

C: We can see that particular entry you’ve described it as a large movement but Type 1 is that right?

VH: [can’t hear]

C: That’s ok, seems to say large movement in volume, type 1 brackets hard and lumps

VH: Yes

C: Type 1. What do you mean by that?

VH: Points for bowel movements… different diagrams for each one, would be referring to the toileting chart

C: Are you familiar with something called the Bristol Stool Chart?

VH: Yes

C: Type 1 is the hardest end of the scale, do you agree with that?

VH: Yes

C: Is the fact someone has passed a large movement of Type 1 a concern?

VH: For someone who that’s not their usual bowel movement it would be

C: So for Sally, would that be a concern?

VH: It would be a normal bowel movement for Sally

C: hard stool, the hardest grade you can categorise it?

VH: That’s what I’d find normal

C: That was normal for you?

VH: It was normal for Sally

C: Sorry, normal for you to notice, ok. I’m going to ask you to look at the Bristol Stool Chart, will ask you to keep that open and get bundle number 4 out as well please, tab no 25 please

Is that the chart you were thinking of?

VH: Yes [fuller answer – can’t hear]

C: Yes. Do you agree that when you’re monitoring bowel movements and stools that really type 4 is what you should be aiming for?

VH: [can’t hear]

C: Let’s take it to the other extreme, if it’s type 7 is that normal? What about for Sally, would type 7 be normal?

VH: [can’t hear]

C: Type 1 is described in brackets hard to pass, that would suggest this sort of bowel movement presents a difficulty for a person to pass, would you agree with that?

VH: Yes, depends on size

C: You’ve recorded in this case was a large bowel movement haven’t you?

VH: [can’t hear]

C: Have you ever received training that’s told you a person passing type 1 stools can be entirely normal, you needn’t realise as a concern at all?

VH: [can’t hear]

C: So it was your own judgement, you’d seen Sally pass stools like this before and as far as you were concerned that’s normal for her?

VH: It was normal

Mr Clarke asked the coroner if he might deal with something on the next page before the bundle was put away. He asked Ms Howe if she recognised the chart, which was used to record someone’s bowel movements. She said that she did but “for Sally I don’t recall seeing it”.

Asked by the coroner what sort of entry she’d need to have made before deciding to give Sally PRN Laxido, she said if she’d not had a bowel movement for three days. The coroner asked more questions, and then asked Ms Howe what she understood the purpose of using Laxido was for Sally.

C: Did you know for example whether Laxido is aimed at getting the bowels moving or changing the nature of the stool itself, turning from hard to soft?

VH: I wasn’t sure

The coroner then took her to another part of the bundle.

C: you’ve got bundle 3 there in front of you, do you agree therefore when you recorded that entry on that occasion, 2 August, that you didn’t give Sally any medication on that occasion?

VH: I didn’t

C: You told us earlier in your evidence that before you started using electric bowel charts you’d use a chart at the back of the daily notes and we found that chart didn’t we?

VH: Yes

C: Ok, I’m going to ask you if you wouldn’t mind Brian, folder 2 please, tab 5E, page 1144

That is an example of one of those charts that does have an entry?

VH: Yes

C: Dated 3 September 2016 and just has words very large in it, is that your writing?

VH: [Can’t hear]

C: Am I right when we talked about this before lunch this was where you recorded entries and you recorded entries about Sally’s bowel movement’s regularly?

VH: I very rarely saw Sally had a bowel movement.

C: Would it surprise you to know from June 2016 and June 2017 this is the only entry on a chart like this at the back of the daily notes that records a bowel movement?

VH: [Can’t hear]

C: Are you surprised was no entries by you over the whole year?

VH: I was only in 2 days a week, not uncommon for me not to have been on shift when she did have a bowel movement

The coroner then moved to another record which he said was the electronic chart for the whole of 2017, there were only 21 entries, of which only one was Ms Howe’s. He asked Ms Howe if that surprised her and she said she only worked 16 hours a week.

C: If we look at all those other entries, most of them made by Stephen Wedgbury, another Support Worker, they all say ‘no bowel movement’ don’t they? They nearly all record the fact there has been no bowel movement?

VH: Yes

C: Can I ask, you don’t appear to have made any entries on electronic chart or daily note charts recording is no bowel movement, can you help us with why not?

VH: I only recorded when she did have a bowel movement

The coroner asked if her training told her it was important to record when Sally didn’t have a bowel movement, but I couldn’t hear her answer. The coroner then said to Ms Howe that she’d told us she’d only give Laxido if there was no bowel movement for three days “how on earth would someone know to give someone Laxido if you weren’t recording they’d not had a bowel movement?”

I couldn’t hear Ms Howe’s answer but I believe I heard the word auditing. The coroner then asked how the key worker would know.

C: How would the key worker know? Let’s say you’re on duty and the key worker isn’t, she’s reliant on these charts isn’t she?

VH: Yes

C: How would she know Sally hasn’t had a bowel movement for 3 days if you’re not recording she hadn’t had a bowel movement?

VH: We’d assume she hadn’t had a bowel movement if it wasn’t recorded, does that make sense?

C: Not really can you explain a bit more please

VH: If she had a bowel movement should be recorded.

C: So if nothing is recorded it’s safe to assume she hasn’t had a bowel movement?

VH: If not recorded [fuller answer, cant hear]

C: If your thinking is right on that, do you agree, because there are no bowel movements recorded in the daily notes in June 2016 to end of that year, do you agree there were many occasions when Laxido should have been administered and wasn’t?

VH: Yes

C: Thank you those are all the questions I have. Mr Clarke any questions?

Mr Clarke asked Ms Howe a series of questions, asked first if she recognised a document she said that she didn’t remember. Asked if she was aware of a link between sepsis and an impacted bowel prior to Sally’s death she said no. Shown another document she said she wasn’t aware of it at the time of Sally’s death, asked if she’d come across it since she said she no longer worked for Dimensions. She told the court she hadn’t received any training on sepsis or the warning signs of sepsis.

SC: In your statement you say, paragraph 11 that towards the end of my shift Sue Casey one of the other support workers, who had been on shift with me and was doing the sleep in that night, said that Sally wasn’t feeling very well.

Mr Clarke asked why Sue said that and Ms Howe said that Sally didn’t feel right, she was hot to touch.

SC: Was there any discussion with Sue about reference to constipation?

VH: I don’t believe we did have that discussion

SC: As far as you were aware was there any reflection on Sally’s behaviour and being hot and clammy to touch?

Ms Howe said that Sally had been hot and clammy that day.

Mr Clarke then took Ms Howe to auditing sheets in the bundle, that refer to first line manager.

SC: Is that the same as daily notes?

VH: Yeh probably the key worker would read that at end of each week, audit for each week and the manager would then audit at the end of each month, I believe

SC: In terms of this period, who was the first line manager who’d be responsible?

VH: Julie McGirr

C: She’d be auditing once a month

VH: Yes

Ms Howe couldn’t help the court with who might have been Sally’s key worker, saying that she didn’t work all the time.

SC: Was it one person who was responsible for Sally or something that changed on a week to week basis?

VH: Shouldn’t have changed, would be same person but I couldn’t tell you who

SC: If you can’t, it would appear this is completely blank, and other sheets are largely blank. Are you aware whether Julie McGirr has spoken to you having conducted a monthly audit about the records you made or fed back on it?

VH: No

SC: Was there ever concern raised by Julie McGirr about monthly logs or what was recorded?

VH: Not to my knowledge

SC: Julie Campbell and Dimensions management, ever any conversation with them about records?

VH: Couldn’t say

Asked if she could remember any quality assurance visits to The Dock during her time working there, Ms Howe responded yes. Asked if there was any feedback from those about record keeping, she said not that she could remember.

Mr Clarke for Sally’s family had no further questions. No questions from counsel for Julie Campbell, the County Council, the CQC or Dr Williamson. Mr Breakell for Dimensions asked Ms Howe to assist the court with explaining what a Support Worker role entailed. Ms Howe responded “supporting all the service users with their personal care, their activities and what’s going on”.

MB: When it came to all those activities you had to record them didn’t you?

VH: Yes

MB: In a log?

VH: Yes

MB: Various places, initially paper format?

VH: Yes

MB: And then moved to electronic?

VH: Yes

MB: It’s fair to say isn’t it, is a lot of documentation around Sally in her support plan?

VH: Yes was folders, whole range [fuller answer – can’t hear]

Mr Breakell then asked Ms Howe if Laxido was the only PRN Sally was on and she said no. He asked her if she recalled “any particular one that would be used a lot”, she didn’t. He then took her to the records and checked that we saw lorazepam, she confirmed that was the case. He said the use drops and asked if she knew why, she said she didn’t so Mr Breakall asked her if she remembered Sally going for an injection for her mental health. Asked who would decide on what medication Sally needed Ms Howe said she thought it would be a psychiatrist.

MB: So a medical professional?

VH: Yes

MB: And you’re not a medical professional?

VH: No

MB: So your role was to support Sally to be as independent as possible?

VH: Yes

MB: And they had capacity to make decisions?

VH: Yes

MB: And where possible you’d accord them with dignity and privacy?

VH: Of course

Mr Breakell suggested that staff were aware that Sally suffered from constipation “although it wasn’t necessarily documented there was a heightened awareness of it”, to which Ms Howe agreed. Asked if she remembered staff discussing concerns they had about Sally’s bowels she recalled one conversation when “Sal did have a bowel movement, was very large”.

MB: So although there were documents that could be completed, most of the time discussions about Sally’s bowels were discussions, not necessarily documented?

VH: Yes

Mr Breakell checked that Ms Howe had worked with Sally the day before she died and that she’d had a normal day with her, she confirmed that was the case.

MB: Any concerns you had throughout day or previous shifts during that period of time?

VH: When was getting Sally ready for bed she did feel very clammy to touch…. Had discussion, assumed she was coming down with the stomach bug that people living with her had, and quite a few members of staff … assumed she was coming down with it

MB: Ok think is fair to say what you said in your statement was at the end of your shift, I think, that you began to have some concerns?

VH: I’d left my shift, Sue rang me and said I don’t think Sally’s right, you need to come back

C: When was that?

VH: I’d left the building and about 2 minutes later she rang me and asked me to come back… she’d been fine when I was there, other than being clammy to touch, she’d said goodbye to me at the door like she did normally.

Asked if she’d documented any concerns during the day she said she hadn’t. Asked if there was any discussion about contacting Sally’s GP or anything like that she said “not to my knowledge”. Asked what would have caused her to call on medical help Ms Howe said something more than her just feeling clammy to the touch. She said Sally wanted her to go, because it was out of her routine for Ms Howe to have left and come back. She left the house for the second time.

Asked if she had any major concerns about Sally at that point, Ms Howe said no.

MB: Just on the point of record keeping around bowel movements, how was Sally with her toileting?

VH: I didn’t witness it very often, probably once maybe twice in the whole time I worked at that service I witnessed Sally have a bowel movement, so I can’t recall

MB: Did she prefer to go by herself?

VH: Oh yes, she was very independent, she’d take herself to the toilet. She was independent, it was only if you needed to go in there before someone else went in that you’d know what type of bowel movement she’d had

MB: In terms of Sally’s behaviour, how was that, was it a calm experience?

VH: She was in and out of the toilet a lot, she was probably agitated, I can’t really remember

MB: I mean generally

VH: [can’t hear]

C: Did I hear you say, generally Sally didn’t flush the toilet herself, someone else would have to do it?

VH: She’d flush it herself but you’d have to re-enter

C: So when you looked after Sally, and she took herself off to the loo, did you make a point of checking what stools she passed?

VH: Yes

C: You did. What sort of stools did Sally generally pass do you remember?

VH: [Can’t hear]

C: Forgive me, you said a moment ago, when Sally came out of the loo you’d go in and check?

VH: Not just me, whoever was on

C: I’m talking about you, if you were the person who was with Sally when she used the loo. Would you go into the loo after and check?

VH: Yes

C: Were there occasions where you checked and she’d passed a bowel movement?

VH: No

C: Because you only witnessed that on one occasion?

MB: It was fair to say it was a point of discussion amongst the team?

VH: Yes

Mr Breakell’s final question for Ms Howe was whether she had any concerns about Sally’s toileting when she was on shift, she responded no. The coroner thanked her and released her.

Laura Rumble

The final live witness today was Ms Rumble. She no longer worked for Dimensions, but had started working for them in September 2017, the month before Sally died. She said that she was based at The Dock and spent her first few weeks training and in the service watching. Asked by the coroner if she’d any experience in support work when she started she explained that she’d done the first two years of a nursing degree, but hadn’t completed it.

She said that she remembered Sally and that they’d met quite a few times in the time she was working at Dimensions and previously when she was a child as family members had worked for the company. The coroner asked her about the training she’d had when she started working at The Dock, specifically about constipation.

C: In the training you had to begin with, were you trained, among other things about constipation and bowel movements and the importance of checking those?

LR: There was some training with regards to bowel movement and constipation. I wouldn’t say it was as complete as I received during my nursing training, but covered the basics and how to [can’t hear]

C: Were you aware at the time of how prolonged constipation could be a serious health issue?

LR: Yes I was

C: Which in severe cases could lead to sepsis and even death?

LR: I was aware of that, yes

C: Were you given any training so far as record keeping was concerned?

LR: We were given some training with regards to record keeping, had had various discussions as well about it. The things I was used to logging as a nurse which we didn’t log in The Dock, bowel movements weren’t as closely monitored as what I was used to in a nursing setting. As a general rule observations were recorded, I had discussion with employee who explained no one in The Dock had met criteria for higher level of bowel movement supervision.

C: So your training first of all, what until you spoke to this colleague, what level of bowel movement did you think should ordinarily be carried out, what sort of monitoring?

LR: In my experience, obviously more clinical setting, every person’s bowel movements should be monitored

C: I take that to be every bowel movement where possible?

LR: Every bowel movement, every patient, if they were under observation [fuller answer – didn’t catch]

C: Can I take it you were before you started working at The Dock for Dimensions, you were experienced and used to completing bowel movement charts?

LR: Yes

C: When you spoke to this colleague who said none of the residents at The Dock met the criteria for higher monitoring of bowel movements, did they tell you what those criteria were?

LR: No they didn’t, but they did explained how they were supporting… not just medical, there was myself and another couple of Support Workers who took Sally on very long walks and ensured the diet in the house was a lot of fresh vegetables, prunes, was a more holistic approach in house of monitoring bowel movements

C: Do you remember who it was you had this conversation with?

Ms Rumble said that she didn’t remember but it was possibly Sonia or Anne.

C: Did you think you ought to know what these criteria were to carry out higher level of monitoring bowel movements?

LR: At the time I didn’t question it, was quite a lot of documents that levelled up through tiers of management. From a visual perspective it looked like it was quite well managed, the information was through in visual manner. After the time of Sally’s death I did, but at the time no I didn’t.

The coroner took her to the bundle.

C: One of the things that can be recorded on there, we can see bowel chart can’t we?

LR: Yes

C: Can I take it your impression was when you started work at The Dock, for none of the patients, Sally included, it wasn’t expected her bowel movements would be monitored?

LR: Although this page was highlighted to me when I started, it wasn’t used very often, there were some staff would make sure it was used, but bowel movements was more in verbal handover than it was in the documentation

C: As someone who’d undergone some nursing training are you familiar with the principle if it isn’t recorded it didn’t happen?

LR: Very much so

C: Were you surprised some staff filled it in and some didn’t?

LR: Yes

C: You were. Did you not raise it? I’m not sure what to do here?

LR: I know consistency of note taking depended on the Support Worker on shift… had been discussed with various staff, was being addressed on 1-1 basis to increase consistency of note keeping

C: But in these 6-8wks you knew sally did you ever fill in either a manual chart or electronic chart of Sally’s bowel movements?

LR: During that time I was still being supervised, so may have been asked to enter things but don’t think I did record documentation for anybody

C: You were being trained so you were always with another member of staff who was taking charge if you like

LR: Yes

C: So although you didn’t complete those charts yourself, did any of the people you shadowed complete manual or electronic bowel records for Sally?

Ms Rumble said one person did, Sonia Parchment

C: Did you ever ask I notice you’re doing it, I’ve been told we don’t, what should we do?

LR: I did ask

C: What did they say?

LR: She said she tried to document as much as possible, although not expected to she said to do what I was comfortable with

C: So when you raised it what you were told in effect was it’s really what you feel comfortable with, rather than this is what should be done?

LR: Yes

C: And you think you raised that with Sonia Parchment?

LR: All discussions at the start of my career were with Sonia Parchment… I trusted her opinion in that

C: Do you yourself recollect witnessing Sally have a bowel movement?

LR: I never saw Sally make a bowel movement, I was aware she had issues with constipation, one of things made aware of, make sure Sally was dinking on regular basis. Few times when had been granulated faecal matter in her pad, did not take that as signs she’d had a bowel movement because I know it’s not necessarily sign of a bowel movement

C: It can be a sign of faecal overloading can’t it?

LR: It can yes. I wasn’t at that stage trained to give medication, but I would have alerted staff to that in her pad

C: Do you remember when you passed that information onto staff what they said about it?

LR: No I don’t, sorry

Asked by the coroner if she were aware what plan was in place to assist Sally with her constipation, Ms Rumble said that she was aware Sally had daily PRN medication for stool softening and she was also very aware, she said, that would only work if her diet and fluid intake was sufficient.

Asked by the coroner if she’d ever witnessed Sally being given PRN medication for her constipation she said on one occasion she recalled her having it, but she couldn’t recall who gave it.

C: We’ve heard another witness say, the general rule of thumb operating at the time was if Sally hadn’t had a bowel movement for 3 days she should be given PRN Laxido. Was that something you were aware of?

LR: I was aware it was if she hadn’t had a bowel movement, but that conflicted with the training I’d had

C: So you’d heard should be given if she hadn’t had a bowel movement, over what period? One day?

LR: 48 hours… if she hadn’t she was to be administered PRN, I’m not aware of what PRN was at that time

C: You said conflicted with your training, what was your training on that then?

LR: Always maintain a soft stool to avoid constipation

C: You’re familiar I take it with the Bristol Stool Scale?

LR: Yes

C: Do I take it its 1-7 and 4 is the ideal?

LR: Yeh, 4 is the optimum… anything on either end, if its 1 or 7 then it’s not acceptable.

C: If it’s a 1 or a 7 what did your training tell you should be done?

LR: Seek medical attention, then they’d be given medicine prescribed, in Sally’s case she did have PRN prescribed, that was then used to bring back towards the general rule.

The coroner asked Ms Rumble if she was working on the 26 October and she said she was and her shift started at 8am. Asked if she spent the day with Sally she became upset and said she’d passed away that morning.

C: Forgive me, I thought you were on duty the day before, when she went to bed?

LR: No I wasn’t

C: So, on 27 October, you arrived with Sonia Parchment, just tell us what you remember happening when you arrived?

LR: We arrived, me and Sonia are early birds, about 10 to 8 when we arrived, Sonia went directly into house while I was faffing at the car, I was a few minutes behind. When I walked in Sonia was doing CPR on the floor in the lounge, Sue was on the phone calling an ambulance. I was asked to move another service user’s car off the drive.

C: So Sue is Sue Casey, she was on the phone for an ambulance?

LR: Yes

C: I’m not going to ask you any more details about what happened that morning

LR: Thank you

C: Given the training you had, from Dimensions, but also in the two years you did the nurses training, were you trained to look for signs of constipation in a patient?

LR: You were, I was trained to look for signs, it was a complete shock to me, Sally didn’t display any of the signs I’d have expected, when I bathed her I’d pay attention to ger stomach, whether tender around her stomach, distended stomach, any shortness of breath

C: You never noticed a distended stomach

LR: No

C: You never noticed shortness of breath?

LR: No

C: Anything else?

LR: She was eating and drinking persistently and was maintaining a very mobile lifestyle, she was still going on walks

C: Ms Rumble, thank you I think those are all the questions I need to ask you at the moment. I’ll ask Mr Clarke if he’s any questions on behalf of Sally’s family.

Mr Clarke asked about her knowledge of constipation from Dimensions training and she said the majority of her knowledge came from her nursing training, and that Dimension’s information on constipation was “half a page A4 information”.

Ms Rumble couldn’t recall who she was shadowing, she said it was different people each day. Asked about the Dimensions constipation training and whether signs of sepsis was covered in it, she said no.

No questions from counsel for Julie Campbell, the County Council, the CQC or Dr Williamson. Mr Breakell for Dimensions suggested to Ms Rumble that nursing setting is very different to supported living, which she agreed with “very much so”.

MB: When you undergo training with Dimensions, was it broad because people had variety of backgrounds and needs?

LR: Yes

MB: You mentioned shadowing, reading through documents, there was also some online training wasn’t there?

LR: There was yes

Mr Breakell then took Ms Rumble to the bundle and highlighted some aspects of documentation relating to Sally such as what was important to her was drinking at regular intervals and eating a healthy diet. He then asked Ms Rumble about Sally’s toileting preferences and she told the court “Sally was exceptionally independent”, and then asked about her understanding of Sally having frequent drinks. Mr Breakell took Ms Rumble to another couple of spots in the bundle and she confirmed she was aware of the documents.

The coroner thanked Ms Rumble and said she was free to stay or leave, as she wished.

Stephen Wedgbury

The last evidence the court heard on Day One of Sally’s inquest was a statement from Support Worker, Mr Wedgbury which the coroner read onto the record. Mr Wedgbury had been a Support Worker with Dimensions from 2003 to 2018. He was initially employed at The Dock, then moved to Stourbridge Road and then back to The Dock again. He told the court he’d usually do a sleep in once or twice a week.

I first met Sally Lewis when she moved into Stourbridge Road although I can’t recall the exact date. I knew from reading Sally’s support plan that she had complex behavioural needs.

Whenever we had a new resident we would always read their individual support plans and associated risk assessments to make sure we had a good understanding and knowledge of their particular needs.

Mr Wedgbury said that Sally was “largely non verbal”.

I was aware that Sally was prescribed bowel medication and did suffer with constipation in the past but it was not something I considered to be an issue at that time or having an impact on Sally’s health at that particular time. From what I can remember it was not the main focus of any discussions or major concerns at that time.

He said a little later on in his statement that:

We, the support staff, wouldn’t necessarily discuss Sally’s bowel issues in great detail from what I can remember. If there were any concerns they would be highlighted on the handover sheets used on a daily basis, or in Sally’s care notes /appointments with the GP. I do recall discussions when Sally had had a large bowel movement only due to the fact that they were extremely large bowel movements and staff had difficulties flushing the toilet afterwards due to the fact they were so large.

Mr Wedgbury told the court that he couldn’t remember whether there was a specific bowel chart in place for Sally but they did move from paper to electronic records. He said that he never had “any major concerns regarding Sally’s health during the time I supported her”.

He ended by saying he was on annual leave the week Sally died so he wasn’t able to comment on how she presented but when he supported her the week before there was nothing unusual in her behaviour and nothing that suggested to him that Sally was struggling with constipation. He ended his statement by saying he was very shocked when he found out Sally had died.

That was the end of the evidence for today and court was adjourned at 15:55.

[It has taken me 7 hours to write this up, longer than we were in court today, apologies for the delay].

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