Mia’s Inquest: Laura Yapichi, Children’s Trust

After reading Emma Dickerson’s statement, the Coroner called Laura Yapici to the stand. She gave an affirmation.

The coroner thanked her for attending and checks how to pronounce her name. She asks Ms Yapichi to explain who she is and her involvement with Mia.

LY: I was a Child Support Assistant with The Children’s Trust. At the time I was just training to be a Shift Leader. Was in the process of training to move up to the next level.

C: What does a Shift Leader mean?

LY: Basically running the shift, making sure all the young people get everything they need [fuller answer – missed]

C: how did you know Mia?

LY: I knew Mia originally when I came on shift over in Camelia, then she started transitioning to Jasmine. We went over to get to know Mia a bit more and get to know her care routine.

C: Thank you very much indeed. I really want to know what was your understanding of her care plan for night time?

LY: So her care plan for night time was to do 15 or 30 minute checks on Mia. She did have a video camera so we could keep an eye on her. To check if she needed personal care overnight.

C: What did you understand by that… [15 minute checks] … in what you were expected to do?

LY: I was expected to go and see if she was ok, if she needed anything, basically that she was breathing. There has been times in the past at the Trust where we’ve been a bit short staffed and I’ve been told by managers can just look at the video camera.

The Coroner checked who had told Ms Yapichi that, and she said one of the past managers.

LY: One of our managers in the past, so.

C: What, um, we’ll come onto the events of 10 September, but what you were told, if you were short staffed. I’ve just read into evidence you weren’t short staffed that night?

LY: No, but if you’re in with another young person, giving personal care or something like that, you take the monitor with you and keep an eye on it while doing something else.

C: We’ll come onto the video camera. You were specifically told you don’t need to go into someone’s room every 15 minutes?

LY: Not all the time

C: Every 15 minute checks?

LY: What I’m trying to get at I think is you can’t just sit and rely on what you see on a camera, it’s there as a back up, so if you’re in with a young person you’ve got the camera there, but originally you do have to go in and check

C: Did you record your checks every 15 minutes?

LY: Yes

C: Did you record whether you did them in the room or by the video camera?

LY: I did record them if I did by the room or camera

C: So you’d determine which one it was, you wouldn’t just tick a box so to speak?

LY: No

C: In terms of your statement, according to the sleep care plan Mia was supposed to be checked every 15 minutes…. check, turn on cupboard light, check whether she’s breathing, settled… sometimes did not go into room because could see Mia moving… was told by managers not going into the room to check was ok.

You said you were familiar with Mia, knew the sounds she made when having a seizure. Did you ever recognise Mia to have a seizure?

LY: Yes

C: Did you ever recognise her to have a seizure at night?

LY: She has had seizures at night yes

C: Do you recall any in the last year of her life?

LY: I don’t remember

C: So you just don’t remember?

LY: She has had them, I just don’t remember

The coroner then moved on to asking about the documenting and recording of Mia’s seizures.

C: How were you tasked to record the seizures?

LY: Before the system went electronic we had paper records, had to document length, time, how it presented, any interventions needed to be done within seizure. Once went electronic was all exactly same, just tablet form.

C: Thank you very much indeed. You say could tell difference between normal movement and seizure on camera. Can you explain that, given she has silent seizures and absence seizures?

LY: If Mia was moving at night she’d get up on her knees to reposition, if she was having a seizure she wouldn’t be getting up on her knees.

C: How about silent seizures?

LY: With Mia’s silent seizures at the start of a seizure Mia took a big intake of air, like a gasp of air before she went into a seizure. You could hear that intake of air as it was quite loud.

C: the audio visual, does that include noise?

LY: It does.

C: Thank you very much indeed. Given you’ve said in paragraph 17 of your statement that you undertake a visual check, can not generally see a great deal in that light but can see colouration and assess wellbeing. Given that’s the case, how does that work with an audio visual camera given its dark?

LY: It’s more the movement you’d see on a video camera

C: If a child is not moving, how do you know that child is alive if you’re only relying on a video camera?

LY: To be honest I don’t recall, sorry

C: No. If a child is not moving, that child could be dead couldn’t it?

LY: In theory

C: In theory, yes, I’m asking you if you don’t go into a room and assess whether someone is breathing, you only rely on audio video things, a lack of movement may indicate is not a seizure but would not indicate if there was a problem with that child?

LY: If for some reason I used camera for my checks I would as soon as I’m able go in to check

C: Yes I think there’s been some issues. It’s difficult to say what requirements for checks were at Tadworth, paragraphs 19 and 20 of your statement.

[Coroner reading from Ms Yapichi’s statement] So I would say over the years at Tadworth there has been mixed messages about the checks. There has been times where I’ve been told by certain people relying on the monitor is fine, and there has been times when people have obviously specified how they want their checks done on that shift. So yeh, it’s been very mixed messages over the years, it’s quite confusing.

C: So in actual fact there was no rigidity of what was expected of you by the site managers and no consistency of how you should undertake the checks on an individual?

LY: Not all the time, no

C: You also say paragraph 20, sometimes relying on the monitor was not unsafe. Can you please explain that?

LY: I was trying to put across I was told by people it was ok to do, it wasn’t an unsafe practice at the time.

C: That was why you thought it was ok to rely on the monitor, ok. What was your role on 10 and 11 September, with regards to Mia?

LY: I was allocated to Mia, with Azri, with 2 or 3 other young people.

C: So 2 people, with 3 or 4 young people?

LY: I can’t remember exactly, might have been 3 or 4 young people

C: How was Mia on that handover?

LY: She was ok from what I can remember, she was a little bit sleepy but the weather was really hot. She was a little bit sleepy and lethargic, but the weather was extremely hot.

C: So your task as someone responsible for undertaking 15 minute checks that night. Can you take the court through your record of how often you used the camera and how often you went to check on Mia? Mr Walsh I’m hoping you’re going to help me out, I’m looking for records of visual and otherwise checks on night 10 into 11 September?

Mr Walsh: It’s C1-2758

C: We’ll put it up on the screen. We have sleep cycle and positioning. Sleep cycle and positioning I think from 8 in the evening, that’s 2754, I wonder if you can just explain what that is.

LY: That’s the 9th

C: My apologies

Mr Walsh: Ma’am 2758

C: Yes date of recording 10 September, which is the 10 to 11th

Mr Walsh: It starts on 2756 and continues to 2757 and 2758

C: Yes. 10th 8pm you’d be on duty then. I wonder if you can take court through what it means, bed self-positioning and ticks. Where does it show where its camera or self?

LY: I cant actually see 8 o’clock yet… where it says the positioning, self-position, we didn’t need to always physically move her. So we hoisted her from her comfy chair into her bed around 8 o’clock I think. That’s what I’ve documented.

C: Yes I know, but from 9 o’clock onwards who undertook the 15 minute checks?

LY: Me

C: Where does it say direct visualisation or camera?

LY: You just sign that you’ve looked.

C: You’ve just given evidence you record whether it’s direct visualisations?

LY: I misunderstood then, sorry.

C: So in actual fact there is no evidence as to when you last looked at Mia as visual in the room?

LY: No, there is no evidence whether I used the camera or physically checked

C: Do you recall when you last did a visual check?

LY: Not at the moment, no, it was a long time ago, sorry

C: Given Mia was found as she was found, I don’t understand how you couldn’t recall the last time

LY: The last time?

C: My understanding is all boxes signed at 9 o’clock, 10, 11 o’clock, midnight, not at 2 o’clock, then 3 o’clock …

LY: Sorry I thought you were talking the 10th

C: My understanding on evidence is you can’t recall when you went into the room or relied on the video camera?

LY: I went into Mia’s room at 6

C: before that, during the night?

LY: To be honest it was more habit that anything

C: What I’m really looking at is how frequently you went in to check on Mia, as opposed to relying on the video camera given the limitations it has on someone who might be moving

LY: I’d say 90% of checks, and if I did rely on camera I’ve have gone in after to check

C: You’ve signed for 6 o’clock, 6:15, 6:30 is that correct?

LY: Yes

C: Can you take us through, can you remember whether you went in to physically check?

LY: I did

C: At 6, 6:15 and 6:30am?

LY: Yes, it might not have been exactly 6am but I went in at 6, then went to draw her medications up so was in there at 6:15 and then 6:30 was when we found Mia unresponsive.

The coroner then moved on to exploring what the checks consisted of, or should have consisted of, when she were checked, and exploring her seizure pillow.

C: How do you ascertain when you go into a room, with Mia, as to whether she was breathing?

LY: You look through, I used to look through the plastic of her bed, the plastic window in her bed, because she had quite tall sides of her bed. I’d look through that, 9 times out of 10 you could see the rise and fall of her chest, or like that, but if you couldn’t you’d then unzip her bed.

C: Knowing Mia as you do, what time did she normally wake up at?

LY: She did like her sleep, so

C: It wouldn’t be unusual for her to be asleep at 06:30?

LY: No it wouldn’t, we’d normally check her personal care when we were given medications, she might stir then but she’d go back to sleep again

C: Thank you, what was in Mia’s bed at the time, throughout that night?

LY: Umm so was her thin, we called it a seizure pillow, her thin pillow and just a fleece blanket, she didn’t have any duvets or anything

C: The evidence we heard might have been a cylindrical pillow in there as well

LY: I recall it being in the room, but definitely wasn’t in her bed when she was in the bed

C: So where was it in the room?

LY: On top of the chest of drawers, or next to the chest of drawers because it was quite a big pillow

C: The evidence was it was on the floor?

LY: It could have been knocked off the side, could have been knocked over.

C: Did you have any guidance of what should be in Mia’s cot?

LY: Yes, the only thing that should be in Mia’s bed was her seizure pillow and a lightweight blanket

The coroner then moved on to asking about the audio visual monitor and its usage.

C: In terms of the camera monitor could it record?

LY: No

C: So it was only live

LY: Yes

C: I wonder if you can explain how it was positioned so you’re able to see Mia?

LY: At the start of the night we’d position it so we could see her, where she was, her position that she was sleeping. Throughout the night when she was moving you’d go then and reposition the camera so was always in the direction of her.

C: How far away was the camera from Mia?

LY: It was quite close to the bed

C: So it was in the cot?

LY: It wasn’t in the cot, it was on a stand next to it, but pushed close to the bed so could see in quite clearly.

C: I know you say you can see clearly, but it was dark?

LY: You know some baby monitors give some extra light

C: You’d said Mia’s cot sides were quite tall, so how far away was the camera from Mia?

LY: I can’t say how far it was from Mia, but can say how far was away from the bed… probably from me to the microphone (about 50cm)

C: Would Mia be at the lowest position … if someone is breathing shallowly as someone like Mia might do, when asleep, how is it possible something a couple feet away overlooking a cot at the lowest level able to see whether someone is breathing or not? Can see whether someone is moving, but in your experience are you able to say whether someone is breathing from looking at audio visual camera?

LY: You can see depending on how loud they are

C: I understand loud… if breathing quietly it’s not sufficiently sensitive to pick up breathing?

LY: That’s right, its ok for movement, but for breathing you’d have to go physically check.

C: So, it could be at 6 o’clock in the morning or earlier Mia might not be alive.

LY: She was because I physically checked her at 6 o’clock

C: How did you check her?

LY: I went in and checked that she was breathing.

C: I’m slightly jumping around with your statement… checks shared with other staff…. You carried out from 05:45 onwards. As you were most senior person on call in that area, what advice did you give to others about checking whether it was audio visual or checking visually?

LY: On that night shift

C: Yes

LY: I probably wouldn’t, because they were all experienced on my corridor

C: The evidence was one of them was her first shift?

LY: On Jasmine, but she was experienced at the Trust

C: I’m grateful, thank you indeed. Did you hear any noise from Mia’s room that night of 11 September in the early hours of the morning?

LY: Only when she was moving around, repositioning. You could hear the rustle of her sheets and stuff, but every time we would like, other than that was no other noise.

C: Did you document that?

LY: That there was no noise

C: No, that there was noise?

LY: No I didn’t document about the noise, no.

The coroner thanked her, flagged that she did not want to cause too much distress to Mia’s family, but asked Ms Yapichi to explain briefly what happened at 06:30.

LY: I entered the room with Emma to administer Mia’s medication. She needed to be repositioned, so we unzipped Mia’s bed. We very quickly noticed something wasn’t right by her colouration and Emma put her hand on Mia. So we quickly turned on the lights, we checked her for response by doing a sternal rub and stroking her face. Emma checked her pulse, at that point we realised she was unresponsive. We shouted for Azri to bring the oxygen and hit the emergency button. And started chest compressions.

C: Thank you very much indeed. The evidence we’ve heard from earlier today was the 999 call was made at 06:39 hours and there is some confusion as to the timing of events. Is that something you can assist the court with, as someone starting chest compressions at 06:30 but it takes 9 minutes for an 999 call to be made?

LY: There was Emma doing chest compressions, Azri brought oxygen and the resuscitation trolley, I started to bag the oxygen. At that point we asked [missed] to call the site manager. After that the staff from Chestnut came down, that was the point we got asked to call.

C: Why did it take 9 minutes?

LY: Wholeheartedly I can’t say 100% why, the time went so quickly, but we wanted to get the defib and oxygen and everything going. Yeh, I don’t know if it was because [missed] was quite new, he asked the Chestnut people to help him. We were all focused on Mia at that point.

The coroner then moved on to the report conducted by Blue Box Associates. It became clear with a later witness that there had been two investigations into the events of Mia’s death, the first of which The Children’s Trust had deemed was unsatisfactory, so a second investigation was conducted. This was referred to in court as the Blue Box Report.

C: Thank you, I’m sure you know there was an external review regarding the care that Mia received. Have you been able to have sight of that?

LY: Yes

C: I’d be grateful as to what your thoughts are with regards to the reviewer indicating, they did not feel on all occasions that you entered Mia’s room to perform a visual check and you relied on the camera monitor.

LY: My view on that is I didn’t, but I have said sometimes I used the video monitor, but I did mainly do visual checks.

C: It goes on to say, statement h 1-129 you’re unable to recall any details of visual checks you’d signed for… particularly you could not remember any details of the 6 o’clock visual checks. Is that still the case?

LY: It is still the case because it’s a while ago, so

C: But what’s known as the Blue Box Associates investigation also stated, she found you entered Mia’s room at 6:15am to prepare medications, she recalls looking at Mia’s bed, did not remember whether Mia was moving or breathing, did not conduct a visual check during the time was in Mia’s room preparing medication. Do you accept that?

LY: If that’s what I said

C: So, if you’ve not performed any visual checks at 06:15, why have you signed for them?

LY: I looked over to Mia, but might not have done a full visual check

C: But you signed as though you had?

LY: Yes

C: So at 06:15 you can’t confirm to the court whether Mia was alive at that point or not?

LY: I can’t wholeheartedly remember that

C: The report goes on to say there were 19 minutes between visual check of Mia at 06:12 by Nurse Cairns, and visual check of Mia being unresponsive at 06:32…. If Mia had been undergoing a seizure during the time was preparing medication would be aware of that. Does that not indicate to you that Mia sadly had died before you recognised she wasn’t breathing?

LY: Can you say that again sorry

C: Evidence I’ve heard, it was likely therefore there was approximately 19 minutes between visual check at approximately 0612 by Nurse Cairns and the check that identified Mia unresponsive at 06:32… 19 minutes.

The coroner again said that if Mia had a seizure during the time Laura Yapichi was preparing medication for Mia, she would have become aware of this.

LY: If she’d had seizure in room when I was preparing medication, I’d have been aware

C: But does that not indicate she could have had a seizure prior to that, and you’d not recognised it as such?

LY: I don’t know

C reads: Unable to make a reliable finding as to exactly how the pillow was resting in the bed at that location at that time.

Can you assist the court as to where the anti suffocation pillow was, in your recall?

LY: The pillow was at the head of the bed

C: Where was Mia?

LY: At the foot of the bed

C: Were you given any guidance on how to use that pillow?

LY: No

C: So when you repositioned Mia did you not reposition Mia’s head on that pillow?

LY: We did yeh

C: So given the pillow was at the top of the bed, and Mia was at the foot of the bed, how would that come about?  The pillow wasn’t being used in the way it should be used?

LY: No, it probably wasn’t, but there was no clear guidance on how to use the pillow.

C: So the investigator from Blue Box Associates, said even if it was 06:32, in actual fact the phone call was made at 06:38 and call handler found came about 06:39, there was a delay wasn’t there before a 999 call was made?

LY: Possibly there was a bit of a delay, but I don’t 100% remember why. The fact I was in assisting with Mia, I wasn’t aware of what was going on outside of the room.

C: OK, thank you very much, I don’t have any further questions to ask you, thank you.

There were no questions for Ms Yapichi from Paige for Mia’s family, or from Mr Cox for Bracknell Forest Council.

C: Mr Walsh?

Mr Walsh: Madam yes I do. Ms Yapichi, you mention within your statement you’re aware certain managers, you refer to Ms Diane Mansell and clinical site manager Ms Michelle Pallugna [sp?], you knew they wanted you to go into the room at the time. Is that at the time you were caring for Mia?

LY: In general

Mr Walsh: Aside from that you’ve also said, to be fair, you had a recollection others had told you something different in terms of using a monitor on occasions. Can you recall who those persons were who told you that?

LY: No

Mr Walsh: Ms Pallugna was the Clinical Site Manager on that night?

LY: Yes

Mr Walsh: So as far as any management were concerned, line managers were you reporting to Ms Pallugna or who else?

LY: On that shift Azri was Shift Leader, Nurse in Charge of that shift, Michelle was Clinical Site Manager. I report to both of them.

Mr Walsh: Is it correct, that night, both Azri and Ms Pallugna would have wanted you to go in and check in person?

LY: Yes

Mr Walsh: You mentioned protocol for checking a child was to go into the room, turn light on, be careful not to wake them. Is that something you got from protocols? I see you nodding.

LY: Sorry, yes

Mr Walsh: You’re aware of policies that said the same thing, go into room?

LY: Yes, go in but not to disturb young person by turning the overhead light on.

Mr Walsh: But to be close enough to them to check, to see that they’re well and breathing?

LY: Yes

Mr Walsh: In answer to questions put to you for 06:10 or 06:12 time, you said you signed for checks, then after you were dealing with medications, came extra time to be in room? If I put it that way?

LY: Yes

Mr Walsh: But you can’t recall now what you did on that check?

LY: No, I don’t

Mr Walsh: Were you aware around that time Azri also did a check and had her hand on Mia?

LY: I was only aware of that from the Blue Box Report, I wasn’t aware of that.

Mr Walsh: I see. No further questions, thank you.

The coroner thanks Ms Yapichi for attending court, and checked she had nothing further to add, releasing her from her oath at 15:15.

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