We returned to court after lunch on Day 2 of Morgan’s inquest and the coroner called Helen Green. She gave an affirmation.

The coroner thanked her for attending and for her involvement with the investigation into Morgan’s death, and asked her to confirm her name, she died.

She confirmed her statement was dated 4 September 2023, that she had read it prior to the inquest today, and that it was her evidence in respect of her involvement with Morgan.

C: Could I ask you please to confirm your qualifications and the reason for your involvement with Morgan

HG: I’m a social worker in the Assessment and Intervention Team in West Sussex. I was working with Morgan due to safeguarding her son.

C: Thank you. If you could paraphrase your statement for me, confirming your involvement throughout.

HG: My role was as social worker for her son [name withheld]. I had to complete a Child and Family Assessment, I was the allocated social worker from 16 February 2023 … the assessment was indicated from a police referral due to concerns Morgan might harm herself

Helen Green told the court that the duty social worker had visited Morgan and that she then was allocated her case and visited her on [22?] February.

HG: I was advised Morgan had been admitted shortly after my visit.

C: Were you aware she’d been in hospital prior to your visit?

HG: Yes. That was why it was referred in.

Helen Green said that she had contact with various mental health professionals, about her concerns about Morgan being discharged from hospital.

She told the court that she had been asked to write a statement in relation to a conversation she had with Dr Ahwe.

HG: I emailed Dr Ahwe on 28 February 2023 to explain I was very concerned Morgan was released from Section 2 of the Mental Health Act the previous evening. I explained this was after Morgan had assaulted staff, I requested clarification of what had taken place and asked her diagnosis and [missed, think she said treatment plan]

C: This was much later?

HG: I was asked to detail my interactions with Dr Ahwe. When I visited her I had real concerns about how she presented. She seemed very, very low. I’ve visited lots of people in my time and remember how low she seemed, and she spoke openly about wanting to end her life … I knew she had a visit from the Crisis Team shortly after my visit, so I felt reassured by that and subsequently found out the Crisis Team were concerned about her too, and she’d gone back to hospital.

In the email I explained my concern about Morgan being released from hospital and the impact on [her son], with risk Morgan would harm or kill herself…. I also shared I’d viewed her suicide notes which I thought showed Morgan had clear intent to end her life.

I stated prior to this Morgan had stability for a year and her recent behaviour was not her normal presentation.

I requested Dr Ahwe explain his current role [?] and how her safety and [her son’s] safety, could be managed while she was so unwell.

On the 2 March Dr Ahwe responded, apologising for the delay in responding.

He said following the assessment on Monday 27 February 2023 he explained to Morgan they would assess her… explained her mother would be invited to the next ward review.

He said Morgan requested a transfer to Rowan Ward as she had been there the previous week, he said that would be considered with them. He said later in the afternoon he’d had to review Morgan again as she had become increasingly aggressive, threatening and damaging property and there was no evidence of a psychiatric disorder.

He said Morgan assaulted 4 members of staff. He said he’d discussed Morgan’s, and this is a direct quote, “anti-social behaviours” however she did not take any responsibility for her actions.

He said Morgan showed no remorse for her actions and he deemed her to have capacity.

He said Morgan would need to sign a behaviour contract to remain in hospital … Dr Ahwe said Morgan chose to discharge herself against medical advice, and she had the capacity to make this decision. He said that was reported to the police and Morgan was detained.

I felt really concerned so I contacted Joanna Cooper, who is an AMHP.

The coroner asked Helen Green to explain what the acronym AMHP means, she did [Approved Mental Health Professional].

HG: And we were working between ourselves, because I was aware of Morgan having been in custody before and she found that very, very distressing and I was really worried about her being in police custody again in those circumstances.

Helen Green told the court that police custody weren’t keen to share information with her at that point, but Joanna could liaise with everyone in the network, which was partly why she had involved her.

HG: Dr Ahwe said he’d not be able to provide any details of Morgan’s diagnosis and care plan without Morgan’s consent.

His email finished in caps and bold. THERE IS A ZERO TOLERANCE POLICY IN THE NHS AND NO STAFF SHOULD BE SUBJECTED TO VIOLENCE BY PATIENTS WHO ARE NOT MENTALLY UNWELL AND HAVE CAPACITY AND THEY WILL BE DISCHARGED IMMEDIATELY IF THEY ARE DEEMED TO HAVE CAPACITY.

Helen Green said that she had email contact and a telephone call with a staff member at the Woodlands Centre. They said they were planning to discharge Morgan. Helen told the court that she expressed her concerns again.

She said then her contact was limited to email between 2 March and when Morgan sadly died.

C: Your assessment when you saw Morgan on 22^nd was she wasn’t able to look after her son at that time. Is that right?

HG: It wasn’t as simplistic as that. I had a conversation with Dominic around him being the main carer, Morgan agreed with that, that Dominic should be doing the main caring, as she was as worried as I was. Then we looked at the family network, had family network meeting during the assessment period as well.

C: After 22^nd, you didn’t see Morgan?

HG: No

C: There were other contacts you made, other than Dr Ahwe?

HG: Yes. Mental health professionals, the family, but not Morgan.

C: Thank you, I don’t have any other questions.

There were no questions for Helen Green from Ms Agnew for Sussex Partnership Foundation Trust, or from Mr Berlevy for West Sussex County Council. It was then over to Ms Elliott to ask questions for Morgan’s family.

JE: Thank you ma’am. A few questions please. Thank you very much Ms Green for your evidence, just clarification around what you said.

I understand you were involved on 16 February, is that right?

HG: Yes

JE: You aware Morgan was in hospital at that time?

HG: I don’t honestly remember, the Duty Social Worker visited on 15 February, my visit on 22^nd February was to visit Morgan’s son [fuller answer, missed]

JE: Do you know if anyone from the ward actively contacted you at that time?

HG: It may be in Case Notes, but from memory no, we’d had no contact about discharge.

JE: You’d normally be involved in discharge?

HG: Yes

JE: You found Morgan unwell at that time, but were reassured the Crisis Team were coming?

HG: Yes

Ms Elliott said she would read a paragraph from the Crisis Team assessment to check that it fits with what Ms Green saw. I believe she said it was conducted by S J Wickham.

JE: This clinician notes Morgan had been discharged from Rowan Ward yesterday and commented she felt it was too early. She [Morgan] said the ward seemed unable to respond to her distress, she feels the ward is boring and staff are not interested in her needs.

Objectively she appeared low in mood, at times tearful, flat in affect, being home was very overwhelming, she didn’t want be home yet … risk of suicide very high, felt she could not keep herself safe, felt even her baby was no longer a protective factor, she acknowledged Dominic was trying be supportive.

Does that concur with your assessment of her presentation?

HG: Yes. I’ve met lots of mums when doing mental health assessments, she was one of the lowest I’d seen. I felt reassured by the Crisis Team and the fact that Dominic was caring for their son.

JE: She did go back into hospital. I understand the main purpose of your statement is email contact with Dr Ahwe.

The jury have not yet heard from Dr Ahwe, he’s tomorrow morning. What we see on timelines is Morgan on 25 February goes into Maple Ward, on 27 February Section 2 is rescinded and she’s discharged in circumstances of high distress and disruption, which the jury will hear about. Your email was to raise your concern about that discharge, is that right?

HG: Yes. From memory I had difficulties contacting them by telephone, that’s why I sent the email asserting my concerns. They were significant and I wanted to note planning hadn’t involved us as well.

JE: So, discharge didn’t involve you?

HG: No

JE: And you did try to contact the ward and couldn’t get through?

HG: Yes, from memory, is in Case Notes if you want me to check that.

JE: You said you had knowledge of Morgan and this isn’t her usual presentation. How did you have that knowledge?

HG: Children’s Services hadn’t had any contact with her for quite some period, so from conversations with family and getting input from Dominic who knew her best.

JE: So, this was not her normal?

HG: It was out of character was my perception from talking to the family.

JE: You’re aware Dr Ahwe has rescinded, ended the Section 2. Could you give a broad understanding of what a Section 2 is?

Ms Green said that she was not an expert and Ms Elliott noted the court were about to hear from Ms Cooper, who she could ask if she preferred. It was agreed that Ms Cooper was better placed to explain that to the jury.

JE: You knew she’d been de-sectioned and was out of hospital now?

HG: Yes. That was very worrying to me.

JE: In Dr Ahwe’s response, he talks about remorse, capacity, behaviour contracts, then that passage in bold and capitals. How did this read to you? Was this a helpful response to you? To Morgan? Did you know where to go next?

HG: It didn’t feel like a helpful response, no. it felt quite angry, quite frustrated and didn’t match my understanding of what her situation was. She’d been a calm and loving mum, and then if she was behaving aggressively she was unwell.

Ms Elliott asked Ms Green what she was hoping for from Morgan’s care and she told the court she was hoping that Morgan would be cared for, for long enough for her to get back to normal and be able to care for her son.

In response to a further question about follow up, Ms Green said that they held a family network meeting, and that she spoke to Woodlands again.

JE: You said to the coroner you were worried about another discharge?

HG: Yes. I had a similar conversation with a nurse from Woodlands with a similar perception of Morgan to the email, that she had capacity, her behaviour was aggressive.

JE: We have the nurse’s note of that. What is clear is you appear to be fighting to keep Morgan in hospital?

HG: I was really fighting to keep her somewhere safe, so she could get better.

JE: You’ve been in court for family evidence this morning, we also had family evidence yesterday when concerns expressed was that Morgan needed some stabilisation and containment, a longer period on the ward, with hope of recovery. Speaking broadly, were those concerns you shared?

HG: Yes

JE: Do you recall, sounds like, clearly your primary concern was Morgan’s son, it does sound like you’re trying to act in the interests of everyone, Dominic, as well and Morgan.

Do you recall when you were worried about Morgan coming out, she’d be coming to the flat Dominic and [her son] were in. Did you have any contingency plans for them?

HG: Yes, I’d safety planned with Dominic and family members and the nursery, so family members were caring for [their son] until Morgan was well enough to do so. There wouldn’t be any unsupervised contact until she was well enough to care for him.

Ms Elliott said she had no further questions but would turn her back to check with Morgan’s family if they did.

JE: Only thing to do is pass on to the family’s thanks, on Morgan’s behalf.

HG: Thank you, I’m very sorry for your loss.

C: If you could just stay there for one moment, just want to see if there are any questions the jury may have for you.

There are and they are passed up to the coroner.

C asks jury question: This is a question you may not be able to answer, it may be better to be answered by Dr Ahwe tomorrow. You mentioned Morgan had capacity, what in your opinion did this mean Morgan’s state was?

HG: Yes, to be clear I didn’t say she had capacity. It was Dr Ahwe who said she had capacity. I was questioning whether she had capacity to make those decisions.

Helen Green added that she is not a mental health professional and it was probably best to confirm that with Dr Ahwe.

She was thanked and released at 14:18.