The second witness called to give evidence on the final day of Sally’s inquest, was Helen Orford, who is now Managing Director of Discovery, which she described as a subsidiary of the Dimensions Group, at the time of Sally’s death, she told the court she was Regional Managing Director for Dimensions. She said that she’d changed her role two to two and a half years ago.

C: Thank you. We’ve heard following Sally’s death Dimensions conducted their own internal investigation, we’ve heard evidence about that from your colleague Deborah Hubbocks, and Worcestershire County Council, who funding Sally’s placement at The Dock, conducted their own Adult Safeguarding Review. And, in addition, there was a LEDER review?

HO: That’s right

C: You’re fully aware of the outcomes of all of those investigations?

HO: I am, I attended the LEDER review as well.

The coroner said that he’d like to know what action Dimensions took to address the findings of those reviews and investigations.

C: I’d like to hear, given the findings of those reviews and investigations, what action Dimensions have taken to address the issues raised in those investigations and reviews please.

HO: I’d say broadly the organisation, the response of the organisation was far reaching, and not simply limited to The Dock or surrounding areas.

Was a number of things the organisation did as a result of all of those investigations. In addition to things set out in my statement, we have made significant changes to some of our systems, ways of monitoring, auditing to ensure the people we support receive the right quality of care.

And obviously that we ensure they have safe care, and also our Quality Review processes. So we have independent colleagues that visit homes to ensure and satisfy ourselves that we have the right checks in place.

We have also implemented a range of different audit processes and xxx with frontline managers … Operations Directors now have clear audit remits for visiting homes of people we support and also conducting unannounced visits.

That’s true of myself and other senior members of the organisation. We take our responsibilities certainly very seriously in terms of ensuring ourselves, through sample checking and often our system gives us good information that is able to direct us to where we may want to pay greater interest.

Next the coroner moved on to ask about the lack of auditing taking place at the time of Sally’s death, and how that has been addressed.

C: OK. One of the issues this inquest has raised has been record keeping, and the auditing of record keeping, to check records are being kept as they should be. It was quite apparent at the time of these events, no working system was in place to ensure, certainly at The Dock, to ensure Sally’s plans and the charts that needed to be filled in were being filled in. There was no system of checking that, and ensuring was running smoothly, was in place. What changes have you made to that then to ensure there is a rigorous system in place?

HO: Having one system of recording, we have our iplanit record keeping system, this electronic system is in place in the organisation. As heard in evidence it was in trial and pilot stage at time of Sally’s death. That is now embedded within the organisation as the way we work. In terms of checking records, we have clear guidance for our managers to sample check and audit records. Our managers are also now the Registered Managers with the CQC, which they weren’t at the time. They’ve all been independently interviewed and assured their fit and proper to undertake the tasks presented to them. As well we also approximately two years ago introduced a new system which is ?? which is where we now record all accidents and incidents including near misses. We have total visibility across all levels of the organisation and are able to look at trends and themes and assure ourselves again we’re learning from any near misses or incidents that take place.

C: Thank you. We know in Sally’s case there was a paper system. Which consisted of booklets for each month, and that the Locality Manager would be required to audit the notes at the end of each month. With the new electronic system, how often are these checks, audits required of Locality Managers?

HS: Locality Managers, and or their Assistant Locality Managers should be checking the records of the people they support, standard check on a weekly basis. They are required to write a report as to any gaps they find within the records and address with any particular colleague not writing quality notes or where there are gaps in information. That is then addressed through our Support Workers 1-1s with their managers.

[Given the inquest is now over I can add commentary into this post, and I’d just point out that’s exactly the process that was in place at the time of Sally’s death, yet the Key Worker was not auditing weekly, and the Locality Manager and/or Assistant Locality Manager did not identify that, and did not audit themselves. Hence neither the failure to give Sally her as required medication for 10 months before her death, and a failure to monitor and record her bowel movements once she moved to The Dock, 18 months before her death, were not picked up on. So, I’m not sure how this answer really addresses those concerns, other than saying staff are required to do what they were required to do].

The coroner then moved on to ask specifically about changes in relation to constipation.

C: Thank you. So far as the specific issue of constipation is concerned, we’ve heard evidence in this case that those with learning disabilities are at greater risk of constipation, and those on certain types of medication, in particularly psychiatric medication can be at greater risk of constipation. What, if any measures, have Dimensions put in place to ensure staff and managers at your residences understand the importance of monitoring bowel movements and they understand the risks associated with constipation?

HO: Again coverage across the organisation, through a range of learning resources on our learning platforms there are guides for Managers of our Quality Team. We also have recorded webinars. We’ve made constipation one of the Never Events, makes absolutely clear by training and colleagues understanding [this answer was a little hard to hear but I think that’s what she said].

C: What do you mean by Never Events please?

Ms Orford said that it was a well-known concept in the NHS and referred to events clearly identified and measurable that result in death or significant disability that can usually be avoided if everyone acts appropriately and follows established procedures.

HO: Constipation is one of seven Never Events recognised within the organisation.

C: So, in terms of Managers and carers, Support Workers, how have you ensured they understand risks associated and what steps they need to take to ensure those they’re looking after aren’t at risk?

HO: We have a very comprehensive Constipation Tool Kit, with screening tools. We prompted all Managers and colleagues to consider every person we support and whether they are more likely to be prone or disposed to constipation, may be through the medication they’re on, through the way they present in terms of their disabilities. And also not only to limit their understanding, in terms of what they see, but also to engage with health professionals and families, those people who know the people we support best, to ensure ourselves we’re educating everybody really in terms of the perils of constipation.

The coroner’s final questions related to training and resources that have been developed by Dimensions since Sally’s death.

C: In terms of training your staff what training have you provided?

HO: There’s training through a number of different means recognising learning styles are different, training followed up in team meetings and 1-1s with managers as well. Very much a topic constantly referenced and reminded throughout the organisation.

C: Have all your staff at all your residences now received this training?

HO: Through varying resources we have, it’s not one size fits all … bespoke and tailored to each individual persons needs in terms of what’s provided in each home. In the Worcestershire area as well, we have the added benefit of constipation training designed by Worcestershire County Council, which complements our own training. We’ve certainly not felt just because we have our own resources and training… we’ve also engaged with the local authority training.

C: Do you use agency staff?

HO: We do, yes.

C: What steps are taken to ensure the agency staff you use have had this training?

HO: We have an agency worker profile, they have to have completed particular training if support individuals with any particular health related tasks. If they aren’t suitably qualified and competent to undertake that role then they won’t be required to do so.

C: Right. Besides the training, how are those caring for residents able to identify constipation may be an issue in first place, with any particular resident?

HO: Through daily recording and monitoring of someone’s general wellbeing, not limited to constipation … Constipation Toolkit provided is very clear in terms of screening tool and bowel management plan, there are plenty of resources available to guide our colleagues to do the right thing.

C: Besides the training you provided to staff, I get the impression from your statement Dimensions have gone further and provided resources to those outside the organisation, is that right?

HO: Yes, we didn’t limit our findings and the resources developed as a result of Sally’s death wasn’t limited to within the organisation. We engaged other organisations in the work we were doing as well, including our Health and Wellbeing Lead engaging with the British Institute of Learning Disabilities … significant levels in terms of those who can influence the learning that can be taken from this very sad situation.

C: Thank you, those are all the questions I need to ask you at the moment. Mr Clarke?

[Again, some commentary now the inquest is complete, what I can not comprehend, just do not understand, is how it is possible to reconcile all of this activity in light of Sally’s death, with Dimensions UK employing a legal team led by a KC, to argue against their prosecution on a timescale technicality. If they recognised all of their failings, and have apparently gone to such lengths as a result, why try to sink the criminal prosecution? Why not plead guilty, hold your hands up, and do the right thing?]

Mr Clarke for Sally’s family started by asking about the quality assurance processes in Dimensions and whether they still have an internal audit team.

Yes we have our Quality Assurance Team … they visit, they have changed significantly, the process they follow has changed significantly, the Quality Assurance Reviews are carried out in line with CQC Key Lines Of Enquiry. The ratings for homes are combined with ratings CQC would provide, so there’s no ambiguity in terms of expectations of what is required of managers and our colleagues. All reviews where shortfalls or things are found which haven’t been correctly completed will result in an action plan being provided to the Regional Manager and their line manager, and myself as Managing Director, my equivalent for Dimensions receives copies of those.

Ms Orford said that work would happen with Dimensions services that were registered with CQC, and those which aren’t. Mr Clarke then asked what Dimensions had gone since the Worcestershire County Council review in 2017 found that a number of Dimensions homes had similar problems, especially with regard to record keeping and auditing. He asked Ms Orford if Dimensions identified why that had happened, she responded:

We took the findings from the Worcestershire County Council Quality Review and assured ourselves as to what was happening in the local area, in terms of why those gaps really were evidenced. Some of the quality reviews had been picked up and were being worked on through continuous improvement and action plans at the time.

[Again commentary – the inference from this response is that some, including at The Dock, were not. That cost Sally her life].

Mr Clarke’s final question asked how Dimensions would identify if there were gaps in their Quality Assurance processes.

As I said they are much more focused, in line with CQC Key Lines of Enquiry. Often Quality Reviews focus on safe and well-led to ensure services are running safe operations and managers managing homes are doing so in lines with our expectations.

There were no questions for Ms Orford from Mr Cox for Worcestershire County Council, from Mr Mumford for Dr Williamson, from Ms Wilks for CQC or Mr Kay KC for Julie Campbell.

Mr Hassall KC for Dimensions said that he wanted to ask Ms Orford a few questions to “draw out a little bit more” of the detail in her statement about some of the policies and procedures put in place since Sally’s death.

CH: You talked about the Constipation Toolkit which Dimensions developed, just want to ask a few questions, to draw out what exactly that is and what it looks like. Is it right part of it is training? And there is guidance to staff which explains specifically why bowel management is important?

Ms Orford nods

CH: It sets out [can’t hear] methods to manage constipation and then sets out how information should be recorded using the Bristol Stool Chart?

HO: That’s correct

CH: Thank you, so there is now a new proforma for recording bowel information, is that right?

HO: That’s correct

CH: And that was adapted by Dimensions from the Bristol Stool Chart, the nationally recognised scale for bowel movements?

HO: Yes, that’s correct and recognition of the importance of PRN medication was added.

Mr Hassall then discussed some guidance produced by PAMIS, and other contents of this toolkit.

CH: Also specific information about managing bowels and bladders for people with profound and multiple learning disabilities, that was created by an organisation called PAMIS*?

HO: That’s correct

CH: So that is included within the Constipation Toolkit which Dimensions put together?

HO: Yes, correct

CH: And another part of the Toolkit is guidance for support workers? To say how you prepare for a constipation appointment with the person you’re supporting?

HO: Yes gives them some [can’t hear] questions to ask and to be much more curious in those appointments.

CH: And recording agreed action points between the Support Worker and whatever other professional the appointment was with?

HO: Yes, and very, very important to make the contemporaneous notes, so if need to clarify anything is an opportunity to do that with the Doctor or professional.

Mr Hassall then suggested that this work reflected Dimensions’ acceptance that clear record keeping following GP visits had not happened in Sally’s case.

CH: Does that reflect Dimensions’ acceptance that was something that had not happened in Sally’s case? There had not been clear recording of appointments there had been with GPs?

HO: Indeed, yes

CH: Finally is a Constipation Screening Tool, the idea of that document is to help Support Workers recognise the signs of constipation, and also potentially sepsis, arising from constipation?

HO: That’s correct

CH: That Constipation Toolkit is published openly on the Dimensions website**?

HO: Yes

CH: So another thing that happened was a [can’t hear] of PRN medication, as required medication, that renewed guidance from [can’t hear] there was a review and altering of the PRN Protocol document?

HO: That’s correct, we engaged OPUS pharmacy, for training and to review our policies, procedures and associated documents which included PRN Protocols and recording.

Mr Hassall’s final set of questions sought to show how generous Dimensions have been in sharing their learning.

CH: And you told the learned coroner that the review, the learning, the reflection that there was within Dimensions was not kept within the organisation. We’ve dealt with the online publication of the Constipation Toolkit, did Dimensions also create an animated video which was an education guide to constipation?

HO: Yes

CH: And was that to try and get beyond the embarrassment that often belies experience in talking about bowel movements?

HO: Absolutely, we support people with wide ranging and varied needs, even using that kind of material, for people who are a little more independent and are able to go to the toilet independently, finding creative ways to help them understand the effects of the dire consequences really of constipation.

CH: There was a publication of an article on the Dimension’s website, by the former CEO Steve Scown, and it was entitled wasn’t it Why we must talk about constipation. It set out what had been learnt following Sally’s death?

HO: Yes, there was very much an open acknowledgment at the time of Sally’s death.

CH: Dimensions also funded and co-wrote a book with an organisation called Beyond Words, published as a paperback, The Trouble with Poo…. and a project called My GP and me … that was about training within GP surgeries, helped to make their surgeries more accessible for people with learning disabilities?

HO: That’s correct

CH: And one of the things that addressed specifically was making the best use of the valuable learning disability review appointments we heard about from Dr Williamson?

HO: Yes, that’s correct.

CH: Thank you, those are my questions.

The coroner thanks Ms Orford and released her, before the final witness, Susan Wall of the CQC.

[*PAMIS Guidance – Some more commentary here from me. This guidance was written by PAMIS in 2011, and funded by the Scottish Government, so I’m really not sure why Dimensions are claiming this as mitigation for having included it in a toolkit, which sounds like a collection of resources, after Sally’s death. This guidance was available long before Sally died, and was nothing to do with Dimensions. Ironically when I visited the link on their website to the guide this morning it was not working.

** There was a lot of talk about the Constipation Toolkit in court, but it’s hard to ascertain where that is, or indeed if it is ‘a toolkit’ or just a lot of links on a section of the Dimension’s website, the link is to what I think they’re referring, but interestingly they don’t link to ‘the toolkit’ in their own statement issued after Sally’s inquest concluded]