The final witness to give live evidence on Day 1 of Mia’s inquest was Ms Claire Shiels. She gave an affirmation and the coroner asked who she is.

CS: Claire Shiels, I’m Head of Nursing at The Children’s Trust and also registered manager for regulatory purposes. I started there in 2019, been there 4.5 years, prior to that I worked as a nurse in a variety of roles in the NHS.

C: Touched on Blue Box findings, I’d be grateful if you can explain what was important and what changes were made. You appointed an independent expert, is that correct?

CS: Yes, we did

C: By Blue Box and you’ve taken that report?

CS: Yes

C: What were the significant aspects?

CS: For me, the three I felt were particularly significant were around frequency of monitoring and checks, particularly overnight but across the whole 24 hour period.

C: I’ll take that one first. What was your understanding in terms of frequency of monitoring, what was your understanding of expected practice?

CS: In general you mean?

C: For Mia

CS: For Mia, she was commissioned to receive shared care, she’d be allocated two members of staff to support her throughout the shift. Expectation was they’d physically check every 15 minutes if she were on her own, if she were in bed, but continuously observed if she were on the floor at school or in the lounge at home.

C: 15 minute checks, I wonder if you could explain what was expected of those checks?

CS: Visual checks, entering the room and being in the room where the child is, visually checking they are well, not distressed, comfortable.

C: How would you expect them to check someone is breathing?

CS: Has to be an element of clinical judgement, but need to be close enough to ascertain the child is well and breathing. You can only do that if you’re close enough to do that. If child isn’t moving around and obviously breathing, you’d then need to touch.

Having discussed the format checks should take, the coroner moved on to discussing auditing practice.

C: Thank you. What audits did you have in place to assess whether visual records were being maintained?

CS: The main formal audit we used was an audit of the sleep wake cycle recording chart, the one we referred to earlier

C: Yes, but what audit did you check? The evidence we heard from Ms Yapichi was this was not universally agreed upon, what was expected of observations. What I want to understand is what audits did you take to check… using in way intended, anyone could sign the checks.

CS: Yes, formal audit, people signed to say undertaken check. Policy was mandatory read.

C: What does that mean?

CS: Policy you have to read when starting in the organisation, or when its updated

C: Evidence is they weren’t given proper training about observations. Do you accept that?

CS: I accept from staff if they say they didn’t have training, yes I do, but some staff have described what a check was.

C: What in house audit was taken to ensure checks were being complied with within the care plan?

CS: A lot was observation of site managers when they went around to do their checks. We stipulated they’d do three checks

C: Three checks a night, per day, per house, per year?

CS: Three checks per shift

C: Thank you. Would you agree your audit and assessment of audio visual checks was insufficiently robust?

CS: I think, I think it needs to be strengthened and that’s what we’ve tried to do, I think we relied a lot on, a lot on that documentation, audits of the Clinical Site Managers with their three shift rounds, and we relied a lot on the practice we’d witness, that I witnessed when I was on house during the day. That’s where we’ve tried to strengthen that.

C: I’m not asking what you do now, I’m asking then. It wasn’t sufficiently robust to reassure you as Registered Manager it was being complied with?

CS: I think it could be more robust yes… was reliance [fuller answer – missed]

C: Were you aware people were using audio cameras to assess whether someone was breathing?

CS: Not in place of visual checks, no.

C: Why not?

CS: Because we relied on the reports of Clinical Site Managers and their documentation.

C: Did you ask any Clinical Site Managers for their checks? The evidence we’ve heard is there seemed to be mixed messages, it was ok to do it sometimes, wasn’t others. Why as the Registered Manager were you not aware was perhaps a less than robust approach to something that was part of a care plan?

CS: We did talk about it all the time. I spoke to House Managers and Clinical Site Managers, we had numerous conversations. I talk about it on induction to all clinical staff. I went to induction programme, spoke about it on induction programme about observations overnight.

C: Did you assess whether at night, you can use a video camera to assess someone’s breathing? How can you?

CS: I don’t believe you can. Which is why the policy stated visual monitors weren’t being used for that purpose.

C: So you can’t confirm by video camera whether someone is alive?

CS: Not every time, no, that’s why that wasn’t the basis of the checks.

C: Why couldn’t the video camera be recorded?

CS: For safeguarding purposes, we wouldn’t allow anyone to record children.

Discussion then moved on to the lack of curiosity when Mia suddenly appeared to stop having seizures at night time, despite this never happening at all since her epilepsy had developed when she was 18 months old.

C: You said you relied on paperwork, why was it not possible to have a separate form for whether undertaken by video or in person? Do you think the form was robust enough for any night, particularly for 10/11 September?

CS: Documentation is the child’s sleep cycle and positioning chart. Used to record how positioned and whether or not they were asleep or awake. Expectation if child checked every 30 minutes or hour, indication whether asleep or awake, if on side, left or right, if needed to be repositioned

C: Why didn’t you? You could have made it much more robust couldn’t you?

CS: We could have done.

C: I mentioned this to Dr O’Connell, indeed what other steps were taken? What is of concern to me is there’s no documented night seizures throughout the whole of 2023, then on one occasion there was a night seizure that led to Mia’s death. Did that not raise any index of suspicion for you that they weren’t being recorded?

CS: I think there were some night seizures in 2023

C: Not that I’ve got documented. None. I’ve got a number of seizures, none for the whole of 2023. Some in August 2020. Frequent absences, well not frequent but present in 2021, variable 2022 there’s some, none in the whole of 2023.

CS: Ok, I thought there were

C: There may be, but you haven’t provided the court with that.

CS: In terms of what was provided I thought there was some

C: I can show you if you think there are

CS: No, there’s no need

C: Well there is. What I’m concerned about is the lack of assessment, given use video camera, don’t know which was camera, which was visual observations. Video camera can’t tell whether breathing or absence seizures, even with reduction in medication was no documentation of any absence seizures in the whole of 2023.

CS: I thought there was when I glanced earlier

C: I’m very happy to be corrected

CS: Equally I could be wrong

C: Well the problem is you’re under oath

Mr Walsh: Madam we do have in spreadsheet, bit clearer, we have timings of seizures

C: Yes I know, but you provided this for the court, in 2020, 2021, 2022 its documented night seizures, I cant see anything documented here.

Mr Walsh: Madam the spreadsheet is only 2023

C: Yes I know, but I’m looking at these. April 2023 number seizures, no absences in May, in June, in July, in August is no indication of absence seizures, just seizures. I appreciate if I go through bit by bit I can see what happened, but I don’t have any timings

Mr Walsh: in the fourth column … on 15 March there’s 4

C: So the documentation has not been accurate then. That’s afternoon. June… heavy breathing but that’s not documented as to when timings are. Essentially were some night seizures, but they weren’t documented as night seizures or absences

Mr Walsh: When you say they’re not documented, they’re documented here.

C: Given the difficulties I have in working it out, how were you able to work out during Mia’s life, whether she needed to be seen due to the number of seizures and the like? I’m troubled with the lack of robustness about the nature of seizures, duration of seizures, what steps were put in place for seizures. Particularly on a background of two different sets of clinicians giving medication, and how you’re assessing it. I wonder if you could assist the court.

CS: Nursing care staff would document every seizure that they witnessed, which would cover time, duration, description, any triggers and if there’s any intervention required, if child needed escalation of protocol

C: Would be right to say, whether someone needs intervention at time, that in of itself should not prevent further assessment of someone’s neurological status and modification of medication?

CS: Yes, I’d agree. They’d document all the seizures, would record them and report at handover for next shift, so next shift are aware child had seizure on shift before. Then I think Dr O’Connell mentioned the weekly rounds doctors do, where nursing staff bring records over week.

C: I understand that, but we’re looking at continuity over time… appreciate seizures are variable, but Mia’s medication stopped in July, in August there’s an increase of seizures. Was that picked up as an issue?

CS: I can’t answer personally

C: Do you have any documentation, increase in seizures sometimes twice a day, to whether was appropriate to stop the [medication]?

Mr Walsh corrects which medication was changed.

C: I’m looking at the robustness of records, of when is necessary to intervene. Is that something you’ve taken into consideration after Mia’s death?

CS: We record all seizures

C: Yes, you record all seizures, it’s what you do with them

[I missed Ms Shiels response, apologies]

C: Evidence we’ve got is no medical record, annotation perhaps, of whether any further assessment is needed. Knowing Mia had complex epilepsy, I am concerned she was not sufficiently assessed, and addressed at earlier opportunity when decrease in medication. That it was somehow accepted that Mia had epilepsy.

CS: I don’t think it’s the case that it was accepted

C: What steps did you, as an organisation with responsibility for the medical care of Mia, take? For example, you’ve stopped the [medication], do we need to do something here given increase of seizures? I can’t see you’ve done anything as an organisation?

CS: Ok, I’m not sure exactly what has been done in this case

Mr Walsh: Ma’am I can assist with the documentation of Dr Aylett… letter from November 2022, at 1285, can see letter from Dr Aylett to Dr N? [missed], the advice such as it was, appears to be if increase in seizures [medication] can be increased.

C: Yes

Mr Walsh: To reach xx twice daily. We can see from prescriptions was increase to 200mg twice daily.

There was then a discussion between the coroner and Mr Walsh, counsel for The Children’s Trust about changes in medication. He appeared to be trying to reassure the coroner that medication had been increased in line with earlier medical guidance, she appeared to understand that and be asking what assessment was conducted when changes in Mia’s seizures continued.

C: I appreciate that but what I’m looking at is in July 2023, after the [medication] had been discontinued, slowly weaned off and stopped, there was an increase in seizures, whether there was any steps taken at that time?

Mr Walsh: The only increase in 2023, we can see in 1831 was increased to 200 at that stage, by 3 April was increased.

C: I appreciate that, recached steady state in July, [medication] stopped, then increase in seizures in July. Appreciate indeed the number of seizures is variable, but here is someone you’ve stopped the [medication], the [medication 2] is at maximum dose, had been for several months, whether that should have triggered further assessment?

Mr Walsh: We have 15 seizures in March, 14 in April, 9 in May, 20 in June and 11 in July.

C: I understand, but here is still ongoing seizures, it’s not the fact whether they need intervention or not. How often whether stopped the [medication]… I’m looking at frequency of assessments and care in someone not being seen by the NHS.

Mr Walsh: I only raise it because this witness isn’t clinical, wasn’t matter picked up by Blue Box because have variability, and have advice about increase in [medication], which occurred.

C: Yes, I appreciate that, but Mia was a child in care. In terms of assessment, other medical condition, independent of Blue Box Associates, is there anything you have learnt, to implement further care in circumstances in the future?

Silence

C: Let me be clearer. What we’ve heard is Mia required care for her activities of daily living and all her medical care. She had seizures on a regular basis. There doesn’t appear to be any assessment other than June 2021. We’ve got Dr Aylett who appears in some non-NHS capacity. She was last seen by the hospital in June 2022 because of an increase in seizures. What was the plan for the management of those seizures? We’ve got Dr Aylett varying the drugs, but what was the ongoing management plan, on a day to day, or week to week basis, as to whether there needed to be further intervention? I understand you keep a record, but what do you do with that record?

CS: I don’t have information on this particular case. Generally, what we’d do is go to tertiary services and ask for early review if that needed to be the case. Nursing Care Team would escalate on the day if they felt a child needed to be seen. Is that what you mean?

C: Yes. I’m looking for a plan of how frequently a plan should be made. I appreciate Dr Aylett is employed privately. Mia was someone with complex needs in terms of her epilepsy, would she not have benefitted from someone with wider expertise in terms of management?

CS: We use a range of services, tertiary services in The Children’s Trust. A lot of our children experience more than one, a lot are under gastroenterology…

C interjects: I understand. We’ve got a care plan, Dr Aylett’s plan, but how was it acted upon in terms of ongoing management of her seizures, Mia’s seizures?

CS: These things are regularly discussed

C: I know they’re discussed, but what action took place?

CS: The team around the child discuss their health needs and what’s happening, how they’ve been, they look whether they need change in medication, make referral, ask for that child to be seen.

C: Was there a care plan in place for Mia which would trigger that referral?

CS: I’d have to remind myself what her care plan said but there’s a protocol for each child. I know Mia, I think she had 3 protocols, they said in Mia’s case if she were to have seizures on consecutive days or something like that.

Mr Walsh: To assist its c1-860 dated August 2020

He asks for that document to be put on screen. It is. It’s titled: seizure protocol/guideline.

C: Yes, I’ve seen that, I’m aware of that. What I’m looking at is a dynamic… that’s 2020.

Mr Walsh: Below it 862 is December 2021, below it September 2022

C: Thank you

Mr Walsh: Last one is February 2023

C: This is for management plan if severe seizure. What I’m looking for is a plan with regards to tertiary referral if needed to be. This is management plan, if there’ s a seizure, some issue with regards to using [medication] or [medication]…. I’m looking for care plan for the ongoing management of seizures. Do you have one?

CS: There was a care plan in her notes in her care plan file, that’s the Nursing and Care Plan file

C: It’s about what the care plan was for ongoing management? Six monthly or yearly reviews? Or was it just accepted that Mia had seizures?

CS: No, it wasn’t accepted but that would be in her medical plan.

C: I haven’ t got a medical plan.

CS: It would be in the Emergency Transfer Letter, who she’s under, when she’s seen, but that’s in the Doctor’s Plan.

C: Dr O’Connell doesn’t have a Doctor’s Plan. There’s an emergency transfer letter but that’s not about routine follow up of patients

In a very unusual move, Dr O’Connell who was not in the witness box, nor under oath, said something to the court which I didn’t catch and then this:

Dr O’ Connell: We make changes very slowly with our anti-epileptic drugs and was no change to increase another novel drug at that time, her seizures were better, they didn’t need rescue, they were on a different plateau. Our next meeting with Dr Aylett would be a discussion whether we try another anti-epileptic drug or not really. Was a plan if had been chaotic increase in seizures with risk, that would have been fast forwarded.

C: Thank you very much, that’s very helpful. I’m going to move on now to talk about the Blue Box Associates and really what your understanding is of that, and what changes have taken place. Do you agree with everything Blue Box have said with regards observations?

CS: Yes

C: And do you accept they were simply not good enough?

CS: Yes

C: Do you accept there was no detailed guidance in Mia’s plan as to how her anti-suffocation pillow was to be used?

CS: Yes, we don’t use those pillows at The Children’s Trust.

C: If you don’t use them, why was it there?

CS: Should have been more questioning about why it was there. Nursing Care Staff very diligently put the pillow in every night without sufficient thought of how it was being used.

C: How did that come about?

CS: I think it just wasn’t questioned really. There’s very little evidence base for the use of those pillows, it wasn’t really given that much thought really. The sleep care plan looks at positioning, Mia was independently mobile, she didn’t have lots of sleep systems and blocks.

C: No. Why was a risk assessment not undertaken with regards to the use of the pillow in Mia’s bed? She’d been with you at that time for 3 years.

CS: Had been considered, was in her care plan but wasn’t sufficiently dealt with in there. Care plan said it should be placed in the bed at the head of the bed. Nursing Care Staff would if they went in to do checks, sometimes would move it, sometimes wouldn’t. It wasn’t stipulated within the care plan and it should have been.

C: Again, I’m slightly perplexed by that answer. The evidence you’ve given is it wasn’t necessary, so why was it there? Why was it allowed to be there?

CS: There is little evidence for their use, there was no evidence they are harmful, no evidence not to.

C: Was there any evidence of any other pillows in Mia’s cot?

CS: No. Do you mean from Blue Box?

C: Was a cylindrical pillow, the police seemed to indicate?

CS: It was felt not

C: Did you explore that with staff?

CS: Not on the day, but I did explore it afterwards yes

The coroner then checked Ms Shiels response to a number of findings from the Blue Box Investigation.

C: Do you accept the findings with regards monitoring was poor?  That there was insufficient visual recognition of actually checking Mia on 10 and 11 September, checking whether she was still alive and breathing?

CS: I accept the findings of Blue Box yes, without looking at it, I think it described checks she could confidently believe were done physically and then others that weren’t.

C: Are you able to explain why there was a delay in calling emergency services, albeit a short delay?

CS: This is something that has been stressed on basic life support training, ABC. My thoughts would be that it’s the staff aren’t used to being in those situations, it’s the panic of being in those situations really. I mean we do, alongside basic life support training, we do simulation training and things like that for staff. I guess it’s difficult to know how much that prepares you I think, for an event like that.

C: Yes, I think Blue Box commented on your own investigation process and found it lacking. Do you accept that?

CS: The initial investigation? Yes. It was the very next day after Mia passed I requested an investigation from another company and yes, that wasn’t as robust as we’d have liked.

C: Indeed. I think the Blue Box Associates commented would have been helpful if those involved in the preservation of the scene had provided a written report of their observations. Is that something you accept?

CS: Yes, that will be part of protocol

The coroner then asked about The Children’s Trust’s failure to discharge their Duty of Candour obligations.

C: They also said you did not discharge your duty of candour responsibilities. Do you accept that?

CS: Yes

C: In what way did you not?

CS: I emailed KR to do an investigation, we should have invited the family to be part of that investigation, and we didn’t do that.

C: That’s a significant lapse isn’t it?

CS: Yes

C: Blue Box said there was no communication with the family to say a notifiable incident had occurred, no apology was given to the family … they were not invited to contribute to the first investigation. For a period of three to five months following Mia’s death, the Children’s Trust were in breach of it’s regulatory obligations, and at risk of prosecution by the CQC.

CS: Well we spoke

C: Why?

CS: We got it wrong, in terms of the statutory responsibilities, we sent a statutory letter to the local authority, and we had a meeting on the same day actually as this happened, where we talked about informal support for the family. The Medical Team were speaking with the family, we also spoke to Shooting Stars to see if they could offer

C: That’s the hospice, is that correct?

CS: Yes, who were aware of Mia, to see if they could offer bereavement support if the family would like that. I think we just got it wrong in terms of what was our statutory responsibility and supporting the family.

C: How did you support the family after Mia’s death?

CS: We didn’t, we didn’t. The intention was to talk to the family about the first investigation, it quickly became clear that first investigation wasn’t sufficiently rigorous.

C: I appreciate you might have tasked someone with investigation, does that absolve you of your responsibilities as responsible clinician to inform the family?

CS: No. When you say inform them?

C: Well speak to the family

CS: No, we didn’t discharge our duty, no. I’ve reflected on that, and as organisation on that, and how we got that wrong to make sure it’s much clearer moving forward.

JOC interjected from the back of the court: On a more personal level I have to say myself and speciality doctor called the family the following day to offer condolences and suggest bereavement services they could use, spoke to the father about that.

C: Thank you.

The coroner then moved to trying to understand what actions had been taken following the Blue Box report.

C: So, what changes have you made?

CS: Specifically, about that?

C: Just generally. Let’s go through them.

CS: Do you want me to talk through the action plan?

C: Yes please, following the recommendations of Blue Box

CS: In terms of frequency of monitoring we have done a lot of work around that. If I speak about some of the things we’ve done, I’ve been and spoken to all the Managers. I know Ms Yapichi in her evidence alluded to certain managers giving incorrect information around that. I’ve been to all Managers Meetings, we’re further reviewing the policy.

C: Are you still using video cameras?

CS: We still use video cameras. That’s another area we’re looking at, making it very explicit in care plans, not relying on change of policy… making sure care plans are more explicit than they were before, makes absolutely clear what is meant by visual check or physical check

C: That’s in Blue Box Associates 77 and 78, Mia’s Frequency of Monitoring Risk Assessments meant Mia was at risk of asphyxiation …. No detail in this document or any of Mia’s care plans as to what amounts to a visual check and what should be included in a visual check. You’d accept that?

CS: Yes

C: Visual check wasn’t defined in Mia’s care plan was in policy, said visual check was going into child’s room, not just reliant on policy but also in care plan being more descriptive about what that means.

CS: That element of care plan was added to each handover, so clear message from Shift Leader, so staff understood

We’ve also brought in more audits of actual practice and audits of understanding of the care plans, more so than the policy.

C: Blue Box say in paragraph 86, the practice of performing visual checks on the monitor and not in the child’s room had developed. She’d indicated that may be due to lack of staff. Is there a staff shortage?

CS: No there isn’t

C: So on that night there was no justification of not undertaking checking due to staff shortages?

CS: No, if staffing was compromised, the directive wouldn’t be to do checks by monitors, we have other contingencies

C: Seems was common practice to use video camera?

CS: Some children are on video monitors because they’ve stated a preference, where safe to do so. Some would prefer that where safe to do so, still be an element of visual checks.

C: What we have through Blue Box Associates, not all staff perform visual checks throughout the night in children’s rooms. So how is that being dealt with?

CS: The other changes is around training. We’re doing a lot of attendance at Team Days and Team Meetings, as well as Manager Meetings I mentioned earlier. Then we’re doing a lot of education in practice. One thing brought in is Patient Safety Brief each shift. One element of that is looking at allocations. Which staff been allocated to whom, checking they have competency and skills and know what they are doing. Audits really around understanding, during day, then larger audit at night once a month, all Clinical Site Managers talking to every staff member on shift to ascertain what their understanding is, of the child they’re caring for.

C: Thank you very much indeed.

CS: The other bit, sorry, the other bit in relation to frequency of monitoring is we’re developing, not quite there yet with it, because of a lack of evidence of similar things can use, have tried to benchmark and evidence around this. We’re developing Clinical Guidelines for staff involved in risk assessments that determine frequency of monitoring, need to get frequency right as well as implementation of it.

C: What does that mean in practice then?

CS: We will put training on for those who do those assessments, its predominantly the nurse in collaboration with the medical team and therapist who complete risk assessments, particularly when a child is first admitted to The Children’s Trust, and then regularly afterwards. We’ve developed guidelines to make sure consistency, and there are no gaps.

C: Any other changes, think there’s a few more?

CS: We changed the sleep wake cycle form, made changes to that, still monitoring sleep wake cycle and positioning, also asking staff indicate how reached that information, whether video or in person.

C: What about checking respiratory rate?

CS: The PEWS chart

C: You might want to explain PEWS care

CS: Paediatric Early Warning System

C: Was undertaken on Mia on 10 September?

CS: It was at the start of the shift, policy at The Children’s Trust is one should be completed at start of every shift, for every child. Unless not indicated, for some children it isn’t, for some its more frequently, for some child might be just temperature if at risk of sepsis.

C: On a case by case basis?

CS: Yes. We made changes, when given on handover, where entered on care plan… so staff can understand importance of it…. Then Patient Safety Briefs, the huddles, on each shift, one area targeted

C: Thank you very much indeed. And?

CS reads from the plan  The other changes are around internal reporting of those things, to ensure reported to the Clinical Governance and Safeguarding Committee, attended by Trustees. Also, changing of record keeping following Doctor’s house rounds, that will be audited.

C: What about the liaison with tertiary services, I appreciate you have Dr Aylett, what about providing a holistic report, for example if anyone has to go into hospital so they have access to all their medical records rather than just clinic letters?

CS: My understanding is that’s on the Emergency Transfer Letter and Emergency Care Pack… [missed section of her answer]. That’s audited every week, goes with child to hospital in an emergency, or for all appointments

C: Thank you. In terms of monitoring, individuals like Mia who have silent seizures, who have only 15 minute checks. I’m aware the evidence from Blue Box was Mia was thought to be alive at 06:12 and died within that 20 minutes. Have you thought of any other pieces of equipment that would be able to assist the staff to know when Mia’s having a seizure or not?

CS: The reason Mia was assessed as needing 15 minute checks, that’s a very high level of checking for us, we say children have to be checked a minimum of every 2 hours, some children on continuous observation but 15 minute checks is high level for us. Reason we put on high level is because a mattress or a watch wouldn’t have been very helpful in Mia’s case, so we chose to do visual checks.

C: Here we have Blue Box saying 06:12 they thought Mia alive, then visual checks weren’t undertaken 3 minutes later. Wonder if you had any thoughts with regard to that?

CS: I think would be very difficult to put every child on continuous observation, is so obtrusive for our young people… a watch or a mattress, Mia moved around so much throughout the night she’d have never go to sleep because it would have been alarming every few minutes. When they look at the risks, when team making those decisions, they will look at seizure frequency, things like that, but also how many times have those seizures self-resolved, how many times required intervention by staff.

C: Is there anything else you would like to add that I haven’t asked you?

CS: No, thank you.

There were no questions for Claire Shiels from Paige, for Mia’s family. It was then over to Mr Cox for Bracknell Forest Council.

Mr Cox: As part of the review carried out, have you gone back and checked the care plans in place for Mia at the time and looked at issues in those?

CS: Yes, in what sense? I’ve reviewed her care plan.

Mr Cox: For example, in sleep section of care plan, c1-194 you told us as part of the review you’ve gone into more detail about how visual observations should be carried out. If you look at this section, it says do I have consent for remote AV monitoring. Who do you get consent from for that?

CS: Parental carer if a child is unable to give consent themselves

Mr Cox: OK, if you scroll down further, p 195, just further down from the review, says, has this been shared with person’s with parental responsibility, and it says no. So, no contribution. Have you reviewed these sorts of discrepancies within the care plan, that appears to be a discrepancy?

CS: I haven’t for this particular case, it’s something we’ve looked at in terms of process. Often when care plan will be updated, some staff will say hasn’t been shared with family if nothing really changed in it. Would only share it again if significant change to it basically. This is something we have looked at in terms of electronic records because it doesn’t make that clear.

Mr Cox: No, it doesn’t does it, is an obvious discrepancy. Also physical care provided to Mia was suggestion she may need turning ever 3 to 4 hours, appreciate heard evidence Mia moved around a lot in bed, however if unwell would need to be repositioned every 2 hours. Earlier on in the Moving and Handling document, it said she’s required re positioning every 2 to 3 hours. Appears to be inconsistency between moving and handling section and what is said here. Have you ironed out inconsistencies in terms of care plans?

CS: We’re looking at how our electronic care plan sections has been configured, section on sleep, equipment, sometimes section gets updated but doesn’t necessarily flag where link to another element of the care plan. We have started some areas where we’ve identified those discrepancies, not always discrepancies but link in care plan. We haven’t got all of them linked at the moment, is a relatively new system for us.

Mr Cox: You’d agree wouldn’t you, for staff reading care plan for the first time is important there’s consistency in instructions?

CS: Yes

C: In terms of your learning statement you’ve just taken us through…. you talked about monthly audit of managers speaking to staff, that’s all well and good, but is day to day need to make sure work is being done in way envisaged should be done?

CS: Overnight?

Mr Cox: Yes, all of it

CS: Site Manager Audit is formal audit monthly, ask each member of staff on shift, … every other night when not doing audit, still go to houses at least 3 times a shift. On night this happened the site manager went on 5 times.

[missed section]

CS: All our staff have safeguarding training every year but I speak about it all the time. I get some reassurance that staff do report incidents, a number of incidents come to my attention because a colleague has blown the whistle so to speak.

Mr Cox: Just going back to question asked earlier about communicating with those with parental responsibility. How are you going to ensure those with parental responsibility are involved in the construction of a care plan?

CS: We try to do as much as we can. Some family members ask us to print them off and copy them [fuller answer, missed]

Mr Cox: How do you ensure you’re satisfied…

CS: I would expect conversations around SUDEP to happen in joint clinics, for a lot of our children family members attend those clinics

Then it was over to Mr Walsh for his questions.

Mr Walsh: Can I take you to the anti-suffocation pillow, its h1 048. Are you aware where the pillow came from and why it was being used at all?

C reads: I have a sleep system .. reposition independently however please turn me every 3 hours if not actively moving…. I have a pink bed in place with zippers each side… do not leave me without securing the zipper and buckles.

I use a sleep safe anti suffocation pillow as from previous placements…

Mr Walsh: Suggestion was it was brought from a previous placement. Was there any further points with regards to whether it should be continued to be used or not used?

CS: We don’t supply them as an organisation, we don’t recommend them or use them as a piece of equipment in our care plans, neither are they harmful so if preference for a child to use them then that is fine. Sorry is that what you meant?

Mr Walsh: You referred to the pillow and I wasn’t entirely clear where it came from, you appear to say.

C: If it helps, I don’t have any concerns about the pillow, it’s about the care plan and the plans for that.

Mr Walsh: You also referred to emergency transfer letter.

[missed her answer/explanation]

Mr Walsh takes her to another document.

Mr Walsh: In the control measures section, for example, it gives information with regards to looking out for increased side effects of medication for example. Would seizures be something to look out for?

CS: Yes

Mr Walsh: This is May 2023 and is risk assessment for frequency of monitoring, is that correct, part of ongoing care plan?

CS: Yes, we do frequency of monitoring risk assessment, that’s where clinical guidelines we’re bringing in

Mr Walsh: I see, I’ll read from it, mentions all seizures will be recorded on seizure chart…

[reads more – missed it]

CS: Yes. All changes in medication is added to handover for 2 weeks … generic house handover that will talk about general things, I don’t know the boilers not working, then for each child how they are, if they’ve had a seizure, if there’s a change in medication its included in that sheet for two week period.

[missed his question/statement]

CS: Elements of the policy changed already implemented e.g. frequency of monitoring will be read out at every handover for every child, already implemented some elements of it.

Think made it as explicit as it can be within the policy… making it completely explicit within care plans, two pronged approach really, and working with staff to ensure they understand those care plans.

Mr Walsh says he wants to discuss what a huddle is, the coroner said she’d already gone over it, he says he doesn’t know what it is.

Ms Shiels gives a long explanation [missed]

Mr Walsh: Alright, it’s a safety talk as it were?

CS: Yes

Mr Walsh: How satisfied are you you’ve addressed all the matters that Blue Box Associates had concerns about?

CS: I think we’ve addressed all of them, some larger pieces of work that are in process. Accepted all of them, developed an action plan, worked hard on most of them to have them completed.

C: Just to confirm, frequency of nighttime checks should be placed on the Board Risk Register, has that been done?

CS: Yes, it has

C: Thank you very much indeed

Mr Walsh: No further questions

The coroner had one final question for Ms Shiels.

C: Recommendation 10, thematic review, not a matter for this court, but senior member at Trustee Level… not directly, but I wonder where that is going?

CS: The group have been established, think they’ve got terms of reference, looked at how they’ll conduct the thematic review.

C: Will you be able to provide the court with the outcome of that review?

CS: Yes

C: That would be very helpful, I’m very grateful indeed.

Ms Shiels was the final witness to give in-person evidence on Day 1.

There was one more statement read onto the record, which I will report, along with Day 2 activity (from yesterday) when I am able. It won’t be before tomorrow. My hands are too sore, and my heart is too heavy, so I’m off for a swim.