In the afternoon of Day 6 the court heard from two witnesses, both in person. The first witness, Dr Makin was very softly spoken and became upset on an occasion (which often leads to witnesses dropping their voices even further).
As I’ve mentioned before, I don’t tend to add trigger warnings to my posts, because most inquest reporting is triggering. However I’ll flag that this post discusses details of the resuscitation attempts on Jessie.
Dr Isobel Makin / On call doctor at Mill View
The first witness was Dr Isobel Makin. I couldn’t hear most of what she told the coroner in relation to her professional status but believe that she said she had since qualified as a GP.
Coroner: You said you were doing your psychiatry rotation, that was at Mill View hospital is that right?
IM: Yes
Coroner: Part of that rotation meant you took turns as the on call doctor is that right?
IM: Yes
Coroner: Just tell the jury when you’re on call, are you up and about all the time for the 24 hour period?
IM: [can’t hear]. At Mill View, you’re on site, there’s a small on call room which has a bed but frequently you wouldn’t have time to sleep, I’d be awake on night shift, would be 12 hours and then handover period.
Coroner: And you cover all the wards?
IM: Yes
Coroner: Before I take you to the night of the 16/17, had you whilst working in the hospital come across Jessie at all?
IM: On two occasions, I reviewed the notes, both physical issues, first she had had a non-epileptic seizure [can’t hear], second was Jessie had been reading about syncope, one of side effects of psychiatric medication, and had pain in her chest and wanted it checked over, and I was happy to do so.
Coroner: As on call doctor are you regularly attending patients who self-harm?
IM: Depends on shift [fuller answer – missed]
Coroner: And tying of ligature, is that a fairly common method of self-harm?
IM: Bearing in mind I was based in outpatients, I don’t feel comfortable answering that
Coroner: That’s fine. 16/17 May, tell the jury what happens, you’re in the little room, what happens?
IM: I receive a bleep on my pager, 5 digit number, I call back but no answer, you call back but can’t see from pager exact location coming from. So I left it a couple seconds and called back, and someone did pick up at that point
Coroner: And what were you told?
IM: Again 18 months ago, but something along the lines of we have a patient who isn’t responding, can you come. I could tell it was an urgent situation so I went straight there.
Coroner: What do you take with you when you go, or do you take anything?
IM: My stethoscope… they have the red bag, an emergency bag [can’t hear]. The defibrillator was there already when I got there.
Coroner: You were told was on Caburn Ward, how far is the distance between Caburn Ward and your room?
IM: I walked extremely quickly, it probably took me xx seconds, it’s just along the corridor and down stairs
Coroner: When you got to Jessie’s room what did you see?
[The witness becomes upset]
IM: She was on the floor, she was purple [can’t hear] a lot of staff, about 5 or 6
Coroner: Did you see whether oxygen was being delivered at that point?
IM: It was being delivered, but I switched it across, different types of oxygen, when I got there I swopped the mask over [can’t hear]
Coroner: Could you see any chest movements or anything at that point?
IM: When I got there? I can’t remember
Coroner: You swopped the mask over, what was next thing you did?
IM: [can’t hear] I wanted to make sure we were doing chest compressions as priority, and [can’t hear] so I checked she had a pulse, [can’t hear] resumed CPR and I ensured the group had [can’t hear] wanted establish that before doing anything. I remember being quite firm asking nurses to do compressions and count out loud [can’t hear] as well as we could.
Coroner: With regards to the defibrilator, do you know what the outcome of it was?
IM: In terms of the rhythm?
Coroner: Did it ask you to shock at all?
IM: [can’t hear]
Coroner: Carrying on these chest compressions etc, were they continuing until the ambulance service arrived?
IM: Yes
Coroner: At any point during that period were you able to get any circulation at all?
IM: No
Coroner: Did you give any adrenaline?
IM: Not until the ambulance arrived, I anticipated getting access would be very difficult and know from the evidence base doing good chest compressions is integral, so given I didn’t have any physical health professionals alongside me, my role was to make sure that continued
Coroner: The ambulance service arrived, you gave them a hand over, what do you remember them doing?
IM: [Can’t hear] We both tried to gain intravenous access initially, which was not possible, so we tried to [can’t hear] go into a bone which can initially be quiet difficult [can’t hear]
Coroner: And how long was she being treated for by yourself and the ambulance service? Roughly?
IM: Can’t remember
Coroner: You can’t remember. Ok. Did there come a point where a decision was made?
IM: [Can’t hear]
Coroner: I’ll just ask you this, but if you don’t know, please say. The ligature that had been used, did you have sight of that ligature at all?
IM: Only on the floor
Coroner: You didn’t see it close up?
IM: No
Coroner: Thank you, if you’d just like to remain there.
It was then over to the family for their questions.
Counsel: Your witness statement paragraph 9 states during the resuscitation you sought to gain as much information as possible about Jessica, is that because detail is important when a patient is in medical crisis?
IM: Of course, several reasons why someone could be in arrest, because of time urgency, medical CPR, it was appropriate to ask exactly what happened at that point [can’t hear] they had mentioned was a ligature [can’t hear] make sure nothing else contributing that we hadn’t excluded.
Counsel: At point more support came for resuscitation, you were able to step back and take account all that background information
IM: Yes.
Counsel: I was informed leading up to Jessie being found, she was on hourly observations, last seen breathing around 00:03. Is that what your recollection was of what you were told?
IM: That’s my recollection, yes
Counsel: Is that the level of detail you were given, that Jessie was seen breathing?
IM: Yes
Counsel: We heard earlier last week from Nurse Ade [Makanjuola] that when Jessie was first found, at 12:15/12:19 he pulled the alarm, checked for pulse, would be weak pulse, could you feel any pulse at time you attended?
IM: No
Counsel: Were you informed by Nurse Ade that he had found a pulse earlier?
IM: No
Counsel: Would that have changed anything in your approach?
IM: No
No further questions from Jessie’s family. No questions from counsel for Brighton and Hove City Council, for East Sussex County Council, or for Sussex Partnership Trust. No jury questions.
Dr Makin was thanked and released at 14:38
Jack Pumphrey / Ward Manager
The second witness to give evidence on the afternoon of Day 6 was Jack Pumphrey, who also gave evidence last week, my report of which you can find here.
The coroner told the members of the jury that the copies of documents they had been given are “quite bad” because they were written in pencil, and light pen, but that this witness would be able to assist them.
Mr Pumphrey gave an affirmation.
Coroner: Mr Pumphrey we asked you to come back to give further evidence to help the jury understand how observations are recorded, and to produce further documents. The jury have limited documents, to produce some additional documentation.
What I’d like you to do is perhaps recap with regards to Jessie’s level of observation at the time of her death.
JP: At the time of Jessie’s death she was nursed on general observations, but was also nursed [can’t hear]
Coroner: Can you confirm, they’re recorded these observations, on two types of sheets, which are in front of the jury. Can you explain what they are looking at.
JP: [Can’t hear] that is the general [can’t hear]. Every patient on the hour, that role is allocated to an individual each hour, that is for everyone.
XX is the large document, that’s general observations for Jessie, should be signed every hour with two members of staff, check her whereabouts. Had that enhanced level of support for Jessie, so could work on 2-1 basis she’d received in the community [can’t hear].
Coroner: So to be clear, the jury have general observation sheet, which one member of staff, may be a different member each hour, records everyone on the ward, even Jessie? The other sheet is specifically for Jessie, because she’s on 2 to 1?
JP: Yes
Coroner: Who decides who does what observations on the ward?
JP: The nurse in charge, at the start of the shift will allocate for the first hour, and then during the first hour will allocate for the rest of the shift.
Coroner: The jury have who was on shift, and what their role was, throughout the shift.
The coroner asked for copy of that document to be given to Mr Pumphrey, to confirm what’s what.
Coroner: Who is doing what in the first hour in respect of Jessie?
JP: First hour [can’t hear] allocated and Ifeoma allocated to general hourly observations for all patients.
Second hour Ifeoma and Connor with Jessie and Prince on general hourly observations.
At 11pm we have Ifeoma and Connor again for Jessie’s 2-1 and Prince is still on the general hourly observations.
Coroner: Now the jury have another document which is a list of names, on that shift there was only one Maria?
JP: Yes
Coroner: With general observations, just a tick or code of some sort, whether present, asleep, out on leave off the ward etc. that provides a snapshot and limited information.
When staff are carrying out 2-1 observations, what’s your expectation as ward manager about what they should record?
JP: My expectation would be each hour, exact time they saw them, what time they saw Jessie, then large box explain what was Jessie doing, maybe she was [can’t hear] and what position she’d be, breathing observed, any clinical indications and last column would be [can’t hear] two staff members [can’t hear].
Coroner: It may be an obvious answer, explain to the jury, why do you need to record whether someone is breathing?
JP: To make sure they’re alive
Coroner: If they’re not breathing, what would spring to mind as possible cause at that point?
JP: It may be that they have self-harmed, may be physical health emergency [can’t hear].
Coroner: I have no further questions, I’ll pass you over. If we go to the family.
Counsel for Jessie’s family: Thank you for providing these new documents. At the time of questioning staff on the ward last week we had the hourly observation log, at H2882, and the jury have copy of that, can I ask Mr Pumphrey to be shown that.
In the course of some questions to Maria Mapunda, I was asking about an entry at 9pm about Jessie pacing, arranging her stuff, moody to staff, do you see that entry at 9pm?
JP: Yes
Counsel: I asked Maria about the box at the end, says Maria HCA, was that you, her evidence was it was not.
I asked what her understanding was as to why it said Maria HCA, and she said “I cannot answer, is not me” and I asked is there a chance you did attend at 9pm and what she told me is “What I’m trying to tell you is that this is not me and this is not my signature”.
I think you’re telling us there was only one Maria on shift at that occasion, and that she was allocated to do Jessie’s observations at 9pm?
JP: Yes
Counsel: I asked about Jessie pacing, and she said she could not remember. As Ward Manager are you aware of any explanation that could explain?
Counsel for Sussex Partnership: [can’t hear]
Coroner: Can he offer any explanation?
Counsel for Jessie’s family: Can you offer any explanation for someone signing?
JP: As Ward Manager my expectation is that someone should sign who carried it out.
Counsel for Sussex Partnership: In fairness to this witness, and the witness Maria as well, her recollection was she couldn’t recall anything around that time, further think that’s an important point, her memory is completely missing, apart from midnight.
Counsel for Jessie’s family: Yes, that’s exactly why reference would help, and why I’m asking about it. Is very important to the family about who carried it out, and that’s why I’m putting it.
Coroner: Yes, I’m not sure this witness can help, the jury can see it for themselves.
Counsel for Jessie’s family: Yes. The allocation table you’ve taken us to, hours along the top and staff on the left hand side. With respect to the 9pm slot, we can see 2-1 next to the name Prince, 2-1 Jess 15, and Maria Jess 15s. What is meant by 15s?
JP: I mean from looking at the other 15s across the sheet I would believe that would mean intermittent observations, but as far as I’m aware Jessie wasn’t on intermittent observations at that time. [Missed section] I can’t comment, could just be error.
Counsel: We have Jessie’s support plan, dated xx, at h2655 and h2656. We have entry here, right at bottom, Shannon on 12 May, says below is the 2-1 support plan for Jessie, altered to meet her needs and encourage independence, changes made agreed by team including ward manager Jack. That’s you?
JP: Yes
Counsel: Right above that says, if you are reduced to general observations and maintain your safety for a further 2 hours, will be able to use leave from the ward with your family. Do you see that, about half way down the page?
JP: Yes
Counsel: Underneath that, it says on return from leave, when Jessie comes back staff will check in with you and will either be nursed on intermittent or general observation. So after a period of leave staff would do an assessment and take a view on that?
JP: Yes
Counsel: Is that your understanding? So was option when Jessie returned from leave, could be nursed in on intermittent, or could change again depending on how she presented?
JP: Yes
Counsel: So when we see Jess 15s with Prince and Maria, could it indicate was assessment when returned from leave need intermittent?
JP: It could be, but I don’t recall her going on leave prior to that shift.
Counsel: She was on leave that day wasn’t she?
JP: She was. Normally I’d expect that documented by the day shift, so increased observations level, documentation [can’t hear].
Counsel: And we don’t have that do we?
JP: No
Counsel: Then says 2-1 hourly from 10pm onwards. So does appear to be some difference, and if is a typo, is corrected from 10pm onwards, so it is not a consistent typo?
JP: No
Counsel: So could be someone took a view from 9pm onwards that Jessie should be nursed on intermittent?
JP: It could do, but there’s no documentation of it. On top of the sheets the jury have got, we have different sheets for intermittent and eyesight observations, if was on intermittent observations would be another sheet.
Coroner: Would you expect to see something in the care notes, if someone’s observations had changed, would have to be recorded?
JP: Yes
Counsel for Jessie’s family: In the same entry, it refers to structured activity check-ins for today e.g. 9am morning chat and things like that, 21:00 hours says plan staff will support you to get ready for sleep for one hour. Were you aware this was part of Jessie’s plan?
JP: Yes
Counsel: For what reason was that put into her structured activity?
JP: To help her, Jessie, slow down and get ready for bed.
Counsel: On xx it doesn’t appear we can see a staff member assigned to provide Jessie with sleep support at 9pm can you help with that?
JP: That would be Prince and Ifeoma on 2-1 [fuller answer, didn’t catch]
Counsel: What is the sleep support, what form is that to take?
JP: Staff supporting Jessie to get changed, get ready for bed, settle down, if she needed drink.
Counsel: We heard evidence last week from Nurse Makajuola that Jessie approached him asking Prince be removed from her observations at 9pm, as he was a member of staff at IMC Locums.
Counsel for Sussex Partnership: At 21:40
Counsel for Jessie’s family: If that suggestion was made at around 21:40, what would the expectation be about who would provide sleep support?
JP: That someone would take over that
Counsel: Are you able to tell us from this sheet, between the hours of 9 and 10pm, who took over that duty?
JP: No
Counsel: We understood from Nurse Makanjuola that as result of what he was told by Jessie he took Prince off Jessie’s observations. In the log, you’ve got that there?
JP: Yes
Counsel: Row 22, that’s where we see observations carried out on Jessie, if we go down that row, get to 10pm and general observations, that’s carried out by Prince is that right?
JP: Yes
Counsel: So, whilst Prince was taken off Jessie’s 2-1 observations, he has then been allocated to her general observations, is that right?
JP: Yes
Coroner: The ward’s general observations, not just hers
Counsel for Jessie’s family: Yes. So general observations aren’t carried out two to one, is an individual on their own. We see in that box is a tick, what do you denote the tick to signify?
JP: That someone is safe and present
Counsel: We then see Prince also carries out the ward general observations at 23:00. Can you tell us what that box says?
JP: Code at the top, one of codes is for people sleeping, make sure observing, this is a very basic form … Jessie on her [can’t hear]
Counsel: We then see the box that says 24:00 hours, can you help with the name that carries that ward observation out?
JP: Looks like its Lena
Counsel: Then we see 1am?
JP: Dawn
Counsel: So this table seems to suggest it was Lena who carried out general observations at 24:00?
If we go down to box for Jessie it’s been scribbled out, are you able to assist us with what that means?
JP: I can’t I’m afraid.
Counsel: Is there any guidance on the practice of drawing through things recorded on observation logs?
JP: Scribbling out?
Counsel: Yes
JP: In terms of amending records, there is, yeh there is.
Counsel: What does it say, what’s the general practice you’d expect
JP: Actions take, would be overseen by line manager, and then [can’t hear]
Counsel: We understood the evidence, before we received this sheet, that it was Dawn tasked with general observations.
Didn’t hear who: Anna
Counsel: Apologies, Anna. Could it be Anna referenced there at 24:00 hours?
JP: Looks like Lena to me
Counsel: And we had understood Lena was asked, to accompany Anna, so it appears a conflict between what we’ve seen here and what’s been heard. Do you accept that?
JP: I do. Sometimes due to acuity on the ward, if an incident is happening somewhere else, it may be somewhere else has been asked to take over observations to ensure they are happening on the hour, but I’m not sure if that was the case in this situation.
Counsel: The police have said who attended the ward after Jessie was found, referred to reviewing Jessie’s medication record, think we touched on this last week. Jessie was on [medication – withheld] and [medication – withheld]. The officer asked staff if it was usually effective and was told when Jessie fell asleep she’d sleep through anything. However she was up at 22:00 hours complaining she was still awake.
Can we take it she was awake at that time?
JP: Could assume, but I haven’t got 2-1 checks, the general observations have to be completed on the hour, not sure what time the 2-1 check was. That was on the hour.
Counsel: Do you see that 22:10 is time Ifeoma and Connor say Jessie was in bed and appears asleep and breathing observed. So, it appears between tick at 10pm and what observed at 10:10 is a difference.
[Can’t hear]
Counsel: Nothing further.
No questions from counsel for Brighton and Hove or for East Sussex County Council.
Next it was over to counsel for Sussex Partnership Trust. She started by taking Mr Pumphrey to the allocation sheet.
Counsel: Can see at the top of the sheet it says [can’t hear]. Could you assist the jury in understanding what that means?
JP: Allocation sheets are completed in the first hour of the shift… nurse in charge would create sheet for the rest of the shift, but because certain things do happen [can’t hear]
Counsel: So on that, in summary, is it fair to say the 21:00 we know is as was allocated at 21:00. Is it also fair to say that after that 21:00 allocation, the allocation sheet would not be certain as to whether that was the same at 9oclock is that right?
JP: That’s correct
Counsel: Because we know its updated as things developed
JP: Yes
Counsel: Is this sheet though, what was present at the end of the shift when Jessie sadly passed?
JP: Yes
Counsel: So we know at 10oclock for certain, according to the sheet, the allocation had changed, well we don’t know but we do know what the allocation was at 10pm, Ifeoma and Connor on 2-1 observations and Prince on general observations. Is that what’s supported by the sheet?
JP: Yes
Counsel: If we go to the midnight, 00:00, and we look at whose on general observations, who is on general observations according to the sheet?
JP: Anna
Counsel: Would that be consistent in Anna being the one to do those observations at that time?
JP: That’s what would be expected
Counsel: Yes, but as I understand your evidence, due to ward acuity, sometimes that is changed?
JP: Yes
Counsel: You had a look at JP1 [can’t hear] additional checks and observations, jury have questions about the checks recorded. When you [can’t hear] the checks in JP1 were you satisfied they were recorded in general with the correct level of information?
JP: Yes, I did note two entries where an hour wasn’t filled in.
Counsel: But where it was filled in, it was filled in in line with your expectations?
JP: Yes
No further questions from Sussex Partnership Trust and it was over to the jury for their questions.
Juror: Two for one checks, and on another one, reason for increased observations is listed allegations, to your understanding what are those allegations?
JP: The reason for 2 to 1 rather than 1 to 1 was to protect Jessie and staff, with two staff being there [can’t hear]
Juror: What was your understanding of what those allegations were?
JP: Jessie had made allegations against staff of physical assault.
Juror: Was that at Mill View?
JP: [Can’t hear]
Juror: Were you aware there was an ongoing safeguarding enquiry that Brighton and Hove City Council were investigating of IMC Locum staff supporting her in the community?
JP: I was aware of the allegations, I wasn’t aware it was IMC Locums
Juror: Is it you that’s responsible for sourcing of the IMC Locums you need to fill the register?
JP: No that’s [can’t hear]
Juror: Would there be any consideration by the bank team not to get IMC Locums to fill the rota?
JP: [Can’t hear]
Then there was a question from another juror.
Juror: I see here, just going through, my question is regarding consistency. You have here 7 in the morning, on 16 May, asleep in bed on her side, breathing observed, and then we have 7:50 we have asleep, breathing observed, same for 8am asleep, breathing observed. Then we go back to 22:00 in bed, appears asleep, breathing observed, then 23:00 in bed, appears asleep, breathing observed. Is that what you’d expect?
JP: It would be. I’d prefer her position to be recorded there, whether on her left or back or right.
Coroner: What’s the reason for that?
JP: If take over observations and someone is in the same position for three hours, or extended periods of time on one side, you start looking at have they moved, is an additional sign of signs of life.
No further jury questions, the coroner thanks Mr Pumphrey and says that he is free to go.
There was some discussion about timetabling and the jury were released at 15:27.