Day 4 and 5 Jessie’s inquest: Healthcare Assistants and Nursing Staff, Caburn Ward

The court heard evidence from two nurses and eight healthcare assistants that were working at Caburn Ward, Mill View Hospital during Jessie’s admission.

I have tried to report Jessie’s inquest in line with the Samaritans media guidance on inquest reporting. The post mortem evidence shared on Day 1 found that Jessie died as a result of compression of the neck by a ligature.

A number of the statements discuss details relating to Jessie’s death, some of which I will withhold and indicate where I’ve done so. I don’t usually add trigger warnings to my posts because I think it’s self evident in reporting from an inquest, but this post discusses the details of Jessie’s death and the treatment provided to her.

Two statements were read onto the record, because all the Interested Persons were in agreement and accepted the evidence, four witnesses gave evidence in person and one statement was read onto the record because the witness was unwell and unable to give evidence, but this evidence was not agreed by all parties.

Abena Yeboah / Healthcare Assistant

Ms Yeboah’s statement was signed 2 September 2022. She told the court that she had been working as a healthcare assistant on Caburn Ward since January 2022.

This was her first job in mental health services, have previously worked in learning disability services. She was involved in Jessie’s care from when she was admitted to the ward.

She told the court Jessie had a diagnosis of Emotionally Unstable Personality Disorder, ADHD and Autism. She said that she had been in services for five years prior to coming to Caburn Ward, and her previous admissions had been to other hospitals in CAMHS and Adult Services.

She told the jury that Jessie was admitted to Caburn Ward after her community package broke down. She said Jessie had an unstable mood, although at times she was bright and engaging, at others times [missed, apologies].

Ms Yeboah told the court that she worked a long day shift the day before Jessie passed away. She said that Jessie seemed fairly settled in her mental state, there was one incident of self-harm but that stopped when staff re-directed her.

She told the court that Jessie was visited by her Dad in the afternoon and he stayed some time. She said Jessie was irritable when he left, due to the abrupt visit of her social worker during her one to one time.

Ms Yeboah’s statement ended with her offering her condolences to Jessie’s family.

Prince Busari / Healthcare Assistant

Mr Busari’s statement was dated 29 November 2022. He told the court that he had been working as an agency healthcare assistant on Caburn Ward at Mill View Hospital on 16 May 2022.

He said that himself and a female carer had been assigned to Jessie, on her two to one observations, at 9pm that night. When they got to Jessie’s room, he said that she was busy arranging items on her table and pacing around her room.

Mr Busari said that they both greeted Jessie and she asked him what he wanted in her room. He told the court he replied telling her that they were there on her two to one observations.

Jessie replied saying that she did not want him in her room or on any of her observations. He told the court that he reported what Jessie had said to the nurse in charge and he was immediately replaced.

He told the court the last he saw of Jessie was at 21:05. He said that Jessie always shut her door. He said the nurse told him not to go near Jessie’s room, when doing standard observations and he complied.

Mr Busari told the court that he went on a break at midnight, returning at 1am. He heard about what happened to Jessie and the nurse assigned him to be with other patients on the ward as most were still awake.

Ifeoma Onyebuchi / Healthcare Assistant

This witness was required to attend the inquest but was unwell. Their statement was not agreed, but because they were unable to attend their evidence was admitted and read onto the record.

Her statement was dated 5 October 2022. It told the court that she was a healthcare assistant trained in PMVA (Prevention and Management of Violence and Aggression) with several months experience working in the mental health sector.

She told the court that she worked as a healthcare assistant in 2021 and 2022. On the 16 May 2022 she was working on Caburn Ward, under the healthcare agency, Casgo Connections. She told the court that she was working alongside 9 other staff members, that they had a handover from the day staff and the nurse in charge asked her to do general observations between 9 and 10pm.

Ms Onyebuchi told the court that she observed Jessie in the hallway on her way to the nurse at the medication dispensary. She said that Jessie spoke to the nurse but she did not hear their conversation. She told the court that afterwards Jessie returned to her room and appeared to be settled.

Ms Onyebuchi’s statement said that at 10pm she was assigned on two to one observations of Jessie, alongside Princse Busari. She told the court that Jessie was in bed, appeared asleep and breathing was observed.

She told the court at 11pm she was reassigned on two to one observations of Jessie, alongside Connor Turner. She told the court at the time of their observation Jessie appeared to be asleep, breathing was observed and no ligature was seen on her neck.

Ms Onyebuchi told the court at midnight she went on her break. She was alerted by a colleague whilst on her break. She said staff assembled in the meeting room “where the devastating news was announced”. Ms Onyebuchi said that she stayed on the ward, the police attended and Jessie’s body was taken out of the ward in the early hours.

[At that point court was adjourned for lunch].

Abegboyjega Makanjuola / Registered Mental Health Nurse

After lunch on Day 4 Nurse Makanjoula was called to give his evidence and he swore an oath. The sound in the afternoon was very difficult to hear and witnesses spoke quickly so I’ll share as much as I can.

Mr Makanjuola told the court that he had been a mental health nurse for 7 years and in that time had worked for Sussex Partnership and other Trusts. Asked what training he had in dealing with patients in autism, he told the court that he had some when training to be a mental health nurse and he had previously worked for Cygnet, and had an understanding from that time, and from working for a healthcare agency.

In response to questions from the coroner he said that he still worked at Mill View, but that he was agency not permanent staff. He told the court he does “a lot of shifts there” and the coroner suggested he was permanent agency staff, and he agreed.

Mr Makanjuola told the court that he was working at Mill View when Jessie was admitted in March 2022 and worked as a nurse there throughout the period that she was in hospital.

Coroner: Tell us little about what you know about Jessie, how was she when you dealing with her on the ward?

AM: Jessie it varies, every day is different. Some days very calm and stable, she had difficulties with noises [can’t hear] and other patients, sometimes she doesn’t want to be, she wants to be by herself… days and nights with her… other times [can’t hear]. Every day is just different.

Coroner: OK, obviously the jury over the last week have heard a lot about Jessie and her mental health difficulties

AM: Yes

Coroner: Can I ask generally on Caburn Ward, are there a lot of people on that ward who also have fluctuating presentation?

AM: Yes… have different types of presentation [can’t hear], some are in their own world don’t want to engage with anybody, some will come out and talk, some manic, some are really loud, some quiet, it’s a mixture of different presentations and diagnoses of people.

I guess we [can’t hear] sometimes very acute patients on Caburn, so difficult to say [can’t hear]. Every day different, different presentations from different patients.

Coroner: Now I’ll take you to the shift on 16/17 May. I understand you were on the night shift?

AM: Yes, I was the nurse in charge

Coroner: You’re in charge of running the shift really?

AM: Yes

Coroner: As part of that responsibility do you allocate out jobs amongst staff?

AM: That is my first job on the shift

Coroner: OK, we heard a handover was conducted when new shift come on, outgoing Charge Nurse hands over to all staff coming in?

AM: That’s correct

Coroner: Can you remember when handed over that evening were there any concerns raised about Jessie?

AM: To the best of my knowledge was under the impression she had good day so far [can’t hear] I can’t remember hearing [can’t hear]

Coroner: Could a good day include fluctuations in presentation, but nothing too acute?

AM: Nothing too acute. A good day with Jess could be a day that she hasn’t presented in, you know, manic behaviour, or self-harming behaviours, or should not [can’t hear]. It could be day she’s engaging well with staff, other patients [can’t hear].

Coroner: Now we’ve heard around the observations that needed to be carried out, we know Jessie was two to one in observations, just tell the jury what that means.

AM: With Jessie 2-1 observations means staff who check on Jess every hour, she’s on hourly observations. For the procedure of allocations, think about [can’t hear] we have 2-1 general observations, which you know, just again an extra measure to protect and keep all staff and patients safe. We check on her every hour on two to one. And again, we will engage with her if she wants to have a chat, do activities, whatever she wants to do with staff, she knows she has two staff for every hour.

Coroner: So when you have a patient on 2 to 1, do you have one main person doing observations? When they have to go to that patient, in this case Jessie, they make sure they have someone else with them?

AM: Yes

Coroner: So it’s not a case you have two people permanently?

AM: We have two people permanently doing checks and another for general observations. She has general observations, then there’s another one with tickbox paper with names of patients on it. They’ll go around every hour and tick it and then we have a separate board.

Coroner: And two people go together to tick it?

AM: Yes

Coroner: Can you remember who you allocated initially to do observation?

AM: Prince and Ifeoma. [can’t hear] after handover I say you go here, you go there, it was Prince and Ifeoma, you read their statements.

Coroner: OK, we heard from Prince it came to the point where he met with Jessie and Jessie asked he not carry out the obervations

AM: Yes

Coroner: Did he then come to see you?

AM: Yes, immediately that happened Prince came to tell me. I went to Jess, no no no, as Prince was telling me Jess went to talk to my colleague… she came to talk to me just after Prince had alerted me. Again she’s still on hourly, so at this point she has decided not to engage with this staff. She cane to get me and said can you take Prince off, I said is there any reason you don’t want Prince on your observations, she said she was [can’t hear] so I didn’t argue with her, then I called Prince into the office and said tell me more, what’s going on.

He said he was part of team that looked after Jess in the community and a lot of issues around the care, blah blah blah. Immediately I spoke to him, I put another staff. You know Jess has favourite staff like any patient on the ward, when it comes to “I don’t want this person, I want this person”, I usually don’t argue with my patients, if they are calm we’ll have a good shift anyway. I immediately swop Jess to this staff member, thinking she’ll settle after.

Coroner: You swopped Prince for Connor?

AM: Yes

Coroner: Can you tell us when you had that conversation with Jess, Jessie sorry, how was she presenting, was she upset?

AM: To be honest she wasn’t upset. Jessie we know when she’s upset you’ll see her body language, you’ll see her [can’t hear] she wasn’t upset, it was a normal conversation with her.

Coroner: We’re going to hear from Connor in due course. Checks were then carried out at 10pm and 11pm?

AM: Yes

Coroner: And nobody raised any issues with you?

AM: No. Then I was on her observation at 00:03

Coroner: You were carrying out observations? Why were you doing the observations and not Connor and Ifeoma?

AM: At certain times some staff have to go on break. As nurse in charge you have to come on ward at certain times. You’ve sorted allocations, I’m not a sit in the office kind of nurse, I like to engage with my patients. The reason midnight check was 00:03 was dealing with another patient who was making noise on ward [fuller answer – didn’t catch]. We don’t just stay in the office.

Coroner: When you saw Jessie at 00:03 how was she at that point?

AM: She was in her bed, she was asleep, as a matter of fact she was snoring. Kind of no concerns at all at three past midnight.

Coroner: We know about 19 mins past, 16 minutes later you were called to Jessie’s room because they’d found Jessie with a ligature?

AM: Yes

Coroner: Do you think you could have missed the ligature when you saw her at three minutes past midnight?

AM: I don’t think so. I think she knew when checks were done, with some patients if you go before the hour they get angry, why you checking me so often… she was settled, was no concern as well [can’t hear].

I felt she’s settled, she said she want to sleep, at time I change staff on her, as we went in was no ligature and she was fast asleep, we believed she was fast asleep and snoring, was no concerns.

Coroner: OK. As I said we’ll hear from the staff member, but at about 19 minutes past you were called to Jessie’s room?

AM: Yes

Coroner: I don’t want you to tell me what other people told you, I want you to tell me what you saw and what you did.

AM: Am I ok to read my statement?

Coroner: Yes, if you want to refresh your memory

AM: About 00:19 staff called me to Jessie’s room, on getting there she was on her left side [can’t hear] I pulled her close to myself and ask staff to check her neck, found ligature [details withheld]

Coroner: I will stop you reading, it’s for you to refresh your memory. You said you spotted the ligature, why were you called to the room in the beginning?

AM: No, I didn’t see ligature, staff observing didn’t see signs of life [can’t hear] normally you see movement, sometimes you hear snoring and all that, staff who went in 19 past, couldn’t see her from the shutter. We went in, she was using the shutter so couldn’t see anything [didn’t catch] then she called anther staff, they said call, so when I went in, when I pulled her closer I saw the ligature because her neck [can’t hear].

Coroner: Can I just ask you before we move on, what are staff required to do on general observations?

AM: To check for signs of life, if you can’t see enough, I normally tell my staff its not enough to say a patient is asleep, you need to see … from 21:00, 22:00, 23:00, midnight that was done

Coroner: OK, are staff required to record what they see?

AM: Now they couldn’t see her neck and couldn’t see her breathe so that was concern, hence they called me in

Coroner: OK, you’ve told us [withheld], what did you then do?

AM: Initially I drew her closer to myself, saw her neck, see ligature… staff ran into the office to get a ligature cutter, handed over to me. Then I cut the ligature off.

The coroner asked Mr Makanjuola how far the ligature cutters were away from Jessie’s bedroom and he told the court that there was just one other room [I think he said a cleaning room] between Jessie’s room and the office where they were stored.

The coroner then discussed the ligature with Mr Makanjuola [I’ll withhold].

She then asked Mr Makanjuola what happened next and he read from his statement. The coroner stopped him, saying that he could read his statement to refresh his memory, but she did not want him to read it to the jury.

Mr Makanjuola told the jury that once the ligature was removed he pulled his alarm, checked Jessie for a pulse and found a weak pulse and asked staff members to bring the crash bag, which was also kept in the office.

AM: She was responding to oxygen, could feel a weak pulse, didn’t commence CPR immediately, oxygen came up to 90s… pulse was also 62, put oxygen on full blast which is 15 litres

Then the SATS came up again… so I thought we’re getting there, when checked oximeter for reading, suddenly started fluctuating and then was not giving any reading. At this point I knew was trouble. At that point put her on the floor and commenced CPR.

Coroner: Did you do the CPR?

AM: Oh yeh.

Coroner: What about the seeking of help?

AM: The alarm had been called. I asked my colleague to get the doctor or call an ambulance, again that was done spontaneously, the doctor came down in a few moments but the ambulance was not too long to come.

The Doctor took over [leading] CPR, telling us what to do, I stayed on compressions. Because she was initially responding I thought there was still hope. Then the ambulance crew came and took her away.

Coroner: So from the moment you started until the ambulance service took her away, CPR continued throughout?

AM: Yes

Coroner: The ambulance service continued with CPR?

AM: Yes, I assisted with compressions.

Coroner: We’ll hear evidence of when paramedics pronounced her sadly deceased. Do you know how long CPR was carried on?

AM: Not less than an hour

Coroner: When you look back on the events of that night, is there anything else you think you could have done to have prevented this incident happening?

AM: It’s a bit difficult to say, for me, I think I would be [can’t hear] myself if I had not changed Prince because I don’t know extent of what occurred, so I spontaneously changed him. I will make a call to psychiatric manager in another place to see if I can swop him altogether, because she’s told me that she doesn’t want him on. I’m thinking I need everyone to rotate so he’s more or less not so useful to me… if I had my way I would have sent him to another ward, I went that far, but then obviously I would have to manage the situation. I told him not to go near her, yeh.

Coroner: As far as you’re aware he didn’t have any more contact with her?

AM: No he didn’t, it’s a difficult one.

The coroner asked Mr Makanjuola to remain where he was for questions from the Interested Persons. First up was counsel on behalf of the family.

Counsel: Can I begin please with your handover. You gave some evidence earlier, said it was handed over to you Jessie had good day, didn’t have any [can’t hear] or manic behaviour. Before lunch had witness statement of Ms Yeboah reference incident where Jessie self-harmed but stopped when redirected. Were you aware of any self-harming in that handover?

AM: No

Counsel: Were you aware of Jessie having any visitors on the 16th?

AM: No

Counsel: We heard it referred to Jessie feeling irritable after an abrupt visit, can we take it that wasn’t handed over to you either?

AM: No

Counsel: Were you aware of the Autism, Crisis and Wellbeing plan?

AM: Yes

Counsel: That plan said Jessie could appear ok in the day and less ok in the evening due to processing delays. Were you aware of that?

AM: Yes

Counsel: But you didn’t know about earlier incident of self-harm or the social worker’s visit?

AM: No

Counsel: In terms of the observations carried out via Prince, I think you told us you assigned observations at the start of your shift?

AM: Yes

Counsel: At that time was any conversation had about whether staff had had any experiences with Jessie?

Mr Makajuola asked counsel to explain her question more.

Counsel: Was any checks made of whether any staff had worked with her as part of IMC at Viaduct Road?

AM: No, I didn’t have prior knowledge of the problem

Counsel: So it would get fixed when drawn to your attention?

AM: Yes

Counsel: You told us you were, your witness statement sets out Jessie told you she didn’t want observations at about 21:40 is that right?

AM: Yes

Counsel: We heard Prince Busari undertook that observation about 9pm?

AM: Yes

Counsel: So it looks like this was passed to you about 40 minutes later?

AM: Yes

Counsel: Were you aware if anything happened between 9 and 9:40pm?

AM: She came to the common area, went about her usual evening, interacting with patients, which to me is a good sign she’s settled, normally if she’s not she won’t. Saw her moving around, saw her talking to my colleague at that time, I think she had her medication. There was nothing to suggest she was angry or [can’t hear].

Counsel: It may help if you’re provided with a laptop for document wish to show you, page H2882. Just want to ask you about the observation log and handwritten comments. Have you got photograph of the handwritten log there?

AM: Yes

Counsel: Grid with hourly stamps, then bit of information, first column is time written in handwriting, second is handwritten comment, column right at the end appears to be people’s signature that they’re the one who’s done that observation. Is that right?

AM: Yes

Counsel: If we look at the observation written for 9pm, can see time says 9:15pm and Prince sign off there?

AM: Yes

Counsel: Comment, it’s difficult because it’s handwritten, appears to say, pacing around her room, arranging her stuff, moody to staff, saying she doesn’t like a carer. That’s the information?

AM: Yes

Counsel: Did you get any of this information from Prince when he was speaking to you about how Jessie presented at the time?

AM: All Prince told me was she said she doesn’t want me, that’s all I was told.

Counsel: On page H2640 it said PBS plan for Jessie, Jessie’s PBS plan, under heading Stage 2, Jessie asked what warning signs are for when she becomes very distressed, one bullet point is shaking her hands, the other was pacing. Were you aware pacing was warning sign for when Jessie was becoming very distressed?

AM: I’m aware because I’d seen that

Counsel: But you weren’t aware she’d been pacing on that night?

AM: No. All I was aware of was she told Prince she didn’t want him on her observation, and she told me that.

Counsel: You then carried out an observation at 00:03 with Maria Mapunda, after some observations by Connor and Ifeoma, is that right?

AM: Yes

Counsel: Did you have any indication from any of them they’d found it difficult to tell whether Jessie was breathing?

AM: No. I went in myself at three past midnight and she was breathing and asleep, my observations were since their previous observations.

Counsel: Yes, when you carried out your observation you weren’t aware of any discussion of issues with Jessie?

AM: No, no, no, half past nine was when she complained about Prince

Counsel: Sorry, maybe I’d not been clear. When you carried out your observation at three minutes past midnight, you weren’t aware Connor and Ifeoma had needed to get some assistance from someone else to confirm Jessie was breathing? Is that right?

AM: Yes

Counsel: You said you say to staff it’s not good enough to say appears asleep, need to say neck cleared, is that your practice now or when you were managing?

AM: It’s always been my practice

Counsel: Can we go to, we can see the observation takes place at 22:10 by Connor and Ifeoma. Says in bed, appears asleep, doesn’t say anything about neck cleared, do you accept that?

AM: I accept that, again it wasn’t said

Counsel: Again next one says appears asleep, breathing, no reference to neck cleared?

AM: When I see neck cleared need to see through door

Counsel: I understood your evidence should be to record neck cleared?

AM: I have instruction just appearing asleep isn’t good enough, you need to see neck cleared.

Counsel: We see your record as well at 00:03 and that says lying in bed on left hand side, appears asleep, breathing observed. No record you say Jessie’s neck was clear on that occasion. Is that right, it’s not recorded?

AM: I saw it, this writing [can’t hear]

Counsel: So what is said there is you, Maria has recorded Jessie was lying in bed on left hand side, appears to be asleep, breathing observed. You said you heard Jessie snoring, is that something which would normally be recorded as well?

AM: Everyone records differently, this is your neck cleared, I’ve seen in various documentations as well, I guess on this day is just unfortunate, I’ve since then documented neck clear.

Counsel: We’re aware you were called back in about 16 minutes later, by staff member called Anna Purnell. Can you help us, give an understanding why Anna Purnell was in Jessie’s room observing her at that time?

AM: As already said, we have someone doing general observations. With some staff at that check in I might go and seek [can’t hear] but because [can’t hear] to double check on patient, on this note, Anna went in.

Counsel: So Anna checked the chart, saw wasn’t tick next to Jessie and went in?

Coroner: I’m not sure he knows, was an assumption, we’ll ask Ms Purnell tomorrow

Counsel: You say you couldn’t have missed ligature on your earlier obserbvation?

AM: Yes

Counsel: We know 16 minutes between that observation and Jessie being found.

Counsel then read an extract from Jessie’s Care Act assessment. Asked by counsel whether he was aware Jessie’s medication had such a sedative effect on her (that if she required clean sheets she would be groggy and need support to change them), Mr Makajuola said he was aware of Jessie’s needs but not what was leading to them.

Counsel: We heard from Dr Cuthbert earlier this week that Jessie was also prescribed something specifically to help her sleep as well, were you aware?

AM: Yes, I’m aware

Counsel: In light of that, and the very short period of time between when you saw her and she was found 16 minutes later, do you still maintain you didn’t miss the ligature?

AM: Five minutes is enough to die, I didn’t miss anything, I’m 100% sure of that.

Counsel then referred to Mr Seares evidence, that he had been told after Jessie’s death that she was awake at 10pm in another patient’s room. Mr Makajoula was asked if he had any recollection of that.

AM: I was not with Jessie at 10pm, she could be in bed at the time of the check and few minutes later anything could have happened. I can’t speak to that, not to my knowledge.

Counsel: We also heard from Andy on Monday

AM: Who’s Andy?

Counsel: Jessie’s father who sits behind me. He said one of Jessie’s shoes was there when he left on evening of 16th, was not in her room when he returned after her death, it was in the nursing room. Have you any idea how that shoe ended up in the nursing room?

AM: I’m not aware, no.

No further questions from Jessie’s family. No questions from East Sussex County Council. Over to Brighton and Hove City Counsel.

Counsel: Have you still got h2881 two to one early checks document in front of you?

AM: Yes

Counsel: You would have inherited this on your shift wouldn’t you?

AM: Yes

Counsel: You see what comes before, on first page sheet, afternoon tells us [reads] 3pm activity hour with staff, irritable, minimal engagement… anything striking about this record for you?

AM: For me this is a typical good day for Jessie.

Counsel: Thank you very much

Then it was over to counsel for Sussex Partnership Trust.

Counsel: Just going back to sheet earlier, recorded someone is sleeping, why is it important at night, when doing a check at night, why is it important to write what you observe?

AM: We want to know what patient is actually doing at any point of time. If patient is asleep, or breathing, is good sign of life, is part of why we’re checking

Counsel: So the point of check is to show and document signs of life?

AM: Yes

Counsel: Is it also right to say would be appropriate just to write appears asleep?

AM: Yes

Counsel: So is it further appropriate to correctly say is breathing observed, that is the important thing that has been noted?

AM: Yes

Then it was over to the jury for their questions.

Juror: When you did your check at 00:03 and someone else went at 16 minutes past, how did that person observe Jessie wasn’t breathing?

Coroner: You’ll have to ask that person. Is a good question, but she’s coming up.

Another two jurors asked questions about the ligature, I’ll not report.

Juror: When the shift started did Prince make any recognition that he was going to be looking after Jessie?

AM: I use my discretion to allocate staff, am aware Jess works better with men than women, I was thinking Prince would be the guy for Jess because she works well with men. It was a shock to me that she complained about it.

Juror follow up: What I was getting at was did he not make any recognition that he’d be nursing Jessie?

AM: No, he didn’t make any recognition.

Another juror then asked about the safeguarding enquiry that was ongoing at the time of Jessie’s death.

Juror: Given the ongoing safeguarding enquiry about IMC Locums, should there be checks done by those in the hospital to make sure the IMC Locums assigned to jessie were not ones in the enquiry?

AM: With hindsight, but that’s not for me

Coroner: If you don’t know and you cant assist, will be others from the Trust; you weren’t aware of any safeguarding enquiry?

AM: No, I knew there was a breakdown of care but I didn’t know it was IMC Locums

Counsel for the family then asked a further question, which they acknowledged was out of turn.

Counsel: Your observations you saw Jessie was snoring. Did you have any observation whether looked like unimpeded snoring or issues with breathing snoring?

AM: Breathing was normal, I went into room with Maria, was nothing in neck, there’s no way we’d check and this ligature [can’t hear]

Counsel: If anyone was struggling with breathing, would you look out for any particular sounds?

AM: Yes

Counsel: What sounds would they be?

AM: It would be a distressing sound [can’t hear]

Counsel: And you’re confident you’d know that difference?

AM: 100%

Counsel: On the basis of your previous experience?

AM: Yes, on the basis of what I know about my patient herself, humans in general, and nursing experience. Distressing snore I’ve heard before and raised alarm.

Counsel for Sussex Partnership then had a follow up question, arising from the jury’s questions.

Counsel: In your evidence to the coroner, as I understood it, Jessie said to you Prince was part of the care team in the community?

AM: Yes

Counsel: Want to be very clear… whether Jessie was saying Prince was someone about whom was allegation, or whether care team in community as whole and he was part of the care team?

AM: In her exact words he was part of the care team in the community that broke down.

Coroner: We can deal with that with Mr Brown if necessary.

Counsel: Thank you

AM: Can I say, this is a sad case and may the soul of Jessie rest in peace and I extend my sincere condolences to Jessie’s family and friends and I pray for fortitude for them with their sad loss

Mr Makajuola was released at 14:49 and Ms Badmus was called.

Islamiat Badmus / Registered Mental Health Nurse

Ms Badmus told the court that she was a registered nurse and had been for 10 years. Asked by the coroner if she had always worked for Sussex Partnership Trust or whether she had also worked in the community, Ms Badmus told the court that she had worked for CAMHS (Child and Adolescent Mental Health Services) for 7 years and she knew Jessie when she was in CAMHS as well.

Asked what sort of training she had around dealing with patients with autism, Ms Badmus said that she did some training on learning disability and different presentations, and that she had worked with people in the community with ADHD as well.

The coroner said that she wanted to take her to the night shift of 16/17 May 2022. She asked Ms Badmus what she meant when she had referred to herself as the “second nurse”, she explained to the court that the previous witness, Mr Makajuola was the nurse in charge and she was the second nurse. She told the court that she was responsible for managing medication, and after that for one to one care with patients.

Coroner: When you came on shift you had a handover provided, what do you recall of the handover in respect of Jessie that day?

IB: Had had a good day, only one incident reported. I knew Jessie very well because I knew her in CAMHS, didn’t trigger any concerns to me, that she was distressed. [Fuller answer, didn’t catch]

Coroner: In your statement you say you saw her briefly at the start of your shift where you exchanged pleasantries

IB: Yes

Coroner: No concerns?

IB: No

Coroner: When doing medication, had you given Jessie her medication that evening?

IB: No I didn’t, Jessie [can’t hear]

Coroner: OK, so her medication before the night shift would that include her sleeping tablet?

IB: Yes

Coroner: We heard whilst doing medication you were approached by Jessie, what sort of time was that?

IB: Twenty five to ten or twenty five past, not really sure, was doing medication …whenever I’m on shift Jessie wants me on her 1-1 because I know her from other setting. First thing she said to me was she’s homeless, I said why are you homeless, she told me about it… on that day she said she didn’t want person on her observation because she said this was the man who assaulted me in my home. I was doing medication, continued what I was doing.

Coroner: So you had this conversation with her?

IB: Yes, briefly

Coroner: She said this person assaulted me in my home, that’s not in your statement is it something your remembered since?

Counsel: It is in her statement.

Coroner: Yes. What did you actually do once she said that?

IB: I helped other patients with their medication … said to Jessie couldn’t do anything then but to go and speak to Nurse Makanhuola [fuller answer – can’t hear]

Coroner: When did you next see her again?

IB: I saw her in her bedroom with a ligature on her neck

Coroner: how did you get to see her?

IB: Inner and outer office, I was in office when I finished medication, trying to [can’t hear] snacking, whilst checking allocation to see what I’m doing next hour, I saw Anna, a HCA, she ran into the office and grabbed the machine, I just ran out into Jessie’s room

Coroner: You saw?

IB: [can’t hear]… had pulse oximeter. I said what happened, have an alarm on me as well, just room between Jessie’s room and office, I ran into office, and paged doctor and called ambulance. Gave them information needed from me and ran back to the room where I’d left Ade and Anna

Coroner: When you went back had they already started CPR?

IB: Yes, when I went back she was on the floor, done CPR, the crash bag was there, she was on oxygen already so I grabbed oxygen… Ade was doing compressions [can’t hear]

Coroner: I understand then the doctor arrived and subsequently ambulance service?

IB: I don’t think the doctor was 5mins from when I paged her

Ms Badmus told the court that she had known Jessie for years, that she stayed in position for 40 minutes and wouldn’t give up. The witness became upset and the coroner asked if she’d like a drink.

Court then adjourned for a short break before questioning continued; starting with questions from Jessie’s family.

Counsel: Good afternoon, couple short questions from me. You made your witness statement in advance of this inquest, dated 9 February 2023, do you have a copy with you there?

IB: [can’t hear]

Counsel: Date is 9 February 2023, in any event before today?

IB: Yes

Counsel: At the time of your witness statement was your recollection better than today?

IB: When I did statement [can’t hear]

Counsel: Earlier in your evidence you were asked about when you had this conversation with Jessie about her issues with Prince and I think you said was either twenty five to ten, or twenty five past nine?

IB: It was twenty five past ten. I did medication from 9pm, I don’t think it was 10pm, I can’t recollect, there was a queue for medication.

Counsel: In your witness statement you say next contact was at 22:35 when she approached you with a complaint?

IB: [can’t hear]

Nothing further from Jessie’s family. No questions from East Sussex County Council. No questions from Brighton and Hove City Council. Over to questions from Sussex Partnership Trust.

Counsel: How was Jessie presenting at the time you saw her in the medication room?

IB: She wasn’t quite the Jessie I know… she was not pleased with particular environment or staff… she was calm, I had a conversation with her, she was able to understand my rationale why I couldn’t leave what I was doing… she walked away calmly [fuller answer, can’t hear]

What did I miss, what could I done differently, was so worrying for me … [can’t hear] she was calm and said ok then and just walked away.

No further questions from the Trust. One question from the jury.

Juror: The concerns Jessie raised to you with regards to the healthcare assistant, did you also share those concerns with Ade [Nurse Makanjuola] as well?

IB: I just continued doing medication, once I’d finished medication, Ade was walking along, he spoke to me before in the clinic room. She was telling me … said contacted the unit coordinator… [can’t hear]

Ms Badmus gave her condolences to the family and said that she’s pray Jessie is at peace. Jessie’s family responded [can’t hear].

Connor Turner / Healthcare Assistant

Mr Turner was called shortly after 15:30 to give his evidence. He told the court that he was a bank healthcare assistant on Caburn Ward. He was asked to tell the jury what that role entailed but I could not hear his response.

Coroner: Bank means not permanent member of staff, you’re agency?

CT: Kind of

Coroner: Permanent agency?

CT: yeh

Coroner: How long had you been working on the Caburn Ward?

CT: Since probably about March

Coroner: Had you previously worked in the mental health hospital environment?

CT: [Can’t hear]

Coroner: Had you had any training at all in dealing with individuals who had autism?

CT: [Can’t hear]

Coroner: You were party to the handover?

CT: Yes

Coroner: You were, standard practice is it?

CT: Yes

Coroner: Were you aware of any specific concerns about Jessie at all?

CT: No

Coroner: You were allocated to Jessie’s 2-1 general observations, who were you working with initially?

CT: [Can’t hear]

Coroner: What’s your understanding, what should you do when carrying out observations?

CT: [Can’t hear]

The coroner asked Mr Turner about his experience of patients tying ligatures, how often he had come across it at the time of Jessie’s death and since. I could not hear any of his answers.

Coroner: You carry out the 10pm check, you say at ten past. What do you observe at that point?

CT: [Can’t hear]

Coroner: 23:02 what do you observe then?

CT: [Can’t hear]

Coroner: Was it easy on that occasion to observe Jessie?

CT: 11 o’clock one slightly harder given the way the duvet was covering her, so I asked a colleague Dawn to come with me in case she woke up and because I couldn’t see her neck

Coroner: At that time you were able to confirm she was breathing?

CT: Yes

Coroner: Did you have any further contact with Jessie that night?

CT: [Can’t hear]

Coroner: I understand the Charge Nurse carried out checks at midnight, why weren’t you there then?

Mr Turner said that he was on his break.

It was then over to counsel for Jessie’s family to ask their questions.

Counsel: You were in the handover Nurse Makanjuola was in?

CT: Yes

Counsel: He gave evidence he wasn’t aware of any incidents earlier in the day, is that the same for you?

CT: Yes

Counsel: We have record h2647

Discussion about question between counsel which I couldn’t hear.

Coroner: The jury is here, you’ll have to put it

Counsel: Record of 16 May 19:57 it says under risk events, it said Jessie was irritable and light [self-harm] this afternoon during her two to one check. I take it you weren’t aware of that?

CT: I can’t remember

Counsel: It also says Jessie was irritable and rude to staff when staff came into her room to inform her of an abrupt visit of her social worker… seen by social worker at 16:08, were you aware of that?

CT: I can’t remember

Counsel: In terms of the checks you did at 10pm and 11pm; your witness statement suggests you needed a third opinion… what caused you to ask for that?

CT: Firstly, the duvet was covering her neck, I didn’t want her to feel uncomfortable given she is asleep, in case she woke up, so got someone who was familiar face, so if she were to wake up she wouldn’t have a panic attack or anything

Counsel: So you thought it would assist to have someone Jessie was more familiar with, is that the reason?

CT: Yes

Counsel: When you had to move the duvet it’s because you weren’t sure if she were breathing, is that right?

CT: Not so much breathing but to check for a ligature, as we do with most patients

Counsel: In your witness statement paragraph two you say ‘initially we had difficulty seeing if Jessie was breathing so asked Dawn Smith to support us with checking’. What prompted you? You weren’t sure?

CT: Yeh, just to triple check…

Counsel: Did you see Jessie at any other time between 10 and 11pm?

CT: [Can’t hear]

Counsel: You’ll note we heard evidence from the previous witness they were approached by Jessie at 10:35pm when handing out medication. Were you aware of that happening?

CT: No

Counsel: Was it just the one occasion in which you were assisted by Dawn Smith?

CT: [Can’t hear]

Counsel: Mr Seares gave evidence on Monday relating to the fact when he attended the ward one of Jessie’s shoes wasn’t in her room… was found in the nursing room, do you have any understanding of how or what went on?

CT: No

No further questions from Jessie’s family. No questions from East Sussex County Council.

Over to counsel for Brighton and Hove City Council.

Counsel: Just briefly, when you came on shift were you aware a Social Worker from Brighton and Hove City Council had arranged an appointment to see Jessie at the hospital that afternoon?

CT: I can’t remember

Counsel: And Jessie’s father had given an account of how it is the Social Worker arrived during one to one and staff on the ward had interrupted the one to one to insist Jessie see the social worker. Are you aware of that?

CT: I can’t recall

Counsel: And Jessie’s father said he went to speak to the social worker who said was prepared to wait, but at that point staff on the ward had decided it was an appointment and should go ahead?

CT: I can’t recall

No further questions from Brighton and Hove. Next was questions from Counsel for Sussex Partnership Trust.

Counsel: One thing to clarify, when you ask Dawn to do the triple check, one was because she’s female and the other was that there’s a familiar face, is that right?

CT: Yes

Counsel: Why did you think it was important to be a familiar face?

CT: Not result in [can’t hear] … Jessie’s past experiences

Counsel: Yes, and would it be right to say, what is your experience of autism?

CT: Personal

Counsel: You have personal experience of autism, did that play into your approach with Jessie?

CT: Yes

Counsel: Yes. And by that, was that your reasoning of making sure it was a familiar face?

CT: Yes

Over to the jury for their questions.

Juror: The time the nurse saying Jessie had fetched her 10:35pm and you doing your checks at 10pm and she was asleep? Is that right? Were times mixed up or ?

Coroner: We can only go on the evidence. You did the check at?

CT: Ten past ten

Coroner: And at that time she was asleep?

CT: Yes

Mr Turner was released and he offered his condolences to Jessie’s family.

The coroner then called the final witness on Day 4.

Dawn Smith / Healthcare Assistant

Dawn Smith told the court that at the time she was working as a bank healthcare assistant at Mill View Hospital. She said that she had been a bank worker since November 2020 working day shifts, and then from approximately March 2022 she did night shifts with more regularity. In response to a question from the coroner she told the court that the day shifts had also been on Caburn Ward.

Coroner: What training had you had in autism?

DS: Prior to working at Mill View Hospital I’d worked in an autism specific service and had a lot of training with them

Coroner: Apart from the period of time Jessie was on Caburn Ward had you met Jessie at all before she came in March?

DS: No

Coroner: Did you have much interaction with Jessie?

DS: Quite a bit, we got on quite well, did work with her quite closely, yes.

Coroner: Do you remember being asked by Connor to check whether Jessie was breathing?

DS: Yes

Coroner: Tell us how that came about and what you found?

DS: Connor and Ifeoma had just done their check and Connor approached and said due to the position Jessie was in, it was difficult to observe a proper breathing pattern. So he asked me to come and check with him to establish that.

Coroner: OK. When you went in, what did you do?

DS: Initially I was stood by the door which would be normal, but due to the difficulty of seeing we went quite a lot closer, and leaned right over to see her neck was clear and that she was breathing.

Coroner: Was that on one occasion or two occasions?

DS: I believe it was on two occasions

Coroner: So that would have been the 10 o’clock and 11 o’clock check?

DS: The first one was approximately 10 o’clock, I’m unsure about the second one, but assume it would be

Coroner: OK, we heard from Connor on both those occasions that Jessie was sleeping. The jury have raised a concern that between those two checks it may well be, depending on their findings, she was out speaking and going to the medication room. Are you sure on both those occasions she was sleeping?

DS: She was in bed, with her eyes closed, which would suggest she was sleeping but I can’t definitely say she was asleep.

Coroner: OK, the check you carry out is not whether or not they’re sleeping, but whether or not they’re breathing. Would that be fair to say?

DS: That would be fair to say

Coroner: Did you have any concerns whilst you were working during that shift, did you have any concerns about Jessie at all?

DS: No, the first interaction I had was when she was asleep checking her with Connor, so I didn’t see her when she was awake. No, no concerns.

It was then over to Jessie’s family for their questions.

Counsel: Your witness statement, dated 11 October 2022, is that the right date?

DS: Yes

Counsel: That’s the date you finalised and provided the statement is that right?

DS: I believe so

Counsel: Do you think your recollection at time of making that statement would be better than it is today?

DS: Yes

Counsel: In your statement you say at paragraph three, you mention about two occasions you were asked to assist. Appears on both you recall being asked to assist Connor and Ifeoma. Asked if you would enter to check, you say I did this and we were able to observe a normal breathing pattern on closer observation, in brackets leaning quite closely towards Jessica and watching her breathing for some time. It doesn’t appear in your written statement you checked for a ligature, are you sure there was a check for a ligature?

DS: I don’t understand

Counsel: Your check was observing closely whether Jessie was breathing, was anything else done during that observation?

DS: Do you mean check for a ligature?

Counsel: Yes

DS: I wasn’t checking specifically for a ligature, however if there had been one there I’d have seen it

Counsel: You’ve heard me ask earlier witnesses about Jessie’s shoe, are you able to assist at all with what went on with that?

DS: No, sorry

Counsel: Are you able to assist us with whether you moved the duvet with either of those checks?

DS: I can’t remember specifically

Counsel: In that case nothing further

No questions for Ms Smith from East Sussex County Council or from Brighton and Hove City Council. Over to counsel for Sussex Partnership Trust.

Counsel: Following on from the question counsel for family asked you [can’t hear] why were you certain?

DS: Because of how close I was to her, had she had a ligature around her neck I’d have seen

Counsel: Going one step further than that, was it necessary to move the duvet to see that?

DS: I don’t remember, I don’t remember if I moved the duvet or not

Counsel: But you’re confident you would have seen?

DS: Yes

There were no jury questions for Ms Smith and she was released shortly before 4pm. She offered her condolences to Jessie’s family and they responded that she was very kind and Jessie appreciated that [I think they said, hard to hear].

Maria Mapunda / Healthcare Assistant

The first witness to give evidence on Day 5 was Maria Mapunda, who told the court that she still works at Mill View.

Coroner: How long have you been a healthcare assistant?

MM: Since February 2022

Coroner: So the events surrounding Jessie’s death happened fairly early on in your career as a healthcare assistant?

MM: Yes

Coroner: Did you do any training on autism at all?

MM: Yes

Coroner: Had you had many interactions with Jessie at all?

MM: Before 16/17 May … I knew Jessie but didn’t work there full time

Coroner: So you’d met with her before?

MM: Yes

Coroner: OK, when you started your shift, we’ve heard quite a lot about this, you come in and had handover?

MM: Yes

Coroner: You start a 9pm is that right?

MM: We start at half eight for handover

Coroner: And at 9 o’clock you’re on the ward, ok. Can you remember if any concerns about Jessie were handed over to you?

MM: What I remember is handover … Jessie was on 2-1 observations, so when went to see her would be two staff

Coroner: Had they mentioned anything that happened with Jessie during the day, that you remember now, anything of concern?

MM: No. .. she was 2-1

Coroner: Ok. At midnight, or around that time, were you carrying out Jessie’s observations?

MM: Yes

Coroner: You said there are two of you, who were you doing that with?

MM: I’ll refer to my statement, at midnight it was me and Ade, the RMN who was in charge of the shift. [Fuller answer – can’t hear]

Coroner: Can you remember roughly what time you carried out the observations on Jessie?

MM: The time we carried out the observation on Jessie was three minutes past twelve.

Coroner: Ok, when you carry out these observations, you record the time do you on the observations sheet?

MM: Yes

Coroner: What did you see when you saw Jessie?

MM: When me and my colleague Ade went to check Jessie, Jessie she was sleeping, and I’ll refer to my statement, we’d just done [can’t hear] we checked her, she was on her left side and her neck was clear, we check the neck as well. Jessie was breathing.

Coroner: OK, you’ve made mention you checked her neck, why would you check someone’s neck?

MM: We check the neck because some patients we have tie ligatures, so we have to check, our nurse who do the check, Ade, he always remind us to check the neck. Sometimes we don’t even put in the sheet that we have check the neck because most patients on the ward ligature is part of the risk… so when we go to check the patient, even if they’re breathing, we check the neck, not just to see but you touch it, sometimes if tie tightly might not be able to see without touching the neck.

Coroner: Can you remember if you touched Jessie’s neck this time?

MM: Yes we did, because she was facing the wall and we had to lift her head

Coroner: Can you remember if it was you that checked the neck, or did you both do it, or can’t you remember?

MM: I checked it because Ade is male and Jessie is female, it’s easier for me to check, but Ade was there with me

Coroner: When you’re doing the observations, there are 19 patients?

MM: 22 when full

Coroner: Did you check every single patient’s neck, unless you can see quite clearly?

MM: The nature of the ward, we have to check. We have to check because there’s a lot [can’t hear] so we need to check, yeh.

Coroner: The jury have heard evidence Jessie is at risk of tying ligatures, how many patients, not exact number, roughly how many patients on the ward are at risk of tying ligatures?

MM: When I work on the wad, that time we had about three serious ones, but we don’t take any chance and we check most everybody

Coroner: I know you were fairly new into your role at that time, when you’re working as a healthcare assistant over a week, not exact number, just to give the jury an idea, how often are you finding patients tying ligatures, not necessarily at night time?

MM: To be honest I don’t do days, I don’t know about days, I do nights but I can’t really say that how many times

Coroner: It happens, or it’s frequent?

MM: It happens but I can’t tell you

Coroner: That’s fair enough. You do observation, what’s the next thing you remember happening?

MM: I’ve done the observation check [can’t hear] so around 19 minutes past twelve, staff went to check

Coroner: At that point you were still together doing observations?

MM: Yes. Staff check, Jessie was facing the wall on her left side

Coroner: Was that in the same position she was when you saw her?

MM: Yes, she was in the same position. They check the neck and [can’t hear]. Pulling Jessie closer they found a ligature on Jessie’s neck.

Coroner: Did you see the ligature?

MM: Yes

Coroner: What happened next?

MM: [Details withheld] the nurse in charge requested to bring a ligature cutter quickly and he cut the ligature

Coroner: OK, did other staff then arrive?

MM: Yes, then alarm was called, then crash bag was called, and oxygen, then the duty doctor came and the ambulance

Coroner: Did you witness this yourself or you know it’s what happened since?

MM: No I witnessed it, I was there

Coroner: From your evidence obviously you’ve got 00:03 the time you carried out her observation, 16 minutes later she’s found with a ligature around her neck, in the same position you say as she was at 00:03. Is there a chance you could have missed that ligature when checking her at midnight?

MM: No chance, because I touched the neck, so no chance of missing it.

It was then over to Jessie’s family for questions. Counsel started by referring Ms Mapunda to the observation log. The coroner said that the log would be provided to the jury.

Counsel: This is the observation log from that night, 16 and 17th. Can I ask you to look at the box that says 21:00 on the second page. Do you have that box? In handwriting says 21:15

MM: Yes

Counsel: Names of people carrying out those observations?

MM: Yes

Counsel: It appears to say Maria HCA, is that you?

MM: That’s not me, because that is not me

Counsel: When we go down to 24:00 we also see Maria HCA

MM: Yes

Counsel: Is that you?

MM: Yes that’s me

Counsel: So Maria HCA at 21:00 is not you?

MM: To be honest I don’t recall this time, whether I did this observation. I recall this midnight 12 o’clock

Counsel: So the record where it says in 24:00 Maria HCA is you? But you don’t recall doing one at 21:00 with staff member Prince?

MM: No, I don’t recall this one

Counsel: Do you recognise the handwriting?

MM: [can’t hear]

Counsel: Do you accept it looks quite similar to the writing in 24:00 hours?

MM: No, I think that’s different

Counsel: That’s different?

Coroner: Can I be clear you wrote the entry?

MM: At 24:00

Counsel: So 21:00 hours it looks potentially like Prince has written the entry. Am suggesting is different handwriting to Maria HCA? Are you saying you didn’t sign 21:00?

MM: I don’t remember this one. We are many staff in the night, then their location is often different hours. The only hours I remember is this one, the 24:03 and in the box is my handwriting

Counsel: What is your understanding at to why it says Maria HCA at 21:00?

MM: I can’t answer for this one, it’s not me. If you’re asking me at different times I’ll have to make it up

Counsel: I don’t want you to speculate. I’m trying to understand whether you recognise your signature there and don’t remember 9pm?

MM: This is not me, and this is not my signature

Coroner: I wonder if she can just be asked though, do you remember Prince being removed from observations because Jessie had indicated she didn’t want him doing them? Does that mean anything to you?

MM: The only thing is, I can not answer [can’t hear]

Coroner: no, no, no, I’m asking you do you have any recollection of that night of Prince being asked to be moved on observations?

MM: Not, no, I was doing what I was doing, I don’t remember that, if Prince is moved it’s up to the person in charge

Coroner: of course, I’m asking if you have any knowledge of that, because if you’d been there at 21:15 that was when Jessie had asked Prince not do observations

MM: I cannot remember that, no

Counsel: We see Jessie is pacing around her room, arranging things, is moody with staff, saying doesn’t like carer… you don’t recall that?

MM: No I don’t recall that, I recall midnight 3 minutes past twelve, this one I don’t remember [cant hear]

Counsel: Are you suggesting there’s another healthcare assistant Maria on night shift of 16th?

MM: No I’m not, I’m trying to say I don’t know anything about this 9:15 so I’m not going to try

Counsel: No. If we then go to your entry the bottom one, Jessie was lying in bed, on the left hand side appeared to be … [can’t hear] When you carried out this observation were you aware of Connor and Ifeoma having issues in their earlier observation around 10 or 11 in telling whether Jessie was breathing?

MM: No.. was not aware, not matter for me, me and Ade go together for observations, so I’m not even have time… I know when we are working there we have responsibility, everyone knows their responsibility, I was clear of my responsibility

Counsel: You’ve written lying in bed, left hand side.. that’s your handwriting?

MM: Yes that’s my handwriting

Counsel: You provided witness statement for this inquest in April this year? Is that right?

MM: Yes

Counsel: When you wrote your witness statement did you rely on your memory of events?

MM: Yes

Counsel: So your witness statement, at pG305 in bundle, sets out the observation at paragraph three. You say, at midnight at around 00:03 Ade RMN and myself were on Jessie’s observation and when we checked her she was on her left side snoring, and her neck was clear and visible at this time. Jessie appeared asleep as she was breathing and snoring. Do you see that?

MM: Yes

Counsel: Do you accept the log where you’ve written observations does not say Jessie’s neck was clear and visible at that time?

MM: Yes. When we check patient [can’t hear] when we are writing here in the document, for one observation, sometimes we don’t write it [can’t hear] but what matters, we always remember to check the neck, even though we are not writing this.

Counsel: Do you also accept the log doesn’t say she was snoring. You say Jessie was breathing and snoring. It says breathing observed?

MM: This is statement, would not expect statement to occupy this log, you see the space. I’ve just written what was happening, but when I checked Jess at three mins past twelve, this was what was happening… we did not, I did not write like this and everything [can’t hear]

Counsel: So the log was completed on the night and your witness statement on 8 April this year?

MM: Yes

Counsel: The witness statement of Nurse Makanjuola also recalls his recollection of this observation. I’m going to read you his commentary about this: At midnight, at around 00:03 Maria and myself were on Jessie’s observation and when we checked her she was on her left side snoring, please note her neck was clear and visible at this time, she appeared asleep as she was breathing, snoring.

Do you accept the account in Nurse Makajuola’s witness statement is almost word for word identical with your witness statement?

MM: I say yes and no. When I wrote my statement [can’t hear] so if we’ve both written the same thing I don’t think it’s wrong to write because him and I go together, this is what I found on Jess, I did not ask him what he wrote.

Counsel: In terms of the way these sentences are structured, they appear very similar, almost word for word?

MM: Because we are working together. For me [can’t hear] if they are wording similar [can’t hear]

Counsel: Are you wanting the jury to accept its coincidence you and Nurse Makajuola have separately, months and months apart, almost identical word for word…

MM: No not accept that, I’m saying what I have written, maybe memory is similar because we were together. For me I’ve just written what I found

Counsel: We see Nurse Makanjuola’s statement is dated on 5 October 2022, your statement came after in April 2023. I’m bound to ask you whether you have any independent recollection of this incident?

MM: What do you mean by independent recollection?

Counsel: Whether you’ve remember this yourself, with your own memory, or whether you’ve consulted with Nurse Makajuola?

MM: You are saying I don’t remember this with my own memory? What I’ve written is what I saw in my own memory [can’t hear]

Counsel: Nurse Mapunda, I have to ask you this out of fairness so you have the opportunity to respond. It could be suggested, the idea you and Nurse Makanjuola came to the wording in your statement, 12 months apart, almost word for word identical… is not a credible explanation and that you don’t have an independent recollection. What do you say to that?

MM: What I have written is what I saw. I did not, I’ve never said [can’t hear] Ade’s statement, that’s what you’re telling me. I didn’t know. As I said before, I’m bank, so I’m not full time, I do not even know what is written or what he’s written, I don’t know. What’s written here is my memory.

Counsel: You’re very sure what is in that statement there is your memory of what’s happened?

Counsel for SPFT: Think she’s already said that several times now

Counsel for family: OK. Today in your evidence you say you touched Jessie’s neck when conducting checks to see if there was a ligature. Do you accept there’s nothing in your witness statement that says you did touch her neck?

MM: I say Jessie’s neck is clear, there was nothing there. I don’t know if you want me to go into details, and mention, I just give you a general what I did. I found, I touched Jessie’s neck and there was no ligature, this is what I’ve written is very clear.

Counsel: What’s in statement is Jessie’s neck is clear and visible, I’m only asking if its correct that you did in fact touch her neck, given how close this observation was to when Jessie was found with a ligature?

MM: This is a thing I’ve repeated maybe 5 times.. I’ve repeated, I touched the neck of Jessie and touch if there was a ligature, even though I did not write here the neck was touched, I checked the neck and it was clear. This is my understanding.

Coroner: OK, I think we can leave this point

Counsel asked Ms Mapunda if she was aware of the Trust’s policy on resuscitation and medical emergencies.

Counsel: Are you aware of the Trust policy on resus and medical emergencies?

MM: I didn’t do the resuscitation

Counsel: I’m asking if you’re aware of the resuscitation and medical emergencies policy from the Trust?

MM: Yes

Counsel: You are aware of it.

MM: Yes

Counsel: We’ve got an annexe in this document I’d like to ask you about, p I106

Coroner: Is she going to need to see it?

Counsel: It may assist ma’am. pI108 refers to airway obstruction, perhaps you could go to pI108

Do you see top of that page says, airway a second heading, says airway obstruction is an emergency, look for signs of airway obstruction and gives bullet points of signs of airway obstruction, do you see that?

MM: Yes

Counsel: 4 bullet points and is noisy breathing, first is expiratory wheeze

Coroner: Can we just go to one relevant please, the jury don’t have this

Counsel: Very last one is snoring, in brackets it says tongue. Do you see that?

MM: Yes

Counsel: Gurgling in brackets fluid, airway obstructed by fluid, snoring in brackets tongue, does that mean snoring sound may mean airway is obstructed by the tongue?

MM: What are you asking?

Counsel: If you’re aware snoring might be an indication of an obstructed airway?

MM: When I checked Jess she was snoring, Jess was always snoring, it was nothing really… that’s why we were not even thinking something is obstructing her airway… snoring is usual… there is nothing about something may be obstructing no, Jess is snoring, no, not even think about this [can’t hear]

No further questions from Jessie’s family. No questions from East Sussex County Council or from Brighton and Hove City Council. Over to counsel for Sussex Partnership Trust.

Counsel: You start your shift at 8:30pm is that right?

MM: Yes

Counsel: We’ve heard, evidence we’ve heard [can’t hear] we heard after handover happens at 8:30

MM: 8:30 until 9pm

Counsel: Yes, is it right at 9 o’clock you go along to your allocated duties?

MM: Yes, yes

Counsel: And is it also right there are two registered mental health nurses on the ward on the shift?

MM: Yes

Counsel: Then a number of HCAs, is that right?

MM: Yes

Counsel: On that particular night you refer to RMN Ade, he was the nurse in charge?

MM: Yes

Counsel: Do you remember there was another nurse on duty that night?

MM: Yes

Counsel: Do you remember the name of that nurse?

MM: There was another nurse

Counsel: Is one of the reasons to have two nurses, is one nurse, nurse in charge is leading allocations and the other is doing medications?

MM: Yes

Counsel: Is she going to do medication straight after handover?

MM: To be honest I don’t know, I don’t know if she was going straight away… [can’t hear] our patients sometimes [can’t hear] not like they walk around with trolley, our patients [can’t hear] some at 10 o’clock, some 11, its different, not patient queue is different. I’m only healthcare.

Counsel: I understand, you’re going about your business and you’re allocated roles?

MM: Yes

Counsel: And just to be clear on your evidence, you cannot recall what your allocated role was at 9 o’clock. Is your recollection, it’s quite some time ago, has the passage of time influenced your ability to recall?

MM asks her to explain her question. Counsel asks her whether she thinks that it is the time that has past since, that has impacted upon her ability to recall. She says no, that she remember the midnight check, but that she does not remember what she was allocated at 9pm. She says 9pm could have been anything and she can not recall.

No further questions from SPFT. Over to the jury for questions.

Juror: Just wanted to ask if your team, or you specifically, are given any training on how to write notes and observations, is there any guidance on that?

MM: Yes, we are given training on the notes, we have to do online training, observations, how to [can’t hear]

Juror follow up: Will people be writing notes in a consistent way?

MM: For me I write in a consistent way, I can’t answer for other people. [can’t hear] if anything happened at handover.

Juror: Thank you

A second juror said that they had a follow up question on that.

Juror: Following on from that, is the note that you write, what is the plan? I suppose what I’m saying, are you meant to write all the details of things like vital signals of the patient?

Coroner: I’m wondering whether this might be better put to Mr Pumphrey?

Counsel for SPFT: We could perhaps take him through more observation sheets as well.

Juror: I do have another question. You said that duty doctor was called?

MM: Yes

Juror: How soon was that, when the duty doctor was called?

Coroner: This witness didn’t call the doctor and the doctor is giving evidence on Monday, so that will help answer that question.

Juror: Something you mentioned, you [can’t hear]

MM: Me and Ade we went to check, wasn’t because of the allegation, because of allegations she was two to one.

Coroner: We have heard evidence Jessie was on two to one observations because of previous allegations she had made

Another juror then had a question.

Juror: You recall being with Ade at twenty past midnight, what were you actually doing?

Coroner: This witness has said they were both doing observations between twelve and one.

Juror: So you were learning what was happening. After the check, you come in, see emergency happening?

MM: After the check she was ok

Juror: You went back?

MM: I went back when Ade was called that they’d found Jessie [can’t hear]

Juror: What were you actually doing while he was trying to resuscitate her?

MM: We work as a team, so someone like Ade would cut, someone else would run… laying Jessie on the floor…. compressions…. Was really important as well, we’re trying to bring Jessie back, we try to bring Jessie back

Coroner: I’ll stop you there, conscious of time, think you’ve answered the question.

The coroner thanks Ms Mapunda for giving evidence and asks her to leave unless there was anything else she wished to say. She said that she would like to say sorry, that it really touched her and she would like to extend her sincere condolences to Jessie’s parents and friends.

The coroner then called the next witness.

Anna Purnell / Healthcare Assistant

Ms Purnell told the court that she is now a Social Worker, but back in 2022 she was a healthcare assistant on Caburn Ward.

She told the court that she didn’t have many interactions with Jessie between March and May 2022, she didn’t remember much input with Jessie but saw her in passing.

Asked whether she had received any training about dealing with patients with autism, Ms Purnell said that she had previously worked with people with autism and had training in previous jobs.

Coroner: Night of 16 into 17th, you were working night shift that evening as a healthcare assistant. When you started your shift we’ve heard there was a handover. Do you recall if anything particular was handed over to you about Jessie, matters of concern for example?

AP: Not that I can remember

Coroner: What was your role initially when you started?

AP: My first hour was allocated to carry out intermittent observations of patients, intermittently check on them. Second hour was supporting a patient 1-1 support, eleven to twelve general support on the floor and when it was 12 o’clock was allocated general observations.

Coroner: Wonder if you could clarify something for me. We know Jessie was on two to one observations, the jury have the observation sheet. If you’re the healthcare assistant or nurse doing general observations, do you still observe those who are on two to one observations?

AP: I don’t have that answer, but I have to say I’d check them, I wouldn’t write it if I haven’t seen it.

Coroner: So you’d see all patients when doing general observations?

AP: Yes

Coroner: You were doing general observations from midnight, did you come to check Jessie?

AP: Yes, at quarter past

Coroner: When you entered room what did you see?

AP: She was on the left side of the bed, her head was at the top of the bed, main lights were off, her fairy lights were on. I couldn’t see her breathing, got colleague Lena to come check with me, got Nurse Ade to come check, we found piece of material around Jessie’s neck.

I ran to the nurse’s station and got the ligature cutter. Ade cut Jessie’s ligature off, I went to the medical room, got medical bag and oxygen, returned to Jessie’s room, put the oxygen mask on Jessie.

Called alarm to get extra support for ward, they came, we got Jessie on the floor and started CPR.

Coroner: I let you run with that. Why did you call Lena, if you’re going to observe and can’t see someone breathing, what was the purpose of that?

AP: My purpose was to double check, I had a gut feeling something was wrong

Coroner: It’s difficult for us to imagine what it’s like doing observations. What gave you this gut feeling?

AP: There was just nothing [can’t hear]

Coroner: I’m not going to ask you to go into detail of what went on after other staff joined, you clearly played a part in supporting Jessie after she was found with the ligature. I don’t think I have any further questions.

Was then over to Jessie’s family for questions.

Counsel: Could you just explain to us, who checked Jessie’s neck?

AP: Myself and Lena, with Ade present

Counsel: Can you remember how the check was conducted?

AP: Her hair was covering her neck, so I moved her hair away, then saw material [can’t hear] and got ligature cutters

Counsel then asked questions about the detail of the ligature, I’ll withhold.

Asked if she had any recollection of Jessie being on the ward, in any area between 10 and 11pm, Ms Purnell said she did not from memory. Asked if she could assist with how one of Jessie’s shoes was found in the nursing room after her death, she said she could not. In response to a final question from counsel she told the court from memory, Jessie’s duvet was not up high.

No questions for Ms Purnell from East Sussex County Council or Brighton and Hove City Council.

Over to counsel for Sussex Partnership Trust.

Counsel: Just one, you were providing general support on the ward between 11 and 12. What does that mean, where are you?

AP: Could be helping someone to make a hot drink, or have catch up with patient, could be in the lounge, an activity, or supporting to the toilet, it varies

Asked if it was fair to say that when the ward is settled there is time to do stuff, and staff would have more time available to them, than if the ward was busy. Ms Purnell agreed.

Counsel: So it wasn’t the situation that the ward was chaos?

AP: No

Nothing further from SPFT. The jury asked a question about the ligature, I’ll withhold the details.

The it was over to the final witness from Caburn Ward to give evidence about the night of 16 to 17 May 2022.

Lena Hjalmmarrson / Healthcare Assistant

Ms Hjalmmarrson said that she was a healthcare assistant and had been in that role for 6.5 years, starting as bank staff but now substantial staff. In response to a question from the coroner she said that initially she worked on a number of wards but she always seemed to end up on Caburn Ward, and that is where she is based now.

The coroner asked if she had many interactions with Jessie between March and May 2022 and she said that she could remember talking to Jessie once and that she was very friendly.

Coroner: You were aware of Jessie?

LH: Yes

Coroner: Were you aware of the risks to Jessie?

LH: Yes

Coroner: Can I turn now to the night of 16 and 17th. You were working as healthcare assistant, had you been allocated any specific roles that day?

LH: I was basically on the floor, in the communal area that night with patients, and quite long time ago, I don’t think I was on observation that night at all, I was just on the floor with the patients.

Coroner: Do you recall something happening about quarter past twelve?

LH: My colleague Anna called me and asked me to come check Jessie in her room.

Coroner: Ok, did she give you an indication as to why?

LH: Anna said she wanted to double check, see and make sure Jessie was ok, asked me to come in, so.

Coroner: You went into Jessie’s room, what did you see, what did you observe?

LH: Jessie was lying facing the wall [can’t hear] and was dark in the room, something was not right in the room.

Coroner: Did you have that gut feeling?

LH: Yes something was not right, hard to explain why, was just feeling.

Coroner: How did you go about checking? We heard the last witness say she lifted the hair, did you get involved in that or just observe?

LH: I was there [can’t hear] saw there was a ligature, and we called the nurse, he came and ligature cutter.

Coroner: Is that the first time you’d come across someone having tied a ligature?

LH: No, unfortunately

Coroner: Ok, can I push you on that, is it a regular occurrence in your role?

LH: Um, I work part time on Caburn Ward, in my years it has happened many times. I’m not able to say how regular, it depends on the patient. Always see patients and always aware of this type of self-harm, yeh.

Coroner: In your statement you say once ligature had been cut, you’re aware someone went to get the medical crash bag, but then you left to support other patients is that right?

LH: Yes

The coroner asked about her recollection of the ligature, I’ll not report. Then it was over to counsel for the family.

Counsel: Question about order of how things happened. In evidence there you said was by bed, lifted blanket, saw ligature and straight away called nurse. Did the nurse come before or after the ligature was found?

LH: The nurse came when we called the nurse, we found the ligature, then we called the nurse, the nurse was just next door and then came with the ligature cutter

Coroner: I think to be fair she ought to be referred to her statement if she’s doing it from memory.

Counsel: You signed your statement in [missed] that’s much closer to the incident?

LH: Yes

Counsel: I’d like you to read paragraph three of your statement to refresh your memory.

LH: I read it this morning

Coroner: Without pressure, just read paragraph three


Counsel: the order you’ve given in evidence is different to your statement, if you could read your statement out.

LH: Went into Jessie’s room together with my colleague, we both checked whether she was breathing. I did not observe her breathing. Colleague called nurse in charge, nurse asked if colleague had checked Jessie’s neck, colleague checked Jessie’s neck and saw she’d tied a ligature.

She was advised that she didn’t need to read the rest and the family had no further questions.

Coroner: I’ll pick up, now you’ve refreshed your memory, did you see the ligature before the nurse came?

LH: Yes

Coroner: That’s not what’s in your statement

LH: No

Coroner: That’s ok, it’s not a test.

LH: My memory isn’t great, what I said here. When we saw Jessie we did not see the ligature, we called the nurse and the nurse came and said have you checked the neck, we checked the neck and then she [can’t hear] to get ligature cutters. We did not see the ligature, sorry about that.

No questions from East Sussex County Council or Brighton and Hove City Council. Over to questions from Sussex Partnership Trust.

Counsel: Certain amount of time passed, can we be clear for jury as to how much time was passing from moment you went in to Ade coming? Really difficult thing to judge in an emergency situation, give an idea for the jury, minutes, seconds?

LH: Very short [can’t hear]

No further questions from SPFT and no jury questions for Ms Hjalmmarrson.

There was then a break before the final witness on Day 5, Mr Jason Brown from IMC Locums.

[I will try to report Mr Brown’s evidence later today, or tomorrow. With thanks to my crowdfunders who support my reporting, and all those reading and sharing. Comments on my reports are disabled until the case concludes but then will be published].

One comment on “Day 4 and 5 Jessie’s inquest: Healthcare Assistants and Nursing Staff, Caburn Ward”

Write a reply or comment

Your email address will not be published. Required fields are marked *