Day 2 Jessie’s inquest: Safeguarding enquiry

There was some difficulty with technical connections this morning as the first witness was joining remotely and it was hard for the jurors to hear. The coroner rose part way through her evidence for the clerks to try and find a better solution, which they did. Ms Woolfenden was accompanied by a senior colleague, Mr Gallagher, who was assisting her with IT and providing support.

Alison Woolfenden, Social Worker, Brighton and Hove City Council

The coroner started by telling Ms Woolfenden she would split her evidence into four parts and would be asking her questions about:

  1. Her knowledge of Jessie Eastland Seares
  2. The safeguarding alert she was asked to investigate and what her role was
  3. The contact she had with Jessie
  4. The events of 16 May 2022.

Asked by the coroner whether she had met Jessie before being given the safeguarding alert to investigate, Ms Woolfenden told the court she had previously worked for West Sussex County Council and in her capacity as an Approved Mental Health Professional (AMHP) she had assessed Jessie under the Mental Health Act at Chalkhill Hospital. She told the court this was a one off meeting on 1 November 2017 and that Jessie had been detained on that occasion under Section 2 of the Mental Health Act.

C: How well would you say you understood Jessie back in 2017 when you assessed her?

AW: Prior to going to see someone we’d always have a look through notes, we have access to Sussex Partnership notes and anything West Sussex held on Jessie. I’d have looked at old AMHP reports as well, often they’re a particularly good source of information, another AMHP would have collated that info.

C: I will stop you, I’m just asking you how well you think you knew her?

AW: I’d some understanding of her, obviously only met her once. On that day, I had a few hours to familiarise myself, so some understanding.

The coroner said 4.5 years later Ms Woolfenden was asked to take on a safeguarding enquiry. She asked her to tell the jury what that meant. Ms Woolfenden told the jury that it fell to Brighton and Hove to make enquiries as Jessie was living in Brighton at the time.

Ms Woolfenden said that she had some experience with safeguarding enquiries when she’d worked in West Sussex and in East Sussex too. She told the court that she believed the concerns had been raised with East Sussex County Council and they’d passed them to Brighton and Hove because Jessie lived there. She told the court that the usual way they would deal with them is “we have a rota, one of the social workers would look through concerns and decide whether it meets threshold under Section 42 of the Care Act and whether there were sufficient concerns that we needed to look into it”.

In response to a question from the coroner Ms Woolfenden said there were two aspects to the safeguarding concern, which was made in October 2021. The first was concerns of the nature of the relationship of Jessie’s father with her, and the second was concerns about the quality of care being provided to Jessie in Brighton by IMC Locums.

The coroner asked Ms Woolfenden once she’d been allocated the safeguarding investigation, what was the normal process she would follow. She told the court she would look at past history, read notes on the system, she said she had access to Sussex Partnership notes and the local authority system, and she’d fmaililarise herself with those “which in Jessie’s case is a lot”.

The coroner asked her to jump to the end and identify what the possible outcomes of the investigation were. Ms Woolfenden said that if on the best evidence the concerns are considered accurate, they are upheld, but obviously sometimes there is no evidence. She said sometimes it may be concerns are not proven, and sometimes it may be some elements are accurate.

In this particular case it turned out to be inconclusive.

Asked where it goes once the investigation is completed, Ms Woolfenden told the court that she’d discuss things with a senior social worker and sometimes it was discussed higher up, in terms of the outcome and what comes from that. In response to the coroner’s question she said there could “potentially” be recommendations from an investigation. The coroner said she appreciated in this case it did not get that far.

Asked by the coroner about her contact with Jessie, she asked Ms Woolfenden to tell the court what she did when she got the safeguarding referral.

AW: OK, it’s probably worth saying there’s a delay in me picking it up. At the time the alert was made I wasn’t at work, but then you look at liaising with other people, might be talking to other agencies, for example talk to East Sussex. Obviously reading the notes is particularly important… care notes, the NHS system and the system that Brighton and Hove use.

C: OK, just stop you there. Can I be clear, the delay was after you were given the investigation? Or before it was given to you to investigate?

AW: The delay was because I was not at work at the point it was raised in October. I was on a phased return to work from November after a period of sickness.

C: OK, in your statement you say your first contact you had with Jessie was on 17 January.

AW: Was that when I went around or spoke to her on the phone?

C: I can’t answer the questions, you’ve got to.

AW: Let me find it. The day before I went to see her I spoke to her on the phone to see if I could visit.

C: I’ll slow you down, you must have your statement in front of you? Paragraph 9 I’m looking at. Tell us what your evidence is then?

AW: I’ll just scroll up … I phoned her on 17 January and made arrangements to visit her to discuss the concerns. Jessie wasn’t particularly happy for me to talk with her directly, I think she found that quite difficult, she passed the phone to her dad, Mr Seares. So I spoke with him and arranged to visit the following day at their home in Brighton.

C: We know the allegations were in respect of Mr Seares. Would it have been appropriate for you to see Jessie with Mr Seares present?

AW: This is one of the difficulties with trying to speak to Jessie alone, was very difficult. It would have been preferable for me to speak to Jessie alone but trying to facilitate that proved very difficult

C: So you arranged to see Jessie the following day, the 18th, did that go ahead?

AW: It did. I arrived and introduced myself to Jessie. I thought it would be helpful for her to give me a chance, to give me context of where she’s living and where she is. She found that quite upsetting, because she’d had various admissions and had moved around. I think she found that quite a distressing thing to talk about, so she became quite distressed and I wasn’t able to speak to her any more. So her dad gave me some background history instead.

C: Were you able to speak to her at all? Or her father, about the concerns raised?

AW: Umm, I certainly on another occasion was able to try and speak to them around the concerns, around the agency

C: I’ll stop you there. We can see Mr Gallagher eating his breakfast, can he be out of sight of your camera please, it’s not appropriate. Did you manages to speak to Jessie or her father about allegations made on that occasion?

AW: If I’m being honest I’m struggling to remember, I know I spoke to them at some point but may have been later occasion

C: If you need to refresh your memory, look at your statement

AW: Sorry it was a long time ago. What I’ve said is because of the fact Jessie had left the room it wasn’t possible for me to speak to her around the concerns with relationship to her father, but was able to gather general information around his concerns with IMC.

C: The second part of the investigation?

AW: Yes

Asked by the coroner what the next thing she did was, when she wasn’t able to take the enquiry forward with Jessie, Ms Woolfenden told the court she had “various online meetings with colleagues in East Sussex, Brighton and Hove and Sussex Partnership”. She said she spoke to the safeguarding lead in Brighton and Hove City Council and sent an email to Surrey Police as well.

The coroner asked Ms Woolfenden if she had managed to speak with Jessie at all during this time. She said she had not at this point, she did not speak to Jessie again until later. She said things were getting difficult for Jessie in the community and she ended up in A&E at the Royal Sussex Hospital “which unfortunately coincided with when I was on leave so one of my colleagues went to see her”.

C: OK, did he get any information about the allegations?

AW: I think he got further information about the care agency … Jessie said it would potentially blow her family apart, so she was reluctant to discuss.

C: OK, so you went on leave. You came back from leave. Did you then go and see Jessie again?

AW: Next time I saw her was unfortunately the day before she passed away. She was in hospital, first of all in Royal Sussex then transferred to Mill View. She was in there from February to May, she was quite unwell.

The coroner asked Ms Woolfenden how her visit to Jessie on 16 May 2022 had come about. She said she’d been to visit someone in Eastbourne on public transport, so she was unable to give an exact time when she would arrive at the hospital but she rang the ward in the morning and asked whether she could see Jessie in the afternoon. She said that she was not told Jessie was having a one to one session, if she had known she would have gone later at 4pm but she told staff she was happy to wait as she thought it was important Jessie had that time.

Ms Woolfenden told the court she arrived at the hospital at 15:35 and it was probably 15:45 when she got let onto the ward. She was shown to a lounge where Jessie’s father was. In response to the coroner’s question, she told the court that she did not know if Jessie or her father knew she was coming.

The coroner asked if she’d explained to Mr Seares why she was there and she said she had, and that he had been quite confused as to why so many different agencies were involved, which she said she could understand.

AW: It does feel quite bureaucratic why Brighton were involved in some parts of her care, East Sussex in some and Sussex Partnership, so completely understand why I had to explain that again.

C: Did you explain to Mr Seares both parts of the investigation, his contact with his daughter and IMC Locums?

AW: Yeh, when I started talking to Jessie I did explain both parts but because Mr Seares was there it wasn’t practical to talk about both parts of it.

C: I’ll stop you there, before you saw Jessie?

AW: I’ll check my statement. What I’ve said in my statement was because he was in the room it was inappropriate really to discuss his relationship with his daughter. Was a very brief passing statement in touching on that matter that day, the rest of the time was spent talking about the care from the agency.

C: Jessie joined you having finished her one to one. Did you revist those allegations when she was present?

AW: I think I probably said I’d come to talk about both, but wasn’t appropriate to talk about the concerns about her father because he was present. I don’t think anything was said, no reaction as far as I can remember, so we talked about the agency and her care.

Ms Woolfenden told the coroner that Jessie was “the best I’d seen her” in terms of her engagement with her. She said Jessie had sat for 10 to 15 minutes, her eye contact was poor “but that was probably quite typical of Jessie, I wouldn’t read too much into that”. Ms Woolfenden said at no point was Jessie paritcularly distressed. She asked her after 15 minutes if she could go have a cigarette and Ms Woolfenden asked Jessie if she could talk to her after and Jessie declined.

Asked by the coroner how Jessie had responded about the concerns relating to IMC Locums, Ms Woolfenden said “she was obviously unhappy about the care she had been provided”. Ms Woolfenden told Jessie it was difficult to move forward because what she’d said was quite general and she needed specific tangible examples, with dates and times and members of staff’s names, to be able to investigate more. Ms Woolfenden told the court that the agency had found it “very difficult to respond when it was such generalised comments”. She told the court she suggested to Jessie she get someone to help her write down more specifics, and either Jessie or her dad suggested she got an advocate to help with that.

Ms Woolfenden in response to the coroner’s question said Jessie did not in any way seem distressed when she was with her.

When she left the room it was done in an appropriate matter, she didn’t storm out, slam the door, scream or anything like that, it was an entirely appropriate way of leaving the room.

When the coroner asked, Ms Woolfenden said at no point did Jessie express any suicidal thoughts to her and that there was “nothing that rang alarm bells in terms of her presentation”.

Counsel for the family then asked questions of Ms Woolfenden. She started by saying that the jury had heard yesterday evidence of Lauren Bernard who had come to the view that Jessie needed access to support with intimate care at Viaduct Road. Ms Woolfenden said it was a long time ago and she was struggling to remember. Asked if it would have been important to her to have known those were Ms Bernard’s views, in relation to the referral she was looking at, Ms Woolfenden agreed. She said she thought she was aware of Jessie having seizures at Viaduct Road.

Counsel: Did you take any steps to discuss your safeguarding enquiry with Jessie’s mother, Kate?

AW: No, I think I spoke to her dad

Counsel: Is there a reason you didn’t speak to Kate during this referral process?

AW: I guess I just spoke to her dad because he was available

Counsel: I think you’ve already spoken about some of the issues here because Andy was the subject of your referral, sometimes it was difficult to touch on that matter with him, so would it not be helpful to get an idea from Kate about Jessie’s needs around intimate care?

AW: Potentially. I’d hope her dad was well versed and would be able to give a good analysis, but do appreciate your point, sometimes can help to have two people’s viewpoints.

Counsel: We also heard evidence from Jessie’s personal advisor, Rob Higgins. He told us he had a good rapport with Jessie and the way he approached her was by speaking with Kate, and getting to know Jessie. He was told to get down to her level and build rapport. Do you agree that interaction with Kate may have helped you build a rapport with Jessie?

AW: Possibly. Yes.

Counsel took Ms Woolfenden to Jessie’s Autism, Crisis and Wellbeing Assessment report dated December 2020. She read an extract from it that said Jessie struggled with changes to her routine or what she had anticipated. It said this was especially the case if it was unexpected or Jessie believes there is no rationale for the change or if Jessie believes the changes was unnecessary or unfair.

Counsel: Were you aware of that particular presentation in Jessie? That she struggled with unexpected changes to her routine?

AW: That’s quite common for people with autism, to struggle with new people, changes to routine, that’s quite a common thing.

Counsel: I think you’re telling us you weren’t provided any specific information about Jessie but might have been in the back of your mind in terms of a general approach?

AW: Yes, yes.

Counsel: But you didn’t inform your approach by reference to this document in particular?

AW: I can’t remember if I’d seen the document, that’s the difficulty.

Counsel: You don’t recollect the passage I’ve read out to you?

AW: It’s a while since I’ve read the information but typically people with autism do find dealing with change quite difficult.

Counsel: Yes, but the reason an Autism, Crisis and Wellbeing Plan is used is people’s presentation is different and it’s important to have sight of the person in front of you?

AW: Yes

Counsel then discussed with Ms Woolfenden an incident on 17 January 2022 when Ruth Nathan met with Jessie and her family. Counsel quoted from a Police report that stated Jessie was within hearing of a conversation about this referral and became angry and aggressive, throwing chairs around the room. Staff retreated and called police. Officers spoke to Ruth Nathan who informed them of the incident and then stated the allegation regarding kissing was withdrawn by the care home.

Counsel asked if Ms Woolfenden had been aware that Jessie overhearing this conversation had caused her to become severely dysregulated, to the extent that the police needed to be called. Ms Woolfenden told the court she believed she was aware of how Jessie had reacted. She also said that these issues would be difficult for Jessie to discuss and she guessed that informed how she tried to work with her.

Counsel took Ms Woolfenden to her own report that referenced a meeting her colleague, Steve, had had with Jessie, alone, at Royal Sussex County Hospital when she had been on annual leave.

Counsel: It describes Jessie appeared agitated and emotionally labile and was eager for her father to return to her bedside. Do you see that?

AW: Yes

Counsel: Jessie was asked about her personal care and indicated she was content with her personal care being provided by her father, and she says she feels mental health services are trying to interfere and tear her family apart

AW: Yes

Counsel: Next is the discussion about IMC and she became more upset when discussing that topic?

AW: Yes

Counsel: Again, it’s likely you’d have had a discussion with Steve about this conversation before visiting Jessie in May?

AW: I’m fairly sure I would have done, was certainly recorded on our recording system at BHCC

Counsel: So it’s important information to you, about how Jessie was perceiving the investigation?

AW: Yes

Counsel: So would give you an indication that Jessie saw this investigation as something seeking to break her family apart?

AW: Yes. I mean, I guess that’s why I was very cautious when I saw her on the 16th. Literally said sentence or two about this, I had hoped to speak about this but it wasn’t appropriate. That was the extent of conversations, was very aware of where she was in terms of being in hospital and the fragility of her mental health, when someone is in her hospital environment, that’s why I didn’t take it any further.

Counsel then asked Ms Woolfenden if she had been provided any information by Ruth Nathan in regard the ward review meeting. She replied “I don’t think so”. Counsel read to her what the record said in the notes:

Ruth Nathan was present at a ward review, Jessie was very angry about the situation but agreed to speak to Ruth about it. She asked Ruth what the fuck she had been doing over the last few months. Boundaries were set around engagement and Jessie rephrased this.

Counsel: So it appears Jessie is angry with Ruth in the context of this ward review. Were you aware of those tensions between Jessie and Ruth?

AW: I guess I was aware of tensions between Jessie and care providers, in terms of the local authority and SPFT.

Counsel: The record goes on to explain Ruth’s ongoing work was supporting Jessie and linking her to the community team. Jessie said to Ruth she felt the allegations were being made because the carers were being fired. Were you aware of that information coming to you before you met up with Jessie?

AW: No. Not that I recall

Counsel: It goes on Ruth says she’s pleased it was discussed today and she’d move forward and try to find Jessie somewhere to stay.

Were you aware Ruth Nathan had said they’d move forward on 9 May and look at accommodation?

AW: I was aware Jessie was becoming frustrated at the length of time it was taking, until there was appropriate after care she was effectively stuck in hospital.

Counsel: We can see in the ward review Jessie is very angry. She has some views on the nature of the allegations being made. Suggestion Ruth will move forward and look at where should be provided. Would that information be relevant to you a week later when you’re planning to meet up with Jessie and discuss this topic?

AW: Possibly. I mean I guess we have to look at allegations in relation to where she had been living, even if she wasn’t going back, clearly need to think whether it’s a safe environment for other people to be in.

Counsel: It’s also relevant for Jessie because you’re not moving forward. Jessie’s expectations need to be managed. This is an ongoing inquiry. Do you agree?

AW: Yes

Counsel: In terms of managing that do you agree you need to have clear communication with Jessie you’re continuing the investigation?

AW: I guess so

Counsel then read an extract from Jessie’s care notes that said Jessie was irritable and lightly [self harm] this afternoon during her two to one check. She was irritated and annoyed at staff when they went to inform her about the “abrupt visit of her social worker”.

Counsel: So Jessie wasn’t aware you were coming, referred to as an abrupt visit… do you agree it appears Jessie wasn’t particularly calm about your attendance on the ward without prior notice?

AW: From what you’ve read out, yes, but obviously I wasn’t party to any conversation she had with ward staff.

Counsel returned to Jessie’s crisis plan and read to the court an extract that said Jessie could appear alright during the day but then upset in the evening. They said that this could be due to Jessie’s processing being delayed so she becomes more aware when she has time to process the events of the day, during the evening.

Ms Woolfenden told the court it was not made clear to her it would be more beneficial for Jessie to see her at a specific time, on another day with advance warning.

Counsel: So given you said you weren’t aware of this specific section of the autism crisis plan. Can I take it from that you didn’t have any conversations with the staff about managing Jessie after your visit?

AW: No

Counsel: Did you have any conversation with staff about your visit?

AW: No … it was a fairly unremarkable visit, by which I mean was nothing that stood out for me that made me concerned for her

There were no further questions from the family.

Counsel for Sussex Partnership Foundation Trust asked questions about the interface between social and health care. Ms Woolfenden in response to her question said there was a range of reasons why she might phone a hospital to arrange to speak with one of her clients.

Counsel: You mentioned your diary a number of times. Is it fair to say there are pressures on diaries?

AW: Yes <laughs> particularly on this occasion with travelling. I was also trying to see someone over in Eastbourne which is a number of hours travel time.

In response to a further question from counsel for SPFT Ms Woolfenden confirmed her conversation with the ward staff on the morning of her visit, was focused on practicalities and timings of her visit to Mill View Hospital.

There were no questions from East Sussex County Council so it was over to counsel for Brighton and Hove City Council.

He started by checking the timeline and Ms Woolfenden confirmed the safeguarding referral was made by email on 21 October 2021. At that time she was working part time having returned to work after a period of ill health.

I was on a phased return to work, there was a period of time when I had no access to case records, because they had to reinstate my access to the IT

Ms Woolfenden confirmed it was January when she first met Jessie. Asked what she’d done in terms of enquiry before then she said “obviously I’d have read some background information about her and I think its fair to say there was a huge amount of information about her, in terms of background information, which obviously you’ve got to try and read. You might make notes on, recall it etc and in the context of dealing with other people allocated to you”.

Counsel asked Ms Woolfenden to confirm what the referrals were about.

There’s a referral from Ruth. She explained who she was, where Jessie was living, a little bit about her diagnosis, then goes on to say she was quite concerned when she met with them on 11 October, were discussions around Jessie’s personal care.

The concerns raised in the other complaint, Ms Woolfenden told the court, were raised by “the family” about the quality of care provided by IMC Locums.

Counsel: Is it before or after you have your meeting with Jess do you contact the police?

AW: I think it was after, I think

Counsel: What was their response?

AW: They declined to be involved

Counsel: Was there a meeting with different agencies?

AW: Yeh we had various agency meetings and discussed the concerns and came up with an action plan in terms of different things different people were going to do.

Counsel: As far as IMC were concerned, are you able in broad terms to tell us what change were made?

AW: I’m aware were certain individuals no longer employed by IMC, they did look into the concerns and tried to request staff worked in different ways with her. For example, were concerns about particular foods they were cooking she found objectionable, they asked them to be more considerate.

Counsel: In terms of referral from the Lead Practitioner, Ruth Nathan. Were there any interim action points in relation to these meetings?

AW: Jessie fairly quickly after I first tried to meet her ended up in hospital. She didn’t end up going back to Viaduct Road, so was obviously out of that environment

Counsel: Was any advice given to anybody?

AW: In what respect?

Counsel: About personal care?

AW: I know we wrote to Mr Seares and his wife and expressed the view, and I believe East Sussex did the same, said it would be inappropriate for him to continue to provide that.

Counsel asked Ms Woolfenden about her visit to Jessie in hospital on 16 May 2022. She told the court Mr Seares was there the whole time that she was there. Asked about the entries in the clinical records that she was taken to earlier Ms Woolfenden said that it “fits in her presentation to me, she was a bit irritable in terms of the fact I’d arrived before the end of her one to one time, but otherwise she was relatively settled”.

Counsel: Very sadly we know Jessie died in the early hours of the next day. On the basis you didn’t know that, as you left the hospital, what were you thinking about where you were at in your investigation?

AW: I guess it was, I was going to be waiting for her to come back. Dad mentioned he’d send me more information about her concerns around IMC. I’d obviously asked her to get an advocate to help write things down so there was something more specific we could go to the agency with.

In terms of concerns around the relationship with her dad that was going to be something to discuss. Where do you go, when it is very difficult to discuss with someone on their own?

Counsel: Would the advocate potentially give you some help with that?

AW: They could do, potentially

Counsel: How would you describe the state of the two investigations at that point?

AW: Still ongoing

There were no further questions from her own counsel, so it was over to the jury for their questions.

Juror: You said in your first conversation you didn’t get any specifics from Jessie about the allegations against IMC and you got some general allegations. What were the general allegations? Can you precis in some way?

AW: General allegations, concern around her care, for example the people were sleeping overnight, the people were talking in their own language, they were people who English was their second language, so they were talking. I know there were concerns around food, food being taken or used, possibly around fish, can I check my notes, is that ok.

… for them to investigate allegations need specifics, time and names, does that make sense?

Juror: No. Can you explain?

AW: When you’re investigating you need specific information. When I raised it with the agency they didn’t feel was specific enough information such as dates, particular staff, what was said. It’s very difficult to investigate when things are general, that was what I’d gone to visit Jessie about the day before she passed away. I needed something more tangible and specific.

The coroner said the jury would hear a statement from Mr Lawton in due course.

Juror follow up: What specific information did you need to act? You said dates and which staff?

AW: Yes something that enables the investigation to look, a bit like if you’re doing police investigation, you need something quite tangible, where was this person on this particular day, what records have we got. That was the difficulty it was very broad which made it difficult for them to respond to it.

Next a different juror asked a question.

Juror: It’s about the timeline, the request was made in October, you spoke to Jessie in January. What happened between those two dates? Any other activities, what else is being done or is that just a gap?

AW: I was allocated it before I’d come back from being sick and was on a phased return to work. Certainly for a number of weeks I didn’t have access to the system to look at background information etc. You’d ooften be speaking to your supervisor, to discuss how to plan the enquiry, obviously there’s other things going on as well yeh

C: I think the juror is asking is what are the other things going on?

AW: You’d be looking at background information, if going to see someone, you need to know history and what you were going to ask them. Given Jessie had diagnosis of autism, spending loads of time asking questions you could get from background information isn’t the best use of her time and is likely to get her quite upset. So think important when meeting someone for the first time to have a good understanding of their situation, because there’s a huge amount of information obviously I needed to try and get to grips with some of that so I can make best use of time when go to see someone.

C: You mentioned a number of meetings with other agencies?

AW: Yes I spoke to Simon Hellyer on the phone around that point who explained to me what was happening from their perspective

C: The jury won’t know who you’re talking about

AW: the general adult manager for East Sussex

C: You’d have spoken to him why?

AW: I think he emailed me and suggested we speak, he talked to me about the complexities of the case in terms of her needs, and difficulties they’d had in meeting her needs in terms of hospital care and outside of hospital

C: Are you satisfied things were happening during that period from when the safeguarding allegation was made to the time when you see Jessie?

AW: Ummm, I mean obviously there were times when I was working part time and therefore things weren’t happening from my perspective. However given the allegations had come from East Sussex I know they were also having conversations, liaising as well, because they were providing her care, it was important to them as well

C: When you say liaising going on, there are two separate allegations here, you’re saying going on. We heard evidence from a witness about work they were doing with IMC Locums

AW: Yes was liaising about two strands

Another juror asked Ms Woolfenden to confirm when she returned to work from sick leave and she said she came back in November on a phased return to work. They asked when the safeguarding was raised and the coroner said it was on 21 October. Ms Woolfenden said she wasn’t back at work at that point. She told the court she was on a phased return and had to catch up with mandatory training and it took a few weeks for her IT access to be reinstated.

A different juror asked if it was usual for safeguarding allegations to be allocated to people who were on sick leave and the coroner said we’d be hearing from a manager later in the week. The same juror asked if there was a legal timescale when safeguarding allegations should be addressed and Ms Woolfenden said you couldn’t say “can’t say a particular timescale, some can quickly address, some take longer, they’re all different”.

Another juror asked if there were legal timeframes when investigations need to start. Ms Woolfenden said she didn’t think so.

Juror 1 again: by the sound of it you weren’t the only person investigating this? You said there were other agencies involved, doing their own investigations into allegations, one or two allegations?

AW: It would have been both, because she had care coming from East Sussex and Sussex Partnership, obviously would have been a concern for them. Obviously were meetings where they discussed. Was letter went out from East Sussex Council Manager to the family suggesting they didn’t get involved in her personal care. Does that answer your question?

Juror: Yes

The coroner said that the legalities can be checked with more senior staff members when they give evidence. Counsel clarified the last jury question and Ms Woolfenden’s answer, and she confirmed that Brighton and Hove would be the lead agency with overall responsibility for the safeguarding enquiry because Jessie was living in Brighton.

That was all the questions and Ms Woolfenden was released at 12:39.

[There was one more witness before lunch and two after but I’ll have to stop for today because my hands are now seizing up and I can’t type any more. Apologies for being so behind on reporting, I’m going for depth of coverage over speed – don’t I always. Thanks as always to my brilliant crowdfunders for supporting my reporting. More tomorrow].

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