Earlier on Day 1 the coroner had read onto the record the statement of Emma Dickerson, a Children’s Support Assistant at The Children’s Trust. After the last in-person witness the coroner said that she would deal with some other matters.
C: I know there’s a number of other statements, we have the CQC Report, but it’s so generic I’m not sure it helps me
Mr Walsh: No, but Ms Cairns statement should be read into record. Dr O’Connell has a paper, I’ve a copy for you.
The coroner said that she would read the statement of Azri Cairns onto the record.
She told the court that Ms Cairns gained a Bachelors in Nursing in Australia, qualifying in 2012 and then studied for a postgraduate course in neonatal intensive care. Ms Cairns moved to England and registered as a nurse here in November 2018.
She joined The Children’s Trust in February last year, before that she was working at Guy’s and St Thomas. At the time of Mia’s death she had been working at The Children’s Trust for just over 6 months. She usually worked in Chestnut House and she knew of Mia, and told the court that she had met her on a number of occasions. The first shift that she did in Jasmine House was the shift where Mia died.
She told the court that Jasmine House was without a nurse on that night and Chestnut House had three nurses working, so she elected to go downstairs and help them. She had recently been promoted as Interim Manager for Chestnut House.
On 10 September her shift was from 7pm until 07:30 the following morning. She was the shift lead on Jasmine House for the night shift. There were experienced staff on shift in Jasmine House, but they needed a nurse as there was no one senior enough to be the Shift Lead. Ms Cairns told the court that they were well staffed on shift with four staff, and one child had gone home for the weekend.
She said in the general handover none of the children were understood to be unwell, nothing was flagged at handover. She said that she looked at the children’s care plans as it was good nursing practice to go through care plans.
[The coroner then read a section that I missed – it was towards the end of a long day by then – apologies].
The court heard that all Mia’s observations were within the expected range. Ms Cairns said that she understood Mia’s condition and she knew that she had been unwell previously and admitted into hospital. She knew Mia experienced silent seizures. She said that she would take a close look at whether Mia was moving on the non-recording video camera. For example, if Mia would sit up, Nurse Cairns would go into her room and check she was alright.
She told the court that she could not say for sure how Mia’s seizures presented as she worked with Mia for the first time that evening. She was told by staff that Mia also had vocalisations, but she said, “the point is each child can throw you a curve ball” so it was best to do visual checks.
Ms Cairns told the court that she did remember seeing Mia’s anti suffocation pillow. She said she could see through the plastic windows of Mia’s bed when the doors were shut around her bed. She said that her understanding at the time, was that staff understood the use of the anti-suffocation pillow.
The court heard that the clinical notes she made for 10 September were made retrospectively on the 11th. She said on some nights she would write her notes up later, other nights she would write them up straight away. Which approach was taken depended on what happened during the night.
Ms Cairns said that Mia was settled through the night. She said at 7pm when she went on shift, Mia was still awake. She did her checks at the beginning of her shift while Mia was in her chair.
She told the court that the children were put to bed around 8:30pm. She did some visual checks during night but she said that she assumed Laura had done most of them. She said that she had delegated some things to Emma, and that she was mostly down the other corridor where there was a greater demand for medications.
The court heard Ms Cairns’ practice when she went into a child’s room was to put on the light by the sink or in a cupboard, not the overhead light. She said if you were preparing medications it is possible you could miss silent seizures. When checking a child, she told the court she would go right up to them, she didn’t want to look through the plastic. She said with Mia, as she’d shuffled down her bed completely, they would move her up the bed, and reposition her on her pillow.
She said Mia was on a non-recording video camera, and she would look for visual signs. She said you could observe the rise and fall (of her chest) through the window of her bed, although sometimes she would place a hand on Mia’s back. At times she said the rise and fall would be obvious, but if it weren’t obvious she would open the bed door to have a closer look.
Ms Cairns told the court that Mia’s bed had different levels, and that you could look into it and peer over. She said that she was quite short at 5ft1, so she needed to be on her toes to see In but that was “not to say it was strenuous or too difficult”.
She said to do a visual check she would move the plastic (in Mia’s bed sides) but you could see through the plastic. Lighting, she said, would make a difference to visibility and it was a balance, you do not want to wake a child by putting on the main light, so she would use the light over the sink.
Ms Cairns said that she had worked with Emma before. She told the court Emma (Dickerson) and Laura (Yapichi) both knew how to conduct visual checks. Ms Cairns said that it was possible to see Mia through the non-recording camera, for example see her sitting up in bed.
“If I’d been aware staff were not going into her bedroom, I’d have told them they must, always understood visual check to be looking at a child’.
Ms Cairns said one check occurred around 2am, she said Emma and her were in the room with Mia for about 25 minutes, which she said was why there was no initial in the sleep check at 2am. She said Mia was wet, and after they changed her she put her head back down and went to sleep.
Around 6:10am, Ms Cairns told the court Nurse Pallugna came to Jasmine House to check a controlled drug for a child in another corridor. After administering that for another child Ms Cairns went into Mia’s room to do a check. She told the court that she was breathing, she could see that. She said that she put a hand on her, she knew she wasn’t seizing, “she was just moving to comfort herself I think”. Ms Cairns said she had no concerns at this stage to indicate Mia was seizing.
“She was not face planting at that point, had she been I’d have called for assistance to move her”.
Ms Cairns said that she then left Mia’s room. She did not record this check that she told the court she made just after 6:10am.
She said that Laura went into Mia’s bedroom, she could not recall the exact time. Ms Cairns said that Laura came to another child’s bedroom to ask her to assist with her medication.
Ms Cairns said that she was not in Mia’s room with Laura and she was not able to say whether Laura did a visual check at that time.
She told the court that she was not called back until 6:30am, or thereabouts. Emma and Laura told her they had been into Mia’s bedroom, she was lying prone, with knees under her and on her side. They had called for assistance to reposition her and found Mia to be unresponsive at 06:30am.
The coroner said she was not proposing to read anything further. She said that the statement talked about moving Mia to the floor, and paramedics wanting more space to work. She said Ms Cairns statement was signed and dated 7 June 2024.
C: I appreciate we’ve gone beyond court time, that it’s been a very long and very emotional and difficult day. I do wish to take submissions. I’m not entirely certain it is appropriate to take them at this late stage?
Mr Walsh said given the time he would prefer to give first thing in the morning. The coroner was happy with this approach but told the court that she had a full list of inquests the following day.
A timetabling discussion followed.
The coroner thanked Mia’s family and all the witnesses who had given evidence. It was agreed that we would return to court at 2pm on Wednesday, the following day.
[I am very grateful that the Coroner permitted me to attend remotely for Day 2, which I did and will write up next].