The final two Dimensions UK witnesses were Deborah Hubbocks, a Health and Safety Advisor for Dimensions who conducted their internal investigation after Sally died, and Lorna Owen who was a Support Worker who left Dimensions before Sally died, and her statement was read onto the record by the coroner.

Deborah Hubbocks

Deborah Hubbocks spoke very quietly, so much so that I couldn’t hear her answers to the coroner’s question of what her current position is or how long she’d worked for Dimensions. She told the court she carried out an internal investigation for Dimensions, into Sally’s death in December 2017. She detailed how she reviewed documents, spoke to staff members and carried out a “formal investigation”, writing a report on what she found.

The coroner tried to ascertain the purpose of the investigation through a number of questions before she agreed that she was looking to identify learning points from the circumstances around Sally’s death and what had happened.

C: You want to know what’s gone wrong, that’s the purpose, identifying what’s gone wrong. I just want go through some of your findings with you, we’ve got the report here, begin at paragraph 4.4 of your report. Were you able to satisfy yourself all staff working at The Dock knew about Sally’s long history of constipation?

DH: Yes I spoke to Sue Casey and [can’t hear]

C: You spoke to two staff members, Sue Casey and Sonia Parchment, you saw mention of it in the support plan. Did you speak to the Locality Manager, Julie McGirr?

DH: Yes

C: Did she know about it as well?

DH: I can’t remember.

C: What you said in your paragraph there is all staff at The Dock knew. Can I take it you satisfied yourself all staff at The Dock knew about Sally’s history of constipation?

DH: [Can’t hear]

The coroner then moved on to ask Ms Hubbocks about what her investigation found in relation to medication prescribed to Sally for her constipation.

C: Ok, and furthermore they all knew the medications she was currently prescribed?

DH: Yes

C: You identify in paragraph 4.5 that her Support Plan had been updated to reflect the potential need for a daily dose of Laxido. But you identified possibly a gap in terms of guidance, is that right?

DH: Yes, was no actual physical instructions of when and how, not so much when, but [can’t hear]

C: We’ve heard Laxido was PRN, as required, are you saying the Support Plan should be more specific about circumstances?

DH: Yes, in the Support Plan was no clear instructions for as and when the PRN was needed.

C: Did you review the MAR charts?

DH: Yes

C: There were instructions in those charts. I will start by seeing if we can avoid getting the folder out, the instructions from the doctor were one sachet daily when required to try and get at least one soft daily motion. That’s in the MAR chart, did you feel that wasn’t a clear enough instruction?

DH: [Can’t hear]

C: That instruction from the doctor suggests the Laxido should be used if at the time Sally wasn’t passing at least one soft motion a day.

DH: Was no instructions of how many days that would be. If Sally hadn’t been to the toilet for so many days, give instruction when [can’t hear]

C: You’ll have to forgive me, my reading of the doctor’s instruction is if she went one day without passing a soft stool, staff should be on it and using Laxido. Was that your impression, or did you feel was some ambiguity in that instruction?

DH: [Can’t hear]

The coroner then asked about communication between staff members about Sally’s bowel movements and what Ms Hubbocks internal investigation had found.

C: Ok looking at 4.6 in your report, did you identify was communication going on between staff about Sally’s bowel movements, but that these weren’t being recorded in writing?

DH: [Can’t hear]

C: So again this was based on what the staff were telling you presumably? So, what sort of things were the staff communicating to each other about that helped them work out whether Sally might be constipated or not?

DH: [Can’t hear]

C: Have a look at paragraph 4.6 of your report. What you seem to be saying there is staff told you in your investigation they were commenting with each other, how distended her stomach might be, if she had discomfort when passing stools or sometimes they’d see stools in toilet and comment on the size of them?

DH: Yes

C: So they were talking about those, but they weren’t recording?

DH: Yes

C: We’ve evidence Laxido was not given since December 2016, is that a finding you made in your investigation as well?

DH: Yes

C: Did you speak to staff members about that? Wondering if you raised that with staff members and they said they did give Sally Laxido but didn’t document it?

DH: [Can’t hear]

C: So staff weren’t suggesting to you that although they hadn’t recorded it on the MAR chart they had in fact given Sally some Laxido.

The coroner then moved on to discuss what Ms Hubbock’s had discovered and concluded about medication audits practices at The Dock.

C: Paragraph 4.10 you deal with medication audits, can you explain what a medication audit is?

DH: [can’t hear] check how much medication given, checking system where medication is delivered and also as well, to check [can’t hear]. Just to make sure everything was correct.

C: So in a medication audit, if someone prescribed PRN medication like Sally had here, the Laxido, if that hadn’t been given for an extended period of time at all, would that be something a medication audit would have been expected to pick up?

DH: [Can’t hear] Medication audit is carried out by internal staff teams.

C: Who was expected to carry out a medication audit?

DH: The staff team [can’t hear]

C: Did you get the impression that those who were meant to carry out the medication audits at The Dock knew properly how to carry out such an audit?

DH: I don’t know.

C: You say in your report it appears support staff had not been shown how to complete audits, paragraph 4.10. That was a finding of yours. Can I take it you included that finding because some support staff were expected to be carrying out medication audits it’s just in your view they didn’t know properly how to do it?

DH: Yes.

Next the coroner asked Ms Hubbocks about what she’d found in relation to the recording and monitoring of Sally’s bowel movements.

C: OK. Paragraph 4.12, in daily records in year up to Sally’s death you say there were approximately 3 entries that recorded bowel motions?

DH: Yes

C: Did your investigation consider whether bowel motions for Sally should have been recorded somewhere else besides the daily records?

DH: [Can’t hear]

C: What about bowel charts?

DH: [Can’t hear]

C: That’s OK, can I take you to document in Bundle 3 please, tab number 8. We’re told this is a document that lists all entries on the electronic bowel charts between 1 January and the date of Sally’s death on 27 October. Did you review these electronic charts?

DH: I reviewed the print outs.

C: OK

DH: [Can’t hear]

C: Not at all. In the course of your investigation did you identify the fact there were only 21 entries in bowel charts for 10 months between the beginning of January and the end of October?

DH: [Can’t hear]

C: You did identify that, what did you conclude about the fact there were only 21 entries?

DH: [Can’t hear] Systems running, would have been paper version and transferred over to new system called iplanit. I reviewed that

C: We’ve been told there aren’t any paper bowel charts for January to October 2017 so you have checked it would seem the only bowel charts that were in existence. I’m just wondering, given what you knew about Sally’s death, any significance in only 21 entries for those 10 months?

DH: [Can’t hear]

C: For example did your investigation identify Sally was someone who needed regular monitoring of her bowel movements?

DH: [Can’t hear] She was allowed to go to the toilet on her own, she didn’t need assisting to the toilet.

C: Who told you that?

DH: [Can’t hear]

C: Alright they told you Sally was independent in her toileting. Were they telling you in effect her bowels didn’t need monitoring? Was that what they were telling you?

DH: [Can’t hear] Staff at the time said Sally would go to the toilet [can’t hear]

C: What I’m trying to understand, is by time you conducted your investigation you were aware I think that Sally’s cause of death was faecal impaction, caused by her severe constipation, is that right?

DH: Yes

C: So you knew potentially there might be an issue about her bowel movements being recorded?

She nods

C: Were you looking to establish whether or not her bowel movements should have been recorded?

DH: [Can’t hear]

C: OK, and you’d been told by support staff she was independent in her toileting. Were you effectively being told by support staff that they weren’t recording her bowel movements?

DH: Yes [fuller answer – can’t hear]

C: So you were being told by staff they weren’t recording her bowel movements because she was independent?

DH: Yes

C: Did you investigate that further? That’s what they’re telling me, is that in fact what did happen?

DH: [Can’t hear]

C: Alright, your investigation is trying to establish what can be learnt from this incident. Sally died effectively because of severe constipation, here are staff saying we didn’t need to monitor her bowel movements because of reasons given, did you try and work out should they have been monitoring? Did you investigate that any further?

DH: [Can’t hear]

C: The Support Plan. What about going through MAR charts and medication?

DH: I checked to see what medication she was on.

C: If you’d been looking through medication you’d have spotted Laxido was required to ensure at least one soft stool a day didn’t you?

DH: Yes.

C: Did that make you think they should have been monitoring Sally’s bowels more closely?

DH: Yes

C: If it made you think that, why didn’t you record in your investigation there should have been monitoring of Sally’s bowels?

DH: [Can’t hear]

C: I realise you’re saying there’s improvement to procedure and associated guidance. I don’t think you say in your report do you, even though staff said they didn’t need to monitor her bowel movements, they should have been?

DH: [Can’t hear]

C: I don’t want to put words in your mouth Ms Hubbocks, please don’t just accept it because I’m suggesting it to you. I’m trying to identify what your investigation was trying to achieve. Did you give any consideration to whether staff should be monitoring bowel movements or whether you were just accepting what staff were telling you?

DH: Accepting what staff said.

Having established that the Dimensions internal investigation tasked with identifying potential learning, just accepted what staff said without scrutiny, the coroner moved on to asking about missed medication and it was established that the court did not have access to any record about the missed dose of Senna that wasn’t given to Sally on the 23 October, 4 days before her death. The coroner then moved on to asking about learning points.

C: That ends on 11 October, don’t think we’ve got actual one that covers the Senna, ok we do have ending 23 October a couple of pages earlier but don’t think it covers the Senna. Alright, we’ll leave that. Now moving onto learning points you identified as a result of your investigation Ms Hubbocks, firstly you make a point about procedure and guidance for recording bowel movements, is that right? Just take us through what you identified and what you thought the learning should be. What issues and then the learning.

DH: [Can’t hear]

C: More information provided to support staff?

DH: Yes. Including more information, whilst some people were supported to toilet, also information for those which are independent and how to monitor those.

C: So one of the concerns raised we‘ve heard in the course of this inquest by support staff, was because Sally was quite independent, she didn’t like people coming to the toilet with her, she didn’t like it when people tried to monitor her bowel movements, did you think was there more advice that could be given to bridge that gap? To monitor Sally’s bowel movements and the opposition she posed?

DH: [Can’t hear] Staff double check she’d been to toilet, or said toilet flushed so knew she’d been [can’t hear].

C: Umm yes. You also identify some learning which was required to enable staff to recognise symptoms of constipation?

DH: Yes in Dimensions we have a Constipation and Bowel Monitoring Policy [can’t hear] also a series of Never Events, was also added in to that.

C: Can I ask you what led you to the conclusion, as things were at that time, staff weren’t entirely capable of recognising symptoms of constipation, what led you to reach that conclusion?

DH: [Can’t hear]

C: When you spoke to staff was it apparent to you they didn’t really know how to identify symptoms of constipation? Is that why you suggested this extra learning?.

DH: [Can’t hear]

C: What led you to that conclusion? Was it because you were speaking to staff and they were saying I don’t know, I don’t know how to recognise constipation?

DH: [Can’t hear]

C: It was. OK. You identified some issues with auditing, is that right?

DH: Yes

C: Tell us what issues were and what learning could be taken from that?

DH: [Can’t hear]

C: You told us earlier I think were no clear instructions about when to give Laxido as required, PRN, you said earlier support staff hadn’t been shown how to complete audits is that right? Was it related to that, or not?

DH: [Can’t hear]

C: Have a look at paragraph 5.3 of your report. When you say in paragraph 5.3 “The investigation identified that the audit of PRN protocols on the use of laxatives was not completely followed in this case”. What do you mean by the PRN protocols?

DH: [Can’t hear]

C: Can you tell me what that sentence means then?

DH: [Can’t hear]

C: OK. Paragraph 5.4 you say “The investigation has identified that possible additional training and guidance on the symptoms and signs of constipation and faecal impaction for staff, to include a greater understanding of long term use of medication side effects”. Can you explain about that a bit more?

DH: Medication given to people we support has adverse effects on their bowel movements.

C: What sort of medication can you remember?

DH: [Can’t hear]

C: So could have specific impact on bowel movements, specifically, was that information you had already?

DH: Would look into it, are some medications, from previous investigations know some can cause constipation.

C: Alright Ms Hubbocks, those are all questions I have for you at the moment.

There were no questions for Ms Hubbocks from Mr Clarke for Sally’s family, from Mr Cox for Worcestershire County Council, from Mr Mumford for Dr Williamson, from Ms Wilks for the CQC, or from Mr Kay KC for Julie Campbell.

Mr Hassall KC for Dimensions asked Ms Hubbocks to explain what she’d meant when she said she’d look at the tablet when asked about the electronic print out the court had, she said that each service had a tablet for using the Iplanit system and each person has their own log in, so she’d looked at that for The Dock.

Mr Hassall asked if she’d looked at paper copies of the MAR charts and the daily logs, I couldn’t hear her answer to either questions. She told the court that she’d looked at the electronic support plans.

CH: So you looked at electronic copies of documents apart from?

DH: MAR charts

CH: At the time of your investigation was Dimensions fully paper based, fully electronic or a mixture of the two?

DH: Mixture of the two.

CH: Why did you not look at the paper records for The Dock?

DH: Normally that’s what I do but unfortunately they’d been left in Sally’s room and they’d been removed with Sally’s belongings.

CH: So the investigation you did was using latest electronic, apart from MAR charts separate to other paper records?

DH: Yes

CH: Thank you

The coroner thanked Ms Hubbocks and released her.

Lorna Owen

This witness was due to give evidence in person but she was in hospital and the coroner asked whether counsel wished for him to read her statement under Rule 23, or whether they preferred to wait and see whether she was well enough to attend court the following week. No one had any objections to her evidence being read onto the record.

The coroner said that this is the statement of Lorna Joanna Owen. She says this, I was previously employed by Dimensions UK Ltd as a Support Worker. I started in 2004 and was in that role for about 11 years. I have a Level 2 and 3 NVQ in Health and Social Care.

I first started supporting Sally when she moved into accommodation at Stourbridge Road in Bromsgrove. I worked there full time until about 2009 and then I went part time, working 3 days a week albeit still at Stourbridge Road. I would also do one sleep-in a week, usually on a Saturday.

In May 2016 all three of the supported people moved from Stourbridge Road to The Dock and I then just worked at The Dock three days a week, still usually including one sleep-in a week. When Sally first moved into Stourbridge Road she was quite calm and all of the staff were really pleased at how she had settled down. Sadly Sally became unwell with Ovarian Cancer and underwent a hysterectomy, following this operation her behaviour started to change and she started presenting with quite challenging behaviour.

Sally could become quite anxious about a number of things and start displaying challenging behaviours, this could include going to the toilet and when she was given personal care. She would start throwing objects, pushing past staff and individuals, stamping her feet and crying.

A lot of the time she became upset with herself and would talk about ‘the book’, which was something that she remembered from being a child at a previous care setting. We understood names would be put in the book as a punishment and if she started mentioning the book then that was an indication that she would start showing challenging behaviours.

I had no concerns over Sally’s general health. She did suffer from constipation, which she had when she came to Stourbridge Road and it was controlled well with Laxido but I can’t remember the exact dose she was prescribed. The Laxido was administered by any staff who had had medication training and that included me.

She was given Laxido on an as required basis and that would usually be if she hadn’t had a bowel movement that day. We would administer it to her on an evening and generally she’d then have a bowel movement the following day.

Sally remained on Laxido when she moved to The Dock but it didn’t seem to work as well, and she became more constipated, although she was still given Laxido to try and help her bowel movements. I do however remember we had to take her back to the GP more regularly about her constipation and we asked on a number of occasions to increase the dosage for a short period to clear her bowels.

I left Dimensions in around September 2016 but I am aware that Sally was also prescribed Senna albeit I had left Dimensions when this was prescribed, I only knew she had been prescribed Senna as I went back to The Dock to cover a shift and noticed this on her MAR chart. We would record in Sally’s daily notes when she went to the toilet and if there was anything of note that needed to be provided to other members of staff then we would do this at the handover between shifts and signpost it in the communications book.

Ms Owen finished her statement by saying because she’d left Dimensions she was unable to comment on how Sally’s health was in the weeks preceding her death.

That was the end of the evidence from Dimensions UK staff.