Day 7 Jessie’s Inquest

The day started with the coroner apologising for keeping the jury waiting. She said that they would deal with the police evidence now, which would be read to them.

She also told the jury that Interested Persons had agreed that it was not necessary to read out the GP’s Summary as they’ve heard from various witnesses about Jessie’s medical conditions and they don’t need to trouble them with that.

The coroner said that she would ask her officer to read out the Police Officer’s Statement.

Report of DS Noel Simmons

The coroner’s officer said that it was the statement of Detective Sergeant Noel Simmons, dated 20 June 2022.

The statement was read very quickly and I missed swathes of it but have reported what I can where I’m confident of my notes.

DS Simmons told the court that on 17 May 2022 he was the night duty sergeant covering Brighton and Hove. At 01:24 he was informed of a ??? which referred to the death of a 19 year old female, Jessie Seares, at Mill View Hospital in Hove.

DS Simmons told the court that he reviewed the police records and noted several markers attached to her record relating to suicide attempts and self-harm. He also told the court that the records noted that Jessie had autism, ADHD and post-traumatic stress disorder.

DC Simmons told the court that he reviewed the most recent police record, which referred to Jessie setting light to a blanket on the ward. He said that there had been multiple records of her attacking staff in recent months and talk of moving ger to another ward.

DC Simmons told the court that he attended with [colleague name – didn’t catch] and at the scene met [two colleagues – didn’t catch].

He told the court that he spoke to Ade Makanjuola and Anna Purnell. He said that Ade informed him that Jessie was on hourly checks and that he had conducted the last check at 00:03, with another member of staff Maria. Jessie had been snoring at the time.

DC Simmons told the court that Nurse Makanjuola had informed him that the locking mechanisms on Jessie’s room meant that only staff and Jessie could access her room. There was no CCTV of her room or the corridor outside, he told the court.

DC Simmons told the court that Anna had checked on Jessie and found a ligature [detail withheld]. She went for help and cut the ligature.

DC Simmons said that he went to Jessie’s room, that it was untidy but there were no signs of a disturbance. He described what he saw in the room in some detail [didn’t catch, apologies]. DC Simmons told the court that “the room was well lived in”.

He said that Jessie was lying on her back on the floor and it was confirmed that she had been moved there, from the bed, for CPR.

DC Simmons said that he had examined Jessie’s body [detail withheld]. He ended by saying that there was some blood inside Jessie’s right nostril and on her tongue and teeth, but other than that there was no injury.

DC Simmons’ report said that the ambulance service received a call at [missed] and arrived on scene at 00:41, confirming life extinct at 01:16. The ambulance service confirmed that the blood in Jessie’s nose and mouth was from resuscitation attempts, and the bruising on her stomach was from anti-coagulant injections.

DC Simmons told the court that he’d reviewed Jessie’s medication records and that she had her most recent [medication – withheld] and [medication – withheld] at [missed] hours. He told the court that he asked staff if that was usually effective and they said once Jessie is asleep she would sleep through anything. DC Simmons told the court Jessie had been up around 22:00 hours complaining that she was still awake.

DC Simmons told the court that he was advised her behaviour had improved significantly since the fire, that she was responding well to a behaviour chart. DC Simmons said that staff told him there was no indication of Jessie’s behaviour that would lead them to believe her risk was elevated.

The coroner then asked her officer what the situation was with regards to the ligature. Her officer confirmed its location and that they are able to collect it if required.

The jury were then let out for a break.

Sarah Kidd / Brighton and Hove City Council

The coroner apologised to the jury for keeping them waiting.

She asked the witness to give her full name and professional status, and she told the court she was Sarah Kidd, and I think that she told the court she was a social worker [sound was very difficult].

Coroner: Now, the jury can’t hear you, need to ask you to repeat that.

SK: [can’t hear]

Coroner: You are very quietly spoken, Mr Downs at the other end of the room will need to hear, if you can keep your voice up I’d be grateful. I’ll start by asking you questions about your involvement following the death of Jessie, ok. Tell us what was requested of you.

SK: What was requested of me was that I consider whether it should be taken forward to a formal safeguarding enquiry under Section 42 of the Care Act

Coroner: The jury know nothing about what Section 42 is, so just explain that to them.

SK: [Can’t hear]

Coroner: OK, now we’ve heard, the jury have heard Jessie was residing in Brighton and Hove, albeit was a placement arranged by East Sussex County Council, just remind the jury as to why Brighton and Hove had to carry out this enquiry?

SK: Brighton and Hove would carry out this enquiry because Jessie was [can’t hear] in the area

Coroner: To assist the jury I’m going to go through the chronology, would like you to tell the jury at what point you became involved, if you disagree with these dates let me know.

There is a note of a safeguarding enquiry raised 5 October 2021 by East Sussex County Council, ok

Then on 21 October 2021 there was an email relating to a safeguarding concern by Ruth Nathan, ok

On 22, the following day, October, a safeguarding referral was made, or provided about care provided by IMC

On 7 December the safeguarding enquiry was allocated to Alison Woolfenden

On 13 January was visit by Alison Woolfenden to Jessie at Viaduct Road, that was her home.

On 16 February was visit by Steve Lawton to jessie at hospital, that was in presence of her father

On 15 March was a case conference

On 16 May was a visit by Alison Woolfenden on the ward, we’ve heard evidence directly from her.

Where did you fit in in this chronology?

SK: Only after Jessie passed away, I was not involved and had never met Jessie

Coroner: OK, why was someone from your team brought in to do this enquiry?

SK: To give it a bit of separation, because of previous involvement by Brighton and Hove social workers

Coroner: OK, when you carry out your role, what access did you have to Jessie’s records?

SK: I have access to [can’t hear]

Coroner: OK, did you also have access to any of the staff that had been working with Jessie?

SK: I met the ward manager and the matron [can’t hear]

Coroner: Where are they from?

SK: From Caburn Ward

Coroner: When you carry out this safeguarding review, what process do you undertake, tell us a little bit more about it

SK: I would review the referral that comes in, the details, look at information on systems and speak to staff involved [can’t hear] in order whether meet three tests

Coroner: You need to tell the jury what the three tests are

SK: Does the person have care and support needs, or not? Are they at risk of abuse or neglect, or experiencing abuse and neglect? As result of needs are they unable to protect themselves against abuse and neglect. [can’t hear]

Coroner: So take us through then what your findings were?

SK: Jessie obviously did have care and support needs, was currently on Caburn Ward, had documented history of variety of diagnoses [can’t hear]

Process then went through was to look at the records, and review care plans and speak to the staff about those incidents, the incident, and my understanding was they’d followed procedures and [can’t hear] had in place, finding she wasn’t at risk of abuse and neglect.

Coroner: Think need to remind jury of what the incident was you were looking at?

SK: [Can’t hear]

Coroner: So are we talking about the events of 16 and 17 May, your investigation was as narrow as that?

SK: Yes

Juror tries to ask a question

Coroner: Wait a moment, not quite sure what. What you looking at and findings were?

SK: Jessie’s death and I [can’t hear] whether care and support needs… however from reviewing records and speaking to staff on duty they did follow care plan in place on that day, so my assessment was she wasn’t at risk of abuse and neglect at that time

Coroner: I’ve probably confused the jury by asking you to go through the safeguarding chronology but your investigation was just in relation to Jessie’s death. Do you know the safeguarding concerns that I gave you the chronology for?

SK: Sorry I don’t

Coroner: Were you aware had been any safeguarding concerns raised in respect of Jessie’s time in Viaduct Road?

SK: I was made aware, can’t remember whether before or after I conducted this enquiry

Coroner: So you carried out this investigation in isolation

SK: Yes

Coroner: Do you know who asked you to investigate [I think she said]

SK: Clinical Lead Nurse Manager of Acute Mental Health Services

Coroner: Do you know if is a requirement on the person in the hospital to make that referral when someone dies in hospital?

SK: Sorry, I don’t know

Coroner: Just to make absolutely sure, you didn’t investigate any other aspect relating to Jessie’s care

SK: No

The coroner asked Ms Kidd to stay where she was and said that there will be questions from others. Questions from Jessie’s family were first.

Counsel: With respect of the process you undertook in your safeguarding enquiry, am I right in thinking your evidence was you spoke to the Ward Manager as part of this enquiry?

SK: Yes

Counsel: We had understood the Ward Manager was not present on the 16th. Did you speak to any of the individuals who carried out the observations?

SK: No I didn’t

Counsel: So your enquiry was based on conversations with the Ward Manager, was that Jack Pumphrey?

SK: It was yes

Asked by counsel if she cross-referenced any of her findings with Jessie’s Autism, Crisis and Wellbeing Plan, Ms Kidd responded that she looked at some documentation

Counsel: What’s on there, is it fair to say you took that at face value, not taken from actual records?

SK: [Can’t hear]

Counsel: In terms of your understanding of the observations undertaken, did you have access to Jessie’s 2-1 observation log?

SK: Yes

Counsel: Did you have access to the general observations log?

SK: Yes

Counsel: Now in respect of the general safeguarding process, if you’re unable to answer this please tell us, you’ve been taken through a number of dates relating to earlier safeguarding issues, it may be that I have questions around those dates, if you feel unable to answer then please tell me.

The first relates to the nature of the safeguarding referral made on 5 October. On page G138 of our bundle.

Coroner: She just needs to be shown it

Counsel for Brighton and Hove City Council: I think this witness will not be able to help, I say this because you’ve elicited [can’t hear]

Counsel for Jessie’s family [can’t hear]

Coroner: OK, let’s see the document, can you remind my officer of the page

Counsel for Jessie’s family: G138. So what we have there is within exhibit of witness Ruth Nathan, we have a chronology where she set out a safeguarding concern for Jessie dated 5 October 2021. Says Jessie placed in Brighton and Hove, this concern raised with Brighton and Hove due to alleged abuse [missed detail] Jess is ATS [long number, missed]. Do you understand what that record appears to be showing?

SK: A safeguarding was raised

Counsel: It continues, following a phone call to Jessie she reports being assaulted by one of the carers and [missed] would you take from that record, even if no prior knowledge of it, would you take safeguarding referral is being raised given issues Jessie had with her carers?

SK: If that had been reported, yes

Coroner: Reported where?

SK: I’m not sure what system this was taken from, if we had received a phone call from a Lead Practitioner for someone, then we would [can’t hear]

Coroner: Would a previous safeguarding concern be accessible to you, if you looked for it?

Counsel for Brighton and Hove: Isn’t this the chronology composed after the death of Jessie? It’s not a record, is chronology by previous witness given.

Coroner: Document is in her statement

Counsel for Jessie’s family: Yes

Counsel for Brighton and Hove: Is a chronology drawn up after the death of Jessie

Coroner: My question is if you are carrying out a safeguarding enquiry, would you have had access to a previous safeguarding enquiry?

SK: Yes

Coroner: They’d have been available to you?

SK: Yes

Coroner: Can you explain why you might not have had sight of this then, if it was reported to Brighton and Hove. I don’t mean this chronology, we were aware from Ms Woolfenden’s evidence she was investigating a matter, just wondering why you wouldn’t have had sight of it when you came to do your enquiry?

SK: I don’t know if I’m honest, it would have been recorded on the system, so, it would have been there.

Counsel for Jessie’s family: Also in reference G148, this is a record made by Lauren Bernard, Jessie’s Social Worker on 15 December 2021, that SECAMB, the Ambulance Service reported a safeguarding concern relating to allegations made about carers. Ruth Nathan previously made aware of concerns and already raised with Brighton and Hove. To your knowledge, you may not be able to assist, would you expect further safeguarding referrals made by other individuals, including the Ambulance Service, to make its way to Brighton and Hove City Council?

SK: Yes

Counsel: Are you aware whether Brighton and Hove did receive, or make, enquiries about safeguarding from the Ambulance Service?

Counsel for Brighton and Hove City Council: Can I say we have not had any disclosure about this, we had 4 PIRs [fuller comment – missed]

Coroner: We have the jury here, want to be careful how we address this, can we generalise, haven’t heard any evidence on this at this stage. Should previous safeguarding, if jury find had been made, should they be accessible to you, is that the point you’re making?

Counsel for Jessie’s family: Yes, if Ms Kidd is taken to the safeguarding chronology that doesn’t include information from the Ambulance, doesn’t explain why it is not in the chronology.

SK: I was aware safeguarding concerns were raised but I was not aware of the details of them

Counsel: We had evidence of Alison Woolfenden regarding the date she was allocated a safeguarding enquiry. Her evidence was it was allocated to her whilst she was on sick leave, and she returned to work in November part-time, to ease back in. Is it regular practice to allocate safeguarding to people on sick leave?

SK: Can’t comment [can’t hear] if, I don’t think it probably has been done, work is allocated as people are coming back, with a view to the appropriate [can’t hear] so its managed on their phased return

Counsel: What consideration is given to the time might need to be taken for safeguarding enquiry to be looked into and resolved, are there any recommendations?

SK: Under safeguarding in Section 42 there isn’t any time limit or time frames given, is talked about doing it in a timely manner

Counsel: We understood Ms Woolfenden’s evidence, she had to wait various weeks for access to systems, spent time catching up on mandatory training and email. In your view is that an appropriate use of the time given the nature of the safeguarding enquiries?

Coroner: She doesn’t know the nature

SK: I can’t answer that question, I’m sorry

Counsel: I’ll just turn my back …Ms Kidd, in relation to your investigation, your safeguarding enquiry of the 16 and 17 May, were you aware of concerns raised by Jessie relating to the presence of an individual on her observations?

SK: Yes [can’t hear]

Counsel: Did you take a view as to the relevance of that?

SK: Yes, again it was something I discussed with the Ward Manager in relation to my understanding that person had been removed, and it was not believed there had been a significant impact

Counsel: That was your understanding from discussion with Jack Pumphrey, who was not on the ward?

SK: Yes

Counsel: Did you have any discussions with the individual?

SK: No

Counsel: Were you aware the individual remained on general observations and was doing observations for the two hours after?

SK: No

Nothing further from the family. No questions from Sussex Partnership Trust or from East Sussex County Council. Over to Brighton and Hove City Council.

Coroner: Mr Downs

Counsel: You’ve attached the tool you used to help you with decision making?

SK: Yes

Counsel: Have you got that in front of you?

SK: Yes

Counsel: On top of the second page of that it gives the reason for the [can’t hear] safeguarding alert referral

SK: Yes

Counsel: What did you understand that to be?

SK: Was taken from the incident report where Jessie was found unresponsive in her bedroom.

Counsel: Do you see the second page, is person aware concerns are raised, no. See there it says this safeguarding concern is being raised as, what did you understand?

SK: Sorry I’m not sure I understand

[can’t hear]

Counsel: Full name… second page first thing says is person aware this concerns is being raised.

SK: Yes

Counsel: Below that does it give a reason for that?

SK: Yes, because Jessie passed away while on the ward, raised as an unexpected inpatient death

Counsel: If go over page to [can’t hear] Prompt for you about Making Safeguarding Personal?

SK: Yes

Counsel: Is there anything you can help the jury with about what safegaurding referrals are meant to achieve?

SK: Safeguarding referrals is about safeguarding people, safeguarding adults, and it’s about working with the person, finding out what their [can’t hear] working with them at their pace to [can’t hear]

Counsel: And what might be a typical outcome?

SK: [Can’t hear] Would depend on what the concern was raised in relation to, would depend, varies from person to person.

Counsel: Right, ok. Would, a full protective plan sometimes be recommended?

SK: Yes, can often be the case, might be around management of person’s finances for example [can’t hear]

Counsel: Have you ever dealt with safeguarding investigations, do, is it possible to say whether they’re, the work is very much done by yourself or are expectations you ask people and they provide details for you?

SK: A lot of the time, some of the time, we are asking other people for information, we can also cause other organisations to undertake enquiries on our behalf, if that’s appropriate [can’t hear]

Counsel: Is it, is there any, is it a static or dynamic exercise, by which I’ll give an example, a police investigation for example might be police go away, investigate then there’s a reveal at end, report to crown prosecution service. Is your investigation a bit like that?

SK: No, it’s a bit different, can change depending on what persons outcomes may be, can change enquiry, and yeh

Counsel: Would there be an attempt to try and deal with the underlying problem whilst the enquiry goes on?

SK: Yes, initial action is to try to reduce harm as far as possible

Counsel: Then you go on to Stage 2 of your test, to look at the guidance [can’t hear] start off with examination of the observations, is that right?

SK: Yes

Counsel: Is that a particular policy you looked at?

SK: The Therapeutic Engagement and Observation Policy

Counsel: You’ve told us you spoke to Mr Pumphrey and Matron, you have access to electronic records, did you look at physical records?

SK: Recording sheets [can’t hear]

Counsel: Did you consider risk around ligatures?

SK: Yes, was in Jessie’s care plan, history of tying ligatures, was something I’d looked at, documented in her care plan [can’t hear]

Counsel: Did the risk assessment address that?

SK: Yes, it did address that

Counsel: And then did you examine, as your report continues, did you go on to examine the events of the last day?

SK: Yes, yes, what had happened on the day before [can’t hear] my understanding was a visit from a Social Worker [can’t hear] staff on the ward, but from records she was able to alert staff to this issue and my understanding was they ensured she didn’t have any further contact.

Counsel: See paragraph before then, did you examine what ward had done to monitor Jessie’s [can’t hear]

SK: On the ward review there was documented she held [can’t hear] On 16 May is reported no ongoing thoughts of suicide [can’t hear]

Counsel: You then went on to consider your third test about guidance and arrived at your conclusion, and your rationale for your conclusion is that right?

SK: Yes

Counsel: What was that?

SK: Jessie didn’t appear to be at risk of abuse and neglect [cant hear]

Coroner: Can you keep your voice up please

SK: [Can’t hear] Had undertaken appropriate levels of observation

Counsel: At time you conducted this Section 42 investigation, preliminary investigation, were you aware of any other steps being made to look into the circumstances of Jessie’s death?

SK: Yes, was aware police involvement and serious incident undertaken by the Trust

Counsel: And there are two electronic notes you have access to, care notes, system used by Sussex Partnership, and a system used by Brighton and Hove at time, is that right?

SK: Yes

Counsel: What was that called?

SK: Eclipse

Counsel: Is it right when that system interrogated for purpose of this inquest, it reveals a note of a safeguarding meeting of 15 March 2022?

SK: Yes

Counsel: Attendees at that meeting, Alison Woolfenden, Steve Lawton, Victoria Cottis, Operations Manager of the City Council, [missed] East Sussex County Council, Ruth Nathan Lead Practitioner, and it records a series of bullet points is that right?

SK: Appears so

Counsel: Records, obviously uses initials but it records Ms Woolfenden to try to meet face to face with Jessie on either Caburn Ward, MV Hove, what’s that?

SK: Mill View Hospital

Counsel: Or polyclinic, to discuss relationship with father, now more stable in mental health, is informal patient, section lifted on [missed]

Other actions Ms Woolfenden to write to Dad again asking for specific issues around agencies as most concerns not specific in nature [can’t hear]

[Section missed – apologies]

Ms Woolfenden to raise issue with local agency, IMC. Ms Woolfenden to write to police to clarify boundaries of when things escalate to criminal matter. OT assessment being completed by Caburn Ward given disparity between what reported to professionals and what observed.

Jessie’s father stating he has to step in due to high needs, some uncertainty around this, parents have stated unable to have return home, unable return to community placement [more detail – missed]

Jessie reluctant to work in an environment aimed at those with EUPD. Can you remind jury what that was? Emerging?

SK: Emotionally unstable personality disorder

Counsel: Next meeting due to take place 21 April 2022, records then revealed next meeting recorded on Eclipse, next note 16 May 2022, note created by social worker, starts, may have to decipher

East ATS safeagurding meeting

[More detail – missed]

Specific try investigate… offered Andy chance phonecall to discuss or email with specifics, agreed to do this, sent complaints to the NMC, regarding one of the staff and said would send some of this to me, he already had my email address, Andy still stated agency not registered with CQC although heard from colleagues in SPFT that they are. Jessie stating preference 2-1 one male and one female.

Appears she’s needed personal care on the ward, although not as much as she’d like, Mr Seares no longer undertaking personal care.

[More detail – missed]

Andy now visiting her 4 days a week and looking at working as a Bank TA. Teaching assistant, is that right?

SK: Assume so

Counsel: With those with special needs, he’s semi retired, currently no plans for discharge, still on Section 3 at present. Andy clear Jessie could not return to the family home as couldn’t cope with her.

Asked for 5 more minutes of time, Jessie declined.

Jessie previously stated to Steve Lawton did not want allegations against her father.

[Can’t hear]

You’re actually a quality specialist in adult social care?

SK: I’m the Operations Manager for the Specialist Older Adults Mental Health Service

Counsel: And strictly speaking Jessie is working age, ok, I’m only saying this so answer you give is in context. Are you able to say anything about the effects of covid on operations of a service? I’m talking 2021, 2022?

SK: It did have an impact on our service, people off on long term sick or who had to shield, so we had less staff available on our service and much more remote working.

Counsel: Now the next thing is about autism awareness, or awareness of autism. Is there been any developments about that, in adult services, at Brighton and Hove?

SK: There’s a mandatory training which we all have to undertake, the Oliver McGowan mandatory training

Counsel: Are you able to say anything about that for the jury

SK: My understanding is mandatory training set up by the mother of somebody who died [can’t hear]

Counsel: And can I say to you, do you recognise this, it’s the approved training framework by NHS England is that right?

SK: I believe so

Counsel: And are you aware of your colleagues, what they’re saying, anything about people being trained to deliver this?

SK: My social work colleagues should all have undertaken that training [can’t hear]

Counsel: I know that this witness will probably want to say something else, don’t know whether you want to deal with that?

Coroner: After the jury I think

Counsel for Jessie’s family: Ma’am evidence given about mandatory training, but don’t believe we’ve been given a date for that

SK: I believe after Jessie’s death [can’t hear]

Counsel for Sussex Partnership: Was some mention by this witness about a serious incident review, going to ask whether you are able to explain, if its outside your remit please say and we’ll deal with another witness to deal with it. Do you know how those serious incident reviews come about?

SK: No

It was then over to the jury for their questions.

Juror: I do have a few questions, so you say, we’re talking about the safeguarding issue regarding IMC Locums, yes, referred to both safeguarding at Viaduct Road and IMC locums, and the one on the actual day, is that right?

Coroner: I don’t want to answer for this witness, but you only investigated events on 16/17 May?

SK: Yes

Juror: What I don’t understand is there was questions about whether you had any knowledge or access to the previous safeguarding enquiry.

SK: I was aware there was safeguarding enquiries ongoing, I didn’t know the details

Juror: Were you expected to know the details, or no?

SK: I don’t think so, no, it was a very specific incident I was asked to look at.

Juror: OK, the other question was about the safeguarding concern raised when she died, that is normal standard procedure to raise that?

SK: I believe so yes

Juror: Finally, there was something about the Ambulance Service, was question about that, you said you had nothing to do, didn’t know about this Ambulance Service. Were you expected to know that? [can’t hear]

SK: I’m not aware of anything to do with the Ambulance Service or any referral coming in, I don’t know.

Juror: And you weren’t expected to know about that?

SK: [can’t hear]

Then a second juror had a question.

Juror: The Serious Incident Investigation is by the Trust?

Coroner: I’ll stop you on that, I think we’ll need another witness to deal with that

[Can’t hear]

Then a third juror had a question. They wanted to ask whether a Safeguarding Adults Review was considered? I couldn’t hear Ms Kidd’s response.

Then a fourth juror had a question.

Juror: You said you spoke to the Ward Manager, did you speak to the people there, her care givers?

SK: No

The juror then asked a follow up of why Ms Kidd had not spoken to the carers are she replied saying that part of her rationale for that was because she was aware other inquiries were going on and she said something about a “safeguarding enquiry is around looking at outcomes” but I couldn’t hear what else was said.

Then a fifth juror had a question.

Juror: Was the fact you were aware other safeguarding enquiries were going on, but didn’t know the details of them, do you feel you were adequately able to determine whether was an issue in this case, and whether no contributory factor linked to previous safeguarding enquiries?

SK: Yes I feel I was able to, with the knowledge I had [can’t hear fuller answer]

Then juror one wanted to ask another question.

Juror: Final question, wasn’t clear, at the end of covid you said was long term issues, are you referring to long covid, or lot of people having covid at time?

SK: I can’t remember if at the time of Jessie’s passing people had covid, but question understood was how managing during covid, in service I worked for did have people with covid.

Ms Kidd offered her condolences to Jessie’s family and was released.

Ms Agnew, for Sussex Partnership Trust, told the coroner that Ms D’Souza was in court for other purposes in the absence of the jury but she wondered if she might be able to help answer the jury’s questions around the SI process.

There were no objections from other parties, so the coroner said that she was very keen to release the jury for the day, but she would use one of the Sussex Partnership staff members to tell them about what an SI is, while it was fresh in everyone’s mind.

Lauren D’Souza / Clinical Lead Nurse Manager SPFT

Asked to give her full name and professional status Lauren D’Souza told the court that she was a registered mental health nurse. She said she had been registered with the NMC since 2005 and had worked in acute mental  health care since 2002. Her current role she said was as Lead Nurse for Acute Services in Brighton and Hove “effectively I manage Mill View Hospital”.

Coroner: First question, just to ask you to clarify, we heard from the last witness a safeguarding referral was made from your hospital to Brighton and Hove. Explain how that comes about, why does that referral get made?

LD’S: As we heard I made the referral to Brighton and Hove Safeguarding. Has always been my understanding that’s the practice, that’s what we should do. Reason I do that is it’s an unexpected death, [can’t hear] she was in the care of Mill View Hospital and I think it’s not for me to make a decision about whether there has been an omission. For me it’s about raising this has happened, for someone else to look at that, it’s about being transparent and open, that was the reasoning for the referral.

Reason I do that, and still continue to do that practice in that way, is I‘m not privy to all circumstances, might be parts of the case I’m not aware of.

Coroner: OK, who investigates safegurding concerns?

LD’S: The local authority, separate to Sussex Partnership.

Coroner: So when there’s a death in Mill View Hospital, who else looks at this death?

LD’S: So in the event of a patient death, there will be a Serious Incident Investigation Review. A Serious Incident Review. We are mandated, the NHS, to carry out these reviews. They’re independent, so I wouldn’t carry out that review, in this case Jessie’s case, Sussex Partnership commissioned someone completely external to SPFT to conduct the review.

In terms of reference for the review, what looking at and figuring out timelines, would happen in any review. The reviewer that’s allocated to that case will look up all evidence available to them, that would include all the care notes for us at Sussex Partnership, the NHS Clinical Records, they will interview witnesses, could be people involved directly with incident, there at that point. The reviewer may choose to interview, for example, the Ward Manager.

Absolutely family will be invited to be part of that review. As a reviewer, when I’ve conducted a review of an incident outside of Brighton and Hove, want to very much hear from the family, want to hear, because review can sometimes answer some of the questions family may have, is really really important.

The reviewer will complete a thorough robust timeline, decide where want to look from, usually finish at the point incident happened. By doing that in that way you’re very much able draw out if any care and service delivery problems, any issues. Then can look to see if any themes as well.

What’s really important is drawing out learning, very much focus on learning, usually recommendations made by reviewer. Recommendations formally made to the service, and then the service or organisation, Sussex Partnership will then produce, work together to produce an action plan.

From my perspective what’s key is to ensure any learning identified from that review is taken forward to improve service delivery, to ultimately improve service for people who use our services.

Coroner: And prevent future deaths?

LD’S: Prevent future deaths, absolutely

Coroner: So for the jury’s benefit, is safeguarding enquiry, sometimes looking at safeguarding aspect, there’s SI review taken in this case by totally independent person, and there’s police investigation.

LD’S: Yes, sorry

Coroner: And finally a coroner’s investigation and inquest?

LD’S: Yes

The coroner asked if any counsel had any questions, they did not. So it was over to the jury.

Juror: So safeguarding review and then a serious incident review?

Ms D’Souza asked them to repeat their question

Coroner: Question is whether is safeguarding review or a SI review

Juror: previous person that spoke?

Coroner: Sarah Kidd

Juror: Is that safeguarding review?

LD’S: I made a safeguarding referral to Brighton and Hove City Council  

Juror: Thank you

Then a second juror had a question.

Juror: Is a Serious Incident review about care received [can’t hear]?

LD’S: It’s our review, Sussex Partnership review, my experience when I have led a review into a completely different incident, I can look at different aspects of the care but it’s very much our review. I wouldn’t for example make recommendations for another agency.

Juror: [can’t hear]

LD’S: Yes, I’ve done that before in different cases, I didn’t undertake this review

Juror: [can’t hear – think they asked if a police investigation was requested]

LD’S: I didn’t ask for it. I’ve heard today it was considered, not surprised it was considered.

Juror: The Trust would have been involved with that, not as far as you’re aware?

LD’S: No hasn’t.

Then a third juror had a question. This juror wanted to ask about bank staffing department at Sussex Partnership using IMC Locums whilst there was an ongoing safeguarding enquiry.

Coroner: I think Ms Agnew this witness, given her role in Mill View would be most appropriate? Can you start question again and break it up if you don’t mind.

Juror: Firstly, were Mill View aware of the ongoing safeguarding enquiry against IMC Locums?

LD’S: Not the detail, I mean I can only provide evidence of what I know today. At time Jessie was admitted to Mill View Hospital in my role I wouldn’t expect to know that level of detail. It’s our largest hospital in Sussex, five wards, a lot of patients.

My understanding is Caburn Ward knew there were safeguarding concerns around the care agency, but not the care agency, they weren’t aware of the detail.

Juror: Do you think it would be helpful to know the detail?

LD’S: It’s always helpful to have a level of detail

Juror: Who does the responsibility lie with for providing that detail?

LD’S: Umm I would expect, that person caring for Jessie, before admission, so Lead Practitioner, and a Social Worker that is carrying out those enquiries relating to safeguarding, would communicate that to Caburn Ward, to their leadership team.

Coroner: With regards to the agencies that provide staff to Mill View, IMC Locums are one of them?

LD’S: One of many

Coroner: So different agencies you could go to, is there a shortage of locum staff available to them? Imagine you’re having to fill gaps in your own staffing levels?

LD’S: Not so much a shortage, we are fortunate, we do have what we call our bank staff, our bank team, NHS bank staff, and we are really fortunate in Mill View hospital, especially with healthcare assistants, very rare, very very rare for us now to be using agency healthcare assistants. Will be very much around short notice, need of ward and patient has suddenly changed, for example short notice sickness, half hour before shift, might be really difficult to source bank cover, on those occasions that would go round because of urgency to agency.

Coroner: Only other question, do the agency staff themselves work for a number of agencies? We know individual on duty on the night works for IMC Locums, do you know if they work across agencies?

LD’S: Wouldn’t know, imagine in theory could be registered with more than one agency.

Coroner: And you don’t have contract with IMC Locums to go with them specifically, that’s just coincidence

LD’S: Yes, the ward will put request out on the system to temporary staffing team on SPFT, say we need HCA support worker on shift tonight, that goes out to all bank staff. If not picked up then go out to NHS Approved Framework Agency, to every agency approved and registered with the NHS.

Then it was back to the juror who asked the first question again.

Juror: You said that you weren’t aware of the levels of that safeguarding enquiry, including the name of Prince. Is there any reason why that kind of thing was not [can’t hear]

Coroner: I’m not sure I understand the question

Juror: So you were not aware?

LD’S: Personally no

Juror: Of the safeguarding enquiry involving this company. Is there any reason why, you think, these details are not made available, other than general headlines, does that make sense?

Coroner: Are you asking about the detail of the safegaurding enquiry or IMC Locums itself?

Juror: That’s the company and this is the person

LD’S: I think, I’m not entirely sure. I would suggest, not suggest, I think because there are a lot, I don’t know how many agencies registered with the NHS that are approved, but a lot, and I think it would be really difficult for that level of detail to be flagged or communicated to Sussex Partnership. Because there wasn’t concerns, I wasn’t aware was concerns about the whole agency, they are still approved with NHS Framework

Counsel for the family: I’m a bit concerned that we’re asking this witness to speculate slightly of what should have been known

Coroner: I understand, but this is the most senior person of Mill View, who holds responsibility I imagine for agency staff

LD’S: Yes

Coroner: To box that off for the jury, is it feasible, bearing in mind how often patients change at Mill View, for you to be aware of every single agency member of staff who had previously worked with patients, and for which could be safeguarding concern?

LD’S: No its not. To clarify I don’t have responsibility for agency staff, that’s managed centrally for Sussex Partnership.

Then I think it was over to another juror [not entirely sure from my note, they’re a very engaged jury at the other end of a large conference room so all I can do is try to distinguish them by voice].

Juror: Given nature of some of presentations we see from patients on Caburn Ward, post traumatic stress disorder, or other scenarios, having that awareness of ongoing safeguarding enquiry, could have been very key to making sure the patient in your care was well protected, is that correct?

LD’S: I can understand why you’d ask that question, I don’t believe it’s feasible still for us to hold that level of detail, there’s Caburn Ward, a patient with that presentation you’ve just described could be admitted to any other ward as well. Not sure how feasible would be to have that communicated, unless founded and significant concerns about an agency

Coroner: So had it been a finding then you would know, this was just, I say just, was allegations?

LD’S: Yes, and I don’t want to minimise those allegations

Then it was back to the first juror who had asked a question of Ms D’Souza, to ask another.

Juror: There hadn’t been an allegation involving that person?

Coroner: We cant answer. Do you know whether or not had been any formal allegation about this individual?

LD’S: I’m not aware

Coroner: Ms Agnew

Counsel for Sussex Partnership: Do you know if there is an allegation found proven about an agency, that agencies ability to continue providing service to the NHS Framework would be compromised?

LD’S: That’s correct

Counsel for Sussex Partnership: At that stage, is it right, they wouldn’t be open to be able to receive putting out that task or role, they wouldn’t be able to receive that and then provide a member of their agency to work?

LD’S: That’s correct, would be a restriction

Counsel for Jessie’s family: Just questions arising. We’ve heard about allegations founded, in context of ongoing safeguarding enquiries, is no decision either way, is still ongoing and being investigated, do you accept that?

LD’S: Yes

Counsel for Jessie’s family: And in circumstances where a patient for example, is knowledge of ongoing safeguarding enquiries

Counsel for Brighton and Hove: Sorry to interrupt, I have difficulties with this, it all presupposes safeguarding complaints against individuals, the evidential nature not laid. Worried is in public, only named person, evidence is exculpated, he in fact helped out, was a good person.

Coroner: You’re very close to giving evidence Mr Downs. Aware we have jury and this witness, anything else the family wish to ask?

Counsel for Jessie’s family: [can’t hear]

Counsel for Brighton and Hove: this is absolutely without any evidential foundation about individuals which have not been made

Coroner: If we can let her finish

Counsel for Jessie’s family: You were discussing the feasibility when looking at staffing, would there have potentially have been an option to ask when allocating staff to specific wards, to show Jessie’s name and ask whether they’d experienced [can’t hear]

LD’S: No I’ve never experienced that before

Counsel: You’ve not experience, but potentially option isn’t it, to say this patient is on Caburn Ward

LD’S: I’m not sure it is an option. We weren’t aware, we as Mill View Hospital, were not aware about that specific agency, the concern was that specific agency, so there’s that. I’m not sure about providing names of inpatients to agencies, about whether or not agencies know patient on ward.

Coroner: No allegation had been made

Counsel for SPFT: Is the suggestion everyone who works on ward who is non-substantiative, patient is given list of all names and asked?

Counsel for Jessie’s family: No

Coroner: Separate out IMC and this individual

Counsel for Brighton and Hove: bit concerned whether that’s possible, what’s to stop moving from one agency to another

Coroner: Mr Downs I will have to stop you, I will have to ask the jury to leave if we’re trespassing into their remit.

I think the answer has come that it is not possible.

Counsel for Jessie’s family: Ma’am I’m very conscious of not allowing counsel to give any evidence. Simply about allocation of staff on to Caburn Ward, understood in any event didn’t have knowledge at the time, so perhaps we can leave it there.

Coroner: I think that’s a good idea.

The coroner thanks Ms D’Souza.

Coroner: Members of the jury we’re going to finish for today as far as you are all concerned. I’m going to adjourn the matter until tomorrow. We’re not going to start until 12 tomorrow, if I can ask you’re here ready to start at 12, we’ll be hearing from one possibly two witnesses tomorrow.

Thank you for your attendance today, sorry you’ve been up and down those stairs numerous times, these things happen, it’s important to have you in court when it’s the right time do so.

I’ll remind you, please don’t discuss outwith your number, please don’t do any research and please remember you are making your findings based on the evidence you’ve heard in this court.

Thank you very much, I’ll see you tomorrow.

The jury left court at 13:28. The coroner and counsel spent the afternoon discussing Prevention of Future Death Report matters. I’m only reporting when the jury are in court, but may report on those later.

With thanks to all of you funding, reading and sharing my reporting.

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