At the start of Day 4 the coroner explained to the jury that they would be hearing from staff at Mill View Hospital today, but before then she would ask Jessie’s father, Andy Seares, to come forward to clarify some things for them.

Andy Seares / Disclosure and Barring Service

Before giving further evidence the coroner asked her Coroner’s Officer to read from an exhibit produced by Ms Woolfenden, an Adult Safeguarding Form.

The extract said that due to Jessie’s death it was impossible to reach a definitive outcome. It said that no definite abuse was disclosed by Jessie and no police action was indicated by the police, however a concern remained about the relationship between Mr Seares and his daughter, and the impact of that on her wellbeing.

The report said that Mr Seares worked as a teaching assistant and volunteer visitor with young people in Brighton and Hove. It said that he had been sent a letter informing him a safeguarding report had been made and asking him to refer from undertaking personal care tasks and spending time alone with Jessie while it was investigated. It continued, Mr Seares did not accept this advice, and there was a concern about his ability to take safeguarding advice. It also said that Jessie’s admission to Mill View was providing an element of protection from the risk of safeguarding concerns in the meantime. It said the local authority was left with concerns about Mr Seares ability to adhered to safeguarding processes and his paid employment and voluntary work with young people. On this basis a referral was made to the Disclosure and Barring Service (DBS).

The coroner told Mr Seares that he was here to give evidence on the outcome of the investigation by the DBS. He confirmed that he had cooperated with the DBS.

Mr Seares read from an outcome form. The final decision for working with children and adults was “not barred”.

He then provided further details from the form that stated Mr Seares and his daughter had raised significant concerns about their daughter’s care and it appears following this a carer has raised concerns of Mr Seares.

Those concerns related to Mr Seares being in his daughters bathroom for long periods of time and helping her to bath, being in his daughters bedroom for long periods of time, and not leaving his daughters cubicle when she was dressing.

[Section that I missed, apologies, too quick].

Mr Seares continued reading from the outcome form. There has been no disclosure from the daughter. The police stated no offences had taken place. No evidence to support anything untoward and there appears to be a lot of supposition on behalf of the person making the claim. Section 42 enquiry failed to come to a definite outcome due to the daughter’s death.

The coroner told the jury that any questions about what the DBS process is will be put to another witness.

There were no counsel or jury questions.

Jack Pumphrey / Ward Manager Mill View Hospital

Jack told the court that he was a mental health nurse and the coroner told the jury that today he would be dealing with evidence about his role as Ward Manager when Jessie was on the ward, and he would return to give evidence at a later stage about other aspects.

I couldn’t hear at what point Jack took over as ward manager but in response to a question from the coroner he said that in 2019 he was a Charge Nurse and had met Jessie in that role a couple of times.

The coroner asked him to explain what a ward manager and what a charge nurse was to the jury. I couldn’t hear most of his response but did catch that he said a Charge Nurse was the next level down below Ward Manager, and they were Deputy Ward Managers. He said that they provide leadership skills in terms of nursing, take charge of shifts, coordinate shifts and provide supervision to HCAs (healthcare assistants).

He told the court that there would be two charge nurses on each shift. That the ward was registered for 8 staff nurses “but we haven’t had that for a while”. He told the court that healthcare assistants provide direct care to patients, conduct physical health checks, blood pressure and so on [couldn’t hear, he was very quiet, apologies].

C: Is there a minimum number of nurses that are required on a shift?

JP: Yes. Shall I talk you through our staffing levels? Our basic, that we have to have on every shift, regardless of how many people are on observations, we have to have 2 nurses and 3 HCAs during the day, and 2 nurses and 2 HCAs during the night. That increases when we have people who require more support, with 1-1 for example.

C: We heard yesterday from one of the doctors about levels of observations. So if very unwell patients are on the ward on 1-1 observations, staffing levels have to increase?

JP: Yes

The coroner said that he wouldn’t take Mr Pumphrey thought Jessie’s history and diagnoses. She asked him if the staff were fairly familiar with Jessie as a patient?

When Jessie was first with us they weren’t. It was her first admission to Caburn Ward… she had a passport with lots of information in it and a Positive Behaviour Support Plan. So staff got to know Jessie through reading those documents, as well as talking with her.

Mr Pumphrey was asked to explain to the court the role of a primary nurse. He said that every patient has a primary nurse, which could be one of the charge nurses or staff nurses that work on the ward. He explained staff nurses are the level below charge nurses. A primary nurse is involved in care planning for a patient [and fuller answer I couldn’t hear]. He also told the court that there were allocated nurses on each shift, so every patient will have an allocated staff member to go to if they need and patients knew who they were.

C: Is the idea for a patient to go to that allocated nurse if they have any concerns, or can seek them out if they want some help in any way?

JP: Yes

C: So the care plan and the risks assessments are completed by the primary nurse?

JP: That is the expectation, but because we have 17 patients, the primary nurses and care plans are updated weekly, it may be other nurses that complete it for them during that time.

Asked by the coroner if Jessie engaged with her primary nurse around care planning Mr Pumphrey said she did, adding “she definitely did it in her own way, she didn’t find it easy”. He explained that Jessie would annotate what the nurse had written and give it back to them, to ensure her thoughts were known.

In response to a question from the coroner about what it was like nursing Jessie, Mr Pumphrey told the court that there were some days when Jessie was more distressed and some where she were less distressed “it really did depend on the day”. He said that Jessie had someone allocated to her every hour, that is whether she was supported on a 1-1 basis or checked hourly.

The coroner asked whether Jessie’s presentation varied between observations, hour by hour and Mr Pumphrey said that it did.

She might be very distressed, it depended a lot on what was happening on the ward, what was going on around her, and what she was fearing.

There was then a discussion about how well the staff on the ward knew Jessie which I didn’t catch, apologies.

Mr Pumphrey explained to the court about the handover process, telling the jury that it would include how Jessie had been on the previous shifts, any incidents that they were aware of and so on. He said handover was given in a very set way, starts with the patient’s name and their legal status, their diagnosis and observations level [fuller answer – didn’t catch].

In response to questions from the coroner, Mr Pumphrey told the court that he saw Jessie’s parents visiting, that he himself didn’t have any dealings with Jessie on 17 May 2022 but saw her on the 16^th. He said he had no concerns about Jessie when he saw her on the 16^th.

It was then over to counsel for the family to ask her questions.

Counsel: Can we just start with some questions about the environment of the ward itself. We have heard evidence through the course of the week about Jessie struggling with noise in the ward environment. Would that be your impression as well?

JP: Yes

Counsel: In your written statement you acknowledge the ward didn’t feel like the right environment for her. What did you do about that?

JP: From the start [can’t hear] she told me she was basically well, highlighted her risks increase when she’s in hospital, this was escalated by our Matron at the time to Director level… who confirmed Jessie was in the appropriate [place? I think he said, hard to hear].

Counsel: In preparation for this inquest you were asked if your staff had any training in autism at the time. You went back to look over that is that right?

JP: Yes

Counsel: Can you explain to us what you found?

JP: At the time Jessie passed, only had one specific training, mandatory training, for inpatient staff in the Trust. They’re mainly directed at nurses, wasn’t directed towards Healthcare Assistants, that was about autism.

Counsel: So what we know about that training is healthcare assistants didn’t get it, you’ve just said, did you do a review of whether nurses were trained?

JP: Yes

Counsel: Can explain the format in which that training is provided?

JP: Online training, information [can’t hear]

Mr Pumphrey told the court, in response to a question from counsel for the family, that to ascertain how many of the nurses that had worked with Jessie had training in autism, he had taken a snapshot of those who had had significant involvement in Jessie’s care. He took this to mean those who had been on shift more than 10 times during Jessie’s admission.

Counsel highlighted that Jessie had been on Caburn Ward for 10 weeks and if he looked for anyone who had worked with her for more than once a week and considered them to have “significant involvement” that there must have been a quite high turnover of staff. Mr Pumphrey agreed with that.

Counsel: So high turnover, new staff coming in who don’t know Jessie, aren’t familiar with the background information and documents about her, do you agree?

JP: Yes

Asked if he had access to the Autism, Crisis and Wellbeing Plan, Mr Pumphrey said that he was not aware of it, but he was familiar with the Positive Behaviour Support plan [I think they’re the same document].

Counsel: Was there any process, that the staff coming and going quite frequently, could sign or register to confirm they had looked at documents?

JP: Was no register at the time. The way we had it was the PBS plan and communication passport displayed in three areas of ward, in the handover room to read coming on shift, in the office… on a clipboard with documents on…. and in addition to that Jessie had copies in her bedroom.

Counsel: Your expectation as ward manager was anyone coming into contact with Jessie had an understanding of how best to approach her. Is that fair?

JP: Yes

Counsel: That’s your expectation

JP: Yes

Counsel: In your second statement you say following Jessie’s death the Caburn Team recognised the need to understand more about how to support people with autism, and there was a training session in August 2022.

JP: Yes

Counsel: Was that recognition in place before Jessie’s death?

JP: It was, there was an initial team day training plan discussed before

Counsel: So it was recognised by yourself and the Caburn Team for the need for information and training to support her?

JP: Yes

Counsel then took Mr Pumphrey to records of a meeting in April 2022 with Jessie’s parents where her mum, Kate, questioned the appropriateness of Jessie being referred to the psychiatric intensive care unit and said that the team should be looking at Jessie’s autism diagnosis.

Counsel read from note: Kate reminded us she was a governor for the Trust and the CEO had recently said that we are at the start of our autism journey.

Counsel: Do you remember that conversation with Kate?

JP: Yes

Counsel: And she raised her concerns at such a high level, do you agree?

JP: Yes

Counsel: She raised her concerns, did you at that point, 28 April, seek to escalate and arrange training?

JP: I sought to arrange a training day for the team.

Counsel took Mr Pumphrey to a later record of a contribution of Jessie’s parents.

Counsel: Jessie’s parents, on 16 May, say “in our view Jessie should not be in Mill View, she should be supported in the community with appropriate care. Staff are not used to the level of personal care that Jessie needs and staff do not understand autism”.

And Jessie died a few hours later. It appears right until the end, Jessie’s parents view was staff on the ward did not understand autism. So it doesn’t appear anything changed between their April view, and May view, is that your understanding?

JP: I think the understanding of autism is so large and so different for every person who is autistic … as Caburn we should have done more work. We still are wanting to do more work, it’s a Trust wide issue. We had documents provided to us, communication passport very helpful, but that isn’t everything … was more for us to learn about Jessie.

Counsel then moved on to Jessie’s physical health whilst she was an inpatient on Caburn Ward. She asked Mr Pumphrey if he were aware that Jessie had seizures, he was. He could not remember whether concern of Jessie’s dad about wishing to have a second mattress placed near her bed in case she fell out whilst having a seizure, was raised with him. Counsel continued this line of questioning but I could not hear Mr Pumphrey’s answer.

Mr Pumphrey confirmed that the wheelchair Jessie used was lost whilst she was on the ward. He said they didn’t understand where it went.

Asked about his recollection of what access Jessie had to occupational therapy whilst she was on the ward, Mr Pumphrey said if he remembered correctly they did not have a Sensory Therapist on the ward at the time Jessie was an inpatient.

Counsel: You say Jessie struggled to engage in a group environment. Was any reasonable adjustment made so she could still have access to therapy on a 1-1 basis?

JP: I don’t recall that from the therapy team

Counsel: We see records Jessie had an OT assessment looking at her ability to have a bath, this is h2668. This assessment takes place on 4 May, at this point Jessie was on the ward quite some time, do you know why it took so long?

JP: Attempts were made previously by our OT but during these attempts Jessie was distressed, or was on visits, or didn’t feel able to engage at the time.

Counsel: You see Jessie declined to walk to the bathroom, can only mobilise around her bedroom at the moment, prefers to use wheelchair outside, was that your understanding?

JP: Yes

There was some further discussion about Jessie’s ability to conduct her own personal care and then counsel for the family said she wished to ask questions about Jessie’s trauma.  

Counsel: Want to ask about Jessie’s trauma. Was it clear to staff that Jessie had a diagnosis of Complex PTSD?

JP: I don’t recall that diagnosis at the time, that wasn’t my understanding

Counsel: So, from March to May you were unaware Jessie had a diagnosis of Post Traumatic Stress Disorder

JP: Yes

Counsel: Did you have discussions with Dr Cuthbert, as her doctor, on this topic?

JP: We discussed diagnoses

Counsel: Did Dr Cuthbert not inform you there was a diagnosis of PTSD?

JP: No. I was aware there was a trauma issue, from the notes I reviewed, I wasn’t aware it was diagnosed as Complex PTSD

Counsel asked that Mr Pumphrey be provided with a copy of Jessie’s Autism, Wellbeing and Crisis Plan, dated 8 October 2020.

Counsel: Are you familiar with this document?

JP: Yes, it’s what we refer to as the PBS plan

Counsel: Exactly. You see at top says how to support me in crisis, the red section of the document, what did you understand this red section to demonstrate?

JP: This is how Jessie was presenting when she was distressed

Counsel: So underneath presentation it says ‘what Jessie says does and looks like that she’s highly anxious, dysregulated and not in control’ and there’s a list of things… you agree?

JP: Yes

Counsel: One of the examples there, right at the top is self-harm [I’ve withheld details]

JP: Yes

Counsel: There were some other items there, if we move on, the 6^th bullet point says racial comments. Note this is activated due to past traumatic experiences…. Were you aware part of presentation when Jessie was feeling highly anxious and not in control?

JP: Yes

Counsel: Next page is called strategies. Section in bold, says aim to resolve as quickly and safely as possible, need help reduce emotional arousal as quickly as possible. You understood to be the aim when Jessie was in this red zone?

JP: Yes

Counsel: Provides some advice as part of strategy on how to do that. The third paragraph says provide 1-1 time, try not to make Jessie feel overwhelmed… provide gentle reassurance… don’t talk too much… validate her distress e.g. I can see you’re really upset and I’m here to help you. So you had a script in a way, of what might help to be said?

JP: Yes

Counsel: And you and other staff on the ward had access to that?

JP: Yes

Counsel: And you’ve told us as Ward Manager, your expectation is staff would be familiar with this, and able to implement it. That’s what your expectation would be?

JP: Yes

Counsel took Mr Pumphrey to an example in the healthcare records of a nursing entry made on 6 May 2022. The entry was made by one of the nurses working on Caburn Ward, who had completed the e-learning module training on autism.

Counsel read from the record that said Jessie was settled most of shift until 7pm when she rejected two members of staff on eyesight, she [self-harmed /details withheld] protesting she can’t have two Nigerian women on her observations. When challenged she became tearful… Jessie said she is not racist and it was a trauma response, she was told that to reject staff based on protected characteristics is racist.

Counsel: So the plan is resolve as quickly as possible e.g. can see you’re really upset, here to help you. We don’t see evidence of that in this entry. Do you agree with that?

JP: Yes I agree

Counsel: We see Jessie so upset she [withheld] that’s a self-harm action, do you agree with that?

JP: Yes

Counsel: Is quite serious… something you want to stop quite quickly, is that fair?

JP: Yes

Counsel: So it’s something you want to de-escalate, best way to refer to this previous plan and red zone advice. Do you agree?

JP: Yes

Counsel: We see here Jessie is self-harming [withheld] and what is triggering to her, when challenged over this racism she became more agitated… So she was challenged, looks like the opposite is happening here, she’s not being de-escalated she’s being challenged on it and becoming more agitated. Do you agree?

JP: Yes

Counsel: Having opposite effect really. Jessie herself tells staff I’m not racist, this is a trauma response. So there’s an element of Jessie trying to communicate that in real time as well. Do you think that’s something should be taken into account by staff?

JP: I agree it should be, but we also have a duty to make sure our staff are comfortable. People perceive discrimination in many different ways, I feel in this incident Matthew was trying to protect staff. Did he follow PBS? No

Counsel: So, it does appear in not following the PBS, there wasn’t a trauma based response to the incident. Do you accept that?

JP: Yes

Counsel: We see the matter doesn’t end there. It goes onto next day, on 6 May at 20:15, this is nursing entry by Lottie Wilcox. Is that a nurse?

JP: That’s a HCA

Counsel: Not someone who’d had training. Says Jessie low in mood this morning because she was racist on yesterday’s shift. So staff appear to say Jessie is racist. Jessie wrote an apology letter… said abused by Nigerian staff in Kent [detail withheld] last sentence says Jessie is very demanding of staff today.

So it appears Jessie is in slightly more distressed state on 6 May, part of this is the issue of her being referred to as racist and trying to deal with that?

JP: Yes

Counsel: She appears to try put down in writing what traumatic event was that led to that behaviour, what view did staff have about the trauma basis of Jessie’s behaviour at that stage?

Coroner: He can only answer for himself

Counsel: Yes, what view did you have?

JP: It’s very tricky, working with variety people and trying to provide trauma informed care, also have people from different backgrounds, and staff members may feel [can’t hear] have conversation with Jessie about it, understand this is traumatic thing but not everyone is like that. I look back and think was that the best option or not, I’m not sure.

Counsel: What we don’t see in that record is a discussion with Jessie exploring that. We actually see she is effectively being called a racist, and she has written an apology letter, it’s unclear how that came about.

We don’t see a staff member has sat down with her and had that conversation in this record, do you accept that?

JP: Yes

Counsel: Moving on, a large meeting, lots present, Dr Cuthbert is present and so are you?

JP: Yes

Counsel: In feedback section states Jessie stating will not accept BAME women on eyesight observations. Boundaries reinforced… Jessie has disclosed abuse in another agency…

So everyone is aware issue came up and the trauma behind it?

JP: Yes

Counsel: Is that fair? Does that recall with your recollection of that meeting?

JP: Meetings were weekly, don’t recall the specifics

Counsel: OK, at the end of the meeting is a section Current Plan. Staff understand what to do going forward, it says report all racist assaults to the police. I’m bound to put to you, that doesn’t appear to be inline in terms of response for Jessie with her PBS?

JP: Yeh

Counsel: Do you think this knowledge of criminal justice type approach would be destabilising for her?

JP: Yes, I think so. I do think there were areas that did need to be reported to the police [can’t hear] but having educated myself a lot since Jessie passed, I look back at Jessie’s notes and the way we worked with Jessie, there are certain aspects that shouldn’t have been dealt with in the way they were dealt with.

Counsel: We see that, think you told us earlier, Jessie would feed into her care and safety plan by annotating it, that was way you’d get Jessie’s views. We see copy, will read out part for you, asks her areas needs help with she says:

I want to get better, I need somewhere to go. Why is everyone letting me down, I just need people to understand me, I need to get the right help.

It appears in her care plan she’s indicated she feels not understood by people, I just need people to understand me. Did you have an awareness of her feeling that at the time?

JP: Yes, I’d say so… [fuller didn’t catch]

Counsel: In your view, as Ward Manager who had contact with her, do you accept that would likely have an ongoing detrimental effect on her wellbeing?

JP: Yes

Counsel: In respect other aspects of approach to Jessie, I understand was a meeting held with Jessie’s parents on 28 April. Followed an incident in which Jessie had set fire to a blanket in her room, were you aware of Jessie’s views of how that incident had come about?

JP: I was aware she was frustrated. I was aware her thought process was self-harm

Counsel: So she indicated to you what she was trying to do was an act of self harm?

JP: Yes

Counsel: Was it concerning to you she was trying to self-harm using fire?

JP: Yes. It wasn’t a known risk.

Counsel: In this meeting, h279, there’s discussion about this incident with Jessie’s parents. It says second paragraph, Kate brought up the fire setting incident and said this was problematic behaviour and would not have happened if Jessie had the support she needed.

Kate said staff referred to this as arson, and this is not appropriate language. So it’s clear Jessie’s parents had concern about how this was being talked about, criminal justice approach to that. Did you understand from that conversation with Kate, was her concern at the time?

JP: Yes

Counsel: On 5 May 16:38 is clinical entry from Connor Turner. Can you explain what his role is please?

JP: Bank healthcare assistant

Counsel: At this point Jessie was on the ward a couple months. Is that  fair?

JP: Yes

Counsel: So some time for institutionally there be some idea of Jessie’s behaviour and needs?

JP: Yes

Counsel: It certainly isn’t the first couple of days she’s been there. It says, in risk events “making threats and throwing her tantrums as usual, screaming for long periods, kicking off and [self-harm] until she gets what she wants” … [fuller extract missed]

What we have there I suggest to you is an experience of Jessie being quite dysregulated, we can see she’s screaming and self-harm… should be a warning to staff she’s in that red zone?

JP: Yes

Counsel: But the language here of her throwing a tantrum until she gets what she wants indicates, I suggest, that PBS plan wasn’t followed, would you agree with that?

JP: Yes

Counsel: Mr Pumphrey I understand you were also involved in a review into an incident where a staff member tried to restrain Jessie in respect of an incident of self-harm. Trainee staff, at university at the time. Do you recall this incident?

JP: Not sure I do, was I physically there?

Counsel says will take to document. At H32689. She tells Mr Pumphrey that this is a safeguarding form dated 8 April 2022. She read an extract from the form [missed detail, apologies].

Counsel: Event happened and Brighton and Hove City Council have looked into it. An event has happened at the ward. Described they entered Jessie’s bedroom and witnessed her pushing another member of staff against a wall whilst attempting to remove item [self-harm will withhold]. She’s described as standing on the bed [withhold] other members of staff [withhold] Jessie resisting this, attempting elbow staff in process… she tried to bite his hand holding her hand… she attempted to punch him, he acknowledged he said in response “Jessica stop fighting or we’ll take you to the fucking floor”.

Then goes on to say she was restrained. Staff member acknowledged use of language was inappropriate and unprofessional.

Do you have a recollection of this, it says discussed with you?

JP: I wasn’t there for time of incident, but the staff member’s response was raised with me.

Counsel: In respect of this conversation what was your view about the way in which Jessie was spoken to during this incident?

JP: The language used was completely inappropriate, no member of staff should be talking to anyone in that way… no one using our services… I was angry when I found out what had taken place.

Counsel said she then wanted to move on to the interactions had between ward staff and social work staff.

Counsel: I’d like to now ask you some questions about interaction you had with some of the services Jessie was engaging with. Jury heard she had a Social Worker, a Lead Practitioner, so would like to ask about a comment you made in your witness statement about this.

You say we tried to engage Social Worker and Lead Practitioner to involve them in her care, however her Lead Practitioner only attended 3 meetings virtually during her admission and to my recollection she never attended Jessie on the ward.

JP: That’s my evidence yes, having been through recently that was correct

Counsel: Your impression there wasn’t much engagement with Jessie from social workers?

JP: Yes, given Jessie didn’t have a discharge plan

Counsel: We know Jessie’s Lead Practitioner Ruth Nathan, is to refer to time she attends virtual meeting on Teams, Jessie very distressed and doesn’t want to be on the call. Doesn’t appear even in virtual meetings was successful engagement, do you agree with that?

JP: Yes. Was very difficult for Jessie… during covid at the time

Coroner: I wonder if these questions are for the Lead Practitioner

Counsel then moved on to ask about the observations policy and its relationship to leave.

Counsel: Just on the topic of observations, we understand form evidence yesterday was policy in place that meant observation level impacted whether or not someone could go on leave from the ward. Is that your understanding?

JP: Yes

Counsel: It’s clear from records, issue of whether serving Jessie was raised by her parents on 28 April. Kate feels therapeutic observation policy is based on a mental health model and does not consider Jessie’s autism… feels Jessie is being treated as a prisoner [can’t hear]. Were you aware of this?

JP: Yes

Counsel: Were you aware when Jessie was at Royal Sussex Hospital, before admission to you Jessie had been given leave?

JP: Yes

Counsel: Dr Gregory for example yesterday said was calming for Jessie to be driven around, for example… were any adjustments made to support Jessie’s wellbeing when she was on the ward?

JP: It’s about the way the policy is phrased… flexibility we took was to go on leave to appointments or things that needed for discharged. If you’re saying you’re not safe to be checked on once an hour, you’re not safe to leave. Do remember times when Jessie was on intermittent observations, at least every 15 minutes, and Dad would take her out… when she was on general observations [can’t hear]. In my opinion that’s the flex we took with that. Do I think the policy needs work around that? I think when you’re writing a policy for the whole Trust [can’t hear].

Counsel said that the September 2022 version states that it is not a blanket rule and Mr Pumphrey said that was a change.

Counsel discussed with Mr Pumphrey how a reduction in observations might be experienced by Jessie as rejection, and she may fear she would receive less support if she were getting better. My Pumphrey agreed and they moved on to discuss a specific incident of self-harm when Jessie was on general observations on 14 May.

Counsel: So your assessment of its seriousness was the impact on her physically. Were you aware of what her intentions were when she did that?

JP: No

Counsel: So you weren’t aware she informed Dr Cuthbert she was feeling suicidal at the point at which she did that?

JP: I wasn’t.

There was then a discussion about changes to the levels of observations that Jessie was on, and how or whether they impacted on her access to creative activities, which were known as a protective factor for her.

Coroner: The points made about reduction in activity, trying to understand what more you could have done other than not put her on general observations.

JP: Quite difficult to answer. Looking back with hindsight, those people were there they could have done more activity with her. We were trying to support Jessie to have independence, being able to recognise how she’s feeling and at what point she does need support.

Coroner: It’s suggested Jessie’s ability to do activities wasn’t there, what you’re saying is it was there?

Counsel: Are you saying two members of staff were with Jessie at all times?

JP: They weren’t with her at all times, but they were on the ward

Counsel: So that’s the change. We see various items get confiscated… the suggestion I’m putting to you, is reduction in having someone there all the time, reduced her access to creative activities. Do you accept that?

JP: I accept that.

There was then some questions about Jessie’s body image and how that related to her levels of distress.

Counsel: We also see in PBS plan that one of the things that may affect Jessie’s hypervigilance is if there are conversations about topics she finds triggering like money. Were you aware of that, as a topic of conversation she found triggering?

JP: No

Counsel: In terms of Jessie’s ability to handle unpredicted appointments or changes in plan. How would you say that affected her?

JP: Would say is quite significant

Counsel: So, you were aware she struggled with change of routines?

JP: Yes

Counsel: You said you were on the ward on 16 May but didn’t have interaction with Jessie?

JP: That’s right

Counsel: Were you aware she had a visit that interrupted her 1-1 time?

JP: No

Counsel for Brighton and Hove City Council said something that I didn’t hear.

Counsel: The PBS plan also refers to impact of trauma on Jessie, we’ve touched on that already. Were you aware particular staff members Jessie had interactions with in the community?

JP: Yes

Counsel: Can you explain what those concerns were?

JP: Some concerns about previous carers… [can’t hear]… IMC Locums is agency we have used at times, were occasions throughout Jessie’s admission where staff members were working on the ward.

Counsel: So these staff members she’d had experiences with in the community?

JP: Yes

No further questions from Jessie’s family. Court was then adjourned for a break.

Counsel for East Sussex County Council asked Mr Pumphrey if he was aware a meeting between Michelle Cook, Jessie’s newly appointed social worker, and Jessie did not take place at the start of April because Jessie had covid. He was aware. He told the court he was aware that part of the purpose of that appointment was to complete a Care Act Assessment for Jessie.

Mr Pumphrey described his involvement in discussions about finding a suitable placement for Jessie, as “only minimal” and he told the court he was aware a number of placements approached prior to Jessie being admitted onto the ward had no capacity or felt they could not meet Jessie’s needs. He also said that he was aware of contact between Dr Cuthbert and others in the background.

No questions from counsel for Brighton and Hove City Council.

Counsel for Sussex Partnership NHS Trust said that she would read a couple of extracts from the Coroner’s Expert’s report and see whether he agreed or disagreed with them.

Counsel reads: Difficulties in past with local authority was the dearth, there’s some question what dearth means, scarcity or lack of, the dearth of specialist providers who could provide Jessie with high quality, consistent care with access to therapies she required.

Would you agree with that?

JP: I’d agree

Counsel: Is it right to say your evidence that Caburn wasn’t appropriate for her is interlinked with that statement. Would you agree with that?

JP: Yes

Counsel: The expert also says people with normal intelligence who have ASD and complex needs are generally poorly catered for in the mental health system. Would you agree?

JP: Yes

Counsel: Why is it difficult to cater for those such as Jessie with ASD and complex needs?

JP: I’ll talk about inpatients

Counsel: Absolutely it’s a wholly open question. Could assist the jury with understanding of types of patients cared for on your ward and what challenges posed [can’t hear]

JP: Autistic people tend to have [can’t hear] sense, such as bright lights, acute hospital wards are loud, busy, bright environments. The reason I feel that is something [can’t hear] patients on ward may present as psychotic, lots of shouting at times, for someone who struggles with noises that would be very distressing for them.

Caburn Ward, 2020 to end 2022 underwent refurbishment to make the ward more autism friendly, colours chosen, [can’t hear] however it still has those bright lights [can’t hear].

Still have got a mixture of people on the ward presenting with different mental illnesses, the environment as a whole does not feel appropriate.

On top of that staff working on ward forming relationships… we have 17 beds [can’t hear] that means staff are meant to be looking after 3 to 4 patients on each shift, can’t give that time to support patients. One thing try to do is reduce restrictions in place for people… spoke about observations policy, use of leave, that are quite strict, don’t have much flexibility for someone who has characteristics that need that flexibilty

Counsel: You told the coroner about challenges [can’t hear] do those challenges impact on ability to give what expert describes as consistent care?

JP: Yes

Counsel: Is that a challenge on the ward?

JP: Yes. We have our team of staff, we do have some agency staff that work on ward very regularly, they’re not directly employed by NHS, we have bank staff internal from NHS, and agency are external.

We have last minute cancellations [can’t hear] and at the start of an 8 hour shift have to induct them to ward environment, introduce their patients, be aware of observations policy, be aware of Section 17 leave policy, a lot to fit in at the start of an 8hr shift.. [can’t hear]

Is consistency of care and carers [can’t hear]

Counsel: Is it fair to say, if simplistic summary, challenges presented by the environment, but also in terms of staffing, and environment being both physical environment and other patients, that contributed to your view that Caburn wasn’t an appropriate place for Jessie. Would that be right?

JP: Yes

In response to a question from counsel Mr Pumphrey told the court that he had contacted the TCAP, Transforming Care and Autism, team within the Trust, to assist the ward. He agreed with her that they were under pressure of resources and the ward would need to wait until they were available.

Counsel suggested to Mr Pumphrey that a patients’ presentation and risk both needed to be “dynamically assessed on a constant basis”.

Counsel: We heard how nurses manage that risk by changing observations level, might be surprising for the jury, might not be. Can you help them understand, we heard from Dr Cuthbert already, there is sometimes an illusion that clinical care is led by a consultant rather than nurses.

Could you perhaps explain how that works on ward, whilst you do have a consultant, it is an active part of nursing care?

Coroner: Ms Agnew I know you’re trying to be quick but there’s a danger you’re leading this witness.

Counsel: How do nurses assess risk?

JP: Nurses assess risk throughout the day, in terms of reviewing observation levels, could look to increase observation level, one person could do that if they think someone’s risk has increased, opposite way of reducing observations, that’s normally a decision by two nurses or consultant and nursing team. Increasing, any member of staff can do that, but reducing that has to be [can’t hear] that’s because reduction has to be taking into account [can’t hear]

Counsel: Thinking about changes of presentation and how that can change, you were taken to p82615… in relation to the discussion with Jessie around racism.

I’m not going to go through all that again, but if I could take you to that on 6 May at 20:15 is entry subsequent to that by Dawn Smith, who we’ll hear from, on 7 May at 06:37 and says night shift. Can you tell us howe documentation works, a night shift entry being made 06:37 following morning, would that be as you’d expect and why?

JP: Yes our day shifts have two times 7am to 3pm, late shift 1pm ends 9pm. Our night shift starts at 8:30pm and ends 07:30 next day. Nursing team write a note for every single patient, will write entry at end of shift to say how patient had been during duration of shift, any changes to observation levels [can’t hear]. A normal time for notes to be written in last hour to 2 hours of shift.

After finishing his evidence Mr Pumphrey gave his condolences to Jessie’s family, saying that his heart went out to them both. Jessie’s mother, Kate, responded “Thank you Jack. You couldn’t have done more, you were one of the good ones in a really difficult situation, we appreciate that”.

There were a number of questions from the jury.

A juror asked what guidance the Trust had on incidents of racism, I couldn’t hear Mr Pumphrey’s response. The same juror asked a follow up question which was in which instances were events referred to the police. They said if it was referred to the police, they wanted to understand whether that was relevant.

The coroner said that we needed to be careful, and that the relevance of it was a matter for the jury. The coroner suggest the question was framed in respect of whether the policies in place at the time were followed as far as Mr Pumphrey knows.

JP: Not policies, but local guidance we had. Also it’s important to know it is staff’s choice if they wish to report to the police. I would not report something to the police.

Juror: So in this case it was a member of staff who referred that to the police?

JP: Yes

A different juror said that Mr Pumphrey had told the court earlier that a trainee nurse had restrained Jessie. They asked if that would have happened under supervision or were they the only person with Jessie.

Mr Pumphrey said that they would not have been the only person there, there was a team there. He said it was important for the jury to know that every member of staff has a personal attack alarm, and when someone presses that alarm it goes off on a pager system around the hospital. He told the court there are 5 wards at Mill View Hospital and one member of staff from each ward would attend that incident. So a minimum of five people attended.

Another juror asked whether all patients detained under the Mental Health Act are sent to Mill View, and whether Jessie would have been better placed in another hospital. Mr Pumphrey explained that Mill View is the Trust’s hospital in Hove, but there are other hospitals in other places. I couldn’t hear his response to the other half of the question.

Counsel for the Trust then asked questions arising from jury questions.

Counsel: does the Trust provide training to staff in relation to violence reduction?

JP: Yes

Counsel: Again it might be difficult for the jury to understand, is it fair to say it’s not uncommon to respond to those alarms

[can’t hear]

Counsel: In relation to other hospital, might be a question for someone later in the week. As far as you were aware is there any other inpatient facility in Sussex that Jessie could have been transferred to?

JP: Yes

Counsel: Would they have been same provision as Mill View?

JP: It’s important to know we try and locate patients based on their area but there are other hospitals across the trust Jessie could have gone to, but she would have been further away from family.

Counsel: It would be a mental health service, wouldn’t be an additional service?

JP: No

Mr Pumphrey was released at 12:40. The coroner said that he was free to leave, but she understood he would remain in court to support the healthcare assistants.

The rest of Day 4 and the morning of Day 5 the jury heard evidence from two nurses and eight healthcare assistants from Caburn Ward.

[I’ll report those witnesses together at some point over the weekend. With thanks to my crowdfunders who support my reporting, and thanks also to those reading and sharing. Given the case is current I’ll not be approving comments until it is over, but appreciate those of you who have commented].