The coroner called Morgan’s partner, Dominic Goddard, to give his evidence at 12:23 on Day 1 of Morgan’s inquest. He was the first witness to give evidence. He swore an oath.
The coroner thanked Mr Goddard “for being involved within the inquest process and our investigation, I appreciate you have provided a witness statement”.
She checked he had a copy with him, he did. It was dated 5 June 2024 and Dominic confirmed that nothing had changed since that statement, in terms of its content.
The coroner said she understood he wished to read his statement to the court. He agreed.
He read his statement to the court. Introducing himself as Morgan’s partner, and father to their young son [the coroner can not make a direction as their son is not a witness but has requested that the media do not name him]. Dominic met Morgan in Year 11, when Morgan moved to his school.
He said that she was very popular with a big friendship group, although she often doubted that. He described Morgan as a “very gentle, kind, caring person”.
He said as a mother, Morgan was what you want a mother to be, “attentive, loving, nurturing, giving and gentle”. He said that she was “totally committed” to always putting their son first, despite her own difficulties with her mental health.
“Morgan and [their son’s] bond was unmatched … until [he] was 1 they spent every hour of every day together. Morgan always found things for her and [their son] to do, trips to the park, trips down the beach, cafes and trips to see grandparents”.
When their son was young Dominic was studying. He said he would travel after college every day to Bognor Regis, Brighton and Chichester, the three places that Morgan lived with their son, to spend time with them. He would also stay with them at the weekends so they could spend time together as a family.
He told the court he had “amazing memories of time spent together” and that they were a “really tight family” and it was “Morgan who always kept us ticking”.
Dominic told the court that he is now a care worker, in a dementia unit. He described the training he had had in that role.
He told the court that Morgan and he had met when they were 16 and both in Year 11 at school. They became good friends and developed a romantic relationship when the country went into lockdown in March 2020. He said a few months after they got together, Morgan became pregnant.
He said at that time Morgan was living in Next Steps, which was her own flat but a support worker came in to check on her every day.
He told the court that it was August 2020 when Morgan became pregnant that she started to become more open with Dominic about her mental health difficulties. He said at that stage Morgan did not have any diagnosis but she had told him she used to self-harm when younger, and she had suffered with a previous sexual assault. She told Dominic about her past trauma.
“I became aware that she had fairly strong suicidal ideation at times, which seemed quite obsessive in that she couldn’t really get the thoughts out of her head and she could spend a lot of time thinking about what it was like.
I remember at some stage I found out that she was in groups on social media that glorified suicide”.
He told the court he couldn’t remember when this was.
He explained that as they had only been together for a few months when Morgan became pregnant he had not had much opportunity to see the impact of her period on her moods.
He said after their son was born there was a discussion about what contraception Morgan might take at that stage. He thought it was Tanya, Morgan’s mum, that told him Morgan struggled a lot more during her period, with a decline in motivation and self-care. He said she had previously taken the mini pill which had helped. She had the contraceptive injection after their son was born, but stopped it around October 2022 as she was worried she was putting on weight. He said Morgan could stay days in bed, missing college and become paranoid, when she had her period.
“There were times, particularly in 2021, when Morgan would have periods of poor mental health. I think this was mainly related to her struggling with social services involvement but I would not say there was any significant self-harm, usually a few scratches or something similar. Morgan would tell me after the event … it was not something I was seriously worried about at the time as I knew she had support workers to help her”.
Dominic told the court that their son was born in March 2021. Morgan lived in a mother and baby unit whilst assessments were carried out by Children’s Services.
“It wasn’t plain sailing but Morgan got through the parenting assessments and she was a brilliant mum to [our son]”.
He described that Morgan lived in a similar set up to Next Steps, with her own flat for her and their son, and Dominic was able to stay there and they could spent time as a family.
“It was the first time we were able to be together properly as a family and I would say that was when Morgan was at her happiest”.
When Morgan turned 18 she moved into a flat in Chichester. Dominic was close by and they spent lots of time together as a family. Later that year Dominic went away to university to study but described that Morgan was doing well. She held down two jobs, first at McDonalds and then at Premier Inn.
He told the court Morgan was a great mother to their son, she was also house proud and the flat was always clean and tidy. He said that Morgan even started her own dog walking business.
“It felt like a real contrast to everything we had been through when [our son] was first born and like we were really starting our family life together”.
In September 2022 Morgan started college. She was studying architecture, and the course was full time. Dominic said Morgan had been concerned that she would not make friends, but her fears were not realised and she made good friends really quickly.
However, a couple months later, certain stresses emerged. Dominic told the court that Morgan’s grades were going down and she didn’t feel like she had enough time to get her work done. He also mentioned fallings out in the friendship group.
“It seemed as if a small trigger would lead to a domino effect and it all started going downhill quickly. Looking back I can see Morgan’s mental health probably started deteriorating in December 2022 but at the time I wouldn’t necessarily have said it was significant”.
Dominic told the court that Morgan was physically unwell, she had strep throat and she was under additional pressure as he himself were physically unwell and having lots of tests.
He said he only really noticed that Morgan’s mental health was deteriorating around the end of January 2023. He described that Morgan’s motivation had completely disappeared and her college attendance had dropped to around 30%. He said he knew Morgan was capable of having low moods when she was physically unwell, but as far as he knew that had not led to self-harm. He thought it was a case of Morgan’s physical health impacting on her mental state.
Dominic said as far as he remember Morgan received her autism diagnosis in January 2023.
“She didn’t receive much information, other than being told she had it. I don’t think she was surprised by the diagnosis and in many ways I think she was quite relieved to have a name for how she felt… but I think she found it quite confusing as she wasn’t sure what it meant for her generally and in terms of support”.
He said he himself was not surprised when Morgan was diagnosed autistic as he already thought she was, partly because she’d always told him she were very autistic, and partly because of certain characteristics.
Dominic told the court it was difficult for him to piece together exactly what happened at the start of February 2023.
He said on the 1st he found out Morgan was suffering from hallucinations. and was hearing voices telling her to jump off a bridge.
“As there is a main road with a bridge close to our flat, I was really worried that she might hurt herself.
She was also acting strangely. She thought that we were going on holiday and started packing her bags. At first, I thought she might have sepsis as she had had this twice before and I thought that this might be causing the hallucinations”.
Dominic told the court he’d not been aware that Morgan heard voices. That she had always said she had two voices in her head which she described as her conscience, one good and one bad voice.
He said this was why he called for an ambulance, as things “felt so serious and different and I couldn’t think what else to do” as he could not take Morgan to hospital as he had to look after their child, and he didn’t feel it was safe for her to go alone.
He recalled the paramedics being reluctant to take Morgan to hospital, but agreeing to take her late that evening.
The following afternoon Morgan returned. He said that she didn’t seem any better.
“I was quite concerned as to why they had discharged her. I think I may have even called the hospital as I was worried about what support she would have. I remember being told there was a plan for the Crisis Team to come and see Morgan that evening, as they didn’t think there was any benefit to her being in hospital and I think they also said they did not have any psychiatric beds at that time”.
Dominic told the court in that call he was told to lock away Morgan’s medication.
“I couldn’t really understand why they were sending her home if she needed medication to be locked up”.
He said he was worried about how he would care for their son and for Morgan.
At this point Ms Elliott, counsel for the family interjected to ask whether it would be helpful for the jury to have the summary chronology in front of them. The coroner wished to continue but said they could have that discussion later on.
Dominic moved on to telling the court about events between 6-8 February 2023.
“On 6 February Morgan left the house and I didn’t know where she was. I was worried she might have hurt himself as she still seemed unwell, so I think I might have called the Crisis Line or the Police”.
He told the court he tried contacting Morgan but she was not answering her phone.
“It was only afterwards that she told me that she had taken too many paracetamol and had decided to take herself to A&E. I believe she was later taken to The Haven but at the time I was not aware of what had led to her being taken there”.
Dominic told the court on the 7 February he got a notification to say his Uber account was being used. Morgan had used it to get a taxi from The Haven.
Morgan told Dominic in a message that she wished to return home and jump off a bridge. He described contacting the police and using the location feature on Morgan’s SnapChat to find her. The police intercepted the taxi and brought Morgan home.
“I told them that she was too unwell to come home but they said there was nothing they could do which I found really shocking as she had said she was going to jump off a bridge”.
Dominic said when Morgan got into their flat she appeared to settle and she told him that she had left The Haven as it was his birthday the following day, and she wished to spend time with him.
He said the following day, 8 February, was his birthday and they went for a family meal during the day. Morgan tried to secure a GP appointment but was told there were no appointments available. He thinks she also contacted 111 and was told the same thing. Both advised her if she needed help to return to A&E.
He believed Morgan had an appointment with the Crisis Team at 4pm that day.
“My memory of that meeting was that it felt like they were not really listening or providing any real solution. They were suggesting things like Morgan going to see her GP but we were both saying that this was not working.
I think that they said they were trying to find a psychiatric bed for Morgan anticipating that she could be admitted the following day and they made a number of phone calls during the meeting asking whether anywhere had a chair or a bed. However, they gave up after contacting about four hospitals as they said no one had any space.
We both knew that Morgan would have to go back to hospital at some point as it was clear she hadn’t got any better and if she didn’t go into hospital she would harm herself”.
He told the court that it was very clear to him that Morgan was very unwell. She was still talking about hearing voices and she was withdrawn. He said they managed to get through the day and things were uneventful until about midnight, by which time Dominic had fallen asleep and Morgan came into their bedroom to wake him and let him know she had called an ambulance as she had taken an overdose of her antidepressant.
He described this as a “cry for help” as Morgan did not think she could last the night, but he said the overdose was of a small number of tablets, which he believed she’d taken so the ambulance would have to take her to hospital. Morgan was taken to A&E at St Richard’s Hospital in Chichester.
“Morgan was very unwell during her stay in A&E. She seemed a bit like a stereotypical psychiatric patient that you see in TV shows. She was pale, her eyes were glazed over, she was very sleepy and she seemed delirious as she seemed to be reacting to things that were not there. She was making jerky movements and not much eye contact. It was very strange seeing her that way, she was unrecognisable”.
Dominic said that he would visit Morgan twice or three times a day during the period she was in A&E. He said she was heavily medicated, asleep or confused and it was difficult to communicate with her.
“The only way I can describe it is it was like working with people with dementia. It was almost as if there was no way of getting through to her during that time, she seemed to be in her own reality”.
He said Morgan talked about wanting to die when she was in A&E, and that she said she wanted to remove herself from her connection with her son, Dominic and people she loved to make that easier.
Dominic told the court Morgan spent from 9 to 13 February in the A&E department. Most of the time was in a side room. He said staff were very good and tried to help her. He said that they would speak to Morgan and do activities with her.
On the 9 February Morgan called Dominic to tell him that she had ordered paracetamol through Uber and had taken some tablets.
“I am not sure how she had been able to do this as I think she was on 1:1 observations at that time. She was very matter of fact about it and said she had taken them to try and kill herself but she was aware that the hospital would try and medically intervene.
I told her I would have to call the hospital. She did not try to stop me but she told me that she would refuse any antidote as she wanted to die”.
Dominic thought he was present for an assessment Morgan had the next day, 10 February. He said a woman was trying to find a bed in another hospital for Morgan, and a male psychiatrist spoke to Dominic most of the time, not Morgan. He told Dominic that Morgan was sectioned. He has no recollection of being asked if he was Morgan’s nearest relative but a few days later he received a booklet in the post telling him about his responsibilities as Morgan’s Nearest Relative.
On 11 February Dominic was FaceTiming Morgan when she put something around her neck. He told the court he called the hospital straight away.
“Morgan was very open about doing it and I am pretty sure that she did it as she wanted help and she knew I would call the hospital”.
He said he did not believe Morgan was trying to frighten him, but “she felt like she wasn’t getting the help she needed and this the only way that she knew how to communicate this”.
He said Morgan was stuck in A&E which isn’t a pleasant environment for anyone, least of all an autistic person. He said it was overstimulating, extremely busy, noisy and bright.
“I think she felt the hospital wouldn’t listen if she told them how she was feeling but she thought they would listen to me.
Her autism meant that for her, everything was very black and white. She could either do something extreme and get help or she could do nothing and get no help”.
On the 12 February when Dominic was visiting Morgan and was about to leave, she said to him that she could not cope anymore and she was going to try to escape. She said that she wanted to go outside for a vape, so a member of staff took her out. Morgan ran off. Dominic ran after her.
“I remember the hospital security said they couldn’t do anything, as they had no legal power to stop her so I needed to run after her. By some miracle, a police car went past and the police officer knew Morgan and so he helped her get back to hospital”.
Dominic said the police officer was kind, calm and authoritative. Morgan was escorted back to her room, given more sedation, once she was drowsy Dominic left.
On 13 February Dominic was on call for work so he was not able to keep in touch with Morgan as much as he had when she was in A&E. She was admitted to Meadowfield Hospital on 13 February.
When they were speaking on the phone on 14 February, Morgan told Dominic that she had made a ligature from [withheld]. He described hanging up immediately and trying to contact Rowan Ward. To do that he had to call a main switchboard number, then wait to be put through, and then wait for someone to answer the ward phone. When they did he said he felt they were quite short and said they would check it out. When he next spoke to Morgan later that day she said it took staff a few minutes to come to her room and when they did, they did not seem to be rushing.
Dominic described calling the ward 2 or 3 further times during the first days of Morgan’s admission, to tell them that she had a ligature and someone needed to go to her room.
“Each time, it was difficult for me to get through and I experienced the same problems of not having a direct number for the ward and it taking a while for someone to pick up. Each time the response I received was fairly short”.
He said he contacted the ward on other occasions, usually to check whether he could visit Morgan. He told the court that generally he found the response from staff to be “quite sour”, they would say that there “isn’t much space but you can sit in the corridor and see her”.
“I cannot remember a time that anyone from Meadowfield actively reached out to me for information about Morgan during any of her three admissions. In fact often when I visited, staff would ask who I was. I thought their communication was really poor. I definitely did not feel I was being involved in Morgan’s care”.
He went on to tell the court on one occasion when he was visiting Dr Julia came to visit Morgan. She asked Morgan how she was, and she said that she was with Dominic, her partner.
“Dr Julia did not acknowledge me or speak to me.
I think it would have been helpful if she had as I could have talked about my knowledge of Morgan, events leading up to her going into hospital and safety issues about Morgan being discharged or what it would be like if she came home, which no one ever asked me about.
It would have also helped me as I would have known more about what behaviour was like and how to support her”.
Dominic felt in the week Morgan was at Meadowfield she “seemed a bit more with it”. She was still experiencing hallucinations, but they seemed less severe than when she had been in A&E. She made some friends on the ward, which seemed to help her, but she told Dominic she was struggling to get on with the staff.
“I was sympathetic to that as from what I had observed when I was visiting the ward, the staff seemed pretty annoyed and like everything was a bit of a chore”.
Dominic said Morgan continued to talk about wanting to die and was pretty clear that she wanted to go home and kill herself. He passed this information onto staff but said he did not receive much response from them.
He remembered mentioning that he had a one year old in the house so it was not safe for Morgan to come home “but the impression I got was that it wasn’t really their problem”.
Dominic told the court he believed it was during this admission that Morgan told him an autism passport had been set up for her, which he understood to be a communication tool to help staff understand more about Morgan’s needs.
“Morgan told me she didn’t think staff paid any attention to it so it wasn’t that helpful”.
On 21 February Dominic spoke to Morgan in the morning, and she seemed to think that she was staying in hospital a little longer.
“However, at around 4 or 5pm that day I received a call from someone on the ward to say that they were discharging Morgan home under the Crisis Team.
They said that they did not think Morgan needed to be in hospital but asked me to lock up any medication she had and to go to A&E if there were any incidents”.
He said there was no discussion with him about whether he was happy with the plan, or how he would manage to keep Morgan or their son safe.
“I couldn’t understand why Morgan was being discharged, it wasn’t safe and it wasn’t practical as I was working and so couldn’t be home to care for her.
There had not been a significant change in her mental state and I just thought we would be going full circle in terms of her coming out and doing something to hurt herself.
I was really worried about her coming home, in terms of what she might do to herself, but I felt I had no power to do anything at all”.
He said when Morgan got home that evening he locked away her medication. He said Morgan spent “99% of the time in bed between getting home and going back in to hospital on 22 February”.
He described her as “very quiet and withdrawn and she didn’t really come out to see [their son] which was a huge sign of how unwell she was”.
On 22 February the Crisis Team visited Morgan.
“I told them that Morgan had been talking about suicide and that I was worried about what she might do. I believe they said that there were no mental health beds available and so it was agreed that Morgan would go back to A&E that evening, which she did”.
Dominic said he did not go to A&E with Morgan that night as he had to stay home and look after their son. Morgan contacted him later that night to say she was at a Co-Op, close to the hospital, she had taken [withheld] and wanted to die.
“I called the hospital to tell them this. I am not exactly sure what happened but I think Morgan went to A&E of her own accord from the shop”.
On 24 February Morgan called Dominic from Priory Park, telling him she was going to [withheld]. He found her location on SnapChat and contacted the police, who went to the park. Morgan thought someone else had also contacted the police.
“My main memory of that time in A&E was Morgan was very unwell”.
On 25 February Morgan was admitted to Meadowfield Hospital again. Dominic told the court he did not visit Morgan on Maple Ward as he had just started a new job and had lots of induction.
He said his mum and Morgan’s mum took over so he could focus more on his new job and their son, so his contact with Morgan was much more limited than it had been.
They did still speak on the phone and he remembered her telling him that she was seeing wasps and bees.
“She felt the staff were horrible and not listening to her. She mentioned asking them about EMDR therapy, which I think she must have read about, but they said this wasn’t available for her and she felt hopeless about that.
Morgan was still very suicidal during that time on Maple Ward and nothing had really changed. She continued to say to me that she was going to commit suicide”.
He told the court it had moved in from I want to do this, to I am going to do this (suicide). He said it felt as thought Morgan’s mind was made up.
“I was not involved in anything that happened on 27 February when Morgan left Maple Ward and was arrested. The next time we had contact was when she was in A&E in Worthing Hospital”.
Dominic told the court he did not visit Morgan when she was in A&E or at Woodlands Centre in Hastings, but they spoke on the phone, although less than they had before.
“Morgan still seemed to be very unwell to me. She was talking about hearing voices and repeatedly saying that she wanted to die. There was no positivity whatsoever. She said nothing will help me now”.
Dominic described that from 27 February when Morgan went into police custody, until her death, she did not see her son once or talk to him. He described it as a “complete disengagement” and he also felt that Morgan was disengaging from him a little bit and holding things back from him.
“I knew this was her plan to disengage so she could die, and so it made me even more worried”.
He told the court when Morgan was at the Woodlands Centre in Hastings someone spoke to him on the phone and told him that Morgan had assaulted a member of staff.
“I found the way they spoke about it and explained it to me really helpful and caring. They explained that Morgan was unwell and how they were managing it and reassured me that it wouldn’t affect the level of care they gave her. The staff member was really reassuring and said he understood that these things happened on psychiatric units. More generally, I also thought the care Morgan received there was very caring”.
He gave an example of a staff member escorting Morgan to the bathroom in the waiting area when she was on the Section 136 suite, to afford her privacy and ensure it was less intrusive.
“It was a small thing but it really made a difference to her. She was still very unwell but I remember her saying at least they’re being kind, compassionate and understanding”.
Dominic told the court he visited Morgan in Meadowfield (we later heard she was transferred back there from the Woodlands Centre in Hastings) twice from 3 March onwards.
He said he knows from messages his first visit was on 4 March but he does not remember it. He was working that week and was quite busy. He said he spoke to Morgan on the phone during that period, but Morgan was mostly negative and there didn’t seem to have been any change in her.
He said Morgan continued to say she wanted to die and she wasn’t feeling any better. He said the tone of the conversation was very much I am going to do this. He tells the court he thinks he was the main person Morgan would talk to about her suicidal thoughts.
“Her feelings were always there but she was on a locked ward, so I didn’t think anything serious could happen to her”.
He said he would often call Rowan Ward to see how Morgan was getting on. He asked to speak to the psychiatrist on one occasion but was told she had gone home.
“There were quite a few times that the person who answered the call said they would call back, but they never did”.
He said he would often contact at night when Morgan was charging her phone so he wouldn’t hear from her for a few hours and would contact the ward to check she was ok.
“Sometimes they wouldn’t answer, but if I did speak to someone, they would usually just say that she was fine. I was still very much on high alert, higher alert if anything as when I was hearing nothing from Morgan it was almost more concerning for me”.
Dominic said he went to see Morgan on 8 March. They went out for a couple of hours, for a walk to the shop and for lunch in the hospital café.
“She seemed pleased to see me but she still was not well. Morgan mentioned the meeting with her psychiatrist that had happened the day before which she said was a horrible experience. It was clear that she was very upset about it. However, she said that it was too upsetting to talk about and she just wanted to focus on us having a nice day together. She did talk about the future a bit and the possibility of going on a trip to the Isle of Wight that her mum had suggested. She said she did not feel ready to come home but we were powerless to do anything”.
Dominic told the court that it was clear to him that Morgan was “anxious about it all”.
“For my part, I was concerned about Morgan being discharged but I also felt I had to trust the opinions of the professionals and I assumed they had done a comprehensive assessment to assess the risks around this”.
He said Morgan and himself spoke on Facetime that evening about normal things. They didn’t speak for long as Dominic was tired so he went to bed early.
“Morgan sent me a text at around 1am asking if I was awake but I wasn’t so I didn’t see the message until the morning, which is when I found out that Morgan had died.
Given how unwell Morgan was and that she repeatedly said she wanted to die, I always thought she might attempt things when she was in hospital but I never thought she’d be able to do anything serious when she was on a psychiatric ward, as I thought it was a safe place.
I thought she was on 15 minute observations and I was never told this had changed. I thought there would have been a member of staff around at all times.
I also thought she didn’t have any items with her she could use as they told me they had confiscated all dangerous items from Morgan when she was first admitted … [missed]If I knew there was a chance she could actually take her own life, or that people had managed to do that before, I would have been telling staff all the time to keep watching her”.
Dominic said when he did call or speak to staff he felt that was unwelcome, and they would dismiss him.
He told the court that Morgan’s overdoses or use of ligatures “came when she was feeling very anxious, overwhelmed or hopeless”.
He said he felt that the A&E staff at St Richard’s Hospital were strongly aware of this; that they had informed police about the possibility of Morgan escaping and put in place specific plans if that was to happen. He said that they put Morgan on 1-1 observations with a senior mental health nurse who Morgan could trust.
“Morgan evidently felt much safer at the A&E department than she did at Meadowfield. I would have hoped that the staff at Meadowfield were adequately trained to recognise abnormal, or erratic behaviour. The fact Morgan was talking about the future wasn’t itself a sign that she wasn’t at risk”.
Dominic told the court he thought the staff at Meadowfield failed to spot behaviour patterns when Morgan was at risk and dismissed ligatures being tied as “normal behaviour”.
“I still can’t quite understand how this could have been the case. I would like to say something about my overall feelings about this tragic case as I feel it is only fair I am heard, the impact this has had is heard, as well as giving my 3 year old son a voice. There is no skirting around the fact the death of such a wonderful mum and partner has had an immense impact on our family. I do believe Morgan’s death could have been prevented.
The care Morgan received, especially from Meadowfield Hospital was in my opinion, totally inadequate and it shocked me that this is how mentally ill people are looked after”.
He said he had to trust the care Morgan was receiving was not like what we see in the news, “unfortunately this was not case”.
“Everything I deeply feared would happen, happened and I was helpless to it. There was nothing I could do. I had to trust the people caring for Morgan, for the sake of my son and her wonderful family”.
Dominic told the court he felt there were some “crucial areas” where he thought Morgan’s care was inadequate.
“Morgan was shipped about from hospital to hospital, despite the fact all staff responsible for her care knew she deeply struggled with transitions and this had caused psychological decline in the past.
I fear staff are not trained to deal with patients in aggressive episodes. It is unfortunately something healthcare staff have to be equipped to deal with, as I do in my job. I often deal with residents in aggressive episodes but would never dream of asking them, or even accepting a letter of apology, as that is totally unprofessional and unkind”.
He continued to tell the court that he considered the impact of the clinician bringing up Morgan’s apology letter was huge on her.
“The impact on Morgan of being grilled about her apology letter in a discharge meeting by Dr Julia, and being questioned on how sincere it was, was huge for Morgan.
This deeply affected her as she was genuinely sorry for her actions. I believe this incident deeply contributed to Morgan’s actions on 9 March.
I think it made her lose hope in the service was meant to help her. She told me she felt helpless after this, and I am not surprised she did”.
He ended his statement by saying that he “strongly hoped” that all staff learnt from this so “no other family has to go through what we went through, and no child is left without a mother two weeks before their second birthday”.
“I believe Morgan’s death was preventable … overall I think Morgan was failed on an institutional and personal level. I think the atmosphere on Rowan Ward was unprofessional and very uncaring to patients and their relatives. Communication was appalling and often times left me scared for Morgan’s safety. I wish those fears had never come true”.
The coroner thanked Dominic, adding she knew that was “very hard for you to go through”. She said she had a few questions but that we would have lunch first.
She told him that he was not allowed to talk to anyone during the lunchbreak. Ms Elliott clarified that the coroner had meant that he was not allowed to discuss his evidence with anyone, but he was allowed to talk to people. The coroner agreed.
Court adjourned shortly after 1pm for an hour’s lunch break. On the return there was a housekeeping discussion that I’ll not report. The jury were brought back into court at 14:20.
The coroner introduced herself to the jury again and thanked them for returning.
C: On your desk is an overview and chronology of Morgan’s admissions to various hospitals between February and March 2023. This may assist you when dealing with the evidence, just gives you an aide memoire as to what happened.
Thank you very much Mr Goddard. I appreciate this is very distressing for you and thank you for being so thorough within your evidence. I just have a few questions. You say there was a trigger in December/January 2023 regarding Morgan’s mental health?
DG: Yes
C: Was anything happening at that point that would cause that trigger?
DG: Around December 2022 to January 2023 Morgan had some significant worries with college. Some of her teachers weren’t turning up and she was falling behind a bit with some of her coursework, she was a busy mother… I was also at university during that December as well until I had to leave due to my own poor health. … she was unwell physically at the beginning of January, she has always been bad mentally when physically unwell… her mental health has declined, she has lost motivation.
As well as that at the end of January, and February as well, around when she went into The Haven in February, was around the start of her period. Me and Morgan’s mum and my mum, all noticed Morgan’s mental health was significantly worse around the time of her period, and at the beginning of her period… [lists difficulties could cause, didn’t catch] … you could see this deterioration on Morgan’s person, her eyes and face would change…. She didn’t have that many periods in the time I was with Morgan due to being pregnant and on injection, from what I did see this was an obvious trigger, together with her grades going down, her teachers not turning up, and her physical health could all be contributing factors.
C: You mentioned in your statement about social services involvement?
DG: Yes
C: Were they still involved?
DG: Not at time Morgan became physically unwell. We had no involvement from the health visitor or social services at that time.
C: We heard in your evidence she had the autism diagnosis at the end of January. What support, did she obtain any support at time of receiving that report?
DG: Not at that current time, that I recall. She tried to get in touch with TCAP (?) but I can’t recall.
C: Of course not, only speak to what you know. Medication, what was she on at the time?
DG: [withheld] Sorry, before she got unwell?
C: At the time she became unwell
DG: At the time she became unwell she was just taking [withheld]
C: For how long?
DG: Around 8 months to a year, before that on other anti-depressants, changed as she found previous one becoming ineffective and she’d been on that for about 3 years
C: Thank you, I’ve got no further questions for you.
No questions for Dominic from Sussex Partnership FT or West Sussex Count Council.
It was over to Jessica Elliott for Morgan’s family to ask Dominic questions next.
JE: Thank you Dominic, I have 3 short areas for you, first is how you thought the hospital could help Morgan. The jury heard she seemed so unwell, in terms of helping her what did you think a stay on a hospital ward could do for her?
DG: Morgan often felt safer when she was detained… although contrary to what a lot of people might feel, it did help Morgan. At times when her mental health was poor in the past she’d self-contained herself, like staying in bed, has actually helped.
Hospital could be supportive by engaging with her about her autism diagnosis. She was very stressed about it and didn’t know much about it, and staff didn’t either, they didn’t have the [missed name, autism diagnosis] report. That could have helped her. As well was staff helping her with her emotions, the traffic light system, that could have helped greatly.
She kept a lot of things in, at some points that came out as anger and frustration. She was feeling frustrated as staff weren’t understanding how she was feeling. Autistic people often struggle to demonstrate how they’re feeling and how others are feeling… would have helped her for staff to be more aware of her feelings.
And having 1-1 time with staff, when she got to trust an individual she could talk to them about a lot of things. Not to someone she didn’t know very well. I know she did talk to a couple of healthcare assistants on the ward, if they engaged with her more about future and her problems, then obviously that could help.
Another one is therapy, I do understand is if difficult with acutely unwell patients, but they dismissed her… no hope … even the hope she might get better and relieve herself of some of her past traumas might have helped her outcome.
JE: So, containment, autism understanding and help with that diagnosis, 1-1 time with staff she had rapport with, and therapy. Were you aware of her having any therapy at this time?
DG: No, she didn’t have any therapy in the time I knew her. She did try greatly to get therapy.
JE: Do you feel with those measures she’d have been able to come through this crisis?
DG: Yes. I think it was totally preventable.
JE: You’d been together with Morgan how long?
DG: Nearly 4 years
JE: Had you seen her get through difficult times before?
DG: Yes. She went thru intense scrutiny, cameras in her bedroom, at Foundations for Families (?), when [our son] was first born, but she did get through it and came out other side even better. At the time she couldn’t see that containment was right thing for her, eventually liked being there, made friends there. At the end was a really positive report from social services, outlines massive change from when she first went in and when she left.
When she first went in, it was similar to when she was going into hospital. They had meeting in the Family Court to remove [our son] from her care as her mental health wasn’t good. They decided not to do that, to help her and it worked. So, hospital could have looked at those reports and seen how previous things had helped Morgan, and done similar.
JE: I want to ask you what you were told about 8 March, she is in her last admission to Rowan Ward. She has two admissions on Rowan Ward, both about a week. She knows at this stage she was due for release. What were you told about ligatures at that time?
DG: Paul Beynon told me after Morgan died, she was found with 2 ligatures on that day. On 8th I wasn’t made aware of this. In days before she had made ligatures, can’t be sure if she told me she had on the 8th. Was told point blank by Paul Beynon she did tie 2 ligatures and they were removed from her on 8th.
I also understand her belongings were removed from her due to staff concern about her state on the 8th, however the bed sheet was not removed.
JE: Do you understand these 2 ligatures were something else?
DG: Yes. I understand these two ligatures were [withheld]…. Was also [withheld] prior incident.
JE: So you’d seen [withheld] ligatures before?
DG: Yes. I’d seen before and had reported to staff on many, many occasions.
JE: The meeting with Paul Beynon on the day after Morgan died, did the issue come up during meeting?
DG: Issue was discussed during the meeting, Paul Beynon didn’t specifically say this happened in the meeting, was on the phone call before. When me and Tanya discussed ligatures with Paul Beynon he didn’t deny ligatures were tied, he said might need looked into further. He wasn’t surprised.
JE: So, you were all proceeding on the basis ligatures were tied?
DG: Yes
JE: Last thing, Morgan’s intentions on the night she died… [missed] your contact, what’s your view of Morgan’s intention on the day Morgan took her life?
DG: I do not believe Morgan intended to take her life. I think was another cry for help, as we’d seen before with a discharge that shouldn’t take place… Morgan was due to go back and stay with her mother, any other time she would love that.
I think Morgan herself knew she was not ready for discharge. I’d have hoped staff were in that corridor at night surveying, always keeping eyes on. I think Morgan would have expected staff to have seen, heard what she was doing, rescued her, had a chat and said you’re clearly not well we won’t discharge you… I do not believe she truly meant to end her life on that night.
No further questions from Ms Elliott.
The jury had a couple of questions, so the coroner asked them to write them down and pass them to her so she could check that they were in scope.
C: I think some of these questions will be used for other witnesses and I don’t think they are the correct questions for this witness, don’t think he’ll be able to answer them. There are two questions I’ll put to the witness, the other questions I think you should keep and ask at a later stage.
I don’t know whether you could explain to the jury why social services were originally involved?
DG: Social services were involved due to Morgan having mental health problems when she as 11… Morgan had a sexual assault at age 13 and an incident with the police which led to her having PTSD symptoms and flashbacks, never to the extent of these levels of poor health.
Also involved because of our age, me and Morgan were only 16 when we found out Morgan was pregnant, you have to have someone called a Special Guardian who is aged over 18… [missed rest of answer but Dominic said the Family Court wanted to assess Morgan’s parenting due to her mental health, assessments which she passed]
Jury question, read by C: Had she expressed a desire to kill herself in previous mental health incidents?
DG: Not directly to me no. As I mentioned in my witness statement, she had had suicidal ideation, that wasn’t so much wanting to kill herself but an obsession with death and suicide. Wasn’t so prevalent once our son was born, she was now a mother and had something else to think about.
Definitely was some suicidal ideation and obsession with afterlife and what happens, but no specific intention to kill herself… she always seemed to find a way out whether that was medication, talking to her GP. She tried to get therapy but didn’t get anywhere with that.
C: Dominic if I can clarify that. It was only this episode of mental ill-health she had suicidal ideation?
DG: When I mention suicidal ideations, I’m talking about obsessive thoughts about suicide. Morgan may have said in the past I wonder what suicide is like, had joined suicide groups online on Instagram and SnapChat which glorified suicide. That obsession was worse when mentally unwell. She’d never said to myself I am going to kill myself.
C: That’s what we refer to as suicidal ideation; so did she have suicidal ideation prior to this?
DG: Not in the time I knew her
Jury question read by C: Another question, unsure whether you’re able to answer, may be better for another witness. Prior to the assault, what happened and what made her write an apology letter?
DG: I’m probably not the right person, I didn’t have much communication with the hospital after the assault, but from what Morgan said to me she felt she had to write an apology letter as staff refused to speak to her after the assault
Jury question read by C: Prior to the assault what care had she been provided with?
DG: I can’t answer that as I didn’t visit the ward she as on at the time.
Jury question read by C: Were the hospital aware of her autism diagnosis?
DG: I can’t comment too much on that either, it didn’t seem to me that many of them were. She didn’t receive much support with this. I know the psychiatrist was aware, she said she knew Morgan was autistic, but she didn’t believe she was during the time Morgan was on the ward, she didn’t believe she saw traits of it.
The coroner told the jury that the remaining questions will be for another witness. At this point there was a further jury question handed up to the coroner.
Jury question read by C: Mr Goddard I know within your statement you’ve talked about Morgan’s decline when she has her period.
DG: Yes
C: Did Morgan seek help for these issues?
DG: Yes. Morgan sought extensive help for these issues and was aware her mental health suffered when she was on her period, which was why she got the contraceptive injection as most common method to stop her period. Will probably hear later in evidence CAMHS dismissed the fact she had Premenstrual Dysphoric Disorder, which led to her losing hope.
Is recurring themes, Morgan was rejected on multiple occasions, before her autism was eventually accepted. She was aware, but lost hope because she couldn’t get a diagnosis.
There were no further jury questions.
C: Thank you for your patience and again I’m so sorry you had to be involved with this process, you are now released.
Dominic was released at 1446