Before the court adjourned for lunch on Day 3 the coroner said that she would ask her Coroner’s Officer, to read the statement of Steve Lawton onto the record.

Steve Lawton / Social Worker Brighton and Hove City Council

His statement was dated 29 September 2022 and in it he told the court that he was a Social Worker for Brighton and Hove City Council, seconded to Sussex Partnership NHS Trust.

He said he was working within the East Assessment and Treatment Service, EATS.

He told the court that ATS is a multidisciplinary team who carry out social worker functions in accordance with Brighton and Hove City Council’s statutory duties.

He gained his social work degree in 2015 and is currently registered to practice with Social Work England. He told the court he is also an Approved Mental Health Professional (AHMP) having completed his training for the role in 2019.

Mr Lawton told the court that he initially became involved in Jessie’s care in December 2021, when he was the enquiry supervisor for two safeguarding enquiries. Subsequently he became Lead Officer in June 2022.

Concerns were raised by East Sussex County Council on 21 October 2021 in relation to a) possible risk of harm to Jessie from her father and b) various forms of neglect and/or abuse by her care provider IMC Locums.

He said as Acting Duty Social Worker for EATS he considered that they met the Care Act Criteria for a Section 42 safeguarding enquiry.

He explained that Jessie’s care was not commissioned by Brighton and Hove, but by East Sussex County Council. He told the court that East Sussex County Council remained responsible for meeting Jessie’s eligible social work needs under the Care Act throughout, however because the abuse and/or neglect was purported to be in the Brighton area, Brighton and Hove City Council had a responsibility to investigate.

Mr Lawton told the court that two separate enquiries were initiated. They had been allocated to Brighton and Hove City Council, Alison Woolfenden on 7 December 2021 to act as Lead Enquiry Officer for both enquiries. He acted as Enquiry Supervisor.

He said that IMC Locums Enquiry was re-allocated to him on 14 June 2022, with manager Victoria Cottis acting as Enquiry Supervisor.

He told the court that although Jessie died it was important to conclude the enquiry.

He said in summary Brighton and Hove City Council made enquiries directly with Jessie and her father and mother. They caused IMC Locums to make enquiries and respond to the concerns raised. East Sussex County Council were asked to provide additional information as the commissioning local authority.

There was sufficient evidence that some care and support Jessie received from IMC Locum’s was of poor quality and some concerns raised amounted to abuse and neglect, and she experienced harm as a result. The concerns raised then were partially substantiated.

Mr Lawton told the court that they were acted upon appropriately by IMC Locums and there was mitigation to reduce the harm to Jessie and other service users.

Staff investigations were conducted and some staff members were dismissed.

East Sussex County Council were provided with a copy of the Section 42 report.

After Mr Lawton’s statement, court adjourned for lunch.

Dr Jemima Gregory / Consultant Psychiatrist Royal Sussex County Hospital Liaison Team

Dr Gregory joined the court remotely and the coroner thanked her for attending.

She told the court her full name, although she uses Jemima for work. She is a Consultant Psychiatrist qualified in general adult psychiatry, with a specialist endorsement in liaison psychiatry.

In February 2022 she was working at Royal Sussex County Hospital with the psychiatric liaison team. The coroner asked her to tell the jury what her role involved.

Quite wide ranging role, seeing patients who present acutely in the emergency department in crisis, or with physical health difficulties that giving symptoms of mental ill health.

Also see patients in the general hospital on wards, if admitted for physical health but also have mental health problems. Wil support those patients and teams looking after them to try to optimise their care.

If patients are subject to the Mental Health Act and detained to Royal Sussex County Hospital, myself or a colleague will become responsible clinician under the Mental Health Act for those patients as well.

Dr Gregory, in response to a question from the coroner, told the court that depending on the presentation of a patient it might be that it is possible to put a support plan in place so that they are discharged home. Some patients might need to be admitted for their physical health needs, or it might be that patients need admitting to a mental health hospital, but unfortunately there is not always a mental health bed immediately available.

C: If no psychiatric bed, your team would look after them within the acute hospital?

JG: Yes generally.

The coroner asked if she was employed by the acute hospital or Sussex Partnership Trust. Dr Gregory said that she is employed by Sussex Partnership but has an honorary contract with the University Hospitals Sussex NHS Foundation Trust to allow her to work in their setting.

C: I assume physical health is looked at first and then patients are passed onto you?

JG: Not exclusively, more and more there’s a move towards co-working and supporting together, such that we wouldn’t say this person needs to be fully physically assessed before we see them, if acute concern about their mental health we’d press on and work alongside physical health colleagues.

Asked if they had a particular area of the hospital allocated to them, or their own ward where they look after patients, Dr Gregory explained that she was not aware of the current situation as there was talk of changing before she went on leave. She told the court they have a mental health liaison suite which is “effectively a safe space to see patients in for assessment, outside that space they’d be in the regular hospital provision, either A&E or one of the A&E linked wards”.

C: OK, so if someone is detained under the Mental Health Act for example but waiting to go to psychiatric hospital, waiting for a bed, could be on a normal ward but nursed by your team?

JG: Would definitely be on a normal ward, to be detained under the Mental Health Act you have to be admitted to hospital. They wouldn’t be nursed by my team, is a small team of specialists, mainly nurse level with consultant presence, that reviews and advises on care of patients, but don’t provide day to day nursing of patients.

May recommend someone needs continuous support by a mental health nurse but that support would then be provided by Royal Sussex… either by Royal Sussex HCA or sub contract nurse via agencies.

C: So if need input from a mental health nurse once admitted to hospital, not managed by your team, but by mental health HCA or nurse employed by the Trust itself?

JG: Yes, if need anything more than daily or twice daily review of mental health nurse or doctor, then that comes via Royal Sussex Hospital… it may have changed since I was last there…

C: The jury heard about levels of observations, so if a patient needed 1-1 observations carried out, the hospital would provide that either via mental health nurse or HCA, depending on the need of the patient?

JG: Yes, need of patient and unfortunately the availability of them getting Registered Mental Health Nurses through agencies.

The coroner told Dr Gregory she would lead her through her evidence to save time. The psychiatric liaison team first became aware of Jessie when she was admitted to the Royal Sussex on 11 February 2022.

Asked why her team got involved, Dr Gregory said that the ward were concerned, Jessie’s father had raised some potential safeguarding concerns about carers in the community, and they knew Jessie was known to mental health services and to the liaison team as well. In the first instance they were contacting for advice on safeguarding a vulnerable person with mental health difficulties.

Dr Gregory told the court that her team never took over Jessie’s care, but they were involved in her care and available in a consultative role. They have a case load that they see regularly.

Dr Gregory said that her team reviewed Jessie’s notes and spoke to the ward team. Dr Gregory, in response to a question from the coroner, told the court that a Mental Health Act assessment was arranged for Jessie, but not by her team. She said at the point at which the mental health liaison team were first contacted on 11 February she didn’t think they were aware that an assessment had been requested. She believed that it was requested by East Sussex County Council Social Services, and that they attended hospital for that assessment without the mental health liaison team being aware of that happening.

Asked about the team’s contact on the 13 February, Dr Gregory told the court that there were some concerns that Jessie was on opioid based medications and other controlled drugs, so the staff wanted them under hospital administration, but Jessie was not open to this way if managing. She was becoming quite distressed and agitated.

Dr Gregory told the court there was some confusion because the carers that had come with Jessie from the community were saying that she had capacity, they couldn’t do anything even if she was becoming agitated. My reading of that was concerns from the ward that they might need to lay hands on her, which unfortunately can happen if people are becoming very distressed in a hospital setting, if they’re at risk to themselves or others, she said.

Dr Gregory said, given the complexity of the lengthy background, the mental health liaison nurse who took that call, decided to contact the Community Lead Practitioner.

The coroner then listed further contact between the psychiatric liaison team and Jessie.

On 14 February Mental Health Nurse Lamble attempted to review Jessie. The liaison team were contacted around anti-psychotic medication. Staff on the Acute Assessment Unit (AAU) were told to liaise with pharmacy.

15 February the team were contacted by Steve Lawton, who was undertaking a Safeguarding Enquiry, requesting an update.

16 February team attempted to review Jessie on AAU. She was sleeping with two carers present. She was concordant with her medication but refusing antibiotics.

Dr Gregory explained that Jessie did not want to take them orally but was happy to take via an intravenous route, which the team said was not indicated, so there was some difficulty at that point.

18 February Jessie was detained under the Mental Health Act, but medically ready to be discharged, awaiting a mental health bed.

19 February Jessie had a non-epileptic attack resulting in a medical team call. Jessie was intermittently tearful and irritable and unclear about why she was detained.

20 February Jessie appeared calmer, engaged well with the mental health nurse, hadn’t self-harmed but expressed that she was in pain and her medication was given at the incorrect time.

The coroner asked Dr Gregory to take the jury through how she became involved with Jessie on 21 February.

Was Monday, first of my working days with her in the hospital, as such reviewed Jessie in my role as consultant liaison psychiatrist as she was detained under the Mental Health Act, as responsible clinician.

I hadn’t met Jessie before, she’d met lots of people from my team leading up to that and medical staff involved. In part due to that and everything else going on, she wasn’t able to engage for very long, but was again really wanting to focus on her lack of clarity around how she’d come to be detained.

She expressed she didn’t think she’d had a Mental Health Act Assessment and she wanted to appeal her section. Discussed with her, was at odds to what I’d read prior to reviewing her. All patients known to mental health services, especially those with a long history, prior to meeting someone for first time will spend long period of time reviewing notes, try to understand what events led to them being in hospital and what their background picture is, so have more of feeling of who they are and where they are.

I was able to speak with Jessie about how the information she was giving to me seemed at odds to information I’d heard and recorded but would try to get to the bottom for myself and her, about what had exactly happened, such that we could have a shared understanding of that.

Dr Gregory saw Jessie again the next day. She told the court it would be standard practice for someone detained under the Mental Health Act to have at least initially, a daily review. It wouldn’t necessarily be herself coming back each day, but because she wanted to get various information from colleagues she said that she would go back the next day.

C: Would you be aware of her diagnosis?

JG: Diagnoses? Yes

C: And you have full access to Sussex Partnership Trust records?

JG: Yes

C: You reviewed her again on 22^nd, also been reviewed by a Consultant Neurologist who we will hear from in a moment, did you have any other input with her, other than reviewing her?

JG: I reviewed her, I also met with her father at the time, discussing with both of them their concerns about whether detention under the Mental Health Act was the right course of action. Although I believed I’d tried to contact colleagues at that point, I hadn’t managed to have those discussions, so I updated them I was continuing to try and gather that information so I could feed back to them.

C: I’ll stop you there, we heard Mr Seares had some concern about the reason for her having been detained. You already mentioned you were looking into that. Have you got your statement, could you explain paragraph 17 with concern about why she was detained.

JG: My recollection at time when recorded notes was Mr Seares told me that the Mental Health Act assessment, the detention of Jessie under the Mental Health Act wasn’t related to concerns about her acute mental health at the time, but more related to safeguarding concerns around her carers. They hoped it would hopefully establish Section 117 aftercare and look at her accommodation, was in what was thought to be unsuitable emergency accommodation.

C: Did you get to the bottom of why she’d been detained?

JG: I spoke to consultant psychiatrist in the community, Sheriff Orekan and to the AMHP Emmanuel XX… both involved in the Mental Health Act Assessment. They were both clear they were concerned about Jessie’s risk in the community, felt her risk to herself had been increasing and they felt wasn’t safe to support Jessie in the community any longer. They’d attempted to engage Jessie in the Mental Health Act Assessment but hadn’t been able to fully engage her, hence perhaps her feeling she hadn’t had an assessment.

C: You saw her again on 24th, spent more time with Jessie. What was the purpose of that meeting?

JG: Again would have been a regular team review. Looking at notes, Jessie was clear she didn’t want to see other members of the team other than myself or lead nurse, Andy Nuttall. As such I saw Jessie more regularly than perhaps would have seen other patients to support that request, continuity is so important due to complexities of interaction between mental health and physical health.

C: You were speaking with her, purpose of review of her at that stage, trying understand what plan was going forward?

JG: At that point she was again medically ready for discharge, she’d had various episodes up until then which meant she’d become unready for discharge again but she was again medically ready for discharge.

Trying to think with her about going forward. She was very clear she didn’t want to be in hospital, or in mental health hospital. She was worried she’d be more at risk in a mental health hospital setting than out in the community.

I was trying to explore with her whether was a way to use that insight to keep her safe, if she did go into a mental health hospital, but also given the nature of her presentation there is risk in being in a mental health hospital, and out of a mental health hospital, there’s always a balance to be struck.

Trying to work with Jessie and services to look at where was the least risky place for Jessie to be at that point in time, try to explore with her.

C: You say she’s medically ready for discharge, physically or mentally?

JG: Physically

C: So she’s still subject to a Section 3 and you’re exploring what options are available, assume wasn’t bed available for her at that time?

JG: Exactly  

C: As result enquiries you made, what were you able to do for Jessie at that stage?

JG: At that point the care package was withdrawn. Was no longer package of care to support Jessie in the community if we were looking at discharges from hospital and section, so any discharge planning was going to take a while, would need care in place to support discharge.

So I agreed with Jessie, or discussed with Jessie how I couldn’t, wasn’t in a position to discharge her because wasn’t enough support in the community at that time, but I took on board her concerns about risk in an acute mental health hospital.

And as such whilst we were waiting for a mental health bed I’d continue to explore other options that might make it less risky to support her in the community, but I explained to her, and I think to her father as well, that would take quite some time. Would involve getting Occupational Therapy Assessments, care packages etc, and in all likelihood a mental health bed would come available before that.

I wouldn’t stand in the way of her being transferred there now she was medically fit for discharge, but whilst she was under my care at Royal Sussex, I’d continue to look into how we could avoid that, because unfortunately sometimes we have patients at Royal Sussex physically ready for discharge but waiting for a mental health bed for weeks at a time. Wanted use the time while Jessie was with us to explore options.

C: A bed on Caburn Ward came up, then it transpired it wasn’t available. You reviewed Jessie again on 1 and 3 March.

JG: Yes

C: Finally on 4 March, you became aware a bed was available and she was transferred to Caburn Ward. When you saw her on 1 and 3 March, had anything significantly changed as far as you were aware?

JG: Had been episodes with her physical health presentation, this is to best of my recollection, non-epileptic attacks etc and I felt that was due to high level of uncertainty about how things were due to proceed. Then bed was available, steeled herself to that and then not going etc. In terms of her overall picture, no, it wasn’t considerably different.

The coroner asked Dr Gregory if a patient is detained under the Mental Health Act at Royal Sussex, whether they were somewhat limited in what they can do for a patient before they go to a mental health hospital. Dr Gregory confirmed that they are, she explained how the physical health hospital is not designed along the same lines as a mental health hospital, and that the majority of staff are trained in physical not mental health. She told the court her team provide some additional training and do what they can to optimise the environment.

Dr Gregory said that they only have a small talking therapy service and that was for patients with major trauma, which Jessie wasn’t.

I believe that the next question was asked by counsel for the family, but it may have been a coroner question [apologies, my note is not definitive].

Counsel: Just to clarify when you saw her and assessed her, was it your view that Jessie was safer with you in the hospital, Royal Sussex, than being at home in the community at that time?

JG: At that particular point in time, yes.

Counsel: Safer in the hospital?

JG: Safer in the hospital.

Counsel: The decision you made about whether to maintain Jessie’s section or not required you to consider tension between harm that might arise in mental health ward and harm that might arise in the community. Fair way of summarising your decision?

JG: Yes

Counsel for the family put to Dr Gregory that in an earlier report the court had seen Jessie thought the ward environment previously was thought to be detrimental, and in the past had been for more traumatic than supportive.

Counsel: Does that align with what you were told by Jessie when you interacted with her?

JG: It does, yes

Counsel: That experience of Jessie in the past, would be indicative of her experience in the future. Do you agree with that?

JG: Yes

Counsel: How relevant was what you were being told by Jessie about her previous experiences?

JG: It was very relevant

Counsel: So it could indicate would be increase of risk to her if she found herself in ward environment?

JG: Yes

Counsel: What did you consider in relation to Jessie’s diagnosis of autism and how that might present on an acute mental health ward?

JG: Acute mental health wards very much do their best to adapt the environment to be supportive of people with autism but I think it’s well recognised that acute mental health wards often aren’t an ideal place for people with autism. At times though it’s the best available option in the short term.

Counsel: Decisions made under the Mental Health Act relating to sectioning required clinicians to consider the least restrictive option. Is that right?

JG: Yes

Counsel: Can explain to the jury what is meant by that principle and how its applied?

JG: Considering least restrictive option is thinking are there ways we can manage and mitigate risk to this person, or that this person poses, in a way that is less restrictive than detaining them under the Mental Health Act, which is by its nature incredibly restrictive, because you are detaining someone to a very specific location and subjecting them to very specific treatment. It’s about trying to think are there ways we can support this person in way which is least restrictive.

Counsel: In considering that question you spoke to Jessie’s consultant psychiatrist in the community?

JG: Yes I didn’t detain Jessie under the Mental Health Act, Dr Orekan was one of the detaining doctors, don’t know who the other was, together with the AMHP. Was my role to consider whether ongoing detention was appropriate, to that end I spoke to Dr Orekan along with other people.

Counsel: You also spoke to the AMHP. What information were you provided by the AHMP?

Dr Gregory said she would need to look at her statement.

JG: As I said in my statement he confirmed that the Mental Health Act Assessing Team did feel they gave Jessie an opportunity to engage in the Mental Health Act Assessment but weren’t able to engage her.

At that point I wasn’t really clear about how Jessie had come to be referred for a Mental Health Act Assessment. It wasn’t clear in the notes and neither Jessie or her father seemed clear either.

He explained referral from East Sussex Social Services, explained both doctors and he himself were all concerned enough about Jessie’s increasing risk in the community as a result of what they perceived to be her declining mental health, such they had no option but to detain Jessie under Section 3 of the Mental Health Act.

Asked by counsel whether she was informed by the AMHP that Jessie’s accommodation was emergency accommodation, Dr Gregory said she could not recall and that was not recorded in her notes. She said that she was aware that there were lots of issues around the care package and that it wasn’t ideal.

Counsel: Do you know if there were any conversations at that time to explore more robust community placement, different to IMC Locums?

JG: My understanding was there were conversations happening about package of care and how best to support Jessie in the community. But there was nothing concrete on the horizon, such that we could look to that with any sort of timescale that meant I could consider that in whether or not the balance of risk in the two environments, wouldn’t affect that at that point in time.

Counsel: Whilst Jessie was on the ward, you say you made the decision she could have leave with her father to leave the grounds is that right?

JG: Yes

Counsel: What was the basis of your decision with respect to her leave given she was under section?

JG: Initially when Jessie and her father made the request for leave, I suggested they try out leaving the ward environment, to see how they manage with that, which is standard practice for patients detained under the Mental Health Act. Then look to increase in step wise manner.

I was aware from Jessie’s previous care plans that she found having time off the ward, and driving around, and support from her father beneficial to her, to her mental health. And that whilst she was in the company of her father, was escorted leave with her father, her risk at that point was contained by that plan. So that felt like a supportive measure we could put in place at that time, which was safe enough.

Counsel: That decision to provide that supportive measure recognised was something important about Jessie having leave to improve her wellbeing, is that right?

JG: Yes, so long as weren’t other factors increasing risk at that time

Counsel: Your view given interaction with Jessie and her father, was that was something that could be done?

JG: Yes

No further questions from counsel for the family. No questions from counsel for Brighton and Hove City Council, East Sussex County Council or Sussex Partnership NHS Trust.

One question from the jury for Dr Gregory, asking if you could explain non-epileptic seizure to them.

The term I’ve used is non-epileptic attack, they’re different from an epileptic seizure. An epileptic seizure occurs when abnormal discharge of electrical discharge in brain leading to physical movements of the body as a rule, non-epileptic attacks happen without that characteristic electrical discharge in the brain.

Often they happen in people who also have epilepsy, can be confusing for people, their family and those looking after them.

Often can happen if don’t have epilepsy, often in the context of extreme stress. If think of computer, if brain is software and your body is hardware, in epilepsy get software malfunction lead to malfunction of hardware, in non-epileptic attack is breakdown in communication between the software and the hardware. You get the hardware malfunctioning without software error.

A follow up question from the jury asked if that was the same as petit mal. Dr Gregory responded that petit mal is a specific type of epilepsy.

The coroner thanked Dr Gregory for her attendance and released her.

Dr Gregory, before she left, said that she was so sorry, and she didn’t know if the family were there but Jessie had really made a mark on her. She said she was very characterful and in preparing to give her evidence she had looked at Jessie’s communication passport with the two wonderful pictures of her.

Jessie’s mum and dad thanked Dr Gregory.

Court was then adjourned for a short break.

In the final hour in court there was a report and a number of statements read onto the record. I’ll not try to report them because my notes were limited, but I’ll list them below:

Occupational Therapy Report from Jigsaw

Statement of Dr Kimber, Consultant Neurologist

[Dr Kimber said his plan was for Jessie to 1) undergo a tilt table test 2) referral to gastroenterology for test for Upper GI problems and 3) recent EEG suggests need for referral to neuro psychology

In his statement he said that the gastroenterology referral was rejected as Jessie was out of area, the tilt table referral to Brighton appears never to have happened. Neuro psychology referral did not happen. The patient had already died by follow up appointment]

Statement of Dr Al-Manar, Consultant Neurologist

Statement of Dr Barritt, Consultant Neurologist

Statement of Dr Panthakalam, Consultant Rheumatologist

Statement of Dr Orekan, Consultant Psychiatrist