Day 8 Jessie’s Inquest: Coroner’s Expert Dr Elizabeth Beber

The final witness on Day 8 was the coroner’s expert, Dr Elizabeth Beber, who attended the court remotely. She gave an affirmation and confirmed she could hear.

This post discusses Jessie’s death and has a little more detail than I would normally report about self-harming, I’ve withheld lots of detail, but had to include some information for a reader to make sense of the expert’s position. Please consider this a trigger warning, above and beyond what is a given for all my reporting.

Coroner: Thank you very much, I wonder if you could tell the jury, give them your full name and professional status please.

EB: Dr Elizabeth Beber, my background is I’m a psychiatrist, my specialist is learning disability and autism, but also working in secure and forensic services.

Coroner: Dr Beber, you were instructed by myself as an expert witness in these proceedings. Can you first of all confirm that you’ve no connection with any of the Interested Persons in this inquest?

EB: Absolutely not as far as I know

Coroner: And you never met Jessie, as far you know?

EB: As far as I know I haven’t

Coroner: You were provided with documentation before you completed your report, and since then you’ve received the statements from Jessie’s parents?

Dr Beber confirmed that was correct. The coroner said that she would arrange for a further document to be sent to her to aid questioning later. The coroner said that she wouldn’t be taking her through her 130+ page report in detail, but would take her to her opinion and the questions that she asked her to consider.

Coroner: First was Jessie’s diagnosis, and in your view the correctness of that diagnosis, and whether you felt there were any [missed]

EB: What I found was over the years Jessie had gone through quite a number of assessments and also had quite a lot of different diagnoses. Starting with severe clinical depression when first admitted, as years went by given a number of other diagnoses including autistic spectrum disorder condition, ADHD, and PTSD, Complex post traumatic stress disorder. And also a diagnosis I’m aware neither Jessie or her parents agreed with, that was emotionally unstable personality disorder.

Coroner: In respect of those diagnoses, you found you were happy with that approach adopted and the outcome of those?

EB: Absolutely, certainly the autism had been investigated and assessed by a professional qualified to do that, certainly from descriptions seen myself in clinical records would agree with that. Similarly ADHD thoroughly assessed. That and other diagnoses reviewed at specialist centre, the Maudsley, and they agreed with those diagnoses.

I noticed on that report they hadn’t mentioned emotionally unstable personality disorder, although given Jessie’s age at the time I am not surprised by that finding, although one of the treatments they recommended at that time was treatment for EUPD, that’s dialectical behaviour therapy.

Coroner: Thank you, the jury have heard about her treatment, we’ve focused on Mill View Hospital. You assessed her journey through CAMHS … did you form any opinion of the appropriateness of her care in her mental health journey at all?

EB: Yes it’s a very familiar journey, not one only see in the region where Jessie lived, have seen a journey like this very many times over in people who I’ve cared for over the years.

Was characterised by multiple moves over years … moved between community and hospital, some time periods in the community were very short, coming out of PICU at Cygnet Bury was very very quick, about 12 hours, community services really do struggle to provide good safe services for people with the kind of presentation Jessie had.

She then moved into adult services. Again periods in community and periods of hospitalisation, during which everyone was clearly struggling to find the right type of care for her, any care, the quality of care she needed and most importantly the consistency of care needed.

You’ve already heard evidence is difficult to find… high risk… problem nationwide [missed]

It was not atypical, in fact very typical, and there were some areas of good practice, she was thoroughly assessed, saw wide range of professionals, then got diagnosis and treatment reviewed at the Maudsley… appeared to have good quality care plans, hospital passports observation plans, all things would expect to see.

What was missing to me, again reflects many people’s journey, being in a situation that gave her consistency of care, and carers, with the right training and more importantly right experience, to have those care plans successfully implemented consistently.

Coroner checks that Dr Beber had said that this was not unique to Sussex and was a national problem.

EB: Absolutely, unfortunately it’s a scenario I’ve seen many times over the years.

Coroner: Can I just explore something, in inpatients admissions, what is your view of inpatient admissions for those diagnosed as Jessie was?

EB: This is very difficult, as intimated in my report, since the abuses in Winterbourne View were identified about 10 years ago, perhaps was more than that now, has been a feeling, certainly political view that inpatient services should be avoided, should be specialist services in the community.

Transforming Care you heard about is all about that, however the reality is more people with ASD and learning disability are inpatients now than there was then, clearly community services just aren’t there, or very few of them are in the quality needed for someone like Jessie.

As a result often we see she ended up in hospital.

As someone who has managed and worked in inpatient services, I don’t think its hospital or community, I can’t go along with the mantra hospital bad, community good, there have been many scandals in the community.

I believe safeguarding raised about care she got from IMC Locums illustrates care is not always good in the community, hospitals aren’t always perfect, I acknowledge that, for me is about appropriateness of care …

That you’ve got people with the right qualifications, right experience particularly, working with people with complex problems and you have the right therapies available.

Coroner: OK, putting to one side the quality of any care, we know that when Jessie was in the community she was supported by IMC Locums, an agency staffing provider, have you seen that before? The jury have only heard about this case? Is that sort of care fairly normal where trying to provide provision for someone with autistic spectrum disorder?

EB: Yes it can be, particularly since Winterbourne View, last 10 years, growth in bespoke packages of care, and a move away from what people thought was old fashioned residential care into more personalised care.

Jessie didn’t fit into the categories usually think about, often think of people with severe level of learning disability in a residential setting… someone with normal intelligence but diagnosis ASD, often harder to place people, but particularly more difficult if high risk behaviour Jessie was presenting with.

But no, not unusual, I’ve seen care packages such as this.

Coroner: Moving on to care and treatment provided by Sussex Partnership NHS Trust. They were trying to dealing with mental health admissions, did you take a view of the appropriateness of their care, or any comments on way they dealt with Jessie during admissions?

EB: I think they used the resources they had. Resources for people like Jessie, particularly for women, are far and few between. They tend to be inpatient services, for men with high functioning autism are a lot more services out there, specific services.

For people like Jessie, seen people cared for in lots of different settings over the years, that includes PICUs, PICUs cleared of all other patients over the years…


EB: Psychiatric intensive care unit, smaller ward, with high staffing to patient ratio, where people are very acutely unwell, psychotic or distressed, or people with personality disorder having a crisis …. go for care before felt safe enough on more open ward.

People with quite severe self-harm often find themselves on that type of unit, called PICU.

The coroner said she’d interrupted her and asks her to continue with what she had been saying.

EB: People with diagnosis like Jessie, used to be held in what was called [makes quotation marks in the air] “secure corners”, where someone was cared for in the corner of a ward on their own. I’ve seen people in long term segregation, very much in women’s secures services, low secure services, medium secure services, and WEMS, enhanced medium secure services for women.

Have seen women with self-harm, Jessie presented with a high functioning autism, managed in all those settings, and sometimes also in learning disability services, despite not having a learning disability.

Coroner: Thank you. I want to turn now to Jessie’s last admission on Caburn Ward, I will break it down. First of all, can you comment on the appropriateness of her care plan and risk assessments whilst on Caburn Ward please.

EB: Yes. I mean they were there. Had been completed relatively quickly, which is good. They did cover most of the risks really, fairly standard, what I’d expect to see on an admissions unit.

One of the things I did, would perhaps have expected to see slightly differently, was the issue of head-banging, was quite specific and chronic, an ongoing long term risk for Jessie.

There wasn’t perhaps a plan of what should have been done after any incident of head-banging, which I’d perhaps have expected to see given we do know an awful lot these days about the ill effects on your cognition of what are repeated head injuries.

Coroner: When you say you didn’t see something in place, do you mean Trust policy?

EB: I wasn’t given Trust policies, but would expect something on care plan, please after head-banging can you follow the procedure we use, which might be doing things such as MEWS scores and neurological observations

Coroner: You mention another area of concern, relating to visits to the ward, can you tell us what your concerns are about that. Don’t want to go into detail.

EB: No no no, given there was an ongoing investigation, a Section 62, about a member of the family, I’m not trying to make any judgment whether true or not, but given those allegations made and ongoing investigation, would perhaps expected to see some specific guidelines about the member of family visiting, in terms of what observations were appropriate, to protect Jessie potentially and also the family member from other allegations, protection that works both ways.

Coroner: Jessie was detained under the Mental Health Act. Any observations of her treatment under the Mental Health Act?

EB: As far as the treatment, I think that would be the same whether she was under the Act or not, but know some dispute about whether the Mental Health Act was used appropriately, personally having looked after many people like Jessie over the years, I’d be very uncomfortable treating her without a legal framework, and the most appropriate one for inpatient settings is generally the Mental Health Act.

I say that for a number reasons, one her capacity to agree to her care and treatment, been mentioned few times her capacity was assessed at various times, she was still making statements such as not believing she had a mental illness, may indicate hasn’t capacity to consent to inpatient treatment.

Often people with good expressive language skills may seem competent but when processing skills are impaired may not appear to understand quite as much as appears, think important thing to think about when thinking about Jessie’s ability to consent to her treatment.

Also frequent crises when she self-harmed where she wasn’t quite able to process and think rationally, were quite frequent, long standing, nature of condition.

The degree of self-harm was life threatening [lists self-harm I’ll withhold] all potentially life threatening self-harm.

Coroner: Will explore little further, one of the things the jury have to consider is what Jessie’s intention was at the time she tied the ligature. Can you assist the jury in when somebody is deregulated, can say deregulated?

EB: Yes

Coroner: As to whether they have an understanding of what they’re doing or would understand the consequences of what they’re doing, or is it impossible to say?

EB: Impossible to say on individual basis, anything on the night Jessie sadly died is speculation. Can speak more generally having worked with people like Jessie for many years, when people become dysregulated, can be number of reasons, we know Jessie had Complex PTSD, and EUPD, on top of a background of neurodevelopmental disorder.

We do know she had the propensity to become dysregulated, sometimes there were triggers for that, sometimes wasn’t. She reacted by sometimes self-harming.

People I’ve worked with over the years describe intense psychological pain, and one of the methods they use to dull that pain is self-harm, and they’ll say they are very effective methods.

People are described as attention seeking and it is very unusual that’s the case. Is usually about relieving what’s going on inside them and the very unpleasant experiences they have… to them they work, so self-harming is done in the context of the rational reasonable part of the mind, the wise mind, closes down and they just become focused on all they want to do is get rid of this awful psychological pain they’ve got and will use any method available to them, or they are used to using.

Coroner: Would they be aware of the consequences? Of the outcome of self-harming?

EB: Not always, self-harming isn’t always, sometimes look at it like people are trying to kill themselves, they’re not always. The self-harm often has a different function. The wise mind, the rational mind closes down, people aren’t always aware of the consequences.

Through the enormous bundle I read, I read on several occasions, Jessie wasn’t always aware of what would happen if she followed through with something. I saw one statement where she said no I don’t think this will lead to my death.

Coroner: We know Jessie regularly tied ligatures, fact she’d done that and there has been no consequence, would that have informed her mind? I’m talking in a very basic way, if someone does something and gets away with it, so to speak, would that inform them going forward?

EB: Yes. If you look at Jessie’s history of self-harm she’d done some very risky things and until that dreadful night she had got away with it, she was still ok.

Coroner: Moving on from that subject and onto observation levels and how Jessie was managed by levels of observations, can you explain whether that felt appropriate to her stay?

EB: Again difficult one, with hindsight can say no, it was not, because of what happened.

Can see rationale for observation level she was on, has been well documented. As I said in my report it wasn’t an off the cuff decision, the team had thought about it, well aware of the risks, wasn’t done without due consideration.

From what I can glean of Jessie’s life in the community, she wasn’t constantly in eyesight of the carers she was with, again from previous admissions could see at least one where it didn’t seem she was on eyesight, enhanced support throughout her admission.

Background reasons to think this is a safe thing to do, positive risk taking, rather than capricious risk taking.

Yes, have experience myself, put people on enhanced support, high level, designated staffing, 1 2 3 sometimes 4 people who are with you constantly, specify whether in eyesight, arm’s length or linked arms. Incredibly intrusive, very hard from dignity and privacy point of view, not pleasant for the person experiencing or for staff, in some cases increases risks. Can increase risks to staff and aggression, can increase risk as far as self-harm, so not a good thing, people don’t like to do it for good reasons, finding a safe way to wean someone off that support is generally a good thing.

Clearly we’ve got hindsight and that wasn’t the case.

Also I did note the observation level was dropped progressively, didn’t go from enhanced support to once an hour check. Also went down with full discussion w Jessie, saw in plan was discussed with her and written down with her.

Coroner: Can I go to the notes you saw in the week leading up to Jessie’s death. We heard evidence on 12 May Jessie was found [self-harm withheld], we then know on 14 May she [self-harm withheld], from the 14 onwards was there anything that gave you concern about Jessie’s presentation?

EB: Didn’t seem to be anything obviously different, given the [self-harm behaviours x 2 withheld] self-harm of other sorts, were very long standing behaviours, all I can say is from the notes I’ve seen, there was nothing immediately make me think, oh there’s something different in her presentation.

The only thing, I don’t know if you want me to talk about it now, only thing which would have raised my concerns about whether need do anything differently in respect of observation, was the fact had social work visit that day to talk about something which could potentially have a very negative impact on her mental state.

Coroner: Can you help the jury, they’ve heard Jessie’s presentation was such it took a while for her to process information, can’t remember the phrase, delayed processing, processing delay. We know the visit from the social worker happened in the afternoon, later in the afternoon and we know events that led to Jessie’s sad death were around, after midnight, perhaps, depending on the findings of the jury. That’s quite a period of time, would that be normal for someone to process and become deregulated? That period of time after this visit?

EB: I don’t think it would necessarily just be someone with delays in processing, I think for anybody pondering it anyway, yeh, absolutely.

Certainly in my inpatient experience, we have lots of professionals from the local authority, the police, coming in to interview patients quite regularly, and we know the impact it can have, both at the time of the interview and for some period afterwards, usually these interviews are not about pleasant things, usually about things very serious and upsetting.

Coroner: What would you have liked to see the ward do following that visit?

EB: As I said in my report, normally if get visit from outside professionals which has potential to be problematic to someone’s mental state, would hope to see really good inter-agency practices.

As responsible clinician, the consultant responsible for someone’s care, would hope I’d know about the visit, talk to clinical need, its needful, its got to happen, but let’s see how we can reduce the impact.

Think about preparing the person for the visit, do you want a member of staff you trust or like in with you for that visit, you might not, that’s fine, then to think about what do we do afterwards.

Often we’ll say we try to plan a nice activity for someone afterwards, to help them, bring arousal down.

Then depending on circumstances, you make think about reviewing someone’s observation level.

Coroner: OK, can I move on then to her medication. Any observation about her medication and the appropriateness of it?

EB: Yes. She was taking a lot of medication, a lot of sedative medication at that. Yes if you look at all individual diagnoses, as individual diagnoses and NICE Guidelines for them, you can see justification, her initial presentation [missed] given anti-depressant and anti-psychotic… of all medications only positive comment I could see was Jessie say when I went on [medication withheld] the weight lifted.

She’s on a lot of anti-psychotics, she doesn’t have a psychotic disorder. Can be used on and off licence, usually for reducing dysregulation, for Complex PTSD, then may wish to use an anti-psychotic to help, EUPD Guidelines say absolutely not, to use psychological methods.

You may have put in an anti-epileptic as a mood stabiliser. She was on xxx as an anti-epileptic, as someone with a background in learning disability and ASD, it wouldn’t be the one I’d have chosen. Did used to be very involved with treatment of epilepsy, not one I would use, can worsen behavioural disturbance in that population.

Very thorough review at Maudsley, starting to be followed, intro of xxx for ADHD, may have helped reduce some of her impulsivity.

Overall, she was on a lot of medication, however I would say she had been for a very long time, relatively speaking she’d been on the ward a short period of time. Any changes made to medication would expect to be done very slowly.

One perhaps could be concerned about for anxiety disorder, benzodiazepines are not really recommended, people do still use them, the problem is you get addicted and become intolerant to them.

Would have started to reduce that. I did raise my eyebrows about the PRN route being started, if I’ve understood that correctly.

Coroner: But overall nothing in medication that could have contributed to her death?

EB: No unfortunately is a list see quite often, is guidance out there from STOMP of not over medicating people with learning disabilities and autism. Very, very complex unfortunately quite often see lists of medications like that.

Coroner: Will jump ahead in your report and then come back to suitability of Mill View for someone with Jessie’s diagnosis. Can I move onto policies and procedures in place at the Trust. Those you saw were they applied correctly as far as you’re aware?

EV: There were no policies and procedures provided to me in the bundle, what I saw were included in reports, such as the SI report.

Coroner: As far as clinical standards, were usual clinical standards applied as far as you can see?

EB: Yes for an acute admissions ward yes, I did take to heart Ms Eastland’s notes about someone having to be on general observations before granted leave, yes she’s quite right, very inflexible for someone with ASD… legitimate to have for an acute admissions ward, usually means if you’re on enhanced observations you’re very ill and not going out, for someone in Jessie’s position, very different view of the risks because so chronic, would agree flexibility is needed.

There was work done years ago through the Green Light Toolkit. Was a drive, for generic wards, such as general adult admission wards, to be flexible and know what to do if someone with learning disability or ASD were admitted to them.

Was more about someone with those diagnoses who had acute onset of schizophrenia… not perhaps for people as complex as Jessie but it was a drive to make sure there was some flexibility and acknowledgement people with these really complex disorders, particularly autism, may need a more flexible approach.

Appeared to be a lack from what I could see, may not be in full knowledge of everything, but did appear to be lacking.

Coroner: Thank you. Go back to Mill View, know you touched on it, Jessie’s mental health deteriorated so needed hospital admission, supported sectioned under Section 3 of the Mental Health Act. How did you view the suitability of Mill View?

EB: As I think I said in the report, it felt like a no win, no win situation, both for the ward and for Jessie. I know from bitter experience how difficult it is to manage someone with Jessie’s presentation on an acute admissions ward.

Acute admissions ward is geared up, often staffed by highly qualified, highly experienced, highly specialised people who know how to deal with people with acute relapse schizophrenia, acute depression or [missed] crisis, they know how to do that, and do a good job,

Trying to manage someone with range difficulties and chronicity of difficulties as Jessie in that environment is very difficult.

I’ve not visited the ward, not seen the layout, often environments aren’t suitable, acute admission wards are noisy, chaotic, unpredictable, have high turnover staff unfortunately these days, everything you don’t need in someone with ASD, particularly Complex ASD.

Coroner: OK, what are the other options?

EB: That’s the difficulty, acutely, there are very few options. A PICU might have been used, again advantage, is conversely PICUs can be more settled places than acute admissions ward. I’ve worked in and manged PICU quite recently. Tend to have fewer patients and high staff ratios, may have acute suite, pros and cons people can become isolated and that’s not a good thing.

The difficulty was there were no other immediate options.

The coroner said that she needed to back to cause of death but didn’t wish to uspet the jury.

Coroner: Post mortem report, we know cause of death provided by the pathologist was in his opinion, 1a due to compression of neck by [withheld] ligature

Obviously the pathologist doesn’t have the knowledge of the mental health journey of the patient he’s dealing with, only has limited information. Do you take the view Jessie’s mental health played a part at all in her death?

EB: Yes I do

Coroner: Would you say it was a direct cause, or more a contributing factor?

EB: Its difficult to know, we can only speculate about her intentions at the time. What we do know is Jessie had a long history of self-harm [details withheld] and engaging in other types of self-harm which were high risk and could have led to her death at any time really, so yes, it’s a direct result.

Coroner: Would you, if you were asked to pinpoint, in a few words, Jessie’s mental health condition that could have been the cause of her death, would you say that’s the ASD, or list all of the diagnoses?

EB: Think it’s impossible to say, there’s a very complex interaction of all the elements, we know she had ASD and quite concrete way thinking of some things, she also had ADHD which is often seen hand in hand with autism which makes her impulsive. We have this diagnosis of PTSD, Complex PTSD, EUPD, lot of overlapping symptoms, know can lead to outbursts of impulsivity, and also the need to deal with that internal psychological pain. I think taken all together, my opinion is all those diagnoses would have contributed.

Coroner: Just have to put something to you, I know if I don’t one of the other advocates will, leading from the post mortem report, members of the jury don’t want to cause you any distress, just need read this to you.

The coroner then read from the pathologist’s report – I’ll withhold this and most of the detail in her question.

Coroner: Does that evidence alter your view whether or not she intended to take her life?

EB: Again, don’t think can say for certain, she had stated previously she didn’t think self-harm would cause her demise, would be speculation, but [withhold]

Coroner: Thank you, I don’t have any further questions, will pass now to other IPs, perhaps family first if happy?

There was then a discussion about order which I couldn’t hear clearly but I believe Jessie’s family asked to go last. There was further discussion about whether the documentation of the Mental Health Act assessment had been provided to Dr Beber, the coroner asked her officer to ensure it was sent, and then it was over to counsel for Sussex Partnership, Ms Agnew, to go first.

Counsel: Dr Beber I ask questions on behalf of Sussex Partnership NHS Foundation Trust and my first point isn’t a question. Just wanted to thank you on behalf of the Trust for your thorough, helpful report, and on behalf of Dr Cuthbert in particular, took on board points you rightly raised in relation to head-banging, and her and Ms D’Souza took on board your point about communication with family…. those actions are in chain, very grateful for that and wanted to thank you for it.

One question for you, matter for the jury, you won’t have been in court for evidence of Alison Woolfenden, who was the Social Worker who visited the ward, her evidence the jury heard, so want to ask one specific question based on your report… my understanding from your report was no evidence within the documents staff knew of the conversation taking place between the Social Worker and Jessie that afternoon?

EB: That’s right, not in the documentation I had access to

Counsel: Thank you, nothing further.

It was then over to counsel for East Sussex County Council, Ms Walker. She checks that Dr Beber can hear her, she can.

Counsel: Dr Beber I wondered if you could assist the jury with explaining how far back the incidents of self-harm, you’ve referred to tying ligatures and other instances of self-harm, how far back are they going? When did they start?

EB: From what was made available, certainly around the age of 14, in original Mental Health Assessment, she said she had been in low mood for 3yrs prior to that, so certainly around the age of 14

Counsel: From 2016? That point onward, how frequent were these incidents of self-harming behaviour?

EB: I hadn’t time to add them up and chart them, but certainly frequently, that’s what I’d say. Accounts in the records of numerous episodes and numerous attendances at A&E, pretty frequent occurrence.

Counsel: From that early point what is the range of those behaviours include?

EB: [Details, I’ll withhold] All very risky, high-risk behaviours.

Counsel: From outset were they always high risk behaviours that were putting her life at risk?

EB: Absolutely, also consequences, she had a lot of endoscopies, they’re frequently done on people, but there’s always a risk with those kinds of procedures, so self-harm itself and treatment for self-harm was placing her at risk.

Counsel: You said Jessie was going in and out of community placements and hospital admissions from about the age of 14, is that right?

EB: Yes

Counsel: Wonder if you could assist the jury as to how, when she was in the community, how those earlier placements when she was a child were being managed. Community placement at Lee Road in 2020 is that right?

EB: I believe so, yes. I was asked about this earlier, these packages of care aren’t unusual. She was with a set of carers, various ones mentioned Wrixham Care was one of them, these would be individuals probably had some degree of training, various support workers would have looked after her, similarly with other packages of care, depending what individual needs how many carers have, what level of input, whether on sleepover or not. From what I’ve seen she had 24 hour input from those carers.

Counsel: Did you see evidence, for example, when at Lee Road, 2020, did you see evidence from records of allegations being made against staff?

EB: Other than going through my report, can’t honestly remember about carers there. I think there were complaints made about the quality of care, and certainly was about IMC carers, quite a lot in the bundle in relation to that.

Counsel for East Sussex CC says that she will take Dr Beber to sections of her report.

Counsel: Next question I’m going ask you is did you see incidents in the records of concerning behaviour, and challenging behaviour towards care staff when she was at Lee Road?

EB: Yes, yes, they were clearly struggling to manage her.

Counsel: Could you recall any of those incidents and what that behaviour looked like?

EB: I’ll have to go back to my report, let me get it up, it was a very lengthy report I’m afraid, if you’ve got the section it would be really helpful for me

A discussion followed about which section they were both referring to. Ms Walker directed Dr Beber to the section she wished her to look at.

Counsel: This is talking about, continues what you were saying, when she was at Lee Road, latter part of 2020, despite level of input Jessie continued to engage in high risk behaviours. She was admitted to hospital, whilst she was in hospital also..

Counsel read from the report, listing instances of self-harm and distress behaviours [details withheld]. She then asked Dr Beber if an Occupational Therapy assessment and TCAT, were indications of the wide level of assessments that she had indicated Jessie had.

EB: Yes, TCAT and Jigsaw and Help for Psychology, and education as well, number of agencies involved.

Counsel: Want to ask you about the EUPD diagnosis. To be clear, your view was at the time raised was appropriately raised at that point?

EB: Yes personality disorder is something we don’t tend, we don’t give a diagnosis of in someone under 18. We refer to it as an emerging personality disorder, in CAMHS, how see constellation of behaviours referred to.

Also in anyone with any developmental disability would possibly want to not give diagnosis because still developmentally time to run.

Not something do lightly but in practice you often see, those particular behaviours which would lead to a diagnosis, you do see already well formed, sometimes at a young age.

Counsel: If that diagnosis was accepted, we know it wasn’t by Jessie and her parents, would it have opened up treatment options for her?

EB: Yes and no. Have long standing experience in dialectical behaviour therapy, one of the gold standards of treatment for EUPD, sometimes takes long time to accept diagnosis because was very stigmatising diagnosis for a long period of time… sometime people need long period in hospital… to build relationships with people or team, to be ready to accept therapy and do that.

One of the problems in inpatient services, you bring someone in and commissioners [clicks her fingers] say come on therapy, and often isn’t appropriate…. Take long time to establish relationships with people and often people are too immature at that time to engage in those therapies…

[fuller answer – missed]

It may have just been Jessie wasn’t ready at that time.

Counsel: Placement may have expertise meeting the needs of young people and people with EUPD, was that something you were aware of?

EB: There are a number of services around the country with expertise in treating EUPD, with all different levels of [missed]

Counsel: You refer to non-epileptic AD, what’s the A and the D?

EB: Non epileptic attack disorder, used to be called pseudo seizures, wasn’t a helpful term, sometimes still see written today.

Counsel: You refer to dissociative episodes, are they one and the same thing then?

EB: Not necessarily… spoke earlier about overwhelming psychological pain, sometimes people do deal with that by disassociating, the focus narrows in and they’ve become unaware of what’s happening around them, sometimes quite legitimately, but what we’re saying is this episode is not caused by same type of electronic activity that causes tonic clonic seizure.

Some colleagues refer to them as non-electrical attack, some people become very upset, believe Jessie was, they say you’re saying we’re faking it, that’s not what we’re saying, what we’re saying is that it is not caused by electrical activity, as see in seizures.

Counsel: Apart from these non-epileptic seizures, did you see any evidence Jessie had epilepsy?

EB: I couldn’t see any, that’s not to say, often non-epileptic attacks often occur with epilepsy. There was some difference between the neurologists, some said could be mixed, others probably not.

Counsel: Is there a treatment plan you’re aware of for non-epileptic seizures?

EB: Really treating the underlying causes, aimed at actual diagnosis, for Complex PTSD and EUPD, different types of cognitive therapy, dialectical behaviour therapy


Counsel reads from Dr Beber’s report.

Counsel: Prior to that you talk about challenging behaviour continuing, on one occasion assaulted hospital staff… on another occasion assaulted police officer…

Dealing with the allegations against staff, in someone w Jessie’s presentation, whilst accepting of course some of those allegations and concerns are well founded, is there a reason you might see a pattern of allegations and complaints?

EB: Difficult to see in Jessie what might be, over years have met many people who make false allegations for all sorts of reasons, to get member of staff removed or because of the power differential of people who feel powerless, but also can be more complex than that. Jessie had autism, and that pathological demand avoidance element to it as well. People like Jessie do see things very differently, might be something staff member done, not intended, we say people make false allegations, in their head it’s not, it is how they see it… can’t assume they’re just making things up.

Counsel: Yes, but those allegations, where might be a concern, sorry, were something may have been misinterpreted for example, in combination with challenging behaviour, in combination with risk to life through self-harm behaviours, does that present significant difficulties in being able to manage a young person in the community?

EB: Presents very difficult situation, allegations, whatever the cause of them, makes providers very, very reluctant to take people. High risk behaviours put person at risk of harm, staff at risk of harm, concern for loss of livelihood for staff or reputation for care provider, all situations where people probably say they don’t want to provide a service for this individual.

Counsel: Do you think that might be mitigated with training, but even with training, such significant challenge providers are reluctant to take it on?

EB: We know from bitter experience that’s the case, people will just say sorry, no.

Counsel: Want to ask a few more questions including Dr Orekan, he had suggested when he first met Jessie she required a low secure placement, and her needs could not be met in the community. Was that assessment one you’d agree with?

EB: Yes, I think if I was in his position that would have been my opinion as well.

Counsel: Wanted to look at the run up to Mill View admission. Were you aware first of all Jessie was initially admitted to hospital on 28 January 2022 because she’d [self-harm, withheld]

Dr Beber said she’d not be able to comment without seeing what she had said in her report. Counsel for East Sussex suggested that it had not made it into her report. The Coroner thought it had.

There was further discussion and then Dr Beber was taken to a record of a Mental Health Act Assessment.

Counsel: After chronology section, psychiatric and social history. Events leading to assessment, current presentation, when move from table form into text.

EB: Yes got that now

Counsel: Paragraph refers to significant self-harm and suicidality… due to risks Jessie is taking she’s at high risk of death by misadventure. Would you agree that’s an accurate assessment at the time?

EB: Absolutely yes

Counsel: 3 February ambulance called due to Jessie self-harming [withheld] ambulance called, Jessie having seizure, became unresponsive, when someone becomes unresponsive what do the implications of that mean?

EB: Very variable, very broad, unresponsive, means she may not be talking to them, if looking from neurological point of view, are various things do to assess on Glasgow Coma Score. Could just mean she’s got her eyes closed, not replying to spoken word or it could mean doesn’t react to extreme pain. It’s impossible to tell from that description.

Counsel: Then it says Fire Service called, removed from her residence by crane… seen at A&E, deemed fit for discharge…. refused to leave…. police called… ran into road… hit by car…

[more detail, didn’t catch, apologies]

Counsel: Do you think that mental health assessment was an appropriate one?

EB: Yes I do

Counsel: rationale for section decision. Refers again to what just discussed, Dr Orekan saying when seen Jessie for the first time, recommended low secure placement but didn’t materialise. Is there a shortage of these low secure placements? Think you’ve already referred to that?

EB: Yes there is and at this time we’d been in a global pandemic and coming out of a global pandemic, services usually available in 2020 had shut their doors to admissions because simply didn’t have the staff. Have never really recovered from that, in 2021 my services weren’t taking people who needed high levels of support because we can’t get staff… never got back to pre-pandemic levels of staffing, lot of people who would have taken people before 2020 were saying no, added to difficulties of getting people placed.

Counsel: Goes on to say IMC Locums not willing, put their pin at risk…. [missed]

EB: Absolutely, staff in the community and in inpatient services are very, very unwilling to work with people who may make allegations against them.

Counsel reads another section of the assessment [didn’t catch, apologies]

Counsel: Is that consistent with section in your report where you indicate there was a dearth of local providers?

EB: Yes

Counsel: Dr Sparks said she’d put herself at risk to get medication, she was asking staff on the ward for [withheld]

The coroner indicated the time and reminded counsel that the court only had this witness until the end of the day.

Counsel: Is it right if somebody was under section would be possible to start then exploring low secure accommodation that might not be possible to do if someone is in the community?

EB: I’m going to say yes, because of the nature of secure services is unusual to have someone there who are informal, not impossible, but unusual. Can have someone there when coming down on other side, we don’t usually take people informally into secure services.

Counsel: Just three more questions in terms of pattern of self-harming behaviour, self-harm Jessie [can’t hear]… consistent with pattern displayed previously?

EB: From what I could see yes

Counsel: Could you see from the records any deterioration, or on par with what experienced previously?

EB: Hard to say, seemed go in waves anyway, periods when things were better, difficult to say with any certainty but at that time engaged in some high risk behaviours.

Counsel: Given seen pattern of admission as informal patient, do you think at this point when admitted under section, at this point was inevitable for her to have a hospital admission?

EB: Would be very difficult to find anywhere else for her, looked like way things were going.

Counsel: You referred earlier when looking at things at Mill View and when on the ward, referred to safeguarding allegations raised, weren’t making judgement of whether true, but expected specific guidelines around visiting… would you have expected similar steps to be taken in the community, to ensure Jessie and family member were safeguarded from further allegations?

EB: Absolutely

Counsel: Would that have involved a level of observations and supervision of any contact?

EB: Yes

No further questions from East Sussex and the coroner suggested a short ten minute comfort break. When the jury returned it was over to Mr Downs, for questions on behalf of Brighton and Hove City Council.

Counsel: You very kindly accepted this instruction to assist, you’re an expert in forensic psychiatry, is that fair to say?

EB: By background I’m a learning disability and autism psychiatrist, but I’ve worked in forensic services for many years.

Counsel: You were very kindly instructed to provide an expert report relating to the treatment provided to Jessie, that’s right isn’t it?

EB: Yes

Counsel: You were given a very extensive bundle of documents which everyone is very grateful you considered. Advised us already understand need to avoid speculation, you yourself volunteered that and also referred to hindsight bias, in forum where people might not be as familiar, if I just put it to you starting point is Jessie died at time and in place she did, and working back from there as to how it occurred, not being too led by that was a certain known event, is that fair to say?

EB: Yes

Counsel made a statement which I missed but ended with: An event becomes more predictable after it becomes known? The coroner warned Mr Downs of the need for him to avoid giving evidence.

Counsel: Luckily I’m getting nods, you accessed the bundle of the reading but not oral evidence we’ve heard in last 8 days and you’re nodding. You didn’t have access to Eclipse, the Brighton and Hove computer system?

EB: That’s right

Counsel: We’ll come to that in one moment, the fact you mentioned that meant was scurrying around to try and get access to those records, that was obviously helpful, the jury has had the notes, the contents of them read to them, and appears to show same difficulties. We’re talking about Ms Woolfenden’s visits, problem was when Ms Woolfenden arrived she finds Jessie was in her 1-1 and staff suggest to Jessie she leave, that’s broadly in line with your understanding, is that right?

EB: Yes

Counsel: And that her father was present throughout, again in accordance with your understanding?

EB: Yes

Counsel: And that Jessie was very much taken with the fact she wanted action taken regard the care agency, IMC, that again in accordance with your understanding what would have gone on?

EB: Yes

Counsel: We know two safeguarding enquiries, one is about IMC, they’re the name of the locum agency, and the second is about the issues of boundaries and involvement of Jessie’s father, those kind of issues, and the computer records appear to say that it could only be done by gentle probing arounds the issues because obviously Jessie’s father was there.

EB: Something like that, it was mentioned in passing.

Counsel: Alright. Then when we’re thinking about what the response appeared to be, Jessie didn’t raise her voice or become agitated apart from leaving for a cigarette, is that your understanding from the evidence?

EB: There’s very little in the actual notes.

Counsel: Ms Woolfenden said she left in an appropriate manner, on face of that, Ms Woolfenden’s account, appears to be quite a low key information sharing meeting. Is that fair?

Counsel for Jessie’s family interjects: Was it, from your view?

EB: I don’t know if it was low key. Although was stated other allegations, not into IMC were mentioned in passing. We can never overestimate or underestimate the impact such an investigation has on anybody, but particularly someone with the complex mental health problems of someone like Jessie. Even being reminded this is an issue, and its ongoing, is I think quite significant.

Counsel: Her father’s account which you’ve now been provided with was that he did manage to calm, yeh, he says his visit when came to end after Ms Woolfenden, he says I left her in calm spirits and making arrangements for the next day. Again, appears to be an indication from those on the ground doesn’t it, that despite fact in inpatient setting or other problems, that her presentation was relatively benign?

EB: It was at that time yes, but as discussed earlier, because these things are so impactful on people, is possible people ruminate, we are speculating, but yes people will ruminate and think about these issues.

Counsel: The other bit of the jigsaw was evidence from ward staff was relatively calm day.

EB: Yes

Counsel: Absolutely understand you have all sorts of thoughts, that’s absolutely fine, you yourself has described them in circumstances as speculation as to consequences

EB: Certainly speculation based on experience of managing people who have to take part in these type of interviews

Counsel: Only other matter is about provision available, we heard evidence that one of, when Jessie was on the ward, considering what options, her consultant could only think of one resource to which she might potentially be suitable, the Mitford Unit in Morpeth and even then she was concerned about whether would be quite the right fit, and also is 350miles away. Is that your understanding of all that is available by way of resources?

EB: It’s my understanding that was what was said, it’s not my understanding that’s the only other available unit where people with presentation like Jessie’s are managed.

Counsel: We’re talking about a unit, with not something bespoke around her in the community, but for a period in which she could be accommodated, 24 hours in residential setting, with treatment

EB: I don’t personally know the Mitford Unit, I’ve not been there, something opened more recently than my last trip to Northgate Hospital, but my understanding is if in hospital likely to be a ward rather than a residential service.

Counsel: Yes OK, an inpatient unit?

EB: I would imagine so, yes

Counsel: So is there other inpatient units available in England?

EB: Yes. Um, yeh. As I said earlier, I’ve managed patients like Jessie and received referrals and gone out and assessed patients similar to Jessie, and seen them managed in very different settings and have referred and passed onto those services.

Counsel: Thank you very much. Thank you ma’am.

Then it was over to Ms Nicolaou to ask questions for Jessie’s family.

Counsel: Good afternoon I ask questions on behalf of the family, would like to begin please by getting an understanding from you about some of the evidence you’ve given about Jessie’s presentation around the time she was sectioned in February 2022.

EB: Yes

Counsel: You’ve been taken to Dr Orekan’s view about appropriateness of community placements… are you aware the position in place for Jessie at Viaduct Road, immediately preceding her sectioning was meant to be emergency, and temporary, provision?

EB: Was some comment in some of the documents in the bundle, wasn’t totally clear, but feeling around that.

Counsel: We’ve heard evidence this week wasn’t something envisaged to meet Jessie’s needs, was temporary emergency position, but we see in the end lasted about 5.5 months. Jessie being assessed in February 2022, followed 5.5 month period, was acknowledged at the time, not with hindsight, this wasn’t the correct package of care for her.

Is it right by the time Jessie came to be assessed in February 2022, she’s assessed in her presentation following 5.5 months of what everyone acknowledges is not sufficient care for her?

EB: Yes

Counsel: Dr Gregory also gave evidence last week about how best to deal with the decision of what to do with Jessie at Royal Sussex Hospital, she was making the decision whether or not to discharge Jessie’s section… at that point care package withdrawn, no care package in the community, any discharge planning would take while, discussed with Jessie that she understood her concerns… she said that she wouldn’t stand in the way of her admission to a psychiatric hospital if a bed became available, but explore other options whilst in my care. Appears a finely balanced decision making process for Dr Gregory at Royal Sussex Hospital, do you agree with that?

EB: Yes, was certainly a very, very difficult predicament for everybody, would never make decision solely to detain someone because no other accommodation was available, certainly.

Counsel: You’ve been asked about patterns of allegations and whether leads to issues obtaining services. We’ve heard evidence from Lauren Bernard, I will be corrected if I’m wrong, she didn’t refer to this being a feature, but has been put to you… are you aware Jessie was involved in a documentary in 2017, where Hard Cash featured her at Priory Ticehurst, footage of her being mistreated by staff?

EB: Think there was something in one of the reports, may have been her parents’ reports, which I didn’t receive until after I wrote my report, I do remember reading it

Counsel: Thank you, can I ask you now some questions about the impact of the ward environment on Jessie. You referred to a no win, no win situation, part of that no win is a mental health ward is not the best therapeutic environment?

EB: Absolutely for all the reasons I stated earlier, yes

Counsel: Again, something that wasn’t said in hindsight, was escalated by Jessie’s Ward Manager to Director level because he thought at the time it wasn’t an appropriate place for her. Extent to which that environment, in and of itself, noise of the ward and hustle and bustle, would that have an impact on Jessie’s general wellbeing?

EB: I imagine so, it’s a difficult environment for most people actually, for people with ASD can be very, very difficult. They’re noisy, turnover of patients and unfortunately staff these days, they’re chaotic, and they can’t guarantee things will happen when they should because they can’t guarantee what will take away staff’s attention. Very difficult places for people with ASD to be

Counsel: In evidence to the coroner you spoke about good quality care plans, but whether or not implemented, do you agree part of it comes down to having good consistent staff available who have knowledge of these plans?

Dr Beber says that is crucial for every patient [missed her exact words, apologies].

EB: Most people need consistency, but you have to multiply that many times for people with ASD, particularly those with PDA, you have to magnify that consistency very much.

Counsel: We heard evidence from Dr Simon Rowe last week, he provided an Autism, Crisis and Wellbeing Plan…. Gave evidence relating to potential triggers and warning signs for Jessie, one related to reminder of past traumatic experience, being reminded of past trauma … understand it was difficult for Jessie on the ward was individuals she recognised who had previous experience with. Would that have an impact on Jessie [can’t hear]

EB: Possibly, as already heard, decreasing number of people in the profession that work, people do tend to work in multiple settings, so that could impact as well. One individual, I think the Ward Manager had recognised that and made efforts to ensure that individual didn’t work with her.

Counsel: We’ve heard evidence since then, will be matter for the jury to make a decision on that, jury heard other evidence to that which you’ve seen. In terms of the impact on an individual, especially one noted with trigger for trauma, could potentially have significant impact on their wellbeing on any given evening?

EB: Yes

Counsel: We also heard evidence last week, this week actually, from Dr Eaton who assessed Jessie back in 2018, sometime before she was on the ward. Her evidence was people with Jessie’s presentation often have cognitive age lower than their chronological age.

EB: That did go out of fashion some time ago, may be useful in a court situation to help people understand level someone is functioning at… I’d put it that people’s brains take longer to mature with neurological problems. Is how mature someone’s cognitive and reasoning processes were. If she were to say probable Jessie were behind what her chronological age was [missed]

Counsel: So we have an issue with terminology, but you agree with the view?

EB: Yes

Counsel: You refer to Jessie had good language skills, may have masked her poorer processing and cognitive skills. Need be familiar with [missed]

EB: Spoke about consistency and quality of staff earlier, that’s one of many reasons, to know when someone says something to not assume they’ve understood or processed it, only get that feel for an individual when you’ve worked with them for a long time

Counsel then asked a question about training, telling Dr Beber that Jack Pumphrey had given evidence that the Trust had ‘Autism spectrum condition and psychosis’ training, which was one-off training and only 14 nurses had completed it.

Counsel: Could you explain to the jury what your views were on that?

EB: My view is its good everyone has some training, all of us working in mental health services, have basic training in ASD and what that means for a person, and also for people with learning disability, earlier people mentioned the Oliver McGowan training. But my opinion would be its only an introduction to some of the concepts, difficulties and joys. It isn’t a substitute for someone with in-depth knowledge and working experience of working with someone with these very complex needs.

Counsel: You identified as well Jack Pumphrey sought to create a list of those who worked on the ward more than 10 times with Jessie. Jessie was on the ward more than 10 weeks, so once a week these individuals meet Jessie, very low level?

EB: It is, and an indication of the churn of staff on the ward as well. Only insight I had into frequency of same faces turning up, as I said consistency really is key for rapport building and understanding what is going on.

Counsel: You provided some evidence on observation levels. You said earlier the team thought about it and were well aware of the risks. Do you agree when taking a decision, awareness of risk, should be kept under review?

EB: Absolutely, observations should be reviewed regularly, no matter what.


Counsel: Was noted because of history of moving from settings, impacted her attachment settings… stated also likely to fear support will be withdrawn if others think she’s getting better or coping… is it important to be aware of those kinds of features, in terms of how a person might react to decisions around their care?

EB: Absolutely, common thing encounter in services I’ve worked in over last few years. Certainly something clinicians are very mindful, particularly when someone has become dependent on a high level of care, how if you think it’s the right thing to do, you tail that back a little, with communication with the person themselves of course

Counsel: Some communication on 27 April. Visit carried out by the PICU unit, they effectively tried to reflect back to Jessie, on previous admission on Coral Ward she’d successfully reduced to general observations. She stated she had an agency staff member who was her go-to staff member, was her perception of how she managed on general observations…. Would that not be a relevant piece of information, as to how such observations can be safely managed? Whether another element of support can be implemented?

EB: Yes it would, when look at what you’re going to do, often look back at what worked before and try to implement that.

Counsel: There’s an email from Kate, 27 April, saying Jessie needs constant reassurance she’s cared for… [missed] … Jessie’s family drawing a clear link between incidents and Jessie’s feelings of being rejected, important corroborative information, because Jessie’s mum has quite a lot of experience of her behaviour?

EB: Yes certainly, people w huge complexities, real difficulties in management, certainly getting tips from family, carers, people who know what works and doesn’t, important part of the care planning process.

Counsel: You were asked some questions about the visit Jessie had on 16 from Alison Woolfenden. Accepted earlier was no evidence staff on the ward knew that conversation was going to take place, is that right?

EB: From the documentation I’ve got from clinical records, yes, that’s what I could conclude.

Counsel: Earlier in your evidence had used words multiagency approach I think?

EB: Yes

Counsel: I’d just like to ask you about something, again in Jessie’s Autism, Crisis and Wellbeing Plan, it is specifically noted Jessie can appear OK during the day and become overwhelmed in the evening… [counsel reads from the report, missed] …. processing delay…. careful consideration needs to be given to pacing of activities throughout the day to help Jessie proactively manage this. Word looking at proactively manage?

EB: Yes

Counsel: Proactively manage Jessie’s needs, would there not have been steps could have been taken to liaise specifically about what that visit would be about?

EB: Absolutely. As I said earlier, know written quite extensively in my report about this. My motivation was not because I’m a great expert on safeguarding process because I’m not, it’s all about the potential for impact, whole process and visits could have had on Jessie’s mental health.

As I said earlier, I’ve managed many of these visits over the years, from police, local authority people, what was in crisis management plan, in a way is exactly what we try to do, for everybody not just people with ASD.

It makes sense, so much more for people with ASD. Things have to be planned, then as I said earlier you look at support and then look at activities, that takes people’s mind off what has been happening.

Dr Beber then had to make her apologies to get up and shut a door that had opened.

EB: Support, to take your mind off it and help process, after the event

Counsel: Two things here, first is unexpected unplanned visit for that day, and the second is the nature of the conversations are a lot for Jessie to deal with?

EB: Absolutely

Counsel: You were asked earlier if your view on that was speculation and you said also based on your own experience. Jury had read to them a statement last week from Abena Yeboah saying Jessie was irritable when her Dad left due to the abrupt visit of her social worker.

EB: Yes, I remember it, I recorded it in my report.

Counsel: So it does appear those who were present on the ward, specifically note down Jessie was feeling irritable, even after her father left, and specifically links that feeling of irritability with the abrupt visit that occurred from Ms Woolfenden, do you agree with that?

EB: Yes they’re linked in the notes, I’ve not cross examined the lady who made it. That’s what it states in the notes, always difficult interpret those type of notes I find.

Counsel: Notes also refer to not just the visit being abrupt but interrupting 1-1 time Jessie had on the ward. Potentially tells us what Jessie’s state of mind was that evening, refers to her at least being irritable

EB: It does, think if look through the notes would also find evenings where she’s irritable despite not receiving visits.

Counsel: You were asked earlier in questions from the coroner about Jessie’s capacity to understand intent when self-harming. In her Autism, Crisis and Wellbeing Plan is an extract saying when Jessie is struggling to regulate herself she engages in high risk behaviour…  its important remember Jessie is managing the best she can…. Needs ongoing support to identify she is starting to struggle and strategies before things escalate. So, needs identification of early warning signs?

EB: Yes, very basic principles of dialectical behaviour therapy, absolutely

Counsel: On the basis that early intervention isn’t provided, when warning signs are there, Jessie could potentially engage in behaviour because she is starting to feel very out of control?

EB: Is right, sometimes you get behaviours without seeing any of early warning signs, that can happen as well

Counsel: Turning later on the evening of 16 May, will ask in general terms, jury heard wealth of evidence you haven’t, what may or may not have been occurring in evening and who may have been involved, in due course they’ll make their findings on that. Your perspective, general principles of risk management, case like this, like Jessie’s, ongoing risk, triggered unexpected changes or trauma, for example, may be necessary to review whether to change observations, even if only temporarily given the way they present on the ward on any given day, do you agree with that ?

EB: Yes

Counsel: Can then be reversed again if present in very stable way, can be changed again?

EB: Yes

Counsel: PBS plan on the ward has section referred to as secondary prevention, speaks about being used if a person becomes agitated, calming, distracting and problem solving behaviours can remove the need for person to use behaviour that challenges. Is that your understanding of what secondary prevention is?

EB: Yes

Counsel: Jessie was asked what her warning signs were for when she becomes very distressed, shaking her arms, pacing, spending increased time in her room… Jessie expressed things she finds effective are 1-1 and art work. Appears the PBS is showing how to identify early warning signs?

EB: Yes

Counsel: So it doesn’t mean Jessie has to go to someone and say I’m feeling very distressed, but are potential behaviours that can show that it?

EB: Yes

Counsel: And things could be utilised to assist Jessie in those circumstances, art work, one of those given, similar to what you spoke about planned activity after, could encompass art work?

EB: Yes art work, did notice she’d been jewellery making at that time too, something like that to engage her.

Counsel: In circumstances where that secondary prevention is not put in place, do you accept could lead to increased risk of someone engaging in high risk behaviour?

EB: It can do yes

Counsel: Are you able to set out a view on levels of likelihood?

EB: No, its so individual, its very individual, if I’d known Jessie clinically

Counsel: That’s fine

EB: I perhaps would have, but not with someone I’ve not seen.

Counsel: Thank you, some final questions on EUPD if I may. In terms of evidence already given, think you’ve alluded to reluctance to diagnose children with EUPD. What is the position in respect of those who may have a younger, to use the term, chronological age than actual age?

EB: As I said earlier, we probably don’t make a full diagnosis until about 25, certainly in people with a learning disability we hold judgement, which is fine, but as said earlier as well, even in adolescence can see traits of what people refer to as emerging personality disorders.

Although won’t make formal diagnosis don’t think would be right to withhold correct treatment, some people do benefit from talking therapies at a younger age and do routinely get them in other services.

Doesn’t mean clinicians would not have in the back of their head and crack on with appropriate treatment.

Counsel: You make reference in your report about stigma and personality disorder, can you tell us more?

EB: For many years personality disorder was a diagnosis of exclusion, used to pick people out of services and say you aren’t ill, was a truth to that, wasn’t good services for people with personality disorder, or autism, or learning disability. That’s changed, there are services out there, both services in the community and in inpatient.

It should no longer attract the stigma it used to. I think part of it was people didn’t feel were effective strategies and was poor prognosis, whereas that’s actually not the case.

Counsel: Finally, Jessie had physical issues, had hypermobility caused pain, and also suffering seizures, in terms of managing her physical issues on the ward, what impact would treatment for physical issues have on a patient’s wellbeing?

EB: Certainly when people are in chronic pain that can be problematic, I understand was receiving pain relief for pain associated with Ehlers Danlos Syndrome, that is impactful. In terms of attacks, those had been and were in the process of being investigated, if any episodes of electrical or actual epilepsy as such, that would need to be treated, also important if attacks aren’t electrical in nature that the correct therapies are applied for those.

No further questions from Jessie’s family. It was then over to the jury for their questions. There was some difficulty with Dr Beber hearing the jury so in some instances the Coroner repeated the question for her to answer.

Juror: Two questions, was question you asked actually, do you take the view if Jessie’s mental health [couldn’t hear]

Coroner: One of the questions I asked you was the role, whether you thought Jessie’s mental health played a part in her death, the jury are looking for some clarification.

EB: Yes. I said in many more words, ultimate answer is yes.

Juror: The other question is whether we can pinpoint a direct correlation between the visit of the social worker to the actions that followed [think she said]

Coroner: Members of the jury that’s for you to grapple with, it’s not for this witness to say whether that happened or not, will give you direction on that.

Juror: Said impossible to say pinpoint, a specific cause?

Coroner: I asked there are many diagnoses for Jessie, I asked whether any one of those particular could have brought on the tying of the ligature, I have a note, the basis of her answer was she couldn’t split them up.

EB: Yes, there’s an interaction and interplay between all those different diagnoses I think, which contributed.

Then over to another juror.

Juror: Questions are around risk assessment and the care plan, mentioned at the start of evidence, good to see in place, formed together quite quickly, felt few bits missing regarding head-banging and safeguarding regarding father. Does that mean, we’ve not seen documents, were safeguarding allegations against IMC included in risk assessment is one question?

Coroner: First question is jury mentioned care plan, you mentioned provision for head banging wasn’t included, was no mention of provision around safeguarding of Jessie’s father, question was, was there anything in there you were aware of around safeguarding of IMC Locums?

EB: I remember reading ward staff were aware of ongoing investigation, can’t remember if in care plans or not. The only thing I’d say is she was now out of the care of them, so wouldn’t be as relevant as other issues you’ve mentioned but do remember mention was awareness.

From the reading I had, Jessie appeared to be really pleased something was happening about the complaints herself and her family had put in, wouldn’t see as particular stressor in same way as the other Section 42 investigation could have been very stressful for her. Wouldn’t really see other than was factor in her life and affected her quality of care before she came into hospital.

Juror follow up: Were you aware Mill View were using IMC Locums on the ward?

Coroner: I’ll ask, were you aware 16 / 17 worker Prince, previously worked for IMC Locums?

EB: Yes, that information was in the bundle

Coroner: I don’t want to put words into the jurors mouth, had asked question previously about should the ward have put in place measures that would prevent that from happening?

EB: Very difficult, not sure what circumstances were, when they booked him if they were aware of that.

Coroner: We’ve heard directly from a witness in respect of that.

EB: If you’re asking could that be a factor, would that be traumatic for her, then yes.

Juror follow up question: Risk assessment, did Mill View have suitable measures or reasonable adjustments in place with risks associated to self-harm given the fact knives and scissors were found in Jessie’s room?

Coroner: Evidence we heard was you were satisfied with care plans and risk assessments, you said were good?

EB: Yes, for an acute admissions ward, can expand on that. Think one of the reasons people refer into secure services, is, or should be, a lot less access to things used to self-harm. Got pros and cons, it’s not a very real world, also people can self-harm on their own clothes, on anything really, the jury on that one is a little bit out, whether that’s helpful or not. Clearly I do remember reading that there had been some thought into that and actually Jessie had self-harmed on lots and lots of everyday objects anyway, not saying that’s right, that was decision taken she still had access, once you start restricting access to things, people get more inventive, it’s very difficult, it’s a very fine balance to get to.

Also got to think this is general adult admission ward, will be informal patients there, what you can do in that environment is very different to what can do in secure environment where all people have the same presentation, therefore can restrict access to certain items, that’s what happens in secure service, particularly women’s secure services.

Much more difficult, practically and ethically, on an acute admissions ward.

Juror follow up again: Finally sorry, we also spoke earlier about how consistency of care provided is very important for Jessie’s presentation, again, was anything in the care plan with recommendations for staff members at Mill View, consistency of staff involved with her was important, given 9 members of staff on duty on night of 16th?

Coroner: Were a number of documents available, not just care plan, was it documented as far as you can see consistency was important, or known to staff in any way?

EB: Certainly, was in previous documents, care plans and PBS come out of specialist providers, did say some of this could be accessed by staff on Caburn Ward.

Not sure exactly what was and was not available in that sense, however would say from my experience of working in acute services, would love to provide in consistency of care to every patients, at moment practicalities are recruiting and retaining staff into mental health services is very, very difficult, and many services are reliant on bank staff and agency staff.

It’s really difficult, not saying that an excuse but it is a reason, all of us providing those services are feeling that at the moment, but you’re right, it’s a critical part of someone’s care.

No further jury questions. The coroner thanked Dr Beber for her contribution to this inquest. She offered Jessie’s family her condolences.

Finally on Day 8 a statement was read onto the record outlining what the Disclosure and Barring Service do. I couldn’t catch it, but there’s more information here if you wanted to know more.

With thanks to those following, reading, sharing and supporting my reporting, none of which would happen without your financial support, thank you. The jury aren’t in court today (Thursday) but return tomorrow for the coroner’s summing up and direction before retiring to consider their conclusions. More tomorrow.

Also, for those of you new to my work, I’ve been reporting from inquests of people with a learning disability and autistic people for over eight years now. Much of what has been shared in court is similar to what has been shared at other inquests. You can find all my inquest reporting here, and you might also be interested in the inquests of Colette McCulloch and Sasha Forster, for some very similar experiences for young autistic women.

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