The second witness called to give evidence at Morgan’s inquest, was her mum Tanya, who swore an oath at 14:47.
C: I appreciate this will be quite difficult for you and you’ve chosen to read your statement?
TB: I have
C: Dated 28 June 2024
TB: I believe so
C: Will be right at back of the statement
TB: Yes
C: All the information in your statement is true?
TB: Yes
C: Nothing has changed since you signed the statement?
TB: That’s correct
The coroner invited her to say anything she’d like about Morgan and to read her statement. Tanya said hello to those present and said that she would read most of her statement, but would take out some of the information at the start because the jury had already heard it in the pen portrait.
[The pen portrait was a video shown at the start. I’ve not reported it yet because I’m hoping the BBC will share some of it, and if they do I’ll share a link].
Tanya introduced herself as Morgan’s mum, shared her date of birth was and told the court that Morgan was 19 when she died.
“Morgan showed great strength and resilience on numerous occasions throughout her life. We are so proud of her. It goes without saying that that we are absolutely heartbroken that she has gone. Life will never be the same again. We have lost so much”.
Tanya explained her professional background to the court, she works as an inclusion welfare officer in a secondary school and had worked for the local authority in various roles, predominantly as a family support worker before that.
“My job involves ensuring children have access to education but we look at this from a whole family perspective. We often create support plans, working in partnership with other organisations to safeguard children.
I work with local authorities and mental health services and as a result, I have a fairly good understanding of those systems and how they operate.
I feel it is important to explain this as it is this experience which meant that I had some understanding of the various systems involved with Morgan and it was through this that I felt I had exhausted all avenues for obtaining support for Morgan”.
Tanya told the court that Morgan’s mental health difficulties started when she was 12 years old.
“It became apparent to us that these mental health difficulties were above and beyond the normal challenges that teenagers face. She would have periods of being particularly agitated, anxious, paranoid and low in mood”.
She said Morgan would think people didn’t like her or were talking about her, and she began to talk about visual and auditory hallucinations. Tanya said she would at time witness Morgan talking to herself and physically reacting by twitching and flinching. There were periods when morgan was unable to attend school, and she had “extended periods of being isolated and withdrawn”.
Tanya said initially they tried to explore whether anything was a trigger for the deterioration in Morgan’s mental state. She said that she is aware Morgan’s records talk about Morgan being sexually assaulted by two boys her age, when she was 13 but Tanya believes this happened when Morgan was 11 or 12, but she had not disclosed it until she was 13. Morgan disclosed it to a professional, would not disclose who the boys were or make a police report. Tanya said it was “very possible that this incident impacted Morgan’s mental state”.
“Shortly after Morgan started her menstrual cycle I noticed that she was experiencing mental health challenges that would exceed what normally would be attributed to PMT. Over time, it became apparent to me and her stepdad that there seemed to be a link between Morgan’s cycle and a significant deterioration in her mental health”.
Tanya described changes in Morgan’s personality and appearance 3 to 5 days before menstruation, during and for 3 to 5 days after.
“During these episodes, Morgan would experience heightened agitation, paranoia, depression, mania, visual and audio hallucinations. As time went on, the episodes became increasingly difficult to manage as Morgan started to self-harm and experience suicidal ideation and insomnia.
This impacted on her ability to learn, keep herself safe, socialise and engage in positive activities.
In her early teens, outside of this menstrual phase, Morgan could experience periods of wellness, although she would remain plagued with intrusive thoughts and severe anxiety”.
Tanya told the court that her and Morgan had raised their concerns about Morgan’s hormonal changes being linked with her increasing mental health challenges with various professionals including her GP, hospital clinicians, CAMHS professionals and other mental health services. She said this included during February and March 2023, the period immediately before Morgan’s death.
“I am aware that Dr Julia’s statement says Premenstrual Dysphoric Disorder was ruled out medically for Morgan but I have not seen any records that confirm this and I am unaware of any tests conducted to rule out any medical link”.
Tanya said when Morgan was about 14 her GP “really listened to the concerns about Morgan’s menstrual cycle and he prescribed her the contraceptive pill”. Tanya said this was really helpful until eventually Morgan stopped taking it, in part because she wanted to have a baby and because her obsessive thoughts would overrule her thinking in such circumstances.
Tanya described obsessive behaviours that Morgan displayed. She said it was not really present when Morgan was young but became worse as she became a teenager.
“We began to notice that she would get an idea in her head and it was as if she would do whatever it took to achieve that thought at the time”.
She described some of the obsessions Morgan had including suicide, drastic diets and handbags.
Tanya told the court that Morgan could communicate her feelings well by writing and drawing. She wrote lists and kept journals. These would include her daily tasks and her future ambitions.
“This would be a healthy strategy to keep focused and to organise her thoughts. However when she was unwell, the content and tone would change to self-hate, hopelessness and suicidal ideation. She would write significant amounts of information or would repeat sentences over and over again. She would use visual aids to communicate when she was aware that she was feeling unwell and this was a very important strategy and coping mechanism for her”.
Tanya then told the court about Morgan’s self-harming behaviour which she first became aware of when Morgan was 13. She described what form this could take [I’ll not report].
When Morgan was 15 this escalated and by the time she was 16 it eventually resulted in Morgan being admitted into hospital and taken into care.
Tanya told the court that in the early years Morgan was very secretive about her self-harming, she wouldn’t share it with Tanya and was always trying to protect her. She said Morgan was always very upset when her self-harm was discovered. Morgan was encouraged to communicate before, during and after periods of self-harming but she said that she did not wish to upset people, and she had to self-harm to stop the voices in her head.
“When her thinking appeared clearer Morgan could communicate to me about her feelings and self-harm and would engage with targeted support organised by school, Children’s Services, Early Help and privately sourced services.
I would not describe Morgan’s behaviour as attention seeking and I would be very concerned if it was characterised in that way, given her mental health needs. I think her self-harming was often a form of communication and, if anything, I would describe it as attention needing”.
Tanya said Morgan was “quiet by nature, easily embarrassed and shy” and therefore “any sort of outburst would be out of character and an indication she was unwell”.
She told the court that Morgan was a “kind and gentle girl” who she would not describe as violent or aggressive, as that was not her or her families experience of Morgan. She said she was aware of Morgan’s medical describing at various points an incident when Morgan was said to have been violent at school. Tanya explained when Morgan was 15 a safeguarding report was made about her self-harming behaviour, after a friend rightly informed the school about it. The school contacted Tanya and Morgan was upset that she had been told. She went to her Year Heads’s office and began shouting and crying about it being discovered. The head teacher told Tanya that Morgan swept items from the desk onto the floor, before leaving the building in a hysterical state. Morgan “had not assaulted anyone or threatened violence”.
Later Tanya and the head agreed that Morgan would benefit from a managed move to a new school to give her an opportunity of a fresh start with support, as it was apparent she was unwell. She then went on to complete her GCSEs.
Tanya then went on to describe an incident that happened in Swindon the following weekend where Morgan was in a state of overwhelm and lashed out and pushed Tanya over. She did not know what to do and contacted the police who arrested Morgan, took her to a police station, where Morgan was stripped of her clothes by 5 officers “which was an extremely traumatic experience for her”.
Tanya told the court about support Morgan had received as a child from Children’s Services when she was 12 and there were concerns about her mental health.
“Initially this did not appear to have any impact but eventually Morgan was referred to the Early Help service in June 2019, when she was 15, which was very beneficial for her and this help supported Morgan to enter a fairly prolonged period of wellness.
Morgan particularly benefitted from the Early Help Family Support Worker advocating for her during official meetings”.
In 2020, Morgan was 16 and had an extended period of being unwell. She was repeatedly self harming and had lost a significant amount of weight. She was on the waiting list for CAMHS support and an autism assessment. At this time she was first prescribed anti depressants by her GP.
“I had been unable to access more support for her and I was concerned about the impact that Morgan’s self-harming behaviour was having on my younger child who was exposed to it within the family home.
I was advised by a number of friends with professional experience that the only way to force the provision of support would be to refuse to have Morgan home, which is what I did in July 2020 when Morgan was admitted to hospital after self-harming and experiencing suicidal thoughts. I did this as I felt I had no other option to keep Morgan safe and I knew that I could not do so if she was at home.
Her periods of illness were increasing in severity with age. Nothing else had worked and I was completely desperate. As a result, Morgan was taken into the care of the local authority and became a looked after child at the age of 16.
We were still in very close contact and I was involved in her care, but it did result in her receiving a much more intensive package of support”.
Less than a month after Morgan went into foster care she discovered she was pregnant.
“Morgan was delighted about being pregnant”.
Tanya described the heavy involvement of the Child Protection team from that point, until Morgan moved to Brighton in 2021.
“My view is that the support from Children’s Services was essential, robust and beneficial. Whilst Morgan did not always want to comply with every request, she engaged well and eventually the involvement of Children’s Services stopped when it was apparent that there were no concerns about Morgan’s parenting abilities.
I would say that the period after [her son] was born, from the middle of 2021, until around January 2023 was the most settled and stable that Morgan had been since childhood”.
Tanya told the court that Morgan had been working whilst pregnant and had started an architecture course at college. She said these were all signs she was going much better, that she wanted to work, to learn and to earn money for her family.
Morgan received her autism diagnosis in January 2023. When Morgan was 15 a social worker informed Tanya and Morgan that she “might be autistic” and she was referred to CAMHS for assessment. Due to the waiting lists this did not happen until Morgan was 18, and she received her diagnosis shortly after her 19th birthday.
Tanya told the court that the “diagnosis made sense to me” and that the “autism diagnosis appeared to be one piece of the puzzle”. Tanya had started learning about autism and how it presented in girls when it was first suggested that Morgan could be neurodiverse. Tanya gave several examples of how Morgan’s life experience and difficulties could be attributed to neurodiversity.
“I think that Morgan struggled to process her diagnosis. She had waited years to get some understanding of her difficulties and then was presented with the diagnosis, but without any suggested support plan other than the generic signposted services printed on the back of her paperwork”.
Tanya said she was not aware if Morgan had attempted to make contact with any of the services or if she’d been offered support by Sussex Partnership Trust, who’d arranged for the autism assessment to take place.
“As a family, we received no guidance from Sussex Partnership about therapeutic support for Morgan.
I know that Morgan found it hard to come to terms with her autism diagnosis. It is not that she disagreed with it but she described feeling like an alien afterwards.
I know she tried to see her GP quite soon after receiving the diagnosis but she was unable to get an appointment.
Within a week or so of receiving the diagnosis of autism, Morgan was in the middle of a crisis and had been admitted to hospital. There was no real space for her to process everything and once she was in hospital, it did not feel like there were any autism specific services being offered to her”.
Tanya told the court she was contacted by Morgan’s college in January 2023 as they had concerns about her attendance. When she spoke to Morgan she revealed stressors in relation to her college work and feeling unsupported by her tutors.
She told the court that she became aware Morgan was feeling unwell in early February. Morgan had flu-like symptoms, her anxiety was increasing and she was hearing voices. She was unable to get a GP appointment.
“Told me that she was going to seek help from A&E, which she had done numerous times in the past. From that point onwards, her mental health declined rapidly”.
On 9 February Tanya became aware Morgan was in crisis, when Dominic contacted her to explain Morgan was in hospital having taken an overdose.
Morgan said she was feeling suicidal and experiencing audio and visual hallucinations.
“She felt she had lost touch with reality but she wanted to feel better”.
Tanya described her visits to Morgan in A&E at St Richard’s Hospital and speaking to her on the phone and on Facetime.
“She seemed low in mood and was very sedated. Morgan did not want to be unwell in hospital. She wanted to feel better and be at home so I knew the fact that she was in hospital and accepting of an admission meant she must be seriously unwell.
It was positive that Morgan had accepted help and I believe that at that stage, she had some element of hope that she could get better. I would describe that initial admission as essential and lifesaving at the time”.
She told the court that Morgan trusted the staff at St Richard’s and she was on 1-1.
“I felt the 1-1 was necessary to keep her safe and alive”.
Tanya was present for Morgan’s Mental Health Act Assessment on 10 February. She spoke about Morgan’s struggles and how she had coped when in crisis in the past. She told the court that she fully supported the decision to admit Morgan to hospital given how unwell she was “and there did not appear to be any support for her in the community”.
Tanya told the court she was glad when they found Morgan a bed at Meadowfield as it was clear to her that Morgan was unwell and needed to be in a safe environment. She said Morgan was motivated to get better and she was committed to focus on her health so she could then be discharged when she was in a better place.
“I remember during the admission Morgan had tried to organise an activity for her and other patients as she said that there was no therapeutic treatments available on the ward.
She was really proud of herself for doing this and had been pleased with the response and support she had received from the other patients”.
Tanya had no contact with anyone from Meadowfield during that admission. She was not contacted for any history about Morgan, or about a care plan, or before she was discharged.
She said she was surprised when Morgan was discharged on 21 February as they had assumed Morgan would remain in hospital until a care package could be put in place for her in the community. Tanya said the discharge was “abrupt” with no safety plan for Morgan or her son that involved any of her support network.
“I was surprised that Morgan had been discharged as her condition had not improved and I was shocked at the total disregard for safeguarding”.
Tanya spoke to Morgan the morning after she was discharged and she seemed relieved to be home. She told Tanya about a meeting she’d had with her son’s social worker that she felt had gone well. That evening she was informed by Dominic that Morgan had been “sent back to A&E by the Crisis Team as she had wanted to jump off a bridge”.
“I believe that her mental state at this time was exacerbated by the lack of a collaborative discharge planning and consideration of withdrawal from PRN medication”.
Tanya sent Morgan messages urging her not to take an overdose and telling her that they loved her.
She did not respond until the following day, 23 February, when she said she was embarrassed about what happened. She told Tanya she had put no next of kin in her records so no one would be bothered by calls about her.
“In Morgan’s mind, I believe she felt like a burden and didn’t want to trouble us with her difficulties. I suspect there were misplaced feelings of embarrassment, guilt and hopelessness”.
Morgan sent Tanya a text on 26 February to tell her she had been admitted to Maple Ward at Meadowfield Hospital. She was hoping for a transfer to Rowan Ward as it was familiar to her.
Tanya and Morgan exchanged a number of texts that day about how Morgan was feeling and arranging for Tanya to visit. Tanya told the court it was clear to her that Morgan was struggling and needed to be in hospital.
Morgan sent Tanya a text saying:
“I hate myself for feeling the way I do and having the thoughts I have. I hate being away from home but at the same time I know I can’t keep myself safe because thoughts are so overwhelming.
I hate having these problems, it is awful and I’m trying my best to be looking on the bright side even when it’s super hard. I just want you to know I’m trying and this is not me”.
Tanya was due to visit Morgan the next day, 27 February. She called that afternoon to check it was OK and a staff member asked her to call back in an hour. She told the court she could hear screaming and banging in the background. She was told Morgan was involved and very distressed.
Shortly after ending the call she received a text from Morgan telling her not to visit as she was being discharged. Tanya said this immediately concerned her as she knew how suicidal Morgan was, and she felt like she was withdrawing.
“I tried to call Morgan to find out what was happening but she didn’t answer her phone. I then called Maple Ward and I could hear Morgan screaming in the background.
I begged the member of staff not to let Morgan leave as she was such high risk. It was apparent to me from what I had heard that Morgan was distressed, I knew that she had poor impulse control and I knew that there had been no change in her risk since she had been admitted and I was scared that she would do something to harm herself if she left hospital.
The member of staff told me that 5 members of staff had been injured. I apologised for any harm Morgan had caused and explained that she very unwell and again pleaded with him not to let her go but he said there was nothing he could do.
Whilst I was still on the phone he said that Morgan had left the ward. I was horrified that Morgan was being abruptly discharged following such a serious incident”.
Tanya told the court she felt as soon as Morgan was released she would attempt to end her life. Morgan was not answering her phone, when Tanya text to say she would collect her Morgan said she was outside the hospital. Worried for Morgan’s safety, Tanya called 999.
“I was pretty certain that she would try to harm herself as a result of being discharged as she was in no fit state to be out on her own and I knew she would have been very distressed by what had happened.
It took around 20 minutes for the emergency services to decide whether an ambulance or the police should attend and eventually it was decided that the police would attend.
I was later informed Morgan had been arrested by the police and taken to custody. As awful as it sounds, I was grateful as I thought she would be safe”.
Tanya remained in the waiting area at Worthing Police Station all of the following day until she was informed that Morgan had been placed under a police mental health section and would be transferred to hospital.
Tanya said that she was relieved when the AMHP [Approved Mental Health Professional] contacted her to tell her that Morgan would be detained under Section 2 of the Mental Health Act, rather than be discharged. She requested that she be involved in any future discharge planning.
Morgan was admitted to the Woodlands Centre from A&E late on 1 March 2023.
“That day I had sent a series of messages to Morgan trying to keep her spirits up and reassuring her that we were trying to get a plan and support in place for her.
I wanted her to feel hopeful for the future and that she would have support to get her through this crisis. I asked her to put me down as her next of kin, which she said she would.
This was all part of trying to ensure that we were engaged in her care and that there would be appropriate support in place as we were all very concerned about the two abrupt discharges that had taken place from both Rowan Ward and Maple Ward”.
Tanya said that although Morgan was only at the Woodlands Centre for a short period (two days) it was “noticeably different to how it had been at Meadowfield Hospital”. Morgan’s family were provided with a Welcome Pack and staff were very communicative with them. Tanya said staff treated Morgan with compassion, whilst putting in place boundaries.
Tanya was invited to attend a ward round on 3 March at Woodlands Centre. She attended by phone with Louise, Dominic’s mother.
“I remember that there was a discussion about the need for Morgan to sign a behaviour contract as this was a requirement by Meadowfield Hospital. Morgan agreed to the contract and had to sign it in order to access the care she needed”.
That day Tanya contacted the Woodlands Centre about Morgan’s autism diagnosis and her autism passport, after it was mentioned that Morgan may have “possible autism” which made her realise they’d not seen the autism assessment report.
A friend of Louise’s had helped prepare an autism passport to help Morgan communicate and feel understood. Tanya though this was an “excellent idea”. She contacted the hospital and explained Morgan had recently diagnosed with autism and the communication passport was designed to help her communicate.
“I wanted staff to be aware that Morgan had the resource and was keen to use it. It was agreed that I would email the formal autism diagnosis to ensure it was in her file. The male nurse was receptive to using the tool and he assured me that he would circulate the information to all relevant staff immediately.
I emailed the hospital with Morgan’s autism diagnosis report and sent it to Richard Lees and Harvey Rose at Sussex Partnership Trust on 2 March 2023”.
She said that her emails were exhibited to her statement and told the court she had received a response from Harvey Rose stating he would forward the report to the relevant people.
“I assumed the report would then be shared with everyone involved in Morgan’s care so that there was no continuing doubt about her diagnosis”.
Tanya did not know when it was decided Morgan should return to Meadowfield Hospital, given what had happened on Maple Ward. She said they had all been relieved when Morgan had transferred to the Woodlands Centre in Hastings as it was such a different atmosphere and approach from staff. Morgan had been happy to remain there and “we would not have had difficulty to maintain visits and contact with Morgan at Hastings, but we were not asked about this at any point by staff”.
Before Morgan returned to Rowan Ward, Louise [Dominic’s mother] had shared with Tanya a letter she had written to Meadowfield Hospital about the management of Morgan’s care over previous weeks. Tanya told the court that she agreed the letter should be sent.
“I thought it was important that the risks that Morgan posed to herself were highlighted as well as the risk of her being prematurely and abruptly discharged as in my view, this needed very careful management to ensure that Morgan understood what was happening and to ensure that she would be safe.
Morgan’s autism meant that how she was communicated with, and planning for any change or transition’ was particularly important”.
Tanya text Morgan to encourage her to complete a ‘Top Tips to Help Me’ sheet that Louise had given her the previous day. Morgan said she had already completed it and given it to the staff the night before.
Tanya told Morgan that they were trying to put a plan together for when she was well enough to be discharged. This was her attempt to show Morgan that they were planning for the future and thinking about how to get her well and get her support in the community.
“As far as I am aware, there was no discussion with Morgan when she returned to Rowan Ward about what had happened on Maple Ward and there was no attempt to help her process this and understand what had happened.
I am aware of the apology letter that Morgan wrote to staff. My recollection is Morgan wrote the letter in the hope that staff would understand that she hadn’t deliberately wanted to harm anybody and that she was sorry that anyone had come to harm.
Morgan wanted staff to have a better understanding of the feelings and triggers that had caused her to lose control. Morgan felt that some staff were hostile to her and that this was preventing her from being able to feel cared for in that environment, so that she could feel better. The hostility from some staff was causing her to feel more isolated and anxious”.
Tanya visited Morgan on 5 March. She told the court she was “sedated and very low in mood”. She said Morgan spoke very quietly and very little. When she mentioned her son in the conversation, Morgan would immediately shut the conversation down.
“Morgan was ruminating on the fact that she said she was being told that there was no treatment for her in hospital. She felt she was continuously being told that she was free to leave, that there was no treatment available for her on the ward, other than arts and crafts, and that she would be better off in the community.
For Morgan, perhaps because of her autism, she felt that this was because her feelings did not matter and staff did not care what happened to her”.
Morgan also told me that day and on other occasions that staff did not like her and were angry with her about what happened on Maple Ward. She felt this was affecting her care and how she was being treated. She told Tanya that some staff were ignoring her and some specific staff members were refusing to work with her.
“Morgan spent a lot of time working on the traffic light autism tool when she was admitted to Meadowfield, however she became very despondent as she felt that staff weren’t interested in using it to support her communication.
She had asked for this to be copied and placed in and out of her room but this was never done. I have a clear recollection of Morgan telling me that she felt upset that staff were not using the tool and that she felt hopeless because of it”.
Tanya told the court that she was questioning whether Morgan was interpreting staff’s behaviour correctly as she was capable of being paranoid and of misreading signals. She delicately questioned Morgan who gave the above examples.
In the afternoon of 6 March Tanya contacted Rowan Ward by telephone, as no one had contacted her since Morgan was admitted three days earlier. She asked to be involved in Morgan’s care planning and any discharge planning that took place.
“I wanted to be sure that Morgan would not be discharged again without a plan in place. I was not seeking Morgan’s discharge but was concerned about the effect that a premature discharge without adequate support could have on her mental state and risk of self-harm”.
Tanya spoke to Morgan after that afternoon’s ward round and she was extremely upset and crying.
“She told me that Dr Julia had questioned her autism diagnosis and told her people were frequently misdiagnosed. Instead, Dr Julia had said that Morgan more likely had Emotionally Unstable Personality Disorder and she was not acutely unwell.
Morgan said she was being told that Meadowfield wasn’t the right place for her and that there was no treatment in hospital that would help. For Morgan, this was like being told that there was no hope and she would not get the support she needed”.
Tanya told the court that Morgan was also very upset because she had been told that the letter she had written “was not deemed genuine by staff and that relationships had been damaged”. References to Morgan’s letter and Louise’s letter caused Morgan great distress as she saw it as another way that staff viewed her negatively.
Tanya called the ward at 4pm on 6 March and asked to speak to the Ward Manager, Jess Archer. This was the first time she spoke with her. Tanya made the call as Morgan had text her saying “please can you get me out of here” and Tanya was worried Morgan would try to discharge herself, and she felt there needed to be a plan in place before Morgan was discharged. She told the court Jess agreed.
“I am aware that the record of that conversation says that I did not feel Morgan being in hospital was beneficial for Morgan and a suggestion that I could potentially take Morgan home the following day.
I definitely did not say to Jess that I wanted to take Morgan home. We had been told on multiple occasions that the hospital was not the right place for Morgan and although we were absolutely certain that her risk remained as high as ever, we were very concerned that Morgan would be discharged in any case, without suitable safety planning.
Professionals consistently told us that Morgan needed to be out of hospital as there was no care for her there.
As Morgan’s family, we absolutely would have preferred Morgan to remain in what we viewed to be a place of safety, observed day and night, more frequently than at home. We were trying to work with professionals who were advising us and trust in their clinical expertise.
At no point did I indicate to Jess, or anyone else, that we wished to override advice given to us by professionals and discharge Morgan before it was appropriate. On the contrary, all our instincts and the many conversations within our family were around the fear that Morgan was going to be discharged far too soon with no robust clinical or safeguarding plan”.
Tanya described walking a difficult line between trying to support Morgan and make her feel heard, and also ensuring she was not discharged without a significant care package in place.
She updated Morgan after speaking with Jess and said Jess would be arranging a discharge planning meeting for the next day. Tanya told the court she urged Morgan not to discharge herself and to stay overnight.
Tanya told the court that she went to Rowan Ward on 7 March to take Morgan out. Morgan was struggling to communicate, very withdrawn, very low and appeared sedated. She said it was difficult to talk to her throughout the day “as she was very detached”. They returned to the ward for the discharge planning meeting that afternoon.
“I went into that meeting in the hope that we could all work together to plan for a safe and successful discharge for Morgan. I did not have any preconceived ideas about timescales in relation to when Morgan would be discharged but I felt strongly that we needed to start the process early to make sure there was a proper package of support in place when she was ready to leave hospital.
I definitely did not expect that there would be an imminent discharge as it was abundantly clear to me that Morgan was too unwell to go home. The risk she posed to herself had not changed and if anything it had got worse since the beginning of February as she felt she had no hope of treatment”.
Tanya told the court who was in the meeting (Morgan, herself, Dr Julia, Jess, someone from the Community Mental Health Team attending remotely and Louise attending by phone). She described how unwell Morgan looked.
“The meeting was led by Dr Julia, who I had not met before. From the beginning, it was apparent that the hospital was working on the basis that Morgan should not stay in hospital.
Dr Julia started out by discussing the discharge as imminent and saying that Morgan would only recover accessing treatment outside of the hospital. Morgan had relayed to me at various points before the meeting that she was being told by Dr Julia that there was no treatment available to her in hospital and that was also confirmed to me directly by Dr Julia in the meeting.
I am not really sure why there was no treatment available. We were just told that treatment for people like Morgan did not happen in hospital and that this had to happen outside hospital. I am not really sure what they meant by people like Morgan and no staff member ever explained this to us or the reason they felt Morgan could not access treatment or help in hospital”.
Tanya told the court that she specifically remembered asking whether she had understood correctly they were saying there was no treatment for Morgan in hospital and being told there was not, and she needed to be in the community. She said she felt they had no option, but she wanted to avoid Morgan becoming a revolving door patient.
Tanya said there was no discussion of impact on Morgan’s son, in that meeting or at any other time during Morgan’s three admissions to Meadowfield Hospital.
“I clearly explained that we felt railroaded into requesting the discharge planning meeting because no one had involved us before now and we had experienced two unsafe and abrupt discharges.
Morgan felt under constant threat of discharge. We were all concerned that there was no consideration for the safeguarding of [Morgan’s son] or my younger daughter”.
Tanya said that she was aware some of Morgan’s notes record that she was in favour of discharge.
“I struggle to understand how anyone could have come away from that meeting thinking that I was positively encouraging Morgan’s discharge. I had made it clear that I felt we had no choice”.
Tanya said she wanted Morgan to have hope and she said something encouraging to her, along the lines of “come on Morgan, if we can get the support, we can make this work”.
Tanya said Morgan appeared heavily medicated during that meeting and that she was struggling to communicate clearly and looked hopeless.
“I know that she found the messages she was receiving very confusing. On the one hand she was told that there was nothing for her in hospital but on the other, she was being told that if she chose to discharge herself then this would be against medical advice and she would not be able to access essential treatment and would have to call for an ambulance or the police if she needed help.
As someone with Morgan’s needs, this nuance was very difficult to understand and overall, I think it just left her thinking that her feelings were not valid and there was no hope.
Morgan felt encouraged and at times pushed to leave the hospital whenever she was struggling, but then she was also being encouraged by her trusting family to remain in a place of safety. This was very difficult for her to understand”.
Tanya said that the apology letter Morgan had written had been “criticised and scrutinised” in at least two meetings with professionals. Morgan told Tanya that staff “did not think it was a real apology, as communicated to her on the ward round the day before, and she had found this very upsetting”.
Tanya told the court Dr Julia repeatedly brought up Morgan’s apology letter in the meeting.
“Several times Dr Julia questioned how genuine the letter was and explained that some staff didn’t feel the apology was genuine. Morgan tried to explain that she felt remorse, but this was continuously challenged by Dr Julia to the point that Morgan burst into tears.
I asked Dr Julia if she felt that this conversation was beneficial in the context that we were meeting, which was to discuss safe discharge, and suggested that we agree to disagree on Morgan’s communication method, which may be different to that of a neurotypical person.
Dr Julia continued referencing the letter and only discontinued when Jess reinforced my statement that it was a good idea to move on”.
Tanya said that Dr Julia also brought up the letter Louise had sent about Morgan’s treatment at Meadowfield, within the context of saying relationships had broken down with the hospital.
“I found this surprising as this had not been raised with any of the family or Louise prior to the meeting and I thought it was inappropriate to discuss this for the first time in front of Morgan and given her mental state.
Dr Julia said that it was clear from the letter that the relationship with staff had broken down and that Meadowfield was not the right place for Morgan.
I was surprised that Dr Julia had responded to the letter in that way rather than seeing it as a family that was raising their concerns”.
Tanya told the court that before that meeting she had questioned what Morgan was telling her about staff not wanting to work with her, but from witnessing how Dr Julia spoke to Morgan she could immediately see why she felt that way.
“I found Dr Julia’s tone to be abrupt, rude, demeaning and humiliating. The content of her discussion was provocative and unnecessary, and in my view had no relevance to what a safe discharge would look like. As her mother, I felt Morgan’s embarrassment, shame and hopelessness”.
Tanya said that she understood the outcome of that meeting to be that Morgan would remain at Meadowfield until the Crisis Team could assess her and decide whether she was well enough to be discharged. “The view of the hospital team was that the only option available to Morgan was to return home”.
“I never for one second believed that when the Crisis Team came to see her that they would tell us that she was fit to leave the hospital. That was because of the way she looked, the way she was presenting in that meeting as really tearful and upset, the risk she presented to herself and because she was frightened of herself and what she might do. I was hoping that the Crisis Team would say that she needed more inpatient care with a carefully planned discharge, with all of us supporting her”.
Tanya said Morgan was very upset after the meeting.
“She was very confused about why they thought she didn’t need to be in hospital and she was worried about how she was going to cope outside the hospital”.
Tanya said even if it had been necessary for them to source therapy privately, they would not have known what therapies would be beneficial or evidence based for Morgan’s recovery.
“This also led us as a family to feel helpless as to how best to support Morgan upon discharge”.
Tanya told the court that she encouraged Morgan to wait and see what the Crisis Team said.
“I genuinely thought that if she was in hospital, she would be safe from harming herself. It was clear to me that Morgan wanted help to get better. She wanted to be with Dominic and their son, but by that stage she had lost hope as she was repeatedly being told that she was not unwell and that there was no treatment available to her in hospital”.
Tanya said Morgan and her exchanged texts that night where Morgan expressed her fears about coming home and not being able to control herself. Tanya said she tried to keep her calm and wait to see what the Crisis Team thought.
On 8 March Tanya and Morgan were in touch by text message. Tanya told her the plans she had to take her and the family to the Isle of Wight, she wanted her to have something to look forward to.
That evening they spoke on the phone and Morgan said she was feeling bad and didn’t want to feel like that. Tanya said she felt desperate after that call and googled to find anything she could to fins any support and hope and she sent Morgan a link to an article about self-care.
“That was the last contact I had with her. The police came to my house in the early hours of 9 March to tell me that Morgan had passed away”.
Tanya said she rang the hospital later that morning and received a call back from Paul Beynon between 2 and 3pm. She asked him to tell her what he knew about the hours leading up to Morgan’s death.
“He told me how Morgan was found. I asked him how Morgan had been that day and Mr Beynon said that Morgan was anxious about her meeting with the Crisis Team the next day and that a member of staff had removed two ligatures from her that day.
I have a really clear memory of this as I then told my husband and Dominic as I was so shocked that she had been found with ligatures and was then able to do what she did.
We had a face to face meeting with Mr Beynon and a colleague of his the following day and we mentioned the two ligatures in that meeting as well, based on what he had told me the previous day.
I have since been told by the Trust, via my solicitor, that this information from Mr Beynon was inaccurate.
It is obviously extremely upsetting that such significant information was relayed to us as a family if it was incorrect.
Morgan’s belongings were returned to me by the police after her death. They contained two ligatures”.
Tanya told the court that she did not believe Morgan intended to die on 8 March.
“I do not believe that Morgan intended to die on 8 March. I believe that what she did was an act of desperation as she had repeatedly reached out and had not received the help that she needed.
I believe that she was so overwhelmed at the prospect of being put out of the hospital and continuing to feel the way that she did, that she did something to try and stop it all but without truly understanding the permanence of her actions.
I believe what she did was a reaction to feeling that she was not being listened to and that the true agony of how she was feeling was not being noticed. I know that she wanted help to make those feelings stop”.
Tanya concluded her statement by telling the court about the concerns she had about Morgan’s care.
“It is very hard to know where to start in explaining my concerns about Morgan’s care as I have so many of them.
I feel that she was totally let down by the people who should have been caring for her and keeping her safe.
Over the course of 35 days, Morgan had two long admissions to Accident and Emergency, four different mental health bed admissions and spent a day in police custody. She came across countless professionals during that time.
I believe that this movement between so many different environments over such a short space of time caused Morgan irreparable damage. She was passed from pillar to post as if no one wanted to help her. For someone with autism like Morgan who struggled with transitions and trusting new people, this was catastrophic.
I know that it caused her to feel completely hopeless. The cycle of admissions and discharges, with no planning at all, caused a complete deterioration in her, physically and mentally.
I have been absolutely horrified to read that so many incidents of Morgan’s self-harm were not documented in incident reports. I cannot understand how anyone felt able to understand her true level of risk if all of those incredibly concerning events were not documented and pulled together”.
Tanya said that this fed into Morgan’s sense she was not believed and her risk was constantly underplayed by professionals.
“There was a complete lack of communication across the board from Sussex Partnership, with Morgan, with us as her family, and with other services involved in her care”.
Tanya said that she believed there should have been a Professionals Meeting called with everyone who knew Morgan, to help them get an understanding of Morgan and to enable a proper safety plan to be put in place. She said instead they were excluded or ignored.
“I fully understand why inpatient environments are often not the right environment for autistic people and particularly in the long term. However, when someone is in crisis and at such a high risk of hurting themselves, they need to be in a safe space until there is a proper plan to manage that crisis. That never happened for Morgan. She was not safe and as a family, we will have to live with that forever”.
C: Thank you so much, you’re so brave in giving that evidence today, thank you for your involvement with the coroner’s service. Just a couple of questions I’d like to ask. In respect of the discharge on the 21 February, was she discharged back to your house?
TB: No straight back to Dominic and hers, where he was caring for her young son. I wasn’t informed of that discharge at all.
C: Paragraph 36 of your statement you say discharge on the 22 February and withdrawal of PRN medication. What do you mean?
TB: During Morgan’s time in the hospital she was more frequently as time went on and she became more unwell needing PRN, my understanding means as required, medication. Her presentation was becoming more challenging in the hospital so she was given more sedation in the hospital, they’re addictive.
C: As and when her presentation required?
TB: Yes… she was frequently being given that medication and we know that because she wrote that down
C: On top of Lorazepam?
TB: Yes, and other benzodiazepines.. she was frequently telling me she was about to get medication, and she documented it. When those discharges occurred there was absolutely no consideration of those addictive medication she’d been pumped full off, so she was sent out with nothing.
C: With none?
TB: With none. So of course she was going to have a crash, because its withdrawal and we highlighted that, as did Louise in her letter.
JE says she can find the reference in the bundle if helpful
C: So the Crisis Team were due to see Morgan on 9 March?
TB: That’s correct, originally when discussed in the discharge planning meeting, aim was for Morgan to be assessed the following day, they were very keen for her to be discharged, but the Crisis Team couldn’t make that appointment which is why it was the next day… plan was the Crisis Team would assess on the 9th, I was due to be present for that assessment as well to support her, as allowed really.
C: I couldn’t see in the bundle there was any letter or note a discharge appointment had been made, couldn’t see if she’d had the appointment?
TB: Sadly we didn’t get to have that final assessment in the hospital because she’d gone by then.
C: Incident on 27 February. Did Morgan discuss that with you?
TB: Yes
C: What did she say?
TB: Morgan explained to me, she didn’t know why she was experiencing this phenomenon, it was a physical reaction that occurred where her skin felt she was being covered in thousands of wasps, she experiencing it as insects biting her skin. She was in pain, terrified and believing she was being stung by insects so she approached staff.
C: And that’s what she wrote in her note?
TB: Yes, when she came out of it she was able to recognise it wasn’t actually happening, but she was experiencing that. Don’t know if it was a psychotic episode, or high sensitivity as we know autistic people can have, whatever was happening she approached staff in a desperate situation.
C: Had she had that before?
TB: I know Dominic said he’d not experienced visual auditory episodes before, but I had as her mum.
The coroner asks when Morgan had experienced these.
TB: I’d say when she was 15, as if something was behind her, talking to her or affecting her, she’d do strange movements, wouldn’t know why, but compelled carry out certain movements and appease what was in her mind and being said to her effectively. So difficult to understand as you can imagine, you can offer reassurance but she’s in that moment.
C: In those episodes you had did she strike out like that?
TB: No, no. The only time Morgan was ever in a situation deemed violent was when she was restrained. From a little tiny tot never had any violence towards myself or anyone else. Only time violent incident documented when she was extremely unwell and threatened by people trying to keep her safe, understand restraint, but when people are putting hands on or she’s been cornered by a large number of people
C: OK
TB: I would like to add as well the incident I mention in my statement, the Swindon incident when I had to call 999, as a terrified mother, didn’t know what’s wrong with my child… they sent the Police, she should have been taken to hospital, she got PTSD from that, she was stripped naked and held in a cell, so when she was unwell again and staff approach her to restrain her you can imagine the impact.
C: Thank you, I don’t have any other questions. Ms Agnew do you have any questions?
RA: Can I clarify one thing, in relation to the Crisis Resolution and Home Treatment Team. I want to check your evidence about the plan for her to be assessed tragically on the 9th. That didn’t happen, can I check that was something you were happy with? [fuller question, missed]
TB: To a certain point to be brutally honest with you, we were so fearful of these abrupt discharges happening, clearly dangerous, felt very backed in to a corner about that. When they said Crisis Team would assess I thought you’d take one look at the girl and be sure there’s no way this girl is fit to be in the community, would assess her and know like we did as a family she was acutely unwell and she needs to remain in a place of safety, we thought they might add… we were very welcoming of any services, any professional who wanted to work with us, we were trusting of all those recommendations as well.
RA: I understand, and as I understand it Morgan had some contact with Crisis Team so they had some background knowledge?
TB: Could argue they didn’t, she was discharged in the morning, seen a few hours later, but they had had one dealing with her
RA: Thank you.
No questions from Mr Berlevy for West Sussex County Council.
Then it was over to Jessica Elliott for Morgan’s family.
JE: We heard a lot about what felt like it as going wrong in hospital, what did you hope it would look like if it were to go well…. what the hospital could provide for Morgan and did you have hope she could improve?
TB: When Morgan reached crisis my hope was not handing over, but working alongside professionals with experience in these conditions, obviously I don’t. What had worked in the past was Morgan being contained in a safe environment, I couldn’t understand it years ago but was this sense of being contained and safe… for me a period of containment, in a safe environment. Morgan was being really sensible, she knew she had her son to think about and didn’t trust herself, so was relying on the hospital to keep her safe, so she could assess things she needed to get well and return to her family.
Safe discharge, me ringing up, idea was provide reassurance to Morgan her feelings were being validated, we were all listening and trying to help her get healthy again.
I know if that meeting had gone well, if we had a clear plan, everyone doing their part, family and other professionals, my daughter would have felt safer and more able to access services in the community.
JE: [couldn’t catch it] … crises that calmed down when going somewhere for a while
TB: That’s correct
JE: You mention some admissions to hospital before Dominic knew Morgan in April 2018 for 6 days and July 2020 in East Surrey for 2 weeks?
TB: Yes
JE: She had suicidal thoughts?
TB: Yes
JE: We know the answer, she came through that?
TB: Yes, similar to something Dominic said about treatment about the Woodlands, professionals being firm but clear, she felt safe with clear planning and actions to work towards in the future. Yes, she had felt better after having those episodes in hospital, she felt safer. Each time there was something to try afterwards, we’ll look into this therapy or CAMHS will do an assessment… they helped her understand herself better, Morgan was confused for many years about why she felt the way she did.
JE: The jury will hear there were times when Morgan says she doesn’t want help or rejects therapy or family involvement …but you feel she did want help?
TB: Yes, that not wanting was a point of real hopelessness for her, would often be the case, however I really believe this, if the health services had worked with us and Children Services, they’d have understood Morgan … unfortunately we weren’t able to get that across.
JE: 2 February Dr Crow (?) at St Richards notes, ‘you are currently struggling with your mood and suicidal thoughts although trying fight these because you want to be alive and have…’ So she did still work, and had hope?
TB: Absolutely. I am so proud of my daughter, from a very young age, we went through every service known to man through the local authority, or any links I had through my job. That girl worked with anyone who tried to help her, Early Help Service really helped Morgan, Care Leavers Service did help… I’d just like to touch on what you just said there about another health professional noting Morgan was trying hard to overcome these things, suicidal ideation would obviously be right I want to die then, what she was communicating wasn’t I want to be dead and buried in the ground, but I want what I’m experiencing to stop…. Only way had to communicate that was I just want to die, she just wanted these really terrible feelings to stop.
Ms Elliott checked, and Tanya confirmed, that she had known that Morgan experienced suicidal ideation.
She then said she wished to look at the autism diagnosis report and some of the things in it. The coroner’s officer took Tanya a copy of the report.
JE: Could you just explain what this report was, this diagnosis building for a while, this report was commissioned?
TB: I’ll be completely honest with you, I’m not sure whether this assessment occurred because of the original assessment to CAMHS, or multiple GP referrals when Morgan was a much younger person or off the back of Childrens Services Involvement. It was my hope Morgan would get the assessment she needed.
JE: This report is a detailed diagnosis of Morgan’s autistic features?
TB: That’s right
JE: Could we first explain to the jury, you had a concern staff didn’t have this report?
TB: Yes
JE: You emailed it in?
TB: Yes
JE: Concern arose when Morgan was in Woodlands?
TB: Yes was the phrase used by staff who’d been very good, was ‘possible autism’, and I was like no, no it’s not possible, there’s a formal diagnosis. Which led me to believe they’re not in receipt of this diagnosis.
JE: And we know its correct, and even after you emailed in, it is not uploaded to the notes until May, which was far too late [Morgan died in March].
JE outlined the content of the report which included sections such as a developmental history, social communication observation, a list of names of the multi disciplinary team involved, a history from Morgan and her mother, an ADOS autistic diagnostic observation schedule, and screening questionnaires.
JE: A very thorough process?
TB: Yes. We spent hours with the psychiatrist answering all these questions, my husband was involved, we were very consulted, it was very important to us the accurate information was out there, we were desperate to help our child, it’s very thorough.
JE: Indeed, its 22 pages, so I won’t go through it all but could I ask you to turn to the summary on it, page 11
TB: Yes
JE: Strengths at the top…. four down, talking about Morgan being responsible, managing living on her own with her son very well, earlier in the report talked about job, going to college
TB: Yes
JE: So, backs up what you were saying about this period of Morgan’s life being stable?
TB: Yes. Morgan was a really lovely bright young woman who wanted to do well, she had good morals, just really sad she became unwell.
JE: Yes, clinical observation features in social interactions, difficulty initiating conversations… Morgan approaching people, was that an issue for her on the ward?
TB: Without question
JE: What did Morgan need in the ward environment to help with that?
TB: It wouldn’t be an awful lot, just regular check in to see how are we feeling.
JE: Someone approaching Morgan?
TB: Yes, it wouldn’t have taken much, they’d asked her to do it the other way after the incident saying she should approach staff but she asked for the other way, she wouldn’t have the confidence to do that
JE: Traffic light tool… done that to help staff respond to her without her needing to make those initiations?
TB: Yes, absolutely and she also did it for us at home, so we could adopt the same approach so she could have it on her door. So, anything we were recommending to staff would be exactly what we would try to do as a family as well.
JE: Thank you, that’s helpful. Before move on from page, big paragraph, 5 lines down it is increasingly well recognised that autism spectrum in girls and women presents differently than males… higher tendency to mask… is that something that could happen with Morgan?
TB: Absolutely
JE: It says she meets the criteria, sets out difficulties, social communication difficulties… abnormalities in eye contact and body language and use of gestures
TB: Yes
JE: So, something that needs taken into account in clinical interviews?
TB: Yes, some really small adjustments would have made real difference
I missed the next question but it related to ritualised patterns, highlighting stress at changes and difficulty with transitions.
TB: Transitions were really, really tough but wouldn’t need to be tough with the right reassurance put in place in advance.
JE: They could be managed?
TB: Transitions could take place if they were managed …links to our request at the discharge planning meeting from my perspective
JE: That meeting, by then, I can’t count at this moment, she’d had upwards of 8 movements, in and out of home, the police station, A&E
TB: Yes absolutely, we don’t want you here …[fuller answer, missed]
JE: Lastly number 4 hyper reactivity to sensory aspects of environment… could Morgan become overwhelmed on a sensory level?
TB: Absolutely
JE: You mentioned transitions and other services might have been helpful, what other services was Morgan open to at that time?
TB: The Care Leaver Service, she had a personal assistant, care leaver support worker.
JE: Veronica Hillier?
TB: Yes
JE: This Care Leaver Support Service did they help on transitions?
TB: Very much, with Morgan moving from accommodation to accommodation Morgan would involve me in that because they knew Morgan would be highly anxious
JE: Would it have helped to have them linked in to Morgan’s care?
TB: Absolutely, they were very helpful to us and understood where we were coming from as a family. We all had the same focus to keep two vulnerable people in this situation safe, Morgan and her son
At this point the coroner interjected to check timetabling as it was 16:20. Miss Elliott discussed with her solicitor and said that she could leave some of her questions she had intended to ask Tanya for Louise, but she had a few factual questions that she needed to ask her, but she wished her to finish today if possible.
The coroner asked the jury bailiff to check whether the jury had any questions.
JE: Ma’am I’ll be brief, couple of points, 7 March. You’ve given evidence 7 March meeting, given a detailed account of it, you’ve not read the medical records just given your view. I wanted to check a couple of points about Dr Julia’s note of that meeting. So we’re clear, there were some positives to the meeting, in terms of family involved?
TB: That’s right
JE: Dr Julia’s note says Morgan made several comments about staff holding grudges against her… Morgan’s mother said experienced staff as caring and no evidence of treatment Morgan in negative way. Do you know how this could have happened?
TB: I was so keen to work positively with the health professionals, I’m a desperate mother, my daughter is so ill and I don’t know how to help her… I was just so grateful to start thinking about safety plan rather than just discharge, so I was positive about it, I was being involved for the first time
JE: And you’re being encouraging for Morgan?
TB: Yes, and put across what’s in report so staff could adopt strategies not feel I’m telling them how to work
JE: Dr Julia said in terms of the apology letter, Morgan seemed intent on getting praise… is that the right characterisation?
TB: No Morgan would struggle to receive praise in general in her personality, have absolutely no recollection of her wanting to receive praise. What she was actually hoping for was some acknowledgement in that moment she was acutely unwell and not intended to cause harm, that’s what she was trying to get across to the psychiatrist she was not maliciously intending to cause harm, was acutely unwell in that moment
JE: [missed] you felt risk hadn’t changed, she looked physically unwell?
TB: I’d say it had increased
JE: Noted in [missed] review… flat, not responding to stimuli, but you remember her crying?
TB: I wish I had the CCTV from the hospital, as soon as I went out was questioning had Morgan really interpreted situation correctly she had difficulties understanding communications, but after that meeting I understood exactly what she meant.
I hugged her and said I totally understand what you were trying to tell me about the staff, she was very emotional. We hugged outside the hospital, she said I love you mum and I said I was so proud of her. That was my last contact with her.
JE: Thank you.
It was then over to jury questions. The coroner said some were in scope, some were not.
Jury question read by C: What was incorrect about Mr Beynon’s statement?
TB: I think Mr Beynon is now telling me Morgan didn’t have ligatures removed from her earlier that evening. He called me, as you can imagine my child has died, I am going to remember what he said.
That was what was said to me, first contact from him in afternoon…. He said she’d been sort of fine during the day, there had been some ligaturing going on, some ligatures had been removed from her before her death by members of staff, but in effect they’d had to give the bed sheet back, to do with human rights… he told me, but in his statement he then retracts and says it wasn’t accurate.
He said two ligatures were made, he then said wasn’t accurate, but we had the ligatures returned to us in her belongings.
Jury question read by C: Other question regards transfer from Woodlands to Meadowfield. Do you understand why that transfer occurred?
TB: No. Just that it was deemed appropriate at that time. We weren’t told should we, we were told that was happening and was just grateful she’d receive treatment wherever she was told she’d get treatment really.
Jury question read by C: What did you understand the assistance would be after discharge?
TB: Zero understanding, only she’d be assessed by the Crisis Team. For me it was hour by hour at this point, by the time this was happening. Crisis Team there would help access community services was my understanding, was just really hopeful would be clear robust plan in place so we could all support her to be healthy and well in the community, whether that was a bit at my house and being supported with her son that was fine, just wanted to support her to be well.
C: Thank you.
The coroner tells the jury they’ll have a chance to ask more throughout the inquest.
The coroner thanked Tanya for her involvement with the coroner service.
C: I just wanted to say how sorry I am and I’m so sorry this occurred and now you are released.
TB: Thank you for giving me the opportunity to talk.
Court was adjourned at 16:31.