The jury came into court at 11am on Day 9 of Jessie’s inquest, on Friday 1 December.

The coroner apologised for keeping them waiting and told them that they would hear some further evidence, following which they would retire to consider, after she had summed up all the evidence to them.

The coroner said that she would start by asking her officer to read onto the record the statement of the next witness.

James Hazelby / Senior Practitioner, East Sussex County Council

Mr Hazelby told the court that his statement addresses issues that he understood to have been discussed in the course of Jessie’s inquest. He says that he will refer to Jessica as Jessie, and that his statement is based on his knowledge and recollection, and that he had refreshed his memory by checking case notes.

He told the court that from the end of January 2021 until Jessie’s very sad death in May 2022, his role had been as Senior Practitioner. He said that he was Lauren Bernard’s, and later Michelle Cook’s supervisor.

Mr Hazelby told the court that he had regular contact with Lauren and Michelle and other professions. He said that he would liaise with Simon Hellyer, Ruth Nathan and the Occupational Therapy Team. He told the court that he had discussions with the East Sussex County Council brokerage team who were trying to find a permanent placement for Jessie.

Mr Hazelby told the court that he met Jessie once, at their offices in Eastbourne, the day after she was discharged from Woodlands Hospital. He told the court that in August 2021 Jessie moved into Viaduct Road with support from IMC Locums. He said that this was a temporary placement, and only ever supposed to be temporary whilst they tried to find a permenant placement that could meet her complex needs.

Mr Hazelby told the court that it was East Sussex CCG who sourced IMC Locums to provide staff to support Jessie. He said that her placement at Viaduct Road was jointly funded by East Sussex County Council and the CCG.

Mr Hazelby told the court that he knew one of the issues that had come up in Jessie’s inquest was the level of personal care Jessie required at Viaduct Toad.

He described what personal care tasks are [didn’t catch].

He said that support with personal care is very broad and could include physically assisting someone to do a task or doing it for them, prompting them, for example to get their toothbrush, or squeeze toothpaste on the brush. He said that it could also include reminding someone of the need to do a task e.g. saying now it was time to make dinner, or supporting them to do a task, or texting someone to remind them to do a task.

Mr Hazelby told the court that when Jessie moved to Viaduct Road, the understanding was that Jessie was independent in managing her personal care.

He told the court that on 25 August 2021 a Care Act Assessment was carried out jointly by Helen Boyle, the previous Lead Practitioner, and Lauren Bernard.

He quoted from the assessment [missed and not sure what of what follows is from an assessment record and what was from Mr Hazelby, apologies].

Since turning 18 Jessie made the decision, prior to her parents being informed of any decisions, she’d like to be informed first and make a decision of any ongoing health and social care needs.

He told the court that it said Jessie would like to make a decision on each occasion about whether her parents are informed.

Mr Hazelby said that Jessie had a preference for male staff and for staff that she knew, and familiar with her needs. He told the court that Jessie’s preference was for locum staff from IMC Locums, who she works with. He said that she was told they would do their best to accommodate, but all staff Jessie had a preference for, may not be available and alternative carers may need to be arranged.

Mr Hazelby told the court that Jessie stated she does not need any help with her personal care. Stated that she likes doing her hair and makeup and presents herself well. He also said that if Jessie was not well presented, it was an indication that her mental health might be declining.

Mr Hazelby told the court that Jessie can experience night time incontinence and if she was excessively drowsy she may need support with her personal care and to change her sheets.

He told the court that Jessie generally prefers to bathe, although her current placements does not have a bath, she has been using the shower independently.

[Section missed]

Mr Hazelby told the court that a section relating to managing toileting needs, said that Jessie was able to independently manage her toilet needs during the day. That she could be incontinent of urine at night, which was thought to be side effect of one of the medications she was on, due to its sedative effects and her inability to wake, consequently she could need support to change her bedding at night. He also told the court that Jessie may be incontinent of urine during seizures, where support would also be required.

Mr Hazelby told the court that Jessie has a diagnosis of autism with poor interoceptive signals, which meant she often needs to rush to the toilet with a sense of urgency. He told the court that Jessie’s current placement only has one downstairs toilet, which exacerbates this issue. However, he said, there is also a bedroom downstairs she could use overnight to give access to the bathroom.

Mr Hazelby told the court that they had asked Langley Green, where Jessie was resident from February to August 2021 [think those were the dates] to carry out an OT assessment and the report they had from Langley Green was that Jessie was able to manage her personal care independently.

Mr Hazelby told the court that on, or around, [date missed, apologies] he had liaison meetings with Jessie’s family and Simon Hellyer from East Sussex County Council. He told the court that these were usually monthly and were an opportunity for Jessie’s parents to be heard, and to express their concerns.

Mr Hazelby told the court that from the outset Jessie’s parents did not feel that IMC Locums were meeting Jessie’s needs.

[Section missed]

Mr Hazelby told the court that he explained several times that Jessie was their client and they were trying to empower her as a young person to develop her autonomy and identity as an individual.

He told the court that they would take on board the thoughts of the parents, but [missed, apologies]

Mr Hazelby told the court that a request was made for a commode as at night Jessie was using incontinence pads. He told the court that he discussed it with the OT but that it wasn’t ever brought to their attention by Jessie, her carers or staff that they were having to change incontinence pads for her. He told the court that the assessment does refer to changing the sheets.

Mr Hazelby told the court that he received a request from Jessie and Mr Seares for a female carer [missed detail].

The email said that they had received an email which Mr Hazaleby had recalled, and nothing since. It said that the assessment stated Jessie was in education, which she is not, and also stated that her parents would not be doing any of Jessie’s personal care.

Mr Hazelby told the court that Mr Seares email ended “I’m sorry about the emails but until we get the care provision in place that Jessie needs, what else are we going to do?” He said that it also made reference to concerns that a nurse was living in the property for so long, and that this itself was a safeguarding issue.

Mr Hazelby told the court that he replied to that email on 19 October 2021 saying that he had discussed Mr Seares and Jessie’s request for a female carer to support Jessies personal care.

He told the court that it is important to highlight IMC Locums are a nursing agency and their role is to provide whoever is available at the time, the same individual can not be guaranteed.

He said that IMC Locums are an NHS Framework Approved Agency and as such all candidates were vetted. He said whilst care provision is personalised as much as possible, we cannot stipulate and make requests of individual’s ethnicity, as that would be in breach of the Equality Act 2010. He said that nursing staff were booked on the basis of their experience and skills.

Mr Hazelby said that their understanding, and that of IMC Locums, was that Jessie was able to undertake her own personal care.

[Section missed]

Mr Hazelby told the court, as per Jessie’s care plan she had been assessed as being able to undertake personal care independently and that Jessie was able to empty her commode herself… agreed care staff ….role was to support her autonomy as an adult.

He told the court, in regard to the registered mental health nurse living in the property, this had been addressed in an email on 6 October, following our meeting on ?? October, which you should have received.

[Section missed]

Mr Hazelby then told the court that an occupational therapist, Emma Brown [think she was called], had been allocated to assess Jessie. That it had not been possible to complete that assessment by the time Jessie was admitted to hospital on 11 February 2022.

He told the court that he could see from Jason Brown of IMC Locums on 21 October 2022 [?] that the first female carer would be on shift on 30 October [?].

Mr Hazelby told the court that Mr Brown stated carers would be able to support with some aspects of personal care, but not full care.

Mr Hazelby told the court he requested an OT assessment, as there were conflicts between her management in hospital and in the community.

Mr Hazelby told the court that he think that they responded appropriately to a request that Jessie needed more support, that they put in place female carers and an OT assessment.

Mr Hazelby said that he was aware that Lauren Bernard had given evidence that Jessie needed support with intimate personal care and he understood that to be prompting and supervision [missed].

Mr Hazelby said that he did not receive any report from IMC Locums that Jessie required physical assistance with washing, bathing or toileting. He told the court that he would have expected this to be drawn to their attention by those working with Jessie and her support plan would need to be addressed to include tasks that she needed support with.

Mr Hazelby told the court that an OT assessment on 4 May 2022 reported Jessie was able to organise herself for a bath… [missed] able lift arms above head but unable lift jug to wash her hair.

Mr Hazelby said that if that difficulty was assessed as a long term one, and no alternative to a heavy jug was found, may have needed further assessed.

Mr Hazelby told the court that he knew the issue had come up with whether IMC Locums was regulated by CQC. He said an organisation carrying out regulated care, including personal care would need to be regulated.

Mr Hazelby told the court that regulated personal care included physical assistance with the care such as washing a person, or supervision or prompting for someone not able to make a decision about the activity.

Mr Hazelby told the court that if they were supervising or prompting, then Jessie did have capacity to make decisions, so it would not be a regulated activity.

Mr Hazelby said that there had been a number of issues raised by Jessie’s parents during her time at Viaduct Road. He said he took thee up with IMC Locums and he held a meeting with Jessie’s parents with Simon Hellyer and Angela Ferrero, former operations manager at East Sussex County Council. Mr Hazelby told the court that Ms Ferrero recommended Mr Seares should have supervised contact with Jessie.

He told the court that although this recommendation might seem harsh and difficult to understand, it was a standard recommendation to safeguarding Jessie and her father while an enquiry was undertaken.

Mr Hazelby told the court that he had also seen notes of a planning meeting between Brighton and Hove City Council and East Sussex County Council on 7 February 2022, in which it was confirmed carers were to remain in place to provide 2-1 care. He said the difficulty was Jessie could decline their input, and due to Mr Seares being in the house, he would undertake them.

Mr Hazelbv told the court Jessie was admitted to hospital on 28 January 2022 after [self-harm, withhold] and discharged on 29 January 2022.

Mr Hazelby told the court that on 1 February 2022 he attended a professionals meeting with Simon Hellyer, Ruth Nathan, [others – missed] where they discussed an escalation in Jessie’s behaviour and the need for a Mental Health Act assessment.

He told the court that they could see on ??? February Jessie was admitted to hospital overnight after [withhold] and on 3 February she was ready for discharge, but did not wish to leave and so she [withhold] and was discharged the same day with a sprained foot.

Mr Hazleby said that he could see on 3 February a meeting was held which Lauren Bernard attended, with Barry Davidson, Approved Mental Health Professional, where it was discussed Jessie was behaving with risky and impulsive behaviour and it was felt that the level of risk made it very difficult for her to be supported in the community.

He told the court on 8 February 2022 there was a referral for a Mental Health Act assessment made by East Sussex County Council. On 9 February 2022 IMC Locums took Jessie to hospital with a suspected seizure. On 10 February 2022 Jessie was admitted to hospital with infected wounds in her arm.

Mr Hazelby told the court that a Mental Health Act assessment was attempted but it was decided that Jessie was not physically well enough to participate in it. He said it was then carried out on 18 February 2022 by an AMHP with two doctors, Dr Bob Sparks and Dr Sherriff Orekan.

Mr Hazelby said that Dr Orekan said when he had seen Jessie for the first time in the community, he had recommended a low secure placement for her, but that did not materialise. Mr Hazelby told the court that IMC Locums had expressed ongoing allegations against their staff, that would put their pin at risk, meant not many staff would attend on shift to work with Jessie. He said that her current placement was not therapeutic for Jessie as she had no activities and no friends, that she used the carers to do her daily chores. He said it was not certain that IMC Locums would continue and that they find it challenging to work with Jessie [I think that paragraph was all Mr Hazelby taking it from the assessment but can not be sure].

Mr Hazleby said that Dr Sparks said Jessie would put herself at risk to get medication on the ward. He said both doctors agreed that Jessie would benefit from a Section 3 admission, as that would help with the low secure placement.

He said once Jessie was under section of the Mental Health Act, funding was withdrawn for IMC Locums. He said that he understood that Viaduct Road was only considered temporary and they had looked at other options and could only accept a discharge plan that was safe and appropriate.

Mr Hazelby said that he could see Lauren Bernard met with Jessie with ??? about Viaduct Road, and said that the property was not suitable and it was not safe for Jessie to return. Jessie agreed and said the property was not suitable for her physical needs and Jessie said that she would not work with IMC Locums again.

Mr Hazelby told the court that he remembered talking to Lauren Bernard about this time and that the court had been given evidence of the number of providers they had attempted to secure. He said that given Jessie’s needs, it was not simply a case of finding a different property and care agency.

Mr Hazelby ended his statement by offering his condolences to Jessie’s family.

Kate Eastland / Jessie’s mother second statement

Coroner: Members of the jury, Mr Hazelby wasn’t able to come and give evidence in person. There are some matters the family do not agree with in that statement, so I’m going to ask Ms Eastland to come forward please.

Kate Eastland, Jessie’s mother, gives an affirmation.

Coroner: Are you happy to read that statement yourself?

KE: Absolutely

She starts and the coroner says that she doesn’t need to read the first bit out [the bit about who she is and understanding her obligations to the court].

KE: In response to the statement provided by James Hazelby for East Sussex County Council… which refers to an Adult Care Assessment dated ?? 2021.

I am addressing an issue that has arisen around whether Jessie required assistance with intimate personal care. Andy and myself take the view that Jessie’s needs fluctuated and at times she would require intimate personal care.

When Jessie moved to Viaduct Road she had a need for personal care, which increased over the period of time that she remained at Viaduct Road.

Andy and I assisted with Jessie’s personal care, including changing incontinence pads, bathing and assisting with using the toilet. We undertook this care as IMC staff did not and we could not leave our daughter uncared for.

Neither Andy nor I wanted to provide this kind of care for our daughter. From time to time, Andy and I witnessed IMC staff undertake intimate personal care.

On an ongoing basis Andy and I raised Jessie’s developing intimate personal care needs to East Sussex County Council and others.

I have carefully reviewed the assessment and make the following observations:

5.1 The address for Jessie is incorrect

5.2 Jessie had not signed the assessment

5.3 Neither Andy and I were consulted or involved in the assessment. I believe that our contribution would have been essential.

I recall commenting on an assessment dated 9 December 2020 in January 2021. I did not see another assessment until March 2022.

5.4 I am fairly certain Jessie was not consulted in regards this assessment

5.5 The assessment appears to be a copy and paste of an earlier assessment dated July 2021, which too is a copy and paste of previous assessments, rather than a fresh review of Jessie’s needs.

For instance, I note that there is reference to a shower at Viaduct Road, when in fact this was a reference to Lee Road.

5.6 The assessment refers to Helen Boyle who had ceased working with Jessie in March 2021. I do not understand how she continued to contribute to these assessments.

5.7 [missed]

5.8 The assessment is missing information, such as indicating yes or no for specific questions, for instance, whether she had toileting needs.

5.9 I am informed that the assessment was completed by Lauren Bernard however this is not documented and was not in her evidence to the court.

I do not believe this assessment fairly or adequately reflected the needs of Jessie at the time, or as matters evolved.

It did not involve consultation with myself or Andy, and it is unclear whether Jessie was involved.

I believe Andy and I communicated Jessie’s unmet person care needs and I’ll set out the steps we took to try to inform agencies.

Ms Eastland then read an email sent by Andy to Lauren Bernard and others. She told the court this had been edited for brevity but the full email was available on request.

KE: This email said that, at number four, IMC, the agency needs changing urgently which we have asked for numerous times before, they are not right for Jessie at all, Jessie needs support with her personal care and hygiene, she needs staff to clean the house and wash up and so on… sensory issues as well, Jessie can’t cope with these tasks… Jessie needs staff she can engage with and talk things through with… [missed bit]

We have already changed urine soaked sheets and urine soaked pads left next to food, buckets of urine left etc etc

Ms Eastland said that the report says in October 2021 arrangements were put in place for a female carer to join the rota. She told the court that they understood this was to assist with personal care, referred to in Lauren Bernard’s evidence.

She said on 15 October, Andy sent an email to James Hazelby and Simon Hellyer. She read it out to the court.

We saw an email from you that was recalled but nothing since.

I have also just seen the Adult Care Assessment in Jessie’s house which in part is inaccurate but also states Jessie is in Education which she is not and states that as parents we won’t be doing any of Jessie’s personal care.

So, when are the carers going to be helping her with getting dressed, bathing, going shopping for food, helping her cook meals etc. I think for the first time Francis helped her cook pasta the other day as she could not stand up.

I have emailed Jason separately to see about getting a female carer which Jessie wants.

I am sorry about the emails but until we get the care provision in place that Jessie needs what else can we do.

I am also concerned that a nurse was able to stay living in the house unauthorised for so long. I think this is a safeguarding issue in its own right.

The adult care assessment also needs revising as this could be really misleading for carers.

Ms Eastland told the court that on 9 November 2021, a professionals catch up meeting took place Simon Hellyer, Ruth Nathan, Lauren Bernard, James Hazelby, Jason Brown and Debbie ???.

The meeting noted positive feedback from IMC following the introduction of female nursing staff.. Jessie was reported to be beginning to engage with staff with personal care.

Ms Eastland said that an Occupational Therapy assessment was requested in October 2021 to assess Jessie’s ability to manage personal care independently. She said on 23 November 2021, Lauren Bernard conducted a joint visit to Viaduct Road with Emma Brown.

Ms Eastland told the court that at that meeting, Andy stated that he bathed Jessie due to the risk of seizures and that he would be with her when bathing.

The OT concluded that it was not safe for Jessie to bathe unsupervised due to the risk of seizures.

Ms Eastland told the court that from October 2021 to March 2022, Andy continued to provide support for Jessie’s personal care, including monitoring her when she was in the bath, and assisting her out of the bath and directing herself to dry herself and get dressed.

Ms Eastland said that there were ongoing discussions around differences of opinion relating to Jessie’s needs.

She said that on 5 February 2022 she emailed James Hazelby and others. She read the email to the court:

Dear All, not had a response and still have no care plan.

Just to advise the carers yesterday were refusing to assist Jessie with personal care and expecting us to do it, because they had run out of gloves.

There was also no credit on their phone at the weekend so they could not call us. As a result Jessie reported feeling again that they simply did not care about her. She was very low last night when I saw her and stuck in bed.

We have been asked several times about supplies and other issues. The staff do not seem to know the process or who to contact.

Gloves are easily available at several shops within yards of the property, but IMC staff were not prepared to buy them and ask for reimbursement.

They were expecting us to do the personal care yesterday. They say they have constantly asked for PPE and have to take supplies from the hospital when they are there with Jessie, almost daily.

PPE is supposed to being delivered tomorrow.

There have also been letters warning about the water being cut off which we have forwarded to ESCC.

We’ve been informed our expectations are too high… could this be explained please, as even basic care is not being delivered?

Ms Eastland told the court that on 12 February 2022 Andy explained in an email to Ruth Nathan, that IMC should not be undertaking personal care as they were not regulated by CQC.

She then quoted from a text message, sent by Tracey, a carer at IMC Locums, who said “I find Jessie more incontinent now, she needs changing 3 or 4 times a night”.

Ms Eastland said a further text stated that they “should have left her with good carers she was getting used to, especially if she’s needing constant personal care”.

Ms Eastland told the court that in March, a Care Act Assessment recorded that Jessie needs constant supervision in the bath due to risk of seizures and assistance with hair washing. She said that Jessie was awaiting a formal assessment.

The end of her statement expressed her wish that this would assist the court, in understanding the extent to which Jessie’s needs were evidenced and communicated to services.

Coroner: Bear with me. Individual paragraphs in the statement read out, you, the family, disagree with. The first paragraph you disputed was paragraph 6, the Care Act Assessment 5 August, you’ve dealt with that in your statement, not proposing we go over that.

Paragraph 7 when Mr Hazelby talks about asking Lauren Bernard to undertake an assessment. My understanding was you weren’t aware of that assessment?

KE: No

Coroner: But at that time you confirmed she had toileting needs?

KE: Yes

Coroner: And to confirm, if I don’t ask you someone else will, at that point she was over 18?

KE: Yes

Coroner: Paragraph 9, don’t dispute commode requested, but do dispute family didn’t bring it to East Sussex County Council’s attention?

KE: Yes

Coroner: What do you say about the downstairs bedroom?

KE: It was unsuitable, bedroom was used by a nurse at the time, barricading themself in with a mattress. It was also on a thoroughfare, carers were using the front room as their lounge, had to go through the kitchen to the bathroom… also carers were not respectful… it was very busy.

Bedroom upstairs was much larger and nicer in aspect. Jessie used that as her lounge. So used other room upstairs as her bedroom, with commode, that was where she slept.

Coroner: OK, going to the next paragraph, paragraph 10 and 11 exchange Mr Seares request for a female carer and then response by Mr Hazelby. My understanding is you don’t disagree was that exchange, emails speak for themselves, content of Mr Hazelby’s response you don’t agree with?

KE: Yes

Coroner: On paragraph 12, you don’t dispute was contact with occupational therapist, but challenged fact wasn’t possible to do within four months, was the timing it took for that to be done?

KE: Yes

Coroner: Paragraph 15, matter for me really, Mr Hazelby commented on Lauren Bernard’s evidence, but he wasn’t here to hear it, so we can disregard that.

Paragraph 17, this is to do with issue about IMC Locums and being regulated by CQC. Your communication with East Sussex, Mr Hazelby says, as I have said we do not have any evidence IMC Locums healthcare staff thought Jessie required physical assistance with care and staff, if were supervising and prompting, Jessie did have capacity.

You take the view that does not accurately reflect what you’ve been telling East Sussex?

KE: Yes

Coroner: Finally, paragraph 19, they talk about the meeting, not sure I understand that?

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

Coroner: Where it is recommended Mr Seares have supervised contact with Jessie and should not provide personal care for her, your note, family take the view that does not accurately reflect what you recall having been verbally informed in the meeting?

KE: Didn’t know why she was there. We’d never met her, supposed to be our meeting to updated James Hazleby and Simon Hellyer about Jessie’s care needs.

This distressed Andy, being an autistic man himself, they full well knew that, she popped up and said you shouldn’t be providing Jessie’s care.

Whether they agreed or not, whether carers thought she was too lazy, what one of them said, fact is, if we didn’t do it, who was going to do it?

We kept asking them that and they obfuscated and argued, and Andy and I were very clear we would both continue to support as parents, otherwise Jessie was at risk of neglect…

Were many verbal conversations, when we sent a difficult email they’d reply by phone… there were no minutes, was basically our word against theirs, which is very convenient.

Coroner: Don’t know if anyone wants to follow up?

No one does

Coroner: That does conclude the evidence we will hear.

The coroner then explained to the jury that her Coroner’s Officer would be showing them the ligature. That they could move to see it, but it would not be passed around as they were mindful of not causing any distress.

She then moved to sum up the evidence and give her instruction to the jury which I’ll report later. The jury are currently out of court considering their conclusion.