The final witness that we heard from on Day 3 was Julie Harris from Worcestershire County Council. She is an Advanced Social Work Professional in the Safeguarding Adults Team at Worcestershire CC and she managed to speak loudly, clearly and into the microphone and it was an auditory relief. We heard she was the author of a safeguarding enquiry into the circumstances of Sally’s death.

Asked what the role of Worcestershire CC was in relation to Sally’s placement at The Dock, Ms Harris explained that commissioning and registration of services were outside her remit. The coroner explained that he was more interested in any oversight role.

C: More to do with oversight, did the County Council have any regulating or monitoring role?

JH: An annual review would be completed with the service used, a particular resident should have annual review unless it was specified that it was needed any earlier, and we have a Quality Assurance and Commissioning Team who provided support to places such as The Dock, or an agency such as Dimensions, any agencies we commission.

C: I think we heard already the County Council provided and funded Sally’s accommodation?

JH: Yes

C: And we know in May 2016 she moved to The Dock, slightly different model from previously?

JH: Yes

C: But any service user for whom the County Council was providing the funding you’d complete an annual review?

JH: Yes for each service user.

C: For each service user, then if you commission out services such as here you had a QA and Commissioning Team who’d provide advice and support if required?

JH: Yes

The coroner then moved on to ask questions about the role of the Safeguarding Team.

C: In terms of overseeing services commissioned, and check they are operating as they should, unless any concerns are raised with you, would you have any oversight?

JH: My team, not unless concerns were coming into us in safeguarding. My team would [can’t hear] quality.

C: OK. Am I right in thinking after Sally’s death in October 2017 there was a safeguarding concern raised with yourselves?

JH: Yes, concern raised with the Safeguarding Adults Team in January of 2018. This was as a result of Sally’s sister sending a complaint, I don’t know whether electronic or a letter, I don’t know. A complaint came into our Complaints Department.

C: Directed at yourself or Dimensions?

JH: Raising concerns about Sally’s cause of death, and that she was being cared for at The Dock, and we needed to be aware of the concerns. Then our Complaints Department obviously received this complaint, and felt that it was not appropriate for them to deal with, that it needed to come to the Safeguarding Team because it was so serious.

C: So, did you conduct your own investigation?

JH: The Safeguarding Team, when the referral came into the Safeguarding Team, a worker was then allocated, myself, then we’ll open up a Safeguarding Enquiry. Try to gather as much information as we can to look at potentially where things have gone wrong, how we can learn from them, if there was any elements of neglect, those kind of areas, to see whether concerns being raised are substantiated or not.

C: Ok. How did you conduct your Safeguarding Enquiry? What information did you use?

JH: I used, I met with Sally’s sister, which would be normal practice for us to liaise with families.

C: Julie Bennett?

JH: Yes Julie Bennett, to get her perspective on the concerns she raised, and Julie made me aware she had some care plans from The Dock so I reviewed those care files Julie had. I also liaised with our Quality Assurance Team to let them know we’ve got this concern come in. I liaised with the CCG to discuss concerns with them, liaised with CQC, gathered as much information as I could.

I did go to The Dock with another worker in the Quality Assurance Team, we went together. At that point I did ask is there any other documents you’ve got that I need to have access to, anything else in relation with regards to Sally’s care you can provide to me and I was provided with the iplanit recordings.

The coroner asked about the report that Ms Harris produced.

C: OK. You then, I think, produced a report, is that right?

JH: Yes.

C: By the time you produced your report, you were aware of the post mortem examination?

JH: I was aware of that. I think that was mentioned in Julie Bennett’s initial complaint through to us, I think Julie had received that.

C: Ok, I want to go through some of the findings in your report. First I want to ask you about, is the Support Plans produced by Dimensions, what findings did you make about those … Dealing first with the Medication Support Plan, what did you feel about that?

JH: It was a concern for me because it wasn’t detailed. It noted the Laxido was PRN, as required. I hunted for a PRN Protocol Plan and couldn’t find one anywhere, and I’d have expected to see one.

C: What would be the purpose of a PRN Protocol Plan?

JH: Would describe medication, such as Laxido, give indication what medication was used for, outline of prescription details. I know it’s one sachet mixed with water to try to achieve one soft bowel motion. I would expect to see that in there. Also what steps staff need to do if they need to use that medication, what would lead them to think they needed to use PRN medication. Also I’d expect to see in a PRN Protocol, what to do if the medication hasn’t been successful in achieving what it said on the prescription details, escalating that to the GP or health professionals, what next steps could be taken.

C: Thank you, what about the Continence Support Plan?

JH: My report says it makes no mention of Sally’s constipation or how to manage this. No mention of any bowel monitoring that may be required. I’d have expected if PRN Plan is in place for laxatives, would expect to see mention of that in there, history of constipation, medication Sally is taking, signs to look out for and how to monitor that really.

C: Mobility Support Plan?

JH: Yes I looked at this because was mention the night before Sally died that she was very unsteady, wobbling on her feet. Think was comment in there, it noted if Sally was unwell. Mobility Support Plan detailed that Sally’s mobility can deteriorate when she is unwell. For me that linked into the unsteadiness the day before, and that was something potentially could be considered at an earlier stage.

C: We’ve also seen a document entitled Health Action Plan or Health Support Plan, what are you able tell us about that?

JH: For people with a learning disability it was a government recommendation, to try and ensure that someone with learning disabilities, that their health was improved, health and wellbeing, overall really. So Sally did have a Health Action Plan. It did mention Sally suffered …

C: Sorry, I referred initially to the Health Support Plan?

JH: The Health Support Plan made no mention of Sally’s constipation and how to monitor and manage this.

C: Why was that significant?

JH: Because it doesn’t mention the impact of constipation on Sally’s health, and history of constipation.

C: Let’s deal with the Health Action Plan next. Tell us the difference between the Health Support Plan and the Health Action Plan?

JH: Health Action Plan was a government initiative really and recommendation really, to promote the overall health and wellbeing of people with learning disabilities, to try and ensure their health needs are being considered, and how they’re being considered.

C: What did you notice, if anything, about Sally’s Health Action Plan?

JH: It said Sally suffered from constipation, it noted Laxido was PRN, but then my concern was the Health Action Plan didn’t correlate over into the Support Plan.

C: Didn’t correlate with Health Support Plan or overall Support Plan?

JH: I’d say with both.

C: In what way did it not link in?

JH: Like I said the Health Action Plan is saying Sally suffers with constipation, talks about Laxido being PRN. The Health Support Plan didn’t mention Sally’s constipation and neither did the Continence Support Plan, makes no mention of Sally’s constipation or how to manage that. My expectation was those should correlate with each other.

The coroner checked that Ms Harris had been able to see the electronic bowel charts covering 1 January to 27 October 2017, she confirmed she’d seen them in a different format to the coroner’s summary but she’d seen the same contents. The coroner asked if she had any concerns about them.

JH: My investigation enquiries picked up the chart was filled in sporadically by staff and in September 2017 was no recording at all, and staff recorded on the chart a total of 13 times between 23 June 2017 and 16 October 2017. I would have expected there to be more recorded within the document.

C: Just looking at that document, in your view does that give any insight at all as to the state of Sally’s constipation?

JH: It concerns me, concerned me that there is kind of obviously lots of notes of no bowel movement, no bowel movement, then when Sally did have a bowel movement, 17 October, Sally had a very large bowel movement. That would concern me to a degree of the discomfort and the fact then is nothing much recorded, it’s just been sporadically recorded.

C: Not only very large, but type 1 on the Bristol Stool Chart, so very hard. You’d think that might have been very painful, cause of discomfort?

JH: Yes

C: But it doesn’t look like any action has been taken following that?

JH: No

C: Did you form an overall view of the keeping of documentation at Dimensions, at The Dock?

JH: In terms of this specific issue I was really concerned, that it was, that there really wasn’t much reporting, as I’d expect there to be with someone on PRN Laxido, with this history of constipation that Sally had.

C: Recording of bowel movements specifically?

JH: Yes, and also the fact that the PRN medication hasn’t been given was a concern.

The coroner asked a specific question about the administration of Laxido to Sally before her death.

C: Were you able to identify from the information you had, when the last time Sally was given Laxido?

JH: My enquiry states that from looking at MAR charts, and medication stock checks, identify that no Laxido was given to Sally from December 2016 until her death on 27th October 2017

C: OK.

JH: That’s what my findings were.

The coroner then moved on to asking about the knowledge of staff at The Dock, and auditing processes.

C: I may have asked you this already, when you went to The Dock, did you speak to staff members yourself?

JH: I don’t recall speaking to individual staff members, not sure whether it was Julie Campbell who was there, I’m sorry I can’t recall.

C: Were you nonetheless able to reach a conclusion about the state of knowledge staff at The Dock had specifically around bowel care, constipation and the like?

JH: It concerns me Sally had this history, and that she had PRN medication and I couldn’t see the documents I’d expected to have seen there and that concerned me in terms of knowledge, but also in terms of oversight, from more senior management.

The coroner then asked Ms Harris if it was something she’d have expected to be identified.

Absolutely I’d have expected, especially with the auditing we’d have expected to be done, and the oversight of care plans. I would have expected that to be picked up.

The coroner then asked whether Worcestershire County Council identified any action they needed to take following the Safeguarding Enquiry.

JH: We involved, certainly I involved our Quality Assurance and Commissioning, who worked I believe quite closely with Dimensions, in terms of trying to improve the situation and reducing the risk to other service users. So, yes there were specific findings that came out of that. There were a series of meetings with commissioning, I wasn’t party to all of those, would be the Quality Assurance and Commissioning Team and I’m aware improvements were made.

C: Are you aware of specific actions taken as result of your investigation?

JH: I’m aware Bristol Stool Charts were brought in, I’m aware the County Council were providing training to supplement what Dimensions were doing. That was an ongoing piece of work with our Quality Assurance and Commissioning Team and Dimensions.

C: Am I right in thinking for a period of time new referrals to The Dock were suspended?

JH: That’s correct.

C: How long did that remain in place?

JH: I’m sorry I don’t know. Would have been until whatever actions drawn up in the action plan were met, and the risk was reduced.

C: So far as the situation now is concerned, does the County Council still commission services at The Dock?

JH: As far as I’m aware

C: And with Dimensions generally?

JH: As far as I’m aware. Sorry, that’s slightly out of my remit.

That was all of the coroners questions and then it was over to Mr Clarke, for Sally’s family.

SC: Suppose Ms Bennett’s complaint hadn’t reached you, in the case of a death like Sally’s would a Safeguarding Enquiry be started?

JH: If we’re aware of it. I’d have expected the provider to have informed us. They may have informed the social worker and it didn’t come to the Safeguarding Team.

SC: What would be the trigger to make a referral to the Safeguarding Team?

JH: We work under Section42 of the Care Act, initial criteria of Section 42-1 is if an individual has care and support needs, is at risk or experiencing abuse or neglect … it didn’t come through to us, however in the case of Sally the council can also conduct non-statutory safeguarding inquiries, which is where the risk to the individual is no longer there, but there could be a risk to other people in the service.

SC: In terms of the investigation, for example, the (Dimensions) internal investigation identifying concerns about PRN medication, does that trigger a duty to contact the Safeguarding Department?

JH: If there’s an issue with PRN medication, if there’s concerns of harm being caused or experienced then I’d say yes. That would warrant a referral to us, if concern around harm is there.

SC: What about record keeping?

JH: If it was considered neglect, yes. Some other issues, quality assurance issues go to our Quality Assurance Team, but if its neglect that will come to us.

SC: Just to be clear on point about neglect, what is considered neglect in Section 42?

JH: Yeh, omissions that are made, in terms of the care that should be being provided.

SC: In relation to the failures you identified at The Dock, would you consider them to be basic safeguarding failures?

JH: I would consider, yes I would, I would.

No questions from Mr Kay KC, counsel for Julie Campbell. Over to Mr Hassall KC for Dimensions.

CH: You work for part of the local authority, that’s right isn’t it?

JH: Yes

CH: You’re separate to the Quality Assurance Team for social care settings?

JH: Yes

CH: And separate to the general Adult Social Care Team?

JH: Yes

CH: Which would be staffed generally by individuals with responsibility for individual adults with social care needs?

JH: Yes

CH: Local Authority Safeguarding Team has a huge remit, and receives referrals from all sorts of people, all sorts of organisations, about all sorts of risks to individuals?

JH: Yes

CH: And so there was no referral to your team from either the Quality Assurance Team, or the Adult Social Care Team was there?

JH: The safeguarding referral didn’t come from Quality Assurance Team or the Social Work Team.

CH: As you told us following Sally’s death, Worcestershire County Council undertook a review of all care settings of which Dimensions was providing support?

JH: I don’t know, sorry, that falls outside of my remit.

CH: Of course. You’re aware the Quality Assurance Team were looking at, certainly The Dock, where Sally lived?

JH: Yes

CH: And more generally the care Dimensions provided to people?

JH: Yes they did.

Mr Hassall checked that Ms Harris had access to the Dimensions iplanit records, she did; to paper records that Ms Bennett had in her possession, she did; and to the GP’s records, she did. He then asked her whether she saw Sally’s constipation treated in different ways over time.

CH: That’s what I mean, different medication at different times, different doses of those types of medication at different times and also prescription on different basis at different times, so some times PRN and sometimes regular?

JH: Yes

CH: And what you found in relation to Laxido is that the description was one sachet daily, but also as required, to try to get one soft daily motion. So when you were looking at those notes, what did you understand it to be, was it regular or was it as required or PRN ?

JH: I think this is where the importance of the PRN Protocol and the Care Plan being detailed comes in really. My view around that was what the GP was hoping carers could achieve with Sally, was one soft daily motion a day, and the advice around that, to achieve one soft motion a day was as prescribed.

C: Which was what?

JH: Sorry, one sachet dally as required to try to get one soft daily motion.

CH: Did you understand that to be once daily or prescribed on a PRN basis?

JH: That depends on the question doesn’t it, achieving that motion. My interpretation of that, what I would have expected is if Sally wasn’t achieving that one motion daily, then you carry on with one sachet daily but then you escalate concerns back to the GP if that wasn’t working. That would be my expectation.

CH: You describe within your report or your statement, within a section about GP notes just before heading 26 October 2017

JH: Yes, got it yes.

CH: You said: It is unclear why Dimensions staff had not continued with the maintenance dose of Laxido as advised by Dr Sarkar on 05 October 2015. What did you understand her maintenance dose to be in the context of PRN?

JH: Maintenance dose, I would have referred back to the advice which was given by Dr Sarkar, so in terms of maintenance dose, a regular movement, bowel motion by Sally, taking Laxido to maintain that regular soft motion they were trying to achieve

CH: If that was what was required to maintain that motion each day?

JH: Yes.

Mr Hassall then moved to asking Ms Harris questions about a conclusion she made relating to Sally’s annual learning disability review with Dr Williamson.

CH: Then finally, in relation to the advice from the GP you said “when Sally visited Dr Williamson on 7 September 2016 for her annual Learning Disability Review care staff reported occasional use of Laxido and that Sally did not have her bowels open for 7 days and this distressed her”, and you say this “this may have been an opportunity for the GP to question why care staff were only using the Laxido occasionally, when Dr Sarkar had advised of an ongoing maintenance dose daily”. If we work backwards from the end of that, your understanding was what Dr Sarkar had said was it was to be a daily dose, a regular prescription of Laxido?

JH: To achieve that soft bowel motion daily.

CH: So it was daily rather than PRN, and you noted within your Safeguarding Review there doesn’t seem to be any questioning by the GP on that?

JH: Not from the information I was provided, no.

CH: And you were provided with the medical records from the GP surgery as the inquest has been?

JH: Sorry I can’t recall.

CH: No, no. Can I just ask you about this please, think the last page in your report, Analysis of Safeguarding Enquiry and Actions taken, you say “There has been no evidence to support that Sally’s Laxido was ever changed by the GP to PRN”

JH: Yes, that was what I was trying to establish. I’ve not seen any evidence of that.

CH: Is that not covered by ‘as required to achieve one daily motion’?

JH: My understanding was Sally was on previously daily Laxido and I could not see where that had been changed, changed to PRN.

CH: Could you see what was printed on the prescription?

JH: I’m sorry, I can’t recall that.

C: Did you check the MAR charts?

JH: I’m pretty sure I did.

C: Could you have a look please, bundle number 3 go back a couple of tabs to 6.

JH: I’m sure I’ve seen these.

C: You’re sure you’ve seen these. OK, can we just have a look then, I’ll take you to one of the more recent ones. You did see these documents?

JH: 100% I can’t recall, but I’m sure I did.

C: You can see Laxido Orange one sachet daily when required to try and get one daily motion?

JH: Yes

C: Is your interpretation of that, that is one sachet daily or PRN?

JH: My interpretation of this is one sachet daily to achieve that soft bowel motion and you’d continue to take that until the regular pattern of one soft bowel motion a day was achieved.

C: You’ve interpreted that as one sachet daily until you get bowel motion and then stop and restart it?

JH: I think that my feeling would be, you’d need to refer back to the GP about how that was working.

C: Alright, thank you, sorry Mr Hassall.

CH: That was the point I was seeking to explore. On that it doesn’t say as required, it says when required to try to get at least one soft daily motion?

JH: Yes

CH: Alright, thank you. In your analysis at the end you say this “There was perhaps an opportunity where the GP may have also questioned care staff as to why they were dispensing Laxido on an occasional basis, rather than continuing with the maintenance dose”. Again you identify a possible missed opportunity there, but you describe it as a maintenance dose, can I just be clear, that’s not a criticism, but maintenance dose is your phrase looking at all records you looked at?

JH: I can’t be 100% sure, I can’t recall exactly I’m sorry.

CH: You’re not saying maintenance does was description the GP gave?

JH: I can’t recall, sorry.

At this point Mr Clarke and Mr Mumford attempt to help locate reference to maintenance dose in the records.

SC: It may assist to take the witness to email with Dr Williamson, I can see reference to a maintenance dose.

C: Bundle 4, tab number 6, right at the end of the bundle, tab 6 right at the end.

JH: Yes, that’s where it appears.

SC: So to be fair to everyone [reads email – didn’t catch] Reference to ongoing maintenance dose second paragraph down, Dr Sarkar and advice given.

RM: The original electronic note is p3198 [?]

CH: Was this the format in which the information came to you from the GP surgery?

JH: There was also, if I recall, some information from the CCG, information that had been obtained from the GP relevant to this, it was part of the LEDER review as well that looked at this.

CH: Yes, what we don’t have here, correct me if I’m wrong, we don’t have full extracts from the GP records being sent to you?

JH: I can’t recall I’m really sorry, I’d need to check.

CH: Not a criticism, you can’t recall if just this email and original consultation notes?

JH: I can’t recall.

Mr Hassall then asked about other investigations into Sally’s death and Dimensions duty to inform CQC when Sally died.

CH: Finally, was quality assurance work undertaken by the local authority Quality Team? Was your safeguarding review, was also a LEDER review as well, and you were aware there was other investigations going on into the circumstances surrounding Sally’s death?

JH: I was aware of those, yes.

CH: In terms of referrals, we know where the referral to you came from?

JH: Yes

CH: You were aware that Dimensions were required to notify the CQC about Sally’s death?

JH: Yes

CH: And they did that on the day of Sally’s death?

JH: I’m not aware.

CH: You’re aware of the responsibility to do that?

JH: I’m aware they had to notify the CQC, yes.

That was all of the evidence for Day 3 of Sally’s inquest. A housekeeping discussion followed, and we’ll be back in court on Tuesday for Day 4.