The second witness called to give evidence on Day 2 of Sally’s inquest was Sonia Parchment. The coroner asked her a number of questions, and the sound was a bit intermittent but much better than the last witness. He started by asking whether she worked for Dimensions in October 2017, she did, whether she still worked for Dimensions, she does, and how long she’s worked for them, I think she said over 25 years. She told the court she had an NVQ Level 2 and additional Dimensions training, which is currently up to date.
In response to a question from the coroner she said that she’d not visited The Dock regularly. She told the court she’d not been there at all before the week that Sally died, when she was there to cover staff who were off sick. She had worked at Stourbridge Road and knew Sally from her time there. She thought the last time she’d seen Sally was just before she’d moved to The Dock.
Asked if she was ever Sally’s key worker, she said that she wasn’t but her role was over everybody and she provided input here and there.
C: So you supervised the other support workers?
SP: Yes
C: The issues Sally had with constipation, were you aware she was taking regular medication for that?
SC: Yes
C: Am I right in thinking at Stourbridge Road there was a regime in place for Sally’s bowel movements to be monitored?
SP: I know there’s bowel movements at the back of books, for everyone as far as I’m aware.
C: All residents at Stourbridge Road had their bowel movements monitored?
SP: Yes
C: Why was that? Do you know the thinking behind it?
SP: If anyone was on medication for bowel movements you need to have an idea of how regularly they’ve been, general health checks you know
C: Do you remember yourself monitoring Sally’s bowel movements and recording them in charts?
SP: Must have done, yes
C: Do you remember doing it for other residents?
SP: Yes
C: I want to get an idea, was filling in bowel charts at Stourbridge Road something you did regularly?
SP: Yes
C: Do you remember, I appreciate it may be difficult to distinguish between training since Sally’s death and training before, if you’re not sure please say
SP: Yes
C: Around the time of these events, nearly 6 years ago now, had you received training from Dimensions about constipation, sorts of illnesses associated with it? The risks associated with it?
SP: No
C: You hadn’t received any training?
SP: No
The coroner took Ms Parchment to the bundle and asked is one of the records listed in a booklet was bowel charts, she said it was. Asked if she’d use that document to fill in bowel movements of residents at Stourbridge Road, Ms Parchment said she would.
The coroner then went on to ask her about the morning of 27 October 2017. She told the court she’d been asked to work at The Dock due to staff sickness.
SP: Sue was on duty
C: Is that Sue Casey?
SP: Yes
C: Do you remember who the manager was who phoned you?
SP: Julie McGirr
C: Do you remember what time you arrived at The Dock that day?
SP: About 10 to 8
C: What happened when you arrived at The Dock that morning?
SP: I parked the car, walked to the door, saw Sue
C: Where was she?
SP: [Can’t hear] I got to the front door, went in, she still didn’t see me so I knocked the door, from then on I knew something was up [cant hear]
C: She was clearly distracted by something, it was only when you knocked she realised you were there?
SP: Yes
C: So you thought from that something was up?
SP: Yes
C: So what happened after you knocked at the door, did she let you in?
SP: She was standing in front of me and tried to tell me Sally had been up all night, then she was talking very quickly
C: What was her mood like? Was she calm? Was she agitated?
SP: She was agitated
C: What did you do when she told you that?
SP: I went to the lounge
C: Tell us what you saw when you got to the lounge?
SP: Sally was sat upright, slumped in a chair, her jaw was dropped
C: In a chair or on the sofa?
SP: The sofa
C: What did you think when you saw her?
SP: It was quite clear she wasn’t well and I thought she’d passed away.
C: And you actually said that?
SP: Yes
C: What was it about Sally’s appearance that meant you made that comment right away?
SP: The way she was sat in the chair slumped, her jaw was dropped, and around her mouth was a little dark
C: What was Sue’s reaction when you made that comment that you thought she’d died?
SP: [Didn’t hear]
C: What did you think when Sue said that?
SP: I said Sally needed help right away, quickly took my coat off, she’d clearly gone, but with Sue saying it had only just happened, I got Sue to help me get her on the floor. I asked her to get something to wipe her mouth, she came in with dry cloth, I said no, need something wet to wipe it off.
C: So with Sue’s help you got Sally onto the floor
SP: Yes
C: You wiped her mouth?
SP: Yes
C: Then what?
SP: I made sure her mouth was clear as well and then started to do CPR
C: Sorry to ask but when you first touched Sally how did she feel?
SP: I can’t remember
When the coroner asked if she could remember whether or not Sally was still warm she said she thought she was. She told the coroner that while she was doing CPR she looked up and told Ms Casey to call an ambulance.
There were no questions from counsel for Sally’s family, Julie Campbell, Worcestershire County Council, Dr Williamson or the CQC. Mr Hassall for Dimensions had a couple of questions for Ms Parchment.
Mr Hassall said he wanted to ask a couple of questions about how Sally had been earlier in the week when Ms Parchment had worked at The Dock. She said that she looked well.
CH: You had a couple of cups of tea with her?
SP: Yes
CH: She went to bed following her evening medication as usual?
SP: Yes
CH: Can I just ask you about what you said about Stourbridge Road. You said that you thought you’d completed bowel monitoring charts for everyone?
SP: Yes, the charts in the book
CH: So tick charts, what sort would a tick signify?
SP: A tick would signify a bowel movement but wouldn’t stipulate whether it was small, medium or large
CH: So when you were asked to look at page 504[?], additional records completed, your recollection was just a date in the first column and a tick in the box for column of bowel chart?
SP: Yes
Mr Hassall asked if Ms Parchment was working at The Dock on the day Sally died because a member of staff was off sick and she said two were off sick. She agreed that she was aware “something was going around at The Dock”.
Mr Hassall’s final question was about the registration status of The Dock.
CH: Were you ware of the status that particular accommodation had?
SP: Status?
CH: Whether it was supported living accommodation or a care home?
SP: It was supported living accommodation
The coroner thanked and released Ms Parchment shortly after midday, and told her that she was free to stay or leave as she wished.