I’m reporting these witnesses slightly out of order because we heard from the court appointed expert first thing on Day 3, but I’ll finish the Dimensions witnesses first. Ms Campbell was taken through her evidence and questioned by the coroner for about 45 minutes before lunch, and by other counsel for half an hour after lunch. Ms Campbell spoke loudly but she was sat away from the table with the microphone on and kept leaning back so the sound was still somewhat intermittent. Her counsel, Mr Kay KC interjected quite early on to say he’d had a message that someone on Teams (his solicitor I believe) couldn’t hear anything, and the sound improved slightly after lunch when she positioned herself closer to the mic. The coroner has acknowledged the difficulties with sound throughout, and repeatedly asked and reminded witnesses to speak up (for my part as frustrating as it is not being able to clearly and confidently hear, and as difficult as it makes it to report, I am grateful for the opportunity to attend remotely and I do not know if I’d have been able to report without that arrangement on this occasion, so I’m not complaining per se, just letting anyone reading know the limits of the situation).

The court heard that Julie Campbell still works for Dimensions, albeit now in a different role, but at the time of Sally’s death she was the regional Operations Director. The coroner said that the court had heard that Sally moved to The Dock in May 2016 which Ms Campbell agreed, and he then asked her what the reason for the move had been, and questioned whether there was a change in status of where Sally was living.

JC: Stourbridge Road was a registered care home. At the time I was working with Worcestershire County Council to move away from registered care into a Supported Living model, their preferred form of support. I was working to de-register a number of homes, Stourbridge Road was one of them.

The property was quite old and tired, the property at The Dock had become empty because people had moved on, so was a nicer home for people to move to. We spoke to families, families agreed and we moved.

C: This was the Supported Living model, so it wasn’t a registered care home?

JC: No

C: What if any was the role of the local authority, Worcestershire County Council, in relation to The Dock?

JC: [Can’t hear] At the time I recall having numerous meetings about the de-registration project, we called it a project, with the local authority. They were very much involved in the assessment of needs of individuals. We went through a whole reassessment of individual needs to determine what hours of support they required. Sally for example, she was reassessed, was process we needed to go through, deprivation of liberties, a DOLS application, Sally’s family took over some responsibility, in terms of [can’t hear]

C: Did the local authority have any role in the funding of Sally’s placement at The Dock?

JC: Yes. She was fully funded

C: She was fully funded by the local authority?

JC: Yes

C: As a result did the local authority have any duty of oversight, or anything like that, or was responsibility for meeting Sally’s needs wholly on Dimensions?

JC: We were commissioned to provide her support, obviously the local authority was ultimately responsible for the person they allocated support to. We were commissioned to do that job, but they were responsible.

The coroner then moved on and asked more specific questions about arrangements in place at The Dock, where Sally lived for the last 17 months of her life.

C: Taking The Dock then, there was a Locality Manager in place, we’ve heard that was Julie McGirr I think?

JC: Yes

C: Then there were a number of employed carers as well, Support Workers, is that right?

JC: Yes. The number of Support Workers was determined by the number of hours of support required, I believe at The Dock there was about 10 Support Workers in total, on a rota basis.

C: In terms of, we’ve heard evidence already each resident will have a Support Plan, Health Action Plan, Medication Administration Records, all sorts of documentation tailored to their needs. Who’s responsible for drawing up those documents first of all?

JC: Initially social services do an assessment, some information is gathered from the assessment carried out by social services, but ultimately Dimensions staff would then provide, I can’t find the right word, would work together to develop the Support Plan, Dimensions staff would look at that. The responsibility to ensure that was in place was the Locality Manager’s. The Locality Manager would be expected to review that, and ensure [can’t hear]. There may be a time the Locality Manager came back to it to reassess people and therefore there could be changes in the Support Plan required.

C: We’ve heard that Sally had long been recognised as being at risk of constipation. What I’d like to know is at the time that Sally arrived at The Dock was there any guidance in place? Any policies or procedures, to assist staff in dealing with a resident with those particular issues?

JC: [Can’t hear – but did catch that she said there should have been information in the support plan in respect of constipation].

C: Who would provide that guidance?

JC: Ultimately the Locality Manager would ensure what was in the Support Plan… would be training given to staff linked to First Aid, potentially deal with [can’t hear] sepsis for example [can’t hear]. There was no specific constipation training.

C: Now, you’ve said in your statement, paragraph 13, “I was aware that Sally did suffer with constipation but as far as I was concerned or aware it was being managed well and I had no reason to believe otherwise”. How did you satisfy yourself Sally’s constipation issues were being managed well?

JC: Once someone is in place, in this case at The Dock, the responsibility is entirely the Locality Managers to put in place whatever is needed to support residents, in this case with the issues of constipation.

C: You’d have no input into that yourself?

JC: [Can’t hear] I may well get involved, certain examples have been involved, not just about constipation but other health issues and I was very happy to offer that support, but I wasn’t informed there were concerns.

The coroner then asked who was responsible for ensuring MAR (medication administration record) charts were filled in, and completed correctly. I couldn’t hear Ms Campbell’s response to either question. The coroner asked Ms Campbell whether she agreed it was important for Sally’s bowel movements to be monitored and recorded, she said she did. Asked whether the Locality Manager, Julie McGirr, ever raised any concerns about staff’s ability to do that sufficiently, I couldn’t hear her answer.

Ms Campbell confirmed that at this point the daily records were paper based and they were collated into booklets for each month.

C: We’ve seen at the back of each month’s booklet is a separate chart that allows staff to record if separate charts are being filled in, like bowel charts, and where they’re located. If we take June 2016 to June 2017 when paper notes appeared to stop, in that 12 month period, apart from one entry, none of those charts have been completed to indicate there were bowel charts in place. Do you agree with that first of all?

JC: [long answer – can’t hear]

C: You agree those charts at the back should have recorded there were bowel charts in place, if there were?

JC: Yes

C: I saw you hesitate, were you going to say was incorrect, there were bowel charts in place during that period?

JC: [Can’t hear]

C: You say there should be bowel charts in place. Did you satisfy yourself there don’t appear to be bowel charts during that period?

JC: [Can’t hear]

C: Those paper daily records, there is another sheet at the back of each month to suggest some sort of audit should be carried out. Was your understanding that audit should include, whether the sheet indicated bowel charts, and where they should be found? Would that audit expect to check whether that’s filled in completely?

JC: Yes

The coroner asked Ms Campbell how often she’d expect that to be conducted but I couldn’t hear her answer.

C: Who would be responsible for conducting that audit?

JC: [Can’t hear]

C: Thinking about that for a moment. Three residents for The Dock, Julie McGirr was responsible for a number of other properties and residents as well wasn’t she? Eleven in all?

JC: Yes

C: At some point she, or someone she delegated to, had to go through the daily notes for that month for each resident and satisfy themselves everything had been filled in correctly?

JC: [Can’t hear] One of the staff has oversight of the month’s worth of records, the Manager would then be the person that double checks that, and went back through any relevant [issues?]

C: So what would the Support Worker put in the 4+1 document?

JC: Anything significant that month… may well require a change in the Support Plan for example, changing the way support is being delivered.

C: When you say the Support Worker, we’ve heard reference to various Support Workers being Key Workers, did each resident have a nominated Key Worker?

JC: Yes.

C: We heard I think Sally had Susan Casey as her nominated Key Worker?

JC: [Can’t hear]

C: So again your review of the notes, after the event, would suggest that was the case, that Susan Casey was the key worker?

JC: Yes

C: We’ve heard at one stage Callan Glassey’s name mentioned as a co-Key Worker, is that right? Was he a co-Key Worker at the time of these events?

JC: [Can’t hear]

Ms Campbell responded that Callan Glassey was less involved, and that it was the Locality Manager’s decision as to who she thought was most appropriate to be the Key Worker. The coroner then asked a number of questions about auditing.

C: So we’ve got a monthly procedure in place, did Dimensions check? Who audits the auditors?

JC: Quality reviewers then go out to people’s homes, spend time, sometimes for couple days in a home [can’t hear] look at notes, put together a Quality Review Report.

C: The quality auditors, Dimension’s own quality auditors, would they go in simply to review records for one resident at a time or the whole property, whole place?

JC: Where Sally lived they’d probably get the opportunity to do everybody, if it was a larger property they may select.

C: So in the case of The Dock, you’d expect the Quality Review to include review of all documents for all residents?

JC: Yes

C: How often was that Quality Review being conducted?

JC: If just starting support would go in few months, quickly, depending on rating given may go back in after 6 months or 12 months, depended on previous visit really.

C: In the case of The Dock is there a record of when these Quality Reviews were conducted?

JC: I believe it was only a few weeks before Sally passed away, it was September some time.

C: Do you know if there was a Quality Review of The Dock before September 2017, even if you don’t know the exact date?

JC: [Can’t hear]

C: Did that Quality Review in September 17 reveal to you any concerns about record keeping at The Dock?

JC: No

C: Given what we’ve been able to establish during this inquest, that those charts at the back of daily notes weren’t being completed, monthly audit sheets weren’t completed, are you surprised that was the conclusion of the Quality Review? Were no issues or concerns about record keeping?

JC: [Can’t hear]

C: When the paper daily notes stopped being used, and moved onto the electronic system we’ve seen a document which lists all the entries on bowel charts between January 2017 and the date of Sally’s death at the end of October of that year. We’ve seen a total of 22 entries, do you know did the Quality Review consider electronic documents as well?

JC: Electronic recording was very much in the pilot stage … The Dock was in pilot stage so learning from the recording system, I imagine they’d have looked against that information.

C: You suggested 21 entries for 10 months in 2017 on Sally’s bowel charts was inadequate. Would you have expected a Quality Review to have picked up on the lack of entries in the electronic bowel charts?

JC: [Can’t hear]

The coroner asked, and Ms Campbell confirmed, that Medication Administration Records were always paper copies and didn’t become electronic at the time Sally lived at The Dock. The coroner then asked about the failure of the Quality Review to identify that Sally hadn’t been given Laxido for ten months.

C: We know the medication Laxido was prescribed to Sally on an as required, PRN, basis by her GP. Questions are raised over the fact since December 2016 Laxido wasn’t administered to Sally, or wasn’t recorded as having been administered to Sally, on any occasion since December 2016. Would you have expected the Quality Review to have picked up on that and queried it?

JC: [Can’t hear] Would have expected the Locality Manager… what they’d have taken from that I can’t say, they may well have been told Sally hadn’t required…

C: I’m not asking you to speculate what might have been said in discussion, was whether the issue ought to be picked up on in the Quality Review?

JC: All support she’s been given [can’t hear]

C: That’s not quite the issue. The issue is whether the Quality Review would look at MAR charts and spot the fact one prescribed medication, although on a PRN basis, hadn’t been administered at all over a period of 10 months. As Operations Manager at the time, would you expect a Quality Review to have picked up on that?

JC: Yes

C: Was it ever reported back to you this issue had been noticed, and then discussed with the Locality Manager?

JC: No

C: Again, can we take it from that, that the Quality Review did not pick up this particular issue? Otherwise, you would have been informed about it?

JC: [Can’t hear]

C: So, the fact you weren’t informed, can lead us to safely conclude that it wasn’t picked up on.

The coroner said that we’d heard evidence over the course of this inquest that Sally “presented with some challenging behaviours and monitoring her bowel movements could, on occasion, be an issue” to which Ms Campbell nodded. The coroner asked her if this was something she was aware of and whether it had been raised with her at the time, to which she said she was aware that Sally had some constipation but I couldn’t hear the rest of her answer. In response to a further question about whether that could effect the ease with which Sally’s bowels could be monitored she said that she’d picked it up in conversations she’d had.

C: So were there discussions about how to strike a balance between monitoring her bowels adequately and dealing with the challenging behaviour?

JC: I think I recall conversations historically, and there were… from our behavioural specialist supporting the team, with Sally’s behaviours.

C: When you say historically can I take it this was at Stourbridge Road before The Dock?

JC: [Can’t hear]

C: More recently OK, since Sally moved to The Dock, had anyone raised with you a concern they were meant to be monitoring her bowels but this was proving quite difficult?

JC: No

C: We’ve heard evidence from staff who worked with Sally at the time that monitoring her bowel movements proved very difficult because she liked her privacy. Who’s responsibility was it to try and strike that balance and find a way of monitoring her bowels as the GP required to ensure Sally was kept safe?

JC: The GP was the prescriber, staff had responsibility to support Sally… I’d see that as responsibility of Support Workers and Locality Managers. To ensure the GP’s instructions.

C: If that was proving difficult or impossible to do, how should that have been escalated?

JC: [Can’t hear] Could get support from myself, the xx would get involved…

C: I want to understand the chain of command if you like. Would the Locality Manager come to you and say these are issues, what do you suggest, or would you expect the Locality Manager to find a Learning Disability Advisor?

JC: Yes I’d expect them.

C: You’d expect them to do that. You said at the beginning of your evidence was no specific training Dimensions provided to staff about constipation, particular in people with learning disabilities and bowel care. Has that changed since sally’s death?

JC: Yes

C: Tell us what’s changed?

JC: [Can’t hear]

Ms Campbell told the court that training was now available about constipation, how to support people with their diet and that there was also training about recording.

C: So training, including training about the fact that constipation, in severe cases, can lead to severe health issues, sepsis and even death?

JC: Yes

The coroner asked who that training was provided to but I couldn’t hear her answer, later she said that training was made available to other staff, not just Dimensions staff. The coroner asked if she was satisfied that all care staff currently employed by Dimensions had undergone training and she said that she couldn’t answer that. The coroner checked that was the intention behind the training and Ms Campbell confirmed it was. There were then a number of questions where I couldn’t hear answers, and then coroner turned to training about auditing.

C: Are Locality Managers trained in how to audit, and check the records are being completed properly?

JC: Yes

C: The record keeping training provided, again is that one off or are staff regularly receiving updated training?

JC: [Can’t hear]

C: How often?

JC: [Can’t hear]

C: Are you in a position to say you’re satisfied all current Dimension’s staff have received that Dimension’s training as opposed to the County Council’s training?

JC: [Can’t hear]

C: Lastly can I ask you this, as Operations Manager, clearly with a lot of experience in this field, the monitoring of Sally’s bowel movements, the recording of those bowel movements, the provision of medication for Sally’s bowel issues in accordance with the GP’s instructions, would you agree with the suggestion that amounted to a basic level of care for Sally?

Ms Campbell agreed with the coroner’s suggestion.

The court then adjourned for a lunch break, before returning for questions from counsel. The coroner reminded Ms Campbell to speak into the microphone and apologised to those attending on Teams, saying that he thought it was a connection issue rather than the quality of the system in place as this witness spoke appropriately loudly.

Mr Clarke for Sally’s family was up first and he started by asking Ms Campbell if when Stourbridge Road and The Dock were de-registered, any guidance was given about what difference that meant in terms of the care and support provided.

JC: I don’t think was a significant difference in what was expected, it was a difference in the status of the home and in tenancy. Support Workers would be given help to understand how to support someone with their tenancy, in terms of everything they’d have been doing previously, that would have continued.

SC: One of the things was Sonia Parchment’s evidence, the expectation was bowel movement’s would be kept and monitored at Stourbridge Road, at The Dock we see a change, absence of them. Was any advice given to Support Workers about the need to maintain such records at The Dock?

JC: Wasn’t given by myself. That would have been the Locality Manager and [can’t hear]

Mr Clarke then asked about the advice in the 2016 Behaviour Support Plan that suggested the approach was trialled a couple of times, and asked if there was anything that would prevent further advice or support being sought from that team in 2017. Ms Campbell said that there wasn’t any reason not to as far as she was aware, and told Mr Clarke in response to a later question that it would be the Locality Manager who would liaise with that team.

SC: Was that contingent on the Key Worker raising with the Locality Manager, or something they should initiate having reviewed records?

JC: Could be both, could be the Locality Manager realised issues with guidance given from the Behaviour Support Team, or could be review period… [can’t hear]

SC: If that advice was sought, would you have expected that to be documented?

JC: I would have expected it to be documented, yes.

SC: Would it be fair to say if we were looking for that, it would be in the Appendix to the Support Plan?

JC: Not necessarily, it could be an amended Behaviour Support Plan issued.

SC: On the basis the document we have is dated 2015, is it right to infer it appears no such additional advice or support has been requested from that time to Sally’s death?

JC: That’s what I’d assume unless there’s a further report which hasn’t been made available.

SC: We heard evidence from one of the witnesses about changing the way Sally was supported relating to privacy and challenging behaviour. Would you expect that to be dealt with by a Best Interests Decision?

JC: What changes sorry?

SC: Original Behaviour Support Plan makes reference to monitoring Sally, and privacy, in which case carers wouldn’t accompany her. Is that kind of change that would require a Best Interests Decision?

JC: Possibly but it depends on the situation, the support Dimensions deliver, we’d always be looking to encourage people to be as independent as possible… [can’t hear]

SC: Given the history of Sally’s constipation, and the risks associated with that, and the balancing exercise between those considerations … isn’t it important a documented position is taken?

JC: Yes it would help if there was something documented, yes.

SC: In terms of the Care and Support Plan, we’ve heard various evidence. Who is responsible for ensuring the Care and Support Plan is followed practically?

JC: The Locality Manager.

Mr Clarke then moved to ask questions about the Dimensions internal Quality Review of The Dock that took place shortly before Sally died. Asked if it would surprise her that no-one spoke to Sally’s sister, Julie Bennett, or any member of Sally’s family at that time, Ms Campbell responded that she wasn’t aware if the family were spoken to on that occasion. In response to a further question she said that in a small placement the likelihood was that they would try to contact all family members and she said Sally’s mother was her next of kin, and she knew that she was in care at the time.

The coroner interjected to ask whether he could take from Ms Campbell’s answer that she’d have expected the Quality Review team to make contact with Sally’s family, she responded yes.

Mr Clarke then took Ms Campbell to a document in the bundle, an inspection report of a spot check conducted by Worcestershire County Council of services where Ms Campbell was the Registered Manager. She confirmed Julie McGirr wasn’t the Locality Manager of any of those services. Mr Clarke listed a number of issues highlighted in the conclusions of the Worcestershire County Council inspection that included issues about fragmented information, documents kept separately in different places, about the need for monitoring and following on from that information about bowel management. He said that issues raised included monitoring of health conditions such as bowel movements when required, was inconsistent, with different charts used in each home and recording not being clear. The final concern he highlighted was medication audits conducted weekly with errors identified.

SC: Thinking about those concerns, were any of those issues raised with you as Registered Manager, in terms of internal quality auditing?

JC: Not to my knowledge, I can’t say for sure, but not to my knowledge.

SC: Was there any feedback from the Locality Manager about concerns about their quality of auditing?

JC: No

When Mr Clarke asked if there had been changes to how Dimensions conduct audits since Sally’s death, Ms Campbell said there had been significant changes, including that the Quality Assurance Team and the Regional Managing Directors might go into services and do spot checks.

Next Mr Hassall KC for Dimensions asked questions of Julie Campbell (despite Ms Campbell still being a Dimensions employee she is separately represented as an Interested Person).

Mr Hassall started by asking Ms Campbell if another change at Dimensions since Sally’s death was who was registered with CQC as Registered Managers, and how that was organised. Ms Campbell agreed. Mr Hassall said at the time of Sally’s death Ms Campbell was Registered Manager for a much larger number of care settings than would ever be the case now, she agreed. Ms Campbell told the court at the time of Sally’s death she was the Registered Manager with CQC for approximately 38 homes, and a year later CQC registered more homes, bringing the number she was responsible for up to 51 services. Mr Hassall then asked Ms Campbell about the process of becoming a Registered Manager with the CQC. She confirmed that CQC make an assessment of whether someone is a fit and proper person for the role.

CH: Drawing that together then, at the time of Sally’s death, the Locality Manager for The Dock was not the registered manager for CQC?

JC: No, she wasn’t.

CH: So the CQC haven’t undertaken a fit and proper assessment of that person?

JC: Not at the time, but she had previously.

C: To be clear, she wasn’t required to be registered as a Locality Manager?

JC: No, she wasn’t.

CH: So the change that’s been made is Locality Managers are now the same sort of level, they are now Registered Managers. Registered with the CQC?

JC: Yes, that’s correct.

CH: So Locality Managers now, have to pass the CQC fit and proper person test?

JC: Yes, if Julie McGirr was working today she’d have to be registered by the CQC.

CH: Is another effect of that then, those who have Registered Manager status with the CQC have a smaller number of settings they’re the Registered Manager for?

JC: Compared to myself, yes, considerably less.

Mr Hassall then asked Ms Campbell about Deprivation of Liberty orders and checked that there had been alterations to those when Sally moved to The Dock due to a change of address, discussing the Court of Protection involvement. Mr Hassall stated at that time Sally’s next of kin was Julie Bennett, and asked whether she was an Interested Person in the COP proceedings, Ms Campbell agreed with both statements.

Mr Hassall asked Ms Campbell if Sally had been stopped from using the toilet independently to assist with bowel monitoring, she would have considered that an additional deprivation of her liberty, to which she responded “absolutely, yes”, agreeing with his follow up question that any additional deprivation of liberty would require an application to the Court of Protection.

C: Is that right? If that course of action had been proposed, would you have been going back to the Court of Protection to say you need to amend the DOLS order because now we want to monitor Sally’s bowel movements?

JC: [Can’t hear] Different level of restriction, would certainly have required a Best Interests meeting with ourselves and the local authority to determine whether was in her Best Interests, and would have been added to her DOLS.

C: Further application to the Court of Protection?

JC: Yes

C: Thank you.

Mr Hassall continued by asking whether it was Ms Campbell’s understanding that Ms McGirr’s evidence that there was another person supported at The Dock, at the same time as Sally, for whom bowel charts were completed was correct. Ms Campbell said that was her understanding.

CH: That’s your understanding?

JC: Yes

CH: And bowel monitoring was carried out for that person, without as far as we know, any adverse incident?

JC: Yes

CH: Thank you, those are my questions.

C: I realise everyone has their own needs, but are you able to say whether the other resident had the sort of needs and challenges Sally presented with?

JC: I’d say she’s got complex needs.

C: So not straight forward thing to do, but it seems to have been done?

JC: Yes, she wasn’t as independent as Sally in terms of taking herself to the toilet.

C: OK. Mr Kay?

Mr Kay KC, Ms Campbell’s own counsel, asked her to clarify one matter arising out of the questions Mr Hassall had asked, then said he’d give her an opportunity to confirm some points for the purpose of the inquest.

DK: A point arising, is it correct after Sally’s death that the CQC increased your own personal registration to allow you to be the registered person not just for 30 odd settings you’re already responsible for, but another 20 odd settings?

JC: Yes, was one in Oxfordshire, was part of my area, I applied to CQC for registration, and was another 66 people.

DK: So you individually went from being a responsible person for 110 service users, up to about 176?

JC: Yes, that’s correct.

Mr Kay asked about a document he’d shared the previous day with the Dimensions Locality Manager, Ms McGirr, and asked Ms Campbell if that document of roles and responsibilities and delegation, was just for Julie McGirr or was for all Locality Managers at the time. Ms Campbell responded that it was for all Locality Managers who came under the Domiciliary Registration.

Mr Kay said he’d then ask Ms Campbell to clarify a few points.

DK: Did any inspection by the CQC, or any internal audit, suggest to you that there was a problem at The Dock in relation to bowel monitoring or the administration of medication?

JC: No

DK: Did any Support Worker or Support Worker Team Leader or Locality Manager or Assistant Locality Manager ever suggest to you there was a problem in relation to bowel monitoring or medication administration at the dock?

JC: No

DK: Is that something you’d have expected to be brought to your attention?

JC: Yes, absolutely, yes.

DK: Had it been, was it something you could have taken steps to address?

JC: Yes, I’ve got a lot of experience and believe I could have supported.

DK: Did anyone, including Support Workers, Locality Managers, or Sally’s family, ever raise with you any concerns over her health or wellbeing in relation specifically to constipation?

JC: No not with me, no.

DK: Did you have any reason prior to her death to think there was any issue over the health or wellbeing of Sally?

JC: No. The last time I saw Sally she looked very well, we were at an event, a BBQ, and she did look very happy.

DK: Finally, one of the matters raised yesterday by Julie McGirr was what she called out her concerns about capacity. To give you an opportunity to respond to that, did Julie McGirr tell you at any stage before Sally’s death, that she, Julie McGirr, was unable to undertake any part of her job, specifically relating to [can’t hear]?

JC: No. She referred at some point was lots of people being recruited and I gave her extra support for that, but she didn’t raise with me anything about capacity for her job.

That was the end of questioning of Dimensions Operations Director, Julie Campbell. The coroner thanked her for her evidence and told her that she was free to stay or leave, as she wished and that it was a matter for her.