Morgan Betchley’s inquest was due to start at 10am this morning in a room in the council offices. We were forewarned that there would be a 10 minute break to enable the observation of the 2 minute silence at 11am.

The Assistant Coroner, Lisa Milner, came into court at 10:39. The court was busy with a large number of Morgan’s family and friends present.

There are four sets of Interested Persons: Morgan’s family who are represented by Jessica Elliott instructed by Charlotte Haworth-Hird, Sussex Partnership Foundation Trust represented by Ms Agnew, West Sussex County Council represented by Mr Berlevy and University Hospitals Sussex who were unrepresented in court.

As this is a jury inquest I will only be reporting what is said when the jury are in court. Housekeeping discussions between the legal teams lasted some time.

There was a jury pool of 14. Eleven were brought into court and the jury bailiff asked a series of questions of them, including whether they or any members of their immediate family knew Morgan or her family, any of the witnesses, whether they worked or were under the care of any of the Interested Persons, whether they had any ongoing litigation with any of the IPs or any experience of working on an acute mental health ward.

These questions were asked of each juror in turn. As they were it became apparent that two of them, and one of the replacements brought in to replace them had conflicts.

A full jury of eleven people, 4 women and 7 men, was sworn in. This finished at 11:52.

The coroner introduced herself to the jury and checked that they could hear her. They all could.

C: This is an inquest into the death of Morgan Rose Betchley who died on the 9 March 2023. This case concerns a death in Meadowfield Hospital, Arundel Road, Worthing whilst Morgan was a voluntary patient.

I welcome Morgan’s family, Tanya Betchley, Morgan’s mother, Morgan’s partner Dominic and Ms Hodgson, who is Morgan’s mother in law. They wish for the deceased to be called Morgan throughout these proceedings.

The family are represented by Ms Elliott, who is counsel, and Ms Charlotte Haworth Hird who is a solicitor.

The other interested person’s in court are Sussex Partnership Foundation Trust and they are represented by Ms Agnew. West Sussex County Council who are represented by Mr Berlevy. The University Hospitals Trust are unrepresented at this hearing today.

An inquest hears evidence so that you, the jury, can make findings of fact and come to a conclusion about the death. Formerly a conclusion was known as a verdict. Now we use the word conclusion to distinguish the inquest process from a criminal trial. Nobody is on trial here. An inquest does not decide matters of criminal or civil liability. There is no question of attributing blame. The inquest is simply a way of establishing facts about the death of Morgan.

Your role in this inquest is to answer four main questions. Who was the deceased? When, where and how did he/she come by his/her death? You are also required to record particulars for registering the death, such as date and place of birth and occupation. You are not allowed to express an opinion on any other matters.

The record of inquest, in due course, you must complete and sign a document called a Record of Inquest, setting out your findings and a conclusion about the death. That will include the medical cause of death. I will tell you more about this at the end of the inquest.

The procedure, you will shortly be hearing the evidence in this case, all of which will be recorded. I shall take each witness through their evidence. Then the family and other interested persons may ask questions through their counsel or legal representative. After that, you may ask questions to clarify any matters, if you wish. You should write these down and pass them to me. I have a duty to exclude any question that is not relevant to the purpose and scope of the inquest.

We will hear some evidence read out today without the witnesses having come to court. This is because they were not required to attend and their evidence is not in dispute.

I propose to put before you the written evidence as follows: Dr Appleton the pathologist, Dr Moore the toxicologist, Dr Honess, an A&E consultant, Cheryl Wiggs from West Sussex County Council, Becky Orr, a psychiatric nurse from Sussex Partnership Foundation Trust, Stephanie Collins, a psychologist from Sussex Partnership Foundation Trust, Grace Lawani from Sussex Partnership Foundation Trust, DI Alchin Gadd from Sussex Police and Loretta Rogers from West Sussex County Council.

I’m now going to read you a list of the evidence we’re going to hear and ask the Interested Persons to confirm they have a copy of the bundle.

They all do.

C: The evidence I am going to call today is that of: Dominic Goddard, Tanya Betchley, Louise Hodgson, Helen Green, Joanna Cooper, Ms Cherno, Dr Ahwe, Dr Julia, Jessica Archer, Chloe Patrick, John Traynor, Dr Lake, Mr Amosu, Karen Mackley, Katie Mills and Paul Beynon.

At the end of the evidence, I shall sum up the case to you. I shall give you directions on the law, indicating what conclusions you may consider and what factual findings are required to support them. I shall also summarise the evidence, reminding you of what is important in the evidence. Some of you may also find it helpful to take a brief note during the evidence. I shall then invite you to retire to consider your findings and conclusion.

Before proceedings start I have an important warning to provide to you, as members of the jury, you will decide the questions that arise in this inquest on the evidence which you see and hear in court, and on nothing else.

Do not discuss the evidence except amongst yourselves when you are all together in private. Do not discuss the inquest with family or friends when you go home, tempting though that may be, because it will be you and not they who hear the evidence in court, and you and not they who will come to conclusions in due course.

Do not communicate with anyone about the inquest in any way at any time; that includes by phone or text, chat lines, twitter or blogs.

During the case, if you happen to travel to court with a fellow juror, or you happen to bump into one another away from court, please do not discuss the evidence you have heard. Any discussions you have about this inquest should be whilst in the privacy of the jury room.

Do not be tempted to do your own research; just listen to the evidence. Do not go to the scene or make your own inquiries. Do not look anything up on the internet or on social networking sites such as Facebook. None of that is evidence. Why is this rule so important? Because our whole system of justice relies on open justice. All of those involved in this inquest and the public are entitled to know and hear all the evidence on which you have reached your conclusions. If you were to introduce into the jury room the fruits of your own investigations be they on the Internet, Facebook or Twitter then they would not have been tested in open court for all to see and hear. We all know how wonderful the Internet is and how useful search engines such as Google can be. We also all know how unreliable they can sometimes be. Seemingly authoritative pages on the Internet can turn out to be completely false. The simple rule is: do not make your own investigations. Of course this does not mean you cannot use the Internet for your personal affairs. It simply means do not use it to investigate this inquest.

These are important directions, given by me the coroner, and you must follow them. If you disobey them, any of them, it may amount to contempt of court or even a criminal offence, both of which can be punished by a fine or imprisonment.

That is why I must warn you about these things. And if any of it does happen it may bring the inquest grinding to a halt. That might mean having to start all over again with another jury, which would not be good, for the process of justice but also for the family.

Do not let anybody talk to you about the inquest. If anyone tries to, tell the coroner’s officer, who will tell me.

If you have any serious concerns about anything which takes place outside the jury room, or even inside it, do not hesitate to tell the coroner’s officer straightaway, so that I get to know about it.

This inquest is likely to attract some publicity. It is possible that there will be some publicity about this inquest and reporting of it in the press. The press are entitled to publish reports of legal proceedings that are held in public. There are rules governing those reports. It is possible you may see, or hear some of those reports. However good the press reports are, they are unlikely to report all of the evidence that is given in court. Publicity or press reporting is not evidence. Each of you has taken an oath or affirmation to consider the issues and your conclusion in the inquest on the evidence, and it is on the evidence that you hear in court that you will make your decisions. To ensure fairness to all can I ask each of you makes sure that your focus is on what is said in court in your presence and that you ignore any publicity or press reporting the inquest may attract.

At the end of the evidence I will give you directions on the law and provide you with a summary of the evidence that has been given in court. Please keep an open mind. The evidence will be presented to you over the coming hours. Do not jump to conclusions. The time to come to any conclusions is once you have heard all of the evidence and the directions I will give to you and you are in the privacy of your jury room.

You will decide this inquest on the evidence you see and hear in court and on nothing else.

M was a voluntary inpatient at Meadowfield Hosp, she had experienced mental health difficulties for some time and was waiting for a safety plan to be discharged

On 9 March 2023 m was found hanging from the door in her room.

The evidence will cover the main topics, these are the events leading up to the death of Morgan Betchley on 9 March 2023.

To include the care and treatment provided by the mental health services from January 2023 up to and including the date of death.

You will recall at the beginning of my speech I advised you we need to ascertain the questions we need to answer are when, where and how Morgan died including the circumstances and the medical cause of death of Morgan.

The evidence you will hear will include personal background of Morgan, events leading up to Morgan’s death.

Although this, there may be change of evidence as we unfold I expect the main issues to be determined are:

• Whether Morgan intended to take her own life
• Whether the care and treatment provided by mental health services caused, or contributed to, Morgan’s death

Members of the jury that is all I wish to say as an instruction. The first piece of evidence the family would like is a pen portrait detailing Morgan. Thank you.