Days 2 and 3 Jessie’s inquest: Dr Cuthbert

Doctor Sharon Cuthbert gave her evidence in the afternoon of Day 2 and morning of Day 3 of Jessie’s inquest.

Dr Cuthbert / Consultant Psychiatrist and Jessie’s Responsible Clinician

Day 2

She told the court she is employed as a Consultant Psychiatrist at Mill View Hospital and works on Caburn Ward.

The coroner asked her to tell the jury a little about Mill View Hospital and she explained it was a psychiatric hospital and provided some detail [didn’t catch]. She told the court that Caburn Ward has 17 beds.

She explained that the Section 136 Suite is not directly linked to Caburn Ward, but was attached to the Psychiatric Intensive Care Unit, which also has a seclusion room.

Asked by the coroner what the role of Consultant Psychiatrist entails, Dr Cuthbert told the court that she is the senior doctor on the ward. She has responsibility for the Mental Health Act and managing patients care. She told the court she meets with patients once a week [fuller answer didn’t catch – she speaks very quickly].

C: We know Jessie came on to the Caburn Ward at Mill View Hospital on 4 March 2022. Had you ever met Jessie before that time?

SC: I had a very passing acquaintance with her in another role in the Mental Health Liaison Team. I don’t recall if that was face to face meetings or discussions, but this was the first ward meeting I’d had with her

C: during the course of your treatment with Jessie did you come up with a diagnosis or was there a pre-existing diagnosis?

SC: There was longstanding diagnoses already. Jessie was diagnosed with autism and ADHD in the past and also had a diagnosis of Emotionally Unstable Personality Disorder although that was discussed in different terms with her on the ward.

Asked by the coroner what are the risks associated with these diagnoses Dr Cuthbert told the court they vary very much, depending on what people experience.

She told the court that autism could lead to increased anxiety, depression, stress and things that contribute to feeling unwell and make it hard to engage in day-to-day life. She said that ADHD is associated with impulsivity but one of the main risks or set of risks related to the emotional dysregulation that Jessie experienced, which she told the court was associated with a severe risk of self harm and sometimes aggression towards herself and others. She said that this can sometimes occur with autism, but also occurs with intense emotional dysregulation.

The coroner then asked Dr Cuthbert to expand on a paragraph in her statement that referred to Jessie’s self harm. I won’t report the details here.

In response to a question from the coroner Dr Cuthbert told the court that when Jessie was admitted to Caburn Ward on the 3 February 2021 she had been admitted to Accident and Emergency six times since December, and 82 times in total in the preceding 18 months.

C: For those suffering with the diagnoses you had indicated for Jessie, is that regularity of self harm that you would expect to see?

SC: Sometimes. It is at the higher end of intensity and frequency

C: There was a regularity around her self-harming?

SC: Yes

The coroner asked about the risks associated with Jessie’s self harming behaviours [I’ll not report that discussion here].

The coroner said that this led to her next question which was about Jessie’s capacity and was related to what the previous witness, Dr Rowe, had indicated about Jessie’s mental state when she was dysregulated. The coroner asked Dr Cuthbert if she could explain, or help the jury, to understand whether Jessie would have capacity, or an understanding of the consequences of her self harm.

It’s very difficult to say overall. When I think about someone’s capacity to make a decision, it relates to the ability to understand information to retain that information [can’t hear] we have to think about that every time someone makes a decision, those factors could change and for Jessie they could change [can’t hear].

She might be overwhelmed by very strong emotions or sensory issues, changes that had happened, there will be times when it could be very difficult for her to understand information… She was quite widely read, she was very interested in medicine, she read the BNF, the British National Formulary, our formulary, and would quote it back to us.

She had a lot of understanding about medical knowledge, and on the face of it I think she would understand the risk. There was something about seeking medical treatment that [can’t hear] sometimes she’d have more knowledge and understanding of it than others.

There were times when she was very overwhelmed and there were other times where she could be supported to make a decision.

The coroner said that the records for the 4th of March up until May are substantial and that Dr Cuthbert would be relieved that she would not take her through every entry. The coroner said that she wanted to ascertain when Jessie was admitted what was Dr Cuthbert hoping, as consultant, to achieve?

C: What was the outcome you were hoping to achieve by having her admitted to your ward?

SC: whenever someone is admitted I want an understanding of the difficulties which have brought them into hospital and think about how we can approach these… The ward isn’t a place anyone wants to spend a long time…

When she was admitted I was quite conscious a large part of the reason for her admission was intensifying difficulties. A pattern over a long period of time. Large part of her admission had been the breakdown in care arrangements in her home.

I think from the outset it was clear one of the things we had to think about was where was Jessie going to move on from this. She had a number of assessments [can’t hear]

C: She ended up in hospital, the mental health hospital when things in the community had deteriorated to such an extent that she became dysregulated.

So for some it would seem strange she is coming into hospital for you to push her back out into the community. Can you explain why Jessie is not best to stay in hospital?

SC: there are some situations people find themselves in, where they need very intensive level of treatment for a period of time [can’t hear]… that treatment may only happen in hospital, for example intensive medication regimes… In Jessie’s case she already had a long established high levels of [can’t hear]

Intensity and presentation varied, but there was a baseline of things that were relatively well established, so there wasn’t an expectation that was going to change massively in hospital. It wasn’t an acute period of illness as such, but intensity that was hard to manage… If care had been in the community then the aim would be to help her get back there… I think about why things deteriorated, an aim would be to help her move out.

On an acute ward setting the amount someone can recover is really limited. It’s a restricted environment with 17 other very unwell patients, and changing staff who have to rotate around.

So building your own independence, establishing relationships, getting predictability, can only be achieved in a different sort of setting.

In response to a question from the coroner, Dr Cuthbert told the court an average stay on an acute mental health ward would be around 60 days, although it was slightly longer in their area.

She said this was still a relatively long period of time compared to a medical ward in a general hospital, because of the nature of recovery from psychiatric illness and difficulties in providing care in the community.

The coroner asked Dr Cuthbert if she could explain a little about the discharge process. She asked whether there was a trigger when it was decided someone was ready to discharge, or when did they start to plan for discharge?

Dr Cuthbert responded that in some respects they were planning for discharge from the very start of somebody arriving in hospital. She said it was very difficult and that they were asked to set a date to aim for.

She told the court that early on in an assessment you would get an understanding of whether someone had a home to return to, what their care and support needs were and what they like [fuller answer – can’t hear].

The coroner asked a question about the role of the discharge coordinator but I could not hear Dr Cuthbert’s response.

Coroner: We know Jessie was still with you in May, which is outside the 60 days. Is there any reason she was still with you for that period of time? Or was it due to discharge proving difficult to find the right care she needed?

SC: I think it’s a complicated answer to that question, because there were a lot of incidents during the time Jessie was with us… But there wasn’t anything specific or crucial from a medical point of view preventing her being discharged from hospital, it was really about the availability of suitable care in the community for her.

C: are you talking about incidents, self harm incidents?

SC: Yes

C: Was that still a regular occurrence while she was in hospital?

SC: Yes it was

The coroner asked Dr Cuthbert to explain to the jury what 2 to 1 observations meant. She replied:

It’s a locked ward, staff are available at all times. Patients would be checked within the hour, on general observations. Then enhanced observations might be four times an hour. Sometimes they would have eyesight or arms length observations, at all times, to stop events happening.

During the time she was on the ward Jessie did have periods where she was on eyesight level of observations, those had to be two members of staff due to allegations made by Jessie towards staff working with her.

Asked by the coroner how the ward dealt with Jessie’s physical conditions that needed attention, Dr Cuthbert responded that they have medical training and she has junior doctors that work with her on her ward.

She told the court that she assessed patients regularly and liaised with other hospitals and services, and they were liaising with cardiology and rheumatology and [can’t hear].

Dr Cuthbert then asked the coroner if she wanted her to talk about Jessie’s diagnoses. The coroner said that she should.

Dr Cuthbert started by saying that Jessie was diagnosed with hypermobility and Ehlers Danlos Syndrome, which she said relates to connective tissues.

She told the court that Jessie was hyperflexible more mobile and susceptible to [can’t hear]. She said that it was thought that Jessie might have POTS, postural tachycardia syndrome, which is a change in blood pressure and heart rate which she said was usually managed, sometimes with medication, and supportively.

Dr Cuthbert said EDS caused Jessie quite a lot of pain and she was more likely to suffer fatigue as well.

C: How often would you as consultant see somebody?

SC: I would meet patients on the ward once a week. At least once a week there would be a structured planned meeting… a relatively large meeting, we’d catch up and review what was happening in the week, think about medication, think about the direction things were going.

Sometimes I would see patients on the ward as well as having brief conversations with them.

We have a regular everyday team meeting, and we meet as needed.

On top of that especially for someone like Jessie where quite complex needs and a number of teams involved, we would hold a professionals meeting… a chance to check what was going on…

Complex review panel, you heard about, is even wider meeting of professionals to plan next steps.

C: that complex meeting, is that in every case or more difficult cases?

Not every case. Cases where we thought something was causing difficulty in presentation on the ward or [can’t hear]

C: Jessie’s family were actively involved while she was with you. Can you give the jury a feel of how regularly her family saw Jessie?

SC: Her father tended to visit most days. I know at one point he thought it was hard to be visiting on such a regular basis. And Jessie’s mother attended very regularly, quite a lot of times a week. Jessie’s dad was in most of the meetings we had and we also had scheduled meetings with her mother.

You heard from Jessie’s mum and dad… They were involved in advocating for her. They also had specific concerns they wanted to make us aware of, such as [can’t hear]

… they didn’t agree with the diagnosis of personality disorder. That has an impact on the treatment people receive, many treatments are available through pathways, it’s sometimes more helpful to take a formulation on a patient’s experience… In order to access some treatments around emotional dysregulation they come through a personality disorder pathway.

The coroner said that she would lead Dr Cuthbert through from the 9 May 2022 until the time of Jessie’s death [17 May 2022]. Before she did so she asked Dr Cuthbert whether there were any major changes to Jessie’s medication whilst she was on the ward with her.

C: Was there an overhaul of her medication or just tweaking dosage etc?

SC: I would consider just small changes being made… some medication had been helpful for her in past, and she perceived them as helpful for her…

Dr Cuthbert told the court that it had been difficult to make changes to Jessie’s medication. She said that she was concerned of the burden of side effects on Jessie given her medication regime.

She described that in some detail [I’ll not report].

SC: The plan from the community team was to try and reduce medication so I took the view it was good to try and do that in hospital.

C: … in principle there wasn’t any major changes

SC: No. Slow changes over time.

The coroner said that she wished to move to the 9 May and she wanted to understand how Jessie was presenting over the last week leading up to her death.

She said that Dr Cuthbert reviewed Jessie on 9 May, and she asked her to take the jury through the next few days, starting with the 9th.

SC: This was a weekly review, it followed a meeting I’d had with the Sensory Integration Team and Lead Practitioner Ruth Nathan.

I reviewed Jessie on the 9 May together with one of our ward doctors, Andy, Jessie’s dad, and an advocate.

Jessie had two advocates involved one with her Care Act Assessment and one from MIND to help her voice [couldn’t catch].

A HCA from the ward was also present.

I’m afraid I don’t remember in detail that meeting. The notes indicate she expressed frustration at the lack of process, I think that was with housing…

[missed chunk]

She had asked another medication be added to reduce the symptoms of tachycardia she was having.

She experienced voices, we’ve heard about, and visions, she sometimes described as monsters… more linked to periods of distress… she had reported a number of traumatic experiences.

I don’t have a very detailed memory of that, from the note it looks like she was quite able to engage with it. Sounds like we were able to discuss at some length and she was able to tolerate it.

C: Then the MDT meeting on 10 May. MDT Meeting?

SC: Multi-disciplinary team meeting. At that time a weekly meeting, a little longer than usual handovers, to talk about patients in more depth …

C: Incidents you noted as concern. Not sure we need to get into too much detail [missed]. What was the outcome? What was decided would happen after the 10 May?

SC: we had a few things to discuss. One area of concern was Jessie’s interactions with other patients, for example she’d started an Etsy business with her jewellery. There was a concern about other patients being involved with that. Also she’d printed off some pro anorexia material and there was a concern that she might distribute that…

At that stage she would have still been on 2 to 1 observations, I think. Although they do provide someone there who can intervene if needed, they are not particularly therapeutic for a person. They don’t help develop independence and they can provoke [can’t hear].

If she had needed them they could have been continued.

At that point she was spending a lot of time with other patients on the ward… She was expressing hopefulness, and engaging with future planning and was very keen to be able to spend time off the ward. In order to do that hospital policy is that you need to demonstrate you are safe on the ward first, before you can spend time off the ward, so wanted to move to general observations, it was something that was important to her …

That was a positive move in many ways. She was involved in these discussions, and we agreed to reduce to 15 minute checks and general observations.

C: On 12 May XXX [didn’t catch] and another member of staff met with Jessie’s mother, over Skype. There were some issues of concern that Kate Eastland raised. I don’t know if you were involved with that at all?

SC: I’m aware of the discussion, I wasn’t involved in that call specifically.

C: I think the concerns were about Jessie forming relationships with others, from what you’ve put into your statement, but if you weren’t involved with it I’ll move on.

On 12 May it’s noted Jessie expressed agitation around her physical health. Tell us a bit about that.

SC: I don’t know the details of that event, but she reported vomiting … and she had a non-epileptic seizure also on that day. She was assessed by the medical team, then they could take it forward by going to A&E or manage on the ward.

C: On 13 May it was reported Jessie had knives on her person and [withhold]… she handed these items in and a search was done of her room.

SC: Yes. She’d concealed a knife that had arrived in a parcel, but handed it to staff, and other items were found in her room

C: On 14th she was taken to A&E after [withhold] then returned with no concern.

On 15th she was reported to be engaging with staff and she had leave, was that escorted or unescorted?

SC: Would have been escorted, possibly with family, or staff.

C: On 16 May, you say did have to have discussions about the items found in her room, may have been issues earlier…. she talked about [withhold] I remember her being active about the timetable of activities she’d worked on and she had some frustrations about that, one or two things she hoped would be done but hadn’t always. We talked a little but about that. She said she was generally feeling alright… although she did talk about purging…

SC: We had conversation about different objects on the ward to allow her to explain what had happened…. She was doing bracelet making and I think [can’t hear] She said that was reason for hidden scissors rather than self harming.

She talked about [withhold] and she had voices, but she didn’t any longer and they did come and go.

And we had a discussion about finances … had spoken about on a number of occasions. Jessie often spent quite large amounts of money on things… we discussed it, she was adamant she wanted to manage her finances herself.

I thought we were trying to support her independence and autonomy as a 19 year old taking steps towards independence. She wanted her Dad to transfer some money from savings account and he agreed to do that and we asked her to see our finance services.. [missed]

Remember her talking about plans to go on holiday to Paris, she spoke about that and was quite positive about that and engaging in those different things.

Having looked at notes can see she said in her review notes she was concerned about searches in her room which she found intrusive.

She said she’d been previously suicidal but didn’t seem suicidal then… in many ways she said she felt quite well, was able to talk a little bit about how she could get attention, one difficulty when patients don’t have staff with them at all times, talked about how she could go and talk to people and she was prepared to do that.

C: At that time when you saw her, although she said she’d been previously suicidal, did you believe she was currently suicidal?

SC: No

C: You talk about the Paris trip. What does it say to you as psychiatrist if someone is talking about a holiday?

SC: Shows they can see the future… [missed] this seemed something she genuinely had interest in. Was also positive sign to have that motivation and connect with things then.

C: Clearly Jessie during her stay with you, her presentation had fluctuated. Is there anything when you look back now, would have given you any indications she was about to [withhold].

Dr Cuthbert responded that at that review there was nothing to suggest that Jessie seemed particularly at risk of harm to herself.

C: We know she was visited by a social worker, we heard that evidence this morning. Jessie would have been seen on general observations every hour following that visit. If staff had any concerns about her, what would they have done?

SC: They’d have spoken to her, observed her, thought about whether [cant hear] if she seemed distressed, might have talked about whether she needed more regular checks overnight for example… [fuller answer, didn’t catch]

C: Staff on the ward, are they used to patients who have presentations that fluctuate regularly?

SC: Yes, yes and also patients where, although I said wasn’t anything in that final meeting with Jessie that made me worry in that moment that was time when she was particularly high risk, but she had many things in the past where she was at high risk… in Jessie’s case I think there would be that awareness of staff that things could change quite quickly, might need rapid change [fuller answer, didn’t catch]

C: Anything else you would like to add at this stage at all?

SC: Don’t think there’s anything specific on facts that springs to my mind just now

The coroner then handed over to counsel for the family to start their questions.

Counsel introduces themselves [I’ll aim to get counsel details by the end of the week]

Counsel: Start with your impressions of how Jessie was coping on the ward. You mentioned her time on ward was preceded by a breakdown in community care… were you aware that community placement had been temporarily obtained on an emergency basis? We heard evidence from Lauren Bernard that she agreed with IMC that they were not the correct provider for Jessie. Were you aware of that view?

SC: Yes

Counsel: That precedes Jessie being on the ward. You have a meeting on 7 March, you say she appeared a little anxious at times and described over-stimulation as a significant cause of anxiety. What do you understand that to mean?

SC: The sorts of things described by Dr Rowe, that report, potentially sounds and voices in environment, new information, stimulation could come from range of different sources. So ward review like this, important with team getting to know Jessie, would likely increase her anxiety.

Counsel: When we move on to ward review on 9 May, with Ruth Nathan and others… 4th paragraph of that record states “Jessie mentioned about an individual fired from a previous job caring for her at her house and then he turned up to work here”…. Jessie’s father said it is currently being investigated and Ruth asked if she feels safe here. Jessie said she doesn’t feel safe when the member of staff is working with her… Were you aware Jessie was feeling distressed about a staff member?

SC: I was aware she had a number of incidents where people worked with her, potentially IMC Locums, or in another hospital. Sometimes she saw staff who she’d have interactions which she found distressing. Our staff were trying to avoid that.

Counsel: So a few different things going on, over stimulation, some potential noise issues might be relevant to Jessie’s autism, is that fair?

SC: Yes. They’re long standing issues which could affect her.

Counsel: And potential incidents related to traumatic incidents she’s been through. First is right at the beginning, the second very close to her death on 9 May. Is it fair those issues were consistently present during her time on ward?

SC: Yes… noise levels, Jessie used noise reducing headphones but it’s a busy environment with lots of over-stimulation and staff around.

Counsel: Were you aware of the view communicated by Jessie’s parents to Ruth Nathan on 16 May that they didn’t feel Jessie should be in Mill View?

SC: Yes I was. I wasn’t aware of that explicitly expressed view until after. It was a shared understanding really, an acute ward wasn’t going to be a long term solution for Jessie.

Counsel: One of the specific issues communicated by the family in that discussion with Ruth Nathan, was they think Jessie should be supported in the community with care…. Were you aware her family were concerned staff weren’t aware of Jessie’s needs?

SC: Had access to care plans, to communication passport and reports made at the time … had a very patient centred approach, around autism informed care and trauma informed care, although always more to learn about that.

Were conversations on that occasion with Ruth, and earlier with our Manager Matron Tamsyn about how the ward could become more autism friendly… was just starting introducing a sensory room on the ward [missed chunk]

Dr Cuthbert told the court that they had made a referral to TCAP and that they were trying to help Jessie to access Sensory Integration Therapy.

Asked by counsel if it was correct that during Jessie’s entire time on the ward she had no access to Sensory Integration Therapy, Dr Cuthbert responded that it is a small service with limited resources, and there were concerns about risk, and the service had not been willing to re-start working with Jessie at that time.

Counsel: 3 May we see referral to autism units outstanding. We see the same on 10 May. Does that tell us there hadn’t been update in relation to the TCAP referral?

SC: That wouldn’t be TCAP, they don’t have a unit to provide. There is as far as I know, one specialist autism unit in Northumberland that treats women as well as men, I had previously made a referral to them…. Had made an approach to see if was suitable, some major disadvantages… very far away…. low secure environment, which has much reduced access to stimulation and other things… [missed]

I wasn’t sure if it would be the right place but seemed right for us to take forward as a possible option, in amongst other options. I did take it forward and heard back from them after Jessie’s death and they had a waiting list of at least a year.

Counsel: What was the aim of the TCAP referral at the time Jessie was on the ward?

SC: TCAP could often advise and support on care planning to make sure was tailored to patients, but also would be able to update what we should be looking for or thinking about in terms of best options for Jessie.

She’d been in such a range of placements, homes provided to her, specialist school, PICU, range of CAMHS placements… was going to be difficult to find an option that stand her in really good chance of succeeding in the community and we thought TCAP’s extra involvement would be helpful with that.

Counsel: So TCAP helpful in terms of Jessie’s time on the ward and the discharge process?

SC: Yes

Counsel: So what was outcome of that re-referral?

SC: Recollection was re-directing to existing assessment and coming involved in Complex Case Review Panel due to be held.

Counsel: Due to be held on 17 May. Is that correct?

SC: Yes

Counsel: Were you aware if Jessie was aware of that review taking palce?

SC: I don’t recall she wasn’t…. don’t see in the notes… I don’t think was information we should have withheld from her… wouldn’t be major change immediately, would have been recommendations and where going… wouldn’t have meant discharge immediately.

In response to a question by counsel for the family Dr Cuthbert told the court there wasn’t anything medical that needed to happen that would prevent Jessie being discharged. She said she felt she could bolster Jessie’s care plans and add assessment and try to rationalise her medication, but all of those things could have happened in the community to a large extent.

Counsel: Yes. The principle of detaining people under the Mental Health Act is you have to choose least restrictive method possible?

SC: Yes

Counsel: So the sticking point here is finding a place for Jessie to move onto. You say these are all things that could have happened in the community if there was a robust care package tailored to Jessie in the community?

SC: Yes. For example, changes to medication, sensory integrated therapy, were all things could have happened in the community. Are much more suited to a community environment and long standing care team.

Counsel: You mentioned Jessie’s frustration at the lack of progress

SC: Yes

Counsel: Was it apparent to her what was stopping her leaving the ward was this discharge planning?

SC: She was very conscious. She’d been in a placement far from ideal in Viaduct Road. The care team were struggling in quite difficult circumstances I think. Even that stage the uncertainty was an ongoing frustration for her.

Counsel: We know Jessie was on the ward from 3 March, the Complex Case Meeting was not planned for any time before 17 May. Is there a reason that couldn’t have happened earlier?

SC: Think it was requested much earlier, I can’t remember when it was requested, would have been first couple of weeks of admission. Because meetings take some preparation, require people from lots of areas coming together… pre-scheduled meeting….takes some time.

Was also discussion about whether should have something called a Care and Treatment Review which is best practice for people detained on a ward with autism, the approach the CCG who organised those said they wanted it wrapped into the Complex Case Review.

[Coroner adjourned court at 16:30 on Day 2 and Dr Cuthbert returned for further questioning by Interested Persons on Day 3]

Day 3

The coroner reminded Dr Cuthbert that she was still under oath, and handed over to counsel for the family.

Counsel: You referred yesterday to a ward review that took place on 9 May where Jessie had discussed a traumatic experience she’d had in Kent. There was a discussion about following up on this, think you mentioned art therapy was discussed as a result of that.

We see in record at xxx Jessie said she requested trauma therapy and EMDR, she explained she has flashbacks.

Counsel asked Dr Cuthbert to explain to the jury what EMDR, Eye Movement Desensitisation and Reprocessing, is.

“One of the recommended treatments for trauma but people do need to be in the right place to manage EMDR or trauma therapy”.

She explained to the jury that it’s a specialist form of trauma therapy that uses eye movements [fuller answer – didn’t catch].

Counsel: Is clear Jessie had heard about it and was requesting trauma therapy and EMDR. What was the plan in respect of the therapeutic support she was going to get for trauma?

SC: I’m not sure if at that stage she’d met with a psychologist. One of the reasons for talking about art therapy, was different ways of providing therapy for her… I don’t recall at that time whether she was able to access an art therapy group on the ward… is part of our usual provision but was a period between therapists… might have been when was disjoint in therapy…. That would be one way we’d think about supporting her to access therapy.

The other thing she’s already started work on was work around managing emotional dysregulation… that was using services around emotional regulation in the community and the work they’d routinely do, part of that was trauma therapy [fuller answer – didn’t catch]

Asked by counsel what her understanding was of the way Jessie engaged in group sessions rather than one to one work, Dr Cuthbert responded that people often struggle in groups but Jessie was quite sociable and may have enjoyed it. She also said that she may have found it overwhelming, and that the art therapist did do some one to one sessions.

Counsel: Did you consider 1-1 art therapy for Jessie?

SC: Yes, that’s what we’d have been thinking about, but I don’t remember specifics.

Counsel said that conversation had taken place on 9 May, but Jessie was admitted to the ward much earlier, in March. Counsel said that in a meeting on 22 March Jessie’s father had requested trauma therapy for Jessie.

Counsel: It appears trauma therapy is mentioned almost immediately once Jessie is on the ward, we don’t see any reference to art therapy at this stage.

SC: Is part of standard offering on the ward normally, may have been slight pause in the offering at that stage, I don’t know…. if it was there she would have been able to access it. Part of the discussion would have been around trauma therapy isn’t necessarily an instant offering, or an instant fix, not usually immediately available… when refer limitations of psychology input, would have been talking about how best to understand all of what Jessie was experiencing… all those things wouldn’t be delivered then and there, so would be exploring that and thinking about what’s possible.

Counsel: It comes back to the environment doesn’t it. I think you’re suggesting being on the ward is stopping Jessie accessing some of these?

SC: Partly being on the ward, but I’m not sure they’d be immediately available in any context. Would take some time to establish wherever Jessie was, but certainly the ward had limitations of what it could provide.

There was then a discussion about how Jessie found certain aspects of Cognitive Behavioural Therapy (CBT) useful, but Dialectical Behavioural Therapy (DBT) less so. Dr Cuthbert said that was what was recorded in the notes. She told the court that DBT is recommended for Emotionally Unstable Personality Disorder in particular. Asked if there was the chance that Jessie could have accessed CBT on the ward Dr Cuthbert said that the ward therapist was trained in CBT and would have incorporated many of the skills and aspects of CBT into the groups and activities on the ward.

Counsel: So your evidence is Jessie didn’t undergo any CBT?

SC: No, you need to attend regularly in certain times and tolerate during sessions… it would have been difficult for Jessie, so the approach was take smaller bite size, then might have got to point where she could have it more formally at some stage.

Counsel: We heard Dr Rowe yesterday say it would potentially help with Jessie to have clear signposting of when things would take place… was that something implemented so Jessie knew she had a session of CBT as one of the things on the ward?

SC: I think when she met psychologists that wasn’t thought, sometimes psychologists offer weekly sessions, but that wasn’t felt to be useful.

Dr Cuthbert mentioned group work and sessions with nurses on the ward, she told the court that Jessie did not have any structured psychological therapy.

Asked by counsel if she was aware of the concerns of Jessie’s parents that Jessie was being accommodated on the ward, but wasn’t receiving any structured or focused therapy, Dr Cuthbert responded:

I was aware, tried to explain what is feasible on the ward, we were thinking of trying to help the Sensory Integration Therapist to access the ward, have to think about what’s feasible for the system and the individual… people aren’t always in a position to be able to access therapy.

Counsel said that Jessie was under the care of a rheumatologist, and their statement would be read to the court in due course. She asked Dr Cuthbert if she was aware that when he reviewed Jessie he recommended that she needed physiotherapy and a referral to a pain clinic.

Dr Cuthbert told the court she thought she would have been aware. That she would refer people to their local musculoskeletal service and their local pain service.

Not sure what stage that was at with Jessie. It takes a degree of self-management. When we’ve referred other patients they’ve not been in a place to deal with that. We don’t have physiotherapy on the ward… likewise we don’t have hydrotherapy on the ward and know there are difficulties across the board with hydrotherapy.

Asked about the pain management clinic Dr Cuthbert told the court that was part of the musculoskeletal service and it incorporated CBT and other therapy.

Know at times we’ve had patients not able to engage with that referral and turned down. I don’t know with Jessie whether we made the referral to see what they’d say, or whether we paused it.

Counsel again referred to the evidence the previous day of Dr Rowe, relating to a number of triggers for Jessie, including fatigure.

Counsel: Do you think it is important to get Jessie support for her physical needs?

SC: Yes, chronic pain is something that does cause increased levels of depression and anxiety, important to be aware of, wanted to support Jessie with that… help her build up strength and to pace herself, MSK could have been part of it in future.

Counsel moved on to discussing the Trust’s policy around the safe management of clinical risk. She asked Dr Cuthbert if she accepted that the policy said there should always be an understanding of physical health issues, must be alert to someone’s physical health and their level of risk. Dr Cuthbert told the court it was a well documented risk factor.

Counsel: Given it’s a well documented risk fact and Jessie had been recommended pain management and physiotherapy, but wasn’t receiving it on the ward, that should be set out as a specific risk factor in her plan, do you accept that?

SC: Pain isn’t something that can be resolved in the immediate… developing management plan doesn’t happen immediately, unfortunately. Was difficult for Jessie to access therapies, partly due to regularity she was attending acute hospital, it made it difficult attend therapies in any way.

I absolutely agree would like to have physiotherapy, it’s something I lobby for on a regular basis… hydrotheraapy isn’t available to us, MSK clinic isn’t immediate, Jessie would have to meet threshold.

Counsel: There was recommendation for physiotherapy and a pain clinic

SC: There was a recommendation but it wasn’t [didn’t catch]

Counsel: It wasn’t specific in her risk management

SC: It wasn’t specific, but there was consideration given to the pain she experienced

Counsel asked in regard to Jessie’s pain management medication, what steps were being taken to review the levels she was on. Dr Cuthbert told the court that they regularly review and try to reduce medication. She said in Jessie’s case it was “somewhere down the pecking order really in terms of thinking about the medication she was on”.

Counsel asked if Jessie’s physical health needs were not at the top of the list during her time on the ward and Dr Cuthbert said her medication was not the first she thought that needed to be changed.

Jessie was reviewed really on very many occasions for very many concerns around her physical health, many of those were acute problems often related to self harm… or non-epileptic attacks for examples.. she also had reviews with specialist teams on a number of occasions… spoke specialist teams on a number occasions thinking about physical health needs… often was around urgent something, was disruptive was hard to say what’s best for your health when focusing on immediate needs… in background trying to have conversation about healthy diet, and exercise and pain management… but acute needs often distracted really from her achieving full health.

When counsel asked if it was important to resolve Jessie’s pain, given it was identified as a background setting event for her dysregulation, Dr Cuthbert agreed that it was a “really important topic”. She told the court that Jessie was very anxious about having her medications reduced and so to help with that, she made as requested medication available to Jessie.

There was then a discussion about changing medication which I didn’t catch, apologies.

Counsel: You’ve mentioned referral to the Psychiatric Intensive Care (PICU) unit, what does that unit deal with?

SC: Patients experiencing severely agitated behaviour, posing a risk to others, sometimes to themselves, who need care in environment slightly different to us. For example they have access to seclusion rooms I mentioned before, and have a smaller number of patients.

Counsel: You made a number of referrals to this unit during the time Jessie was on ward, but the referrals were not accepted. Can you explain the rationale for that?

SC: The referrals were made by the whole ward team. Over the time Jessie was on the ward, particularly at the beginning, were very frequent and very difficult episodes to manage of aggression, violence towards staff, very disruptive incidents difficult to manage, posed a risk not only to Jessie but others …

Was thought it would be helpful for me have a discussion with PICU to discuss what we might do differently, but also consideration she’d been at the PICU in the past. That might be a lower stimulus environment for her. There are fewer admissions, tends to be less access to the sorts of things that can be over stimulating.

Dr Cuthbert gave a further explanation which I didn’t catch [apologies].

Counsel: the evidence you gave yesterday related to potential enquiries of an Autism Unit in Cumbria?

SC: Yes

Counsel: You mentioned the high security and rigidity of that, might be more difficult for Jessie’s presentation?

SC: Well would potentially be useful in some ways, given reduction in stimulation, for someone like Jessie was very able in many ways, she liked interaction with other people, she was creative and things like that. So being in environment more stark might be difficult, and she’d have been away from family. Were aspects of it would be difficult for Jessie, think this was the difficulty with placements as well. Finding those opportunities for her to have connections with others…

Counsel: We know on each referral the PICU unit said Jessie doesn’t need admission to our unit. Their view was it was better for her needs not to be dealt with in their environment, is that right?

SC: Yes

Counsel for the family then asked about the Trust policy on leave from the ward. Dr Cuthbert explained that if Jessie wanted to spend time away from the ward, which she was keen to do, then the hospital policy was that she had to demonstrate first that she was safe on the ward, by coping with reduced observations.

It’s part of Trust policy, but actually I think, although there are clear risks associated with reducing observations, often people feel more should be done, there are also risks with someone being on high observations for long period of time and Jessie also demonstrated that.

For example, having somebody, important distinction to make between observations on the ward and being with someone in the community. Observations on the ward is someone is sitting with patient, can’t do anything else other than being eyes on, can’t do anything on their own, must be eyes on the whole time.

People can’t sustain that over a long time so have to change over on an hourly basis, so quite a lot of staff turnover. Many patients find it obtrusive to be under that constant level of observation.

For patients who experience emotional dysregulation, don’t have same level to be in their own space, manage things in own way… sometimes see when observations increase, some other damaging behaviours increase.

All those things [self-harm so withhold] can still happen… what we knew from Jessie’s stay at Langley Green, although little different there, some of time had worker from outside to support Jessie, and at Abbey Ward, noticed as observations reduced some of self-harm reduced.

Counsel said that she would turn to decisions about observation levels in due course, but at the moment her question was about a link between levels of observations and whether or not Jessie can get leave on the ward.

Counsel: It seems to be operational policy Jessie would not have escorted leave until her observations reduced to general [observations]?

SC: That is the policy of the Trust

Counsel: The latest policy of the Trust, as we understand it … paragraph 4.6 refers to leave from hospital whilst on observations and states there isn’t a blanket rule of whether can go on leave on intermittent observations, and may be occasions when leave could enhance care.

4.6 Leave from the Hospital whilst on Observations

Somebody being on enhanced observations is often a result of their level of risk. Given this, it is often that they cannot access leave from the hospital. However, this is not a blanket rule, and there may be exceptional circumstances where the use of leave may enhance the person’s care, safety and experience; in these cases the use of leave should be individually risk assessed, focusing on the identification and balance of clinical risk and benefits. It is important that the terms and conditions of leave are explicit if someone is on enhanced observations is to utilise any leave or time away from the ward, These should be decided as an MDT and in partnership with anyone the person might be going on leave with, and the person themselves. Should someone go on leave while they are on enhanced observations, there should be clear documentation on care notes that evidences a multi disciplinary discussion that clearly weighs up the risk of leave against the risk of restricting leave. This should also be referred to in the person’s care plan and risk assessment. There will need to be a clear leave management plan in place that details support pre, during and post leave, and assessment and management of risk and support at each stage.

Counsel suggested that it appeared after Jessie’s death changes were made to the policy to allow more flexibility. Dr Cuthbert told the court that she was aware that Jessie had leave for discharge planning or for urgent medical appointments.

SC: Jessie did leave for a large number of appointments over the time she was with us

Counsel: The Policy itself doesn’t refer to leave being restricted for medical appointments, simply says not blanket rule and leave may enhance person’s safety and wellbeing

SC: In discussions with Trust management they’ve been clear need to manage on the ward before getting leave

Counsel: So you’re saying there isn’t a change in practice between when  Jessie was on the ward and now?

SC: No

Counsel: So, no reasonable adjustments… none of the benefits of escorted leave?

SC: It’s a tricky issue sometimes and think it can feel very unfair. Actually, is flip side to it, was another thing Jessie found very difficult was grey areas, can I go, can I not go.

In many ways was difficulty we had with managing her as informal patient as she was for a period of time… for period time after Jessie came into hospital, I met with her, seemed she’d be able to agree to be on ward and receive the treatment she was receiving… difficult thing to do, may be reasons someone can’t leave..

It became difficult with Jessie, where discussions about safety and wanting to go on leave, can’t be restricted for someone who isn’t detained. Seemed to inflame the situation and make more difficult for   Jessie to manage.

So bringing under the framework of the Mental Health Act… was some benefit to that clarity of approach rather than a rule that could be interpreted in different ways. And I think that’s why the Trust approach is people need to be on general observations before they can have leave.

Counsel: Could the decision not be made in a structured way from the beginning, and allow her structured periods of leave despite her not having general observations?

SC: At the point Jessie was with us I thought her being on general observations, I thought was safe and positive for her, was part of her having leave which she did have.

Counsel for the family took Dr Cuthbert to the Autism Crisis Plan which Dr Rowe compiled for Jessie which referred to Jessie being moved to a number of settings historically, and how this impacted on her attachment profile. It sets out triggers for Jessie’s distress which included when she had an argument; and she was likely to support would be withdrawn if others feel she is getting better or coping.

Counsel asked Dr Cuthbert if she were aware Jessie was concerned that her support would be withdrawn if she were getting better. Dr Cuthbert told the court that it would be “consistent with my idea of Jessie, I can’t say if taken from the Plan or otherwise”.

Counsel suggested that it was relevant to decisions about observation levels for Jessie and suggested there was an inherent tension between doing better and coping, and her seeking further support through risky behaviours.

Yes reducing that, I suppose I’m very conscious of when people feel need for care and reducing care needs are perceived as not in need, something we do have to navigate carefully, but it’s not a reason to keep care at a very high level… took approach with Jessie, she had a very clear structured plan… reiterating importance of ongoing support and care, all through it was recognised she’d need a high care environment with very gradual increase of her independence.

Discussion moved on to levels of observation.

Counsel referenced a conversation Dr Cuthbert had with Jessie on 7 April 2022 where Jessie had said she needed to be on constant watch, that she couldn’t be left alone for a second or she would be dead.

Counsel: Decision was would be intermittent, would not be on constant watch, despite her indication she needed it?

SC: Yes. Sometimes patients do say something, in anger, or that something will happen if don’t do X, Y or Z. Have to take that information on board as a professional, is it in person’s interest, is it best for staff to do, can’t ask if staff likely to be assaulted… can’t ask my staff, staff on the ward to do, can’t ask.

I understood Jessie could make statements like that, something will happen unless you do this. Wanted to work with her, so she understood she had support available, in a different way.

Counsel: In respect level observations you mentioned, one of the consideration was risk to staff, but also very central is risk to Jessie of harm or risky behaviour?

SC: Jessie’s risk assessment would be about risk to herself, but risk to staff was also a part of ability to give her good care when she’s putting staff at risk.

Police proceedings… people may act with violence and aggression, that has long terms consequences for them, that was a risk for Jessie, but as ward delivering care would also think about risk to staff in terms of their vulnerability to risk and assault.

Counsel: 7 April, when Jessie is on intermittent observations, after she’s told you she needs to be on constant watch, she [self harm / will withhold detail] do you accept that?

SC: She did yes.

Counsel: So these type of observations perceived by Jessie as staff thinking she’s getting better, may enhance her risk profile, because she’s of the view staff would abandon her?

SC: I don’t think that was the context of discussion on 7th, can see she also self-harmed on 8 April… at that stage grabbed staff by leg, banged on wall, self-harmed, under high levels of observations.

There are incidents like that previously and subsequently. I think later on after observations were reduced, in context things stable while, ready introduce leave, was period where Jessie expressed heightened anxiety, was some incidents that might fit more with that pattern you’re talking about, but I don’t think that occasion is around Jessie thinking that. There may be an aspect of her thinking her needs weren’t being met.

Counsel: The examples given on 8 and 9 April, are thereafter you’ve reduced her observations, the point is still relevant, there is a link between reduced observations and self-harm behaviours?

SC: Could probably cherry pick lots of instances. Were number of incidents when Jessie was under high level of observations, and was incidents when under low level of observations, when in the community and at home too. Observations had to be partly around immediate risk and best way to deliver care to Jessie at any particular time, taking various matters into account around that.

Discussion continued with counsel for the family highlighting further examples that she said demonstrated that Jessie was very aware of her risk and how safe she felt on different observation levels. Dr Cuthbert accepted that Jessie’s mother, Kate, had mentioned Jessie’s need for constant reassurance and fear of abandonment and rejection, to staff in a meeting on 27 April.

Counsel said that Jessie felt she was not getting adequate support and that there was a tension.

SC: Was certainly tension… difficulty we had was thinking what is it she needs… care team felt was manageable and appropriate for her to be on that level of observations but they were discussing it with her, and helping her management.

Counsel: It’s referenced that her demands are unrealistic. It wouldn’t be helpful to tell her that is it?

SC: Doesn’t sound like a very gentle phrase, no, that’s what’s written in the notes, don’t know if that was what was said.

Counsel: Same day 11 May, Jessie mentioned she wanted more 1-1 time with staff and it wasn’t fair. Was explained to her she should discuss with team. Again, second time that day issue brought up by Jessie that she feels she hasn’t got enough support? Should be reflected in her risk assessment?

SC: Could be, even when she had staff with her she would feel she wanted more… something they were talking about. She had regular 1-1 time built in with the nursing team both in the day and at night. She would have also had opportunities for contact and regular visits during the day. Those things team think about with her to manage that desire for wanting more contact.

Counsel: 12 May involved incident where Jessie found self-harming in  the toilet. Later became distressed when didn’t have staff members with her. Again issue raised Jessie being distressed when she didn’t have enough staff support.

SC: Yes, it seems she raised she didn’t feel she had enough support, yes

Counsel: 14 May, Jessie taken to A&E following self-harm. Appears to be some risky behaviour coming out in Jessie’s presentation after being reduced in observations. Do you agree?

SC: Yes, that was a potentially risky thing. That’s why she went to A&E, whatever [details withhold] on the ward, I think it’s probably difficult in some ways to understand maybe, that we recognised sometimes people can engage in risky behaviours but not have someone with them all the time.

That does happen in context of people who may engage in self harm behaviours over a period of time, in community or on the ward, increasing observations may not reduce them. We understand may be risk of events happening, but being on the ward, will provide other ways to manage and help in ways more helpful to them.

There was then a discussion about the incident on the 14 May and the text message conversation with 999 operators and the fact that Jessie was of the view that she had to contact 999 directly because staff were not assisting her. Dr Cuthbert said that she did go to A&E and that it would not have been a good use of a 999 call. That the ward had staff available and a medical team who would respond.

Questions returned to the observations policy and the management of someone with potential, if not imminent, risk of self-harm.

SC: Really almost all patients in an acute mental health ward will be at risk. Already area very high intensity input and observations, formal observations check is only one part of engagement on the ward. Engagement with teams in other ways is really important therapeutic aspect. Observations are helpful, but only one part of it.

Counsel: In your risk assessment on 12 May, you noted perpetuating factor of Jessie’s risk is she had chronic risk of self-harm and active risk of death by misadventure. That risk hadn’t gone away?

SC: Yes

Counsel: It was chronic, that’s the word you used?

SC: Yes

Counsel: Protective factors in risk assessment are listed as the support of Jessie’s family and she’s a creative person who likes to spend time with others. Those were thought to guard against risk, is that right?

SC: Yes

Counsel: 16 May, h2626, Jessie parents described to Ruth Nathan they were concerned because Jessie on general observations, she was unable to do her bracelet making, not allowed scissors unsupervised. No therapy offered, no activities for Jessie despite being there 10 weeks.

Family were of the view the change in observations level was obstructing Jessie’s ability to be creative, were you aware of their concern?

SC: I know there was some toing and froing, I think her being on eyesight observations wouldn’t necessarily mean she’d have access to knives and blades… wasn’t restriction on that, was she couldn’t have scissors in her room, slightly less freedom of some creative tasks. Things in her room were risk assessed, were some things could have caused harm, but would have discussed with team and felt would be beneficial to her, for example she had a string of lights with photos on, some patients wouldn’t be allowed but she was.

Counsel: It’s certainly the view of Jessie’s parents that limitation of her ability to do these creative tasks was specifically linked to change in her observations levels.

Dr Cuthbert told the court that they talked about activities Jessie wanted to do in a day. She felt she did have access “to some extent in the ward environment. May be harder to access some things, some she’d have done less easily than in her own home, which unfortunately wasn’t available to her”.

[There was then a 10 minute break before returning for more questioning.]

Counsel for the family discussed with Dr Cuthbert some risk factor triggers for Jessie from Dr Rowe’s report. Dr Cuthbert told the court that she wouldn’t consider them triggers, but part of a cluster of symptoms.

Counsel took Dr Cuthbert to a number of entries in the records to ask whether she accepted that they were indications that Jessie was distressed.

Counsel then moved to 16 May, the day before Jessie died.

Counsel: Note by Ruth Nathan commenting Jessie’s presentation on 16 May, the day before she dies. H2626, one part of that extract is relevant to this, Jessica had been talking of her wish to lose weight, currently eating 500 calories a day. That period is on 16 May, issue is alive in Jessie’s presentation, do you accept that?

SC: Yes

Counsel: Next conversation about Jessie’s money. You said some discussion with Jessie about support for payment plans, because concerns about her spending?

SC: Was a discussion that week, she was particularly clear her dad transfer her some money from her savings account, he was concerned about her over-spending, so we discussed.

Counsel: That was on 16 May, the day before Jessie’s death. On that day, we understand you were present for that conversation is that right?

SC: Yes, yes, it was the ward review.

Counsel: The other aspect of Jessie’s presentation we discussed with Dr Rowe is her response to unpredictability, when there’s an unexpected change of routine. That was something you were aware of as well?

SC: Yes

Counsel discussed Jessie’s safety plan with Dr Cuthbert. It was dated 13 April 2022 and included things that could lead to escalation for Jessie, such as not being involved in planning, hearing of fearing bad news, 5 to 8pm were always really difficult and voices tended to get worse.

She told the court it said in terms of preventing that, planning events in advance, having a clear plan of what to do afterwards e.g. drawing, conversation, distraction techniques. She asked Dr Cuthbert if she were aware of those aspects of Jessie’s safety plan and she responded that it “certainly sounds in keeping with what I’d expect”. She also told the court that it was very frequent for people to be encountering those sorts of stressors.

Counsel: We understand that Jessie was visited on 16 May, and we have a witness we’ll be having statement read at later stage, she states ‘on 16th Jessie was visited by her Dad in the afternoon…   Jessie was irritable when he left due to the abrupt visit by her social worker during her 1-1 time with staff’. Do you agree an abrupt visit would be destabilising for Jessie?

SC: I agree, it would be difficult. I think the nursing team would work with her, her Dad’s visit overlapped, so understand she could use some leave following the visit, hopefully that was soothing for her and helpful for her.

Counsel: In terms of response from staff on ward, given what Jessie’s safety plan says, would you not expected to be some structured activity or distraction technique following?

SC: I think that’s one of range of possibilities, could be offered structure time with staff, sometimes people need rest time as well, engaging in another activity would not always be helpful. Jessie was quite sociable on ward and spent time with other patients, possibly structured activity would be considered or discussed, could be something else.

Dr Cuthbert said she could not say what was offered that evening.

Counsel: We also heard from Dr Rowe about the impact of trauma on Jessie’s dysregulation, and that here may be triggers for Jessie due to her previous experiences, were you aware of that as potential risk factor?

SC: Yes

Counsel: We’ll hear evidence from someone later on in the inquest, is reference to Jessie making request on the evening of the 16th that person carrying out observations be changed because of a previous bad experience in the community. Do you view that as potentially linked to her trigger of trauma?

SC: Yes, she had association with that person she found difficult and didn’t want them involved in her care, imagine degree of distress associated with that.

Counsel: So by time Jessie is going to sleep on the evening of the 16th, she’s made comments that day about restricting calorie intake, requested the last of her depleted savings, had an unannounced visit from a social worker to investigate distressing allegations. The unannounced visit interrupted her 1-1 time with staff, and had an individual on her observations that she had negative experience in community. One of, or a combination, are highly likely to distess Jessie, would you agree?

SC: Yes, one or all would be …. had seen her on many occasions, think some of those things would be part of ongoing…. Financial seemed in context of future, even weighing didn’t seem harming herself but what she wanted to look like… those things didn’t seem to be when I assessed her on the 16th, weren’t things that suggested to me she wants to end her life in the moment, today, tomorrow, this week or this month.

She was thinking about things she wanted to do in the future, was conversation she had with me and her Dad.

Counsel raised what Dr Rowe had told the court the previous day, that because of Jessie’s processing delays, the cumulative impact of some of these risk factors may not be immediately present but as the evening goes on Jessie may worsen. Asked if she was aware of Jessie’s processing delays and that she presented more dysregulated in the evenings, Dr Cuthbert said she was and told the court that evenings are often a more difficult time.

Counsel for the family asked a number of final questions about Jessie’s limitation on her access to creative activities, which had been identified as a protective risk factor for her. Dr Cuthbert told the court that she was sure that would be an “area of distress and frustration” for her and she was sure they’d had a measured conversation about that.

No questions from counsel for Brighton and Hove City Council.

Counsel for East Sussex County Council asked Dr Cuthbert about an email she had sent to Michelle Cook, Jessie’s social worker, about a CTR. Dr Cuthbert was asked to explain to the jury what a CTR was. She explained it was a Care and Treatment Review, for people with autism or learning disabilities who were in hospital or at high risk of hospital admission. She described it as a “meeting as an emergency to scrutinise and provide oversight of treatment and help that person get out of hospital as soon as possible, make sure different things are considered”.

Counsel: In this email you also said, a community placement doesn’t seem feasible, current plan approach specialist providers in absence of alternatives, then you say I’m liaising with specialist units for advice to see if she might be eligible. Is that the specialist unit you mentioned?

SC: I had a few things in mind, said didn’t think necessarily an autism unit was ideal, difficult to know what an ideal placement would be.

Didn’t seem community placement was possible or feasible, we knew she couldn’t go back to Viaduct Road and there wasn’t an agency available to provide care.

Potential thinking other hospital environments, possibly autism unit, one of difficulties, it had a very long waiting list.

One of difficulties Jessie had presented with, and part of the reason being to hospital so many times, is she often presented with physical symptoms quite difficult to manage. Partly symptoms as a result of Ehlers Danlos, POTS and some we’d call medically unexplained symptoms.

One or two specialist units in the country manage those conditions, there are very few. Approached but didn’t think they would necessarily accept patients under section or where risks such as with Jessie. Trying to make enquiries whether any of them would be able to do that, think possibly heard back from one of them about waiting list, I don’t recall much about that.

Third possibility might have been in that email was Specialist Services that manage people with personality disorder, commissioned by the NHS, but also people experiencing emotional dysregulation.

For those service, and the medically unexplained symptoms, the family disagreed with those diagnoses, and Jessie herself, so they may not have been suitable, but I thought it was important to see what they could offer.

Might have been able to offer something related to autism or something else. Made referral to our rehabilitation hub that looks to super specialist referrals, would also be pathway to thinking about the fourth option, which is options in the private sector which are often low secure rehabilitation units.

Our Trust has a lot of reluctance to pursue those because although they are described as specialist units, often they are not using evidenced based treatments and often they are out of area.

The Rehab Hub started thinking of those possibilities.

Asked by counsel about the expression that “community placement doesn’t seem feasible”, Dr Cuthbert told the court that was based on a combination of what was known about the capacity issues, but also about the ability for Jessie’s needs to be met in the community.

There was then a further discussion about levels of observations and what different observations would look like, and how that might work in the community.

Counsel: Various question from family representative about the potential reduction in observations may have been a triggering factor for Jessie. If in fact, let’s say she wanted more observations or observation time, and that level of support in terms of eyes on support, how realistically do you think that could have been achieved in a community setting?

SC: Don’t think would be done in community setting in same way as on the ward, think eyesight observations is particular to psychiatric unit, very intense eyes on.

She would have number staff in community, present and available to her at all times over longer shift, from discussion with Jessie seemed not quite to level of eyesight observations on the ward.

… Would recommend Jessie case would need to be a team of people other than one person, due to risk to her and staff members, then it is not impossible but quite difficult to provide in the community.

Seen some examples where house with team of 2 to 3 staff available to them in house, often requires additional legal framework to be in place, in itself quite time consuming.

Requires team to be place and any additional therapies usually provided by the organisation, so that is a major undertaking, and potentially very difficult to achieve, because of finding an agency.

The agencies approach listed by Lauren Bernard, some of them can provide packages similar to that, some not as restricted, but to mirror what was happening within an impatient ward.

In response to a further question from counsel for East Sussex County Council Dr Cuthbert agreed that Jessie’s profile was consistent with her various diagnoses including Complex Post Traumatic Stress Disorder.

Her final question related to multi-disciplinary working between staff at Sussex Partnership NHS Trust and East Sussex County Council.

Counsel: Lastly want to ask about multi disciplinary approaches… you refer to Complex Case Review taking place on 17 May, and a professionals meeting on 5 May. Was there a multi-disciplinary approach to try and find the best solutions to care and support and accommodation?

SC: I think so. I’d had contact with Lauren on a number of occasions, and later with Michelle. We were liaising, going backward and forwards trying to discuss whether it was the right time to look at care or whether more was needed, came eventually to the conclusion could make some steps, if an agency were to come forward, was possibility, they’d be followed up but actually was agreement that direction setting at Complex Review Panel was really important… are we recommending specialist placement or focusing energies on community placements or were there alternatives not thought about.

Next it was over to counsel for Sussex Partnership NHS Trust.

Firstly she checked with Dr Cuthbert that had accommodation become available in the community, there would not have been a requirement to wait for the Complex Case Panel meeting. Dr Cuthbert said that they would have proceeded but it would take some time to really pull it together.

Counsel then asked Dr Cuthbert if she had seen the report compiled by the Coroner’s Expert, Dr Beber. She had.

Counsel reads from the report: I know the Trust acknowledged the unsuitability of the placement, and they and the Local Authority had made efforts to find suitable accommodation with no success… a meeting of the Complex Case Panel would allow them to discuss further.

Difficulty for the Trust and the Local Authority is a dearth of specialist providers who could provide Jessie with the high quality care she required…

Use of the word dearth, dearth is a strong word, you agree with that?

SC: Yes I do

Asked if anything else resonated for her in the expert’s report, perhaps relating to improvements, Dr Cuthbert said she had made a note of a “couple of quality improvement areas”. [She gave a fuller answer including what they were which I missed].

No jury questions for Dr Cuthbert and she was released at 12:44.

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