Yesterday’s evidence was given by Support Workers at Dimensions, this morning we heard from another two Dimensions Support Workers, the first of whom was Sally’s keyworker.
Just a note on sound, the court are aware of the difficulties for those following on MS Teams, which includes Sally’s brother who lives overseas. The coroner, and counsel, have all attempted to remind witnesses to use the microphone when giving their evidence. That said even the best audio system (which this clearly isn’t) would struggle to pick up whispering witnesses. The first witness this morning was repeatedly asked to raise her voice and speak into the microphone, at times the coroner couldn’t hear her and he’s in the same room. So apologies again for partial reporting.
Ms Casey was a Support Worker at Dimensions in October 2017, at the time of Sally’s death. She said that she’d met Sally before she moved to The Dock, because she’d worked with her at Stourbridge Road. The coroner ascertained that she had been Sally’s key worker, I couldn’t hear whether this was at both locations. She said that she worked at least 37.5 hours per week at The Dock, adding “sometimes could be there for days on end” which I believe was a reference to overtime but I couldn’t hear.
Asked by the coroner whether she, as Sally’s key worker, was the member of staff who had the most contact with her, she said no. When asked who was, she told the coroner that all staff worked with all residents and she’d divide her time equally between all residents.
C: As Sally’s key worker were you familiar with her support plan?
SC: I can’t remember
C: I’m not going to ask you to remember her plan, but have a think, were you familiar with it at the time?
SC: [Can’t hear]
C: As part of the support plan am I right in thinking there was a health action plan?
[I believe she responded that she didn’t know but it was hard to hear]
C: Have a look please, bundle 1 in the box next to you… tab number 1 please. Can you see the document there, entitled ‘My Health Action plan’?
C: I’m not going to ask you to try to remember this document, but is that a document you would have been familiar with?
SC: [Can’t hear]
C: You’d probably read it?
SC: [Can’t hear]
C: Do you remember, did each of the 3 residents have their own health action plan?
SC: I would have thought so, but I don’t remember
The coroner asked Ms Casey to describe Sally’s needs to the court, I couldn’t hear her answer. She agreed that she had learning disabilities and didn’t speak in full sentences. When the coroner asked if Sally was “the sort of person you needed to spend time with to better understand how she worked and expressed herself” she responded yes.
I couldn’t hear Ms Casey’s answer to questions about whether she remembered what Sally’s particular health needs were. The coroner took her to a record in the bundle.
C: It says at the bottom I need help with my bowel function
SC: Yes, I take Laxido daily
C: Does that help you? Did Sally have issues with her bowels?
C: What do you remember about Sally’s bowel issues? Was she someone who had too many bowel movements, was she someone who struggled to have bowel movements?
SC: She used to go to the toilet on her own so don’t really know. Although sometimes she’d block the toilet up, so that was the only time you’d know she’d been to the toilet.
Asked by the coroner if she’d any experience of working in the care sector before working at Dimensions, Ms Casey told the court she’d worked with children, and she had an NVQ. She couldn’t remember exactly what it was called but it was an NVQ in children with learning disabilities.
C: When you started work for Dimensions did you receive any training from them?
C: What sort of things were you trained in?
SC: [Can’t hear]
C: Let me ask you specifically. Were you given any training by Dimensions in relation to people’s bowel movements?
C: Did you understand that constipation could be a serious health issue?
C: And just so I’m clear about this, constipation as in someone not passing stools for a significant period of time, alright?
C: Could lead potentially to them becoming extremely unwell, or in a very extreme case, to them dying?
C: You didn’t know that?
C: Was Sally suffering from constipation, was that something discussed from time to time amongst staff at The Dock?
SC: [Can’t hear start of her answer] I remember she was taking a drink, so as far as I was concerned she was fine.
C: A drink? A medication, for constipation?
SC: Yes, Laxido, it says on here
C: So as far as you were aware her constipation was fine?
C: Were there discussions amongst the team at The Dock, the carers at The Dock that you needed to look out for whether Sally was constipated or not?
C: Just no discussions at all?
The coroner then took Ms Casey to a MARS chart (Medication administration record) in the bundle. Ms Casey confirmed that she knew what it was and that staff would consult it to know what medication to give to residents and when.
C: If we go from top left of that page can see XXX, ignore that, next one down Bisacodyl, what was Bisacodyl?
SC: I don’t know
C: If I was to suggest to you was regular medication for constipation?
SC: Don’t know
The coroner reminded Ms Casey to speak much louder than she would normally and took her to reference to Laxido on the next page of the record.
C: Looks there to be medication to be taken one every night, if you turn over page now and again one more page please. We can see half way down something called Laxido Orange, have you got that?
C: That says there, one sachet daily when required to try and get at least one soft daily motion, ok, have you got that?
C: What do you understand that to mean, as far as Laxido is concerned? How often should Sally be taking it?
SC: As and when required, I can’t remember when we used to give it to her.
The coroner asked if it meant she should be given it every day and Ms Casey responded “to be fair I can’t really remember”. The coroner took her to another MAR chart covering 6 June to 3 July 2016 and Ms Casey agreed that related to when Sally was resident at The Dock.
C: Take it from me, she was at The Dock by that stage. Laxido Orange here, take as and when required
C: What would that mean? How would you know whether Sally required Laxido or not?
SC: Don’t know
C: Have a think. You were her care worker, one of those responsible for giving medication for constipation, if says take as and when required. Have a think, what would make you think Sally needs some Laxido?
SC: If she appeared to be in pain?
C: In pain, ok
SC: Or if she wasn’t eating properly
C: Do you agree that if Sally hadn’t been to the loo and passed a stool, for some time, that might be another reason to give her Laxido?
SC: You wouldn’t know if Sally had been to the toilet or not
C: Weren’t you meant to check?
SC: No because she went into the toilets independently
C: Ok, for a resident who suffered from constipation, wasn’t there a need for staff at least to try and find out whether Sally was passing stools regularly?
Asked by the coroner how staff would know whether Sally was constipated or not Ms Casey replied she didn’t know.
C: How were you going to understand whether she was constipated or not?
SC: If she wasn’t eating or something, I don’t know
C: You were there Ms Casey, and you were Sally’s key worker and her health records said constipation was something she suffered from. How would you and your colleagues know if she was constipated?
SC: We didnt
C: You didn’t. It was just guess work?
SC: If she didn’t eat properly, I don’t know [fuller answer – can’t hear] I don’t know
The coroner asked Ms Casey why they didn’t check if Sally had passed a bowel movement.
SC: She went to the toilet independently so it was none of our business … we were never told to check
C: The GP instructions on there for the Laxido, say you should use when required to try and get one soft daily motion. OK?
C: Those are the instructions from her doctor?
C: How are you going to know whether the Laxido was working or not?
SC: We didn’t
Ms Casey said that they didn’t have bowel charts.
C: Did you ever think when you read the GP’s instructions here, again as Sally’s key worker, did you ever think I wonder how we’re going to know if this was working or not?
C: When the instructions say you’re looking to get Sally to pass at least one soft daily stool, did you ever think to yourself if we are never going to check, how would we tell?
SC: [Can’t hear]
C: Yes I know. She might have been going to the toilet and not doing anything, she might have gone to toilet and been struggling to pass hard stool, did you think how were you going to be able to tell the doctor Sally’s bowels were working fine?
SC: [Can’t hear]
The coroner took Ms Casey to more records in the bundle and checked her understanding of some of them before turning to an electronic record of entries made in bowel charts for Sally between 1 Jan 2017 and the date of her death.
C: We can see there are a total of 21 entries there, just at the top can you see entry dated 16 October?
C: Was that entry made by you?
Ms Casey said it was.
C: Just tell us about that entry if you would please
SC: I wrote very large
C: So, it’s a large movement, yes?
C: Then you’ve put type 1,brackets, hard lumps?
SC: Yes, that was the only time if Sally had been to the toilet
C: What did you mean by type 1?
SC: Type 1 on the Bristol Stool Chart? Can’t remember
C: Why did you feel a need to put an entry in the bowel chart?
SC: Because she blocked the toilet up?
C: That was the only reason you put an entry in the bowel chart?
SC: The only reason I knew she’d been to the toilet was because she blocked the toilet up, otherwise I wouldn’t have known she’d been to the toilet
C: When you put your entry in, were you surprised to see other people had been making entries to say no bowel movement?
C: You weren’t surprised?
SC: No she could have gone to toilet and they’d probably written no bowel movement because she’d been to toilet and they didn’t know if she’d had one
C: That would be misleading wouldn’t it. If the person didn’t know if she’d passed a bowel movement, it would be wrong to write in her record no bowel movement wouldn’t it?
On further questioning Sally’s key worker Ms Casey said she didn’t think why she wasn’t having bowel movements. The coroner took her to the records that indicated there was a gap of two weeks between Sally having a bowel movement between 28 September 2017 and 12 October 2017, Ms Casey said that “is she had gone to the toilet we wouldn’t know”. She also said at the time of Sally’s death there was bug going around.
C: Just looking at this chart here, if you’d seen all these no bowel movement entries would you think to yourself I wonder if Sally needed Laxido?
SC: No because I thought it was recorded no bowel movement because no one had seen her go to the toilet
C: So when someone wrote no bowel movement, that was simply they hadn’t seen her go to the toilet?
C: Rather than she hasn’t been at all?
C: That would be misleading wouldn’t it?
SC: I don’t think so
C: Think about it Ms Casey, there you are, you’re looking after Sally that day, Sally has been to the loo but you’ve no idea if she’s passed stool or not, but you write in her record no bowel movement, would suggest you’re pretty clear she’s not passed stool that day?
SC: That’s what it’s saying
C: The only way you could write that is if you were sure she hadn’t passed a stool that day. If you weren’t sure you’d write not sure or don’t know… did you not read it like that?
C: And you didn’t think to yourself I wonder if Sally needs her laxative medication, Laxido?
C: You didn’t think that?
The coroner then moved on to asking Ms Casey about the day before Sally died. She said that she’d worked with Sally that day and they’d been shopping together in the morning. She said Sally enjoyed her food and had no difficulty eating that day. The coroner asked if Sally went to bed as usual that night and she said no, he asked her to tell the court about bedtime that night and she asked to check her statement, which she did.
C: You told us Sally appeared quite sleepy, do you remember when she started to appear sleepy or tired?
SC: Must have been around 7 o’clock. I asked her if she wanted to go to bed, Sally responded saying no. I made her a drink of hot chocolate. I noted that Sally would normally drink her drink very quickly and Sally didn’t.
The coroner told Ms Casey not to read her statement aloud, that he’d take her through it instead.
C: You think the first time Sally appeared sleepy was around 7pm?
C: Was that usual for her?
C: You made her a drink, do you remember what?
SC: Yes, hot chocolate
C: You said she drank it slowly, was that usual for Sally or did she usually drink quite quickly?
SC: She normally drank it quite quickly
C: But she didn’t on this occasion?
C: So, couple things not usual there for Sally, she was sleepy and didn’t drink her drink down quickly. Did you think that was concerning?
SC: No because was bug going round anyway I thought she might have got the bug
C: Anything about Sally’s appearance that wasn’t quite normal?
C: Just have a read of your statement.
SC: She appeared a bit wobbly
C: Do you remember what gave you that impression?
SC: Thought she might have virus or bug going around
C: So, she was a bit wobbly on her feet
C: Did you do anything having noticed she was tired and sleepy, bit wobbly, hadn’t drunk her drink as normal. Did you do anything?
SC: Asked Vicky to come back
C: Vicky Howe. She’d gone home, she’s another support worker?
C: Why did you ask her to come back?
SC: To see what she thought
C: What did Vicky say?
SC: Was probably due to fact she had the virus
C: So did Vicky come and look at Sally as well?
SC: Yes. And we both walked upstairs with Sally to see if she wanted to go to bed and Sally said no and we went back downstairs. Vicky said she thought Sally was probably alright, was probably the bug and Vicky went home.
C: So once you’d had that discussion with Vicky what did you do?
Ms Casey said she gave Sally her evening medication and she fell asleep about 19:30 which was again unusual for Sally, but again she put it down to the bug. The coroner checked where she fell asleep, and Ms Casey said on the sofa, which again was unusual for Sally. She said that she covered her with a throw and sat with her.
C: Did you think about taking her up to bed if she was falling asleep?
SC: I may have asked her if she wanted to go to bed but I can’t remember
C: In the end Sally was lying on the sofa was she, with a throw over her?
SC: She wasn’t upstairs because I was worried she’d fall down the stairs…. I asked her at 10:45pm if she wanted a drink
C: So she’s fallen asleep on the sofa, you’ve covered her up, she woke up later, how did that happen?
SC: [Can’t hear]
C: Did Sally wake by herself or did you wake her up?
SC: I woke her up to see if she wanted a drink before she went to bed
Ms Casey said this was about 10:30, 10:45pm and she thought she needed to get Sally upstairs to bed. She said Sally had a glass of hot chocolate which she drank.
C: How was she while she was drinking her hot chocolate?
SC: It says she remained quite sleepy
C: Was that usual for her
SC: No, I used to sing 1 2 3 cup of tea with her and then we’d go up to bed
C: You’d sing that together would you?
C: So she doesn’t do that. Did you try and get her to go upstairs?
SC: Yes I asked if she wanted to go upstairs but she appeared wobbly so I kept her downstairs because I didn’t want her to fall over.
C: You said in your statement Sally stood up and sat straight back down?
C: What did you think when you saw her do that?
SC: I thought she’d got the bug and I didn’t want her to go up the stairs in case she fell over
C: And you say I think she was wobbly , I think you used the word she appeared drunk, is that right?
SC: [Can’t hear]
C: This is all pretty unusual for Sally isn’t it?
C: Did you think about calling a doctor?
SC: No, she’s just got the bug the others have got
C: Ok. She’s unwell isn’t she?
C: She’s not someone who’s able to tell you how she’s feeling is she?
C: Someone who’s perhaps not easy to read to tell how unwell she is?
SC: No, but I didn’t think it warranted calling the doctor
Ms Casey told the court that she kept Sally downstairs on the sofa. The coroner asked if she was sitting upright or lying down and Ms Casey said she couldn’t remember and she’d not written it down. She couldn’t remember if she’d been changed into her bed clothes but she covered her with a throw on the sofa.
C: What did you do?
SC: Maybe we watched the telly I can’t remember
C: You were there for the whole night weren’t you?
C: When you were there for the whole night would you go to bed yourself?
C: Is that what you did on this occasion?
Ms Casey said that she went up to bed about 3am and when the coroner asked how Sally was at that point she said “she was settled” and when he asked if there was anything unusual about her she said no.
C: Anything unusual about her at all?
C: How was her breathing?
SC: I think it was normal
C: Just looking at couple sentences before you said in your statement, throughout the night Sally’s breathing was quite heavy. Is that right?
C: You didn’t know if that was normal for her or not?
SC: No. I didn’t usually share a room with Sally
C: So at 3am you thought she was settled so you went to bed?
C: You went to bed upstairs?
C: When did you next check on Sally?
C: How did that come about, did you happen to wake up?
SC: I must have woken up, yeh
Ms Casey told the court that she went down to check on Sally at 5am and she may have got a drink, then she was assisting another resident who was up early that day to get her breakfast. Asked by the coroner if there was anything unusual about Sally’s breathing or position at that point she said that she was asleep on the sofa although she’d sat herself up, but remained sleeping.
C: Do you remember when the last time you checked on Sally was?
C: Tell us what the next think you remember is?
SC: Sonia arrived
Asked what happened when Sonia arrived Ms Casey said that they both walked into the lounge and Sonia passed a comment that Sally looked unwell, before then saying “She looks like she’s dead” before telling Ms Casey to ring 999 while Ms Parchment started CPR.
C: So you both walk into the lounge?
C: Was Sally still sitting up?
SC: I think so
C: Sonia said Sally looked unwell?
C: Then said she thought possibly Sally was deceased?
C: When you first walked into the lounge with Sonia?
C: Did Sally look the same as when you’d last checked on her?
C: So you didn’t notice anything different about Sally?
C: Until Sonia said she thought Sally might have died?
SC: No. The last time I checked her she’d moved from lying down to sitting up so I guessed she was still asleep
C: But when you waked into the lounge with Sonia was Sally breathing?
SC: I can’t remember. No, she can’t have been breathing but I can’t remember now
C: So Sonia makes the comment, just pausing there for a moment, when was the last time you checked on Sally, how long before Sonia arrived had you last checked on Sally?
SC: I guess about 20 minutes before
C: What makes you say that?
SC: Because I was in and out of the lounge, at some point Sally had sat up but I can’t remember the time
C: When you say last time checked on her was 20 minutes before, did you go over to her and check her, or just glance at her and see she was still on the sofa?
SC: [Can’t hear]
C: So, you didn’t go over to her and check her?
C: And that was the first time you noticed she was now sitting up?
C: So, when Sonia comes in and Sonia makes the comment that she thought Sally might have died, what did you think?
SC: She can’t have, that was the last thing I’d expect
C: So, what did you do?
SC: Phoned 999
C: What did Sonia do?
SC: Started CPR
The coroner said we’d hear evidence from the paramedics later and that they’d arrived a few minutes after the call was made. Then it was over to questions from other counsel but Ms Casey switched position or dropped her voice even further, and it was even harder to hear. The coroner asked her a number of times to keep her voice up.
Asked by Mr Clarke if there was a process for writing a support plan for residents she said she couldn’t remember. she also couldn’t remember if resident would have an annual review with the GP.
MrSC: You said if the doctor told you to do something you’d do it, would you record it in the support plan?
SC: I imagine so, I can’t remember
Asked how staff would know what the GP had told them when creating a support plan Ms Casey said through the message book, or it would be communicated verbally. Asked if the message book entry would be hand written by the staff member who attended the GP with a resident, Ms Casey said she couldn’t remember. She didn’t recall if she’d attended GP appointments with Sally for anything other than her regular injection.
MrSC: Given your allocated role as Sally’s key worker, would it not be appropriate for those reviews that you attend the GP appointments?
SC: Whoever was on duty would go
MrSC: One of the things we were told in evidence was key worker should be carrying out a weekly audit of daily notes?
MrSC: Was that something you understood to be your responsibility? As a key worker?
SC: Yes I’d be carrying out that
MrSC: Explain to us what would you be looking for?
SC: I don’t know
MrSC: Think it through. Would you be seeking to identify how Sally had been that week?
SC: Would look through the book and make brief note as far as I remember
MrSC: So, for example, if Sally had difficulty in the toilet would that be something you’d look at?
SC: I don’t remember
Asked where she’d put the outcome of those weekly audits she told the court that she’d “put it in a book, I really can’t remember”. Asked if it were for someone’s key worker to feed back to the GP trends in their health or how medications were working Ms Casey said that any member of regular staff could do that.
I then couldn’t hear Ms Casey’s responses to a number of questions so I’ll not share them here. Mr Clarke took Ms Casey to a section on toileting in a plan in the bundle.
What I can see says when taking Sally to the toilet, prompt her to go to the bathroom but wait outside the door where you can see her. If she doesn’t go, do not make an issue of it but prompt her to go again in 10 minutes?
Ms Casey said that was before she started working there. Asked if when she worked at Stourbridge Road with Sally she accompanied her to the toilet she said she couldn’t remember. Mr Clarke asked Ms Casey if she remembered taking Sally to visit her sister, Julie, at her flower shop, which she did.
MrSC: I just want you to think, as best you can [can’t hear] do you recall Ms Bennett raised with you she was concerned Sally was being very quiet and disengaged?
MrSC: Do you recall Ms Bennett said her behaviour had changed?
SC: [Can’t hear]
There when then more questions I couldn’t hear the answers to before Mr Clarke moved on to ask Ms Casey about her knowledge of Sally’s constipation.
MrSC: One of the things also in evidence was reported by staff that Sally’s continence pads had granulated stools in them, was this something you were made aware of?
MrSC: Was it something discussed in the last 6 to 8 weeks before Sally’s death?
MrSC: To be clear are you saying no because you don’t recall or you’re confident it wasn’t?
SC: I don’t recall
MrSC: We’ve spoken about constipation. Were you ever aware of the link between constipation and sepsis?
MrSC: In terms of training on sepsis was this something you were ever provided training on by Dimensions?
MrSC: Were you aware of any of the symptoms of sepsis?
Mr Clarke then asked Ms Casey if she’d assumed that Sally’s symptoms were down to the bug.
MrSC: Would it be fair to say what happened is Sally appeared to be unwell, you made the assumption was a bug, you didn’t think was this anything else?
MrSC: Given these very unusual behaviour for Sally wouldn’t it have been appropriate to seek some advice at that stage?
MrSC: Why not?
SC: Because she didn’t appear too poorly
MrSC: She’s unstable on her feet, she’s unwilling to go up to bed?
SC: [Can’t hear]
MrSC: You’re saying no
SC: I didn’t think it was appropriate to call a doctor
C: Why not?
SC: If she needed to see a doctor we’d have taken her in the morning, it was not as far as I was concerned an emergency
MrSC: When you made that judgement call, did you check for example the bowel movement charts?
MrSC: Information on iplanet? Any of the other records about how Sally had been presenting more generally?
MrSC: Why not?
SC: As far as I was concerned there was nothing wrong with Sally, she was fine.
MrSC: Except for all these symptoms and unusual behaviours?
SC: I just thought she had the bug that the others had got
MrSC: We spoke about an emergency, did you not think to call the non-emergency number, such as 111?
Before passing over to other counsel the coroner asked Ms Casey if she remembered telling Sonia when she arrived that Sally had been awake all night, I couldn’t hear her answer.
No questions from counsel for Julie Campbell, Worcestershire County Council, Dr Williamson or CQC. Today in court Dimensions were represented by Mr Hassall KC, it was over to him for questions next.
Ms Casey confirmed she was a support worker at Dimensions.
CH: You told us you had an NVQ in relation to working with children with learning disabilities?
CH: Were you, have you ever been, a registered nurse?
CH: Have a medical qualification?
CH: You described in your evidence that your approach was to support Sally?
CH: To do a number of things herself?
CH: Is that the approach that was taken by Dimensions at The Dock?
Mr Hassall took Ms Casey to a document in the bundle, guidelines for support staff in management of challenging behaviour. He said this document was dated some time before Sally’s death in 2015 and asked Ms Casey to read five bullet points to herself.
CH: My question to you is do you recall Sally displaying those behaviours when you used to support her?
CH: We’ve then got common triggers to Sally displaying challenging behaviour, the first of those is when Sally is supported to have her personal care needs met, in particular around being supported to go to the toilet
CH: Again, do you remember that being the case? That it was a common trigger for Sally’s challenging behaviour when she was supported to go to the toilet?
Mr Hassall discussed the document further with Ms Casey before asking some further questions.
CH: Do you recall, this would have been at Stourbridge Road, it was an attempt to help Sally be more independent with using the toilet?
He continued to go through the document asking Ms Casey if she remembered it.
CH: Do you recall the use of the toilet being a trigger for Sally’s sometime challenging behaviour?
SC: Vaguely yes
CH: Your evidence earlier on this morning was your recollection was in general terms Sally was independently going to the toilet?
CH: When you were supporting her at The Dock?
CH: Was there ever any suggestion she should be stopped from going to the toilet on her own so her bowel movements could be monitored?
Mr Hassall asked, and Ms Casey recalled, Sally being given Laxido.
CH: When you were looking at that page you said there were never any bowel charts?
CH: Did you mean there were never any bowel charts for Sally or there were never any bowel charts for anyone?
SC: I can;t remember seeing any bowel charts
C: For anyone or for Sally?
SC: For anyone
That’s the end of the first witness today, I’ll share more later/tomorrow.