After lunch on Day 2 of Morgan’s inquest the coroner called Joanne Cooper from West Sussex County Council. She gave an affirmation, was asked to take a seat and confirmed her name.
The coroner thanked her for her involvement into the investigation of Morgan’s death.
C: I understand you’ve prepared a witness statement, the one I have is dated 4 September 2023?
JC: Yes, same as I have
C: You signed on 4 September 2023, since that date, all the evidence in the statement is accurate. Is that correct?
JC: Yes, just one point I noted where potentially I refer to a diagnosis, there might be a slight discrepancy having heard family evidence this morning.
C: That was one of my questions, so you picked that up.
The coroner asks Joanne Cooper to go through her qualifications and her involvement with Morgan.
JC: I’m a social worker and an Approved Mental Health Professional, which is an AMHP. I am Team Manager for the AMHP Hub at West Sussex. Team of full time permanent AMHPs, who do that role all the time.
The coroner asked her to speak directly into the microphone.
JC: My role as Team Manager is overseeing the work of the team, the referrals that come in, and the assessments we do.
C: Great. If you can just go through your involvement with Morgan, use your statement as an aide memoire as you go through.
JC: In my service statement I’ve referred to a timeline from when we were first contacted by Dominic. Should I start there?
C: Yes, I think that’s a good idea
JC: Bear with me. 6 February we were contacted by Dominic due to concerns Morgan had left home to end her life.
The police had been informed, later Morgan went to The Haven where she could stay for up to 24 hours. The Haven informed the AMHP Hub she was happy to stay informally.
The Haven is a halfway house where people having a mental health crisis can go, be supported by mental health nurses, and see if with support can avert a crisis or step up to a Mental Health Act assessment, or make a plan to go home.
7 February, Morgan absconded from there, took an overdose. The police were called, she didn’t want go with them but Dominic confirmed she wasn’t expressing suicidal ideation, he had a safety plan, he had hidden medication etc. At that point things were stable so we didn’t act at that time but we did have a referral.
Followed up next day, an AMHP gathered information about the current situation. They made a referral to MASH, the Multi-agency Safeguarding Hub in West Sussex
The coroner asked her to explain what that is.
JC: It’s about safeguarding for Morgan and her son
C: A team is it?
JC: Yes, a Safeguarding Team in West Sussex. They’d then refer to Children’s Services as needed.
Plan was for the Crisis Team to visit Morgan at home that evening. As AMHPs we try to be least restrictive, and try to avoid an admission unless it is needed, it’s better for the person unless those risks are really there.
Friday 8 February, AMHPs contacted the Crisis Team about the visit. Still able to safety plan at this time.
Then Morgan took another overdose that evening. She went to St Richard’s Hospital. She was there on 9 February. The AMHP Hub was updated, at this point Morgan was agreeing to an informal admission, again seen as the least restrictive option.
By the following morning Morgan was reported to have ordered pizza and paracetamol over the phone by Uber. [Withheld]. At which point we were getting increasingly concerned. Triaged referral red, highest level of concern in terms of risk.
Another Mental Health Act assessment was planned because of taking [withheld]. We wouldn’t be comfortable with an informal admission as she was showing risk was really there.
10 February Morgan was assessed, two Section 2 medical recommendations were made. You’d always need 2 doctors to assess, more than one doctor’s opinion, and the AMHP.
Section 2 is up to 28 days, for a period of assessment for mental health [explains further] for health of individual, or protection of others, either or both.
No bed at this point, remained at St Richard’s with 1-1 observations. It does happen when people have to wait in A&E.
Bed identified on 13 February on Rowan Ward, conveyed to Meadowfield the same day. That was the 13th.
Apologies on 13th she was detained on Section 2, on 16 February she was discharged from that section, only 3 days later, to mum’s address. She had consented to Crisis Team support.
That evening she was taken to St Richard’s A&E by Crisis Team after a home visit. She was unable to safety plan, intent to take life, feeling very overwhelmed, echoes what has been said.
Plan for her to wait for a bed. 23 February she absconded, the police were alerted.
We were becoming increasingly concerned now, obviously.
Placed under 136. 24 February referral for a Mental Health Act assessment from the AMHP Hub at St Richard’s A&E. Triage risk was red.
Looking for support for once 136 runs out, that is 24 hours. 136 is a police power, rather than a criminal power, is if they believe someone is exhibiting mental distress, the police can detain them for up to 24 hours to be assessed under the Mental Health Act, or they can be discharged by a consultant. Usually we assess.
25 February bed identified on Maple Ward, completed application, arrived there safely on 25th.
When I became much more actively involved 28th, we had an email. We were alerted by Helen, the Children’s Social Worker, that had been alerted by Dominic I think, that there had been an incident at Meadowfield and she’d gone to police custody.
At which point we were shocked by it really. For us its concern about Morgan primarily at that point, but also [her son] if he’s at home, what the plan is etc.
I was included in the email trail. I spoke to Helen directly, told her I wanted to be clear what the plan was. Were there any discharge plans, if there were what would they be. Which there weren’t.
Helen was able to give view it not appropriate at that time for Morgan to return home. Also increasing concern about risk of suicide, main concern at that time.
We agreed I’d take a referral from Helen, I’d intervene and try to speak to the police. I had a conversation with the sergeant to make them aware of Morgan’s mental health, potential risks and also that she couldn’t just go home.
I tried to persuade the police to use their 136 power to keep her safe, then we’d assess again. She was put on 136, then taken I think to St Richard’s again.
There wasn’t a place of safety available at that time. My understanding is she was at St Richard’s, she was then assessed again on 1 March.
JE: Ma’am if I may, it may have been A&E at Worthing.
JC: Apologies, Worthing. At this point assessed by an AHMP from West Sussex, also doctors and AMHP discussion. Decision to raise a Section 140, when we consider there to be special urgency. In those instances, would provide a bed within 3 hours. Again, because of the concerns about the risk.
In my role, I was following that up throughout the day, realising no bed was materialising. There is no legal framework once the 136 expires, I escalated to my Service Manager, suggested we ring the SPFT Bed Co-ordinator. We had a Teams meeting with him just to really convey the risks, we felt we needed a plan when that 136 expired.
C: You had serious concerns, that you wanted her to be detained?
JC: Yes, Morgan’s risks were increased due to autism, fixated on ending her life, had been since we assessed in February.
Rationale accepted, place of safety identified, think plan in place for mum to stay at the hospital until the ambulance, secure transport, got there.
She was then taken to a place of safety to admit to Woodlands.
3 March Morgan reviewed at the place of safety and the Section 2 was rescinded, that’s 2 days later. Morgan chose to remain as in informal patient.
C: Did you get any involvement at all about the rescinding of the Section 2?
JC: No. Only retrospectively, 7 March Mental Health Discharge Team, a social work team, received referral of notification of Morgan’s discharge from Meadowfield Hospital. They would do the discharge planning and someone was allocated to do Care Act Assessment.
Then very sadly on 9 March Morgan passed away.
The coroner said that she had asked her questions during Joanne Cooper’s evidence. Was then over to Ms Agnew, for Sussex Partnership Foundation Trust.
RA: Just one point of clarification, as you’re going, what just describing as identifying elements of the care system involved and who responsible for which bits.
I don’t think you covered in your statement, as I understand it you have a telephone conversation with Sussex Liaison and Diversion Service, in the police station is that right?
JC: No. I spoke directly to the sergeant
RA: So, they’d have passed that information in the police service?
JC: Liaison and Diversion aren’t always present in custody. I imagine they weren’t present at that time or it would have gone to Liaison and Diversion to assess her.
RA: Note of 13 February, says call Jo Cooper, she disclosed concerns about Ms Betchley’s safety on release, particularly potentially unable to return home. Is that the call you made?
JC: Yes. I think I was talking to the sergeant.
RA: Yes, it could be. Is clear communication gets to the Liaison and Diversion service from you helpfully.
JC: Yes, when they’re there. I spoke to them twice, I followed it up to make sure there was a plan, pretty sure was direct with the sergeant.
It was then over to Ms Elliott for Morgan’s family.
JE: I ask questions on behalf of the family. Did just want to go back slightly, Section 2 detaining powers.
You’re an Approved Mental Health Professional. As such you work mainly in the framework of the Mental Health Act 1983, is that right?
JC: Yes
JE: You’re not any old mental health professional, you are particularly concerned with these discussions about Section 2 and the like?
JC: Yes. We’re warranted for a period of up to 5 years by the local authority. Have to have done training to be warranted. What that warrant grants is the legal power to detain as an AMHP.
JE: That has to be carefully managed?
JC: Yes. It’s the AMHP, rather than the doctors.
JE: Doctors are involved, need two doctors?
JC: Yes
JE: One of which is a Section 12 doctor?
JC: Yes
JE: With particular experience in these assessments?
JC: Yes
JE: As a result of that, someone liable for detention, and once found a bed they can then be detained?
JC: Yes, the AMHP can’t make an application unless a named hospital is identified
JE: So, cant detain without a bed … so frantic attempts to find a bed, she needs detained so need to find a bed?
JC: Yes, and legal framework for that, can’t detain to A&E for example
JE: Yes, the jury heard times on A&E… held on A&E to try to keep her safe… Section 136 sometimes rolling, until she’s on the bed trying to keep her safe is that right?
JC: Yes, in best way can
JE: Formal and informal admissions, can you explain that?
JC: Informal is when a person would agree to go into hospital, they’d need understanding of their mental disorder and why they’re going.
JE: Yes, that’s informal, they have consent and have capacity?
JC: Yes, caveat around risk, can still use Section 2 when risks are still there
JE: Yes, one of the assessments Morgan said she was going to consent, but because of the level of risk she was detained under Section 2
JC: Yes
JE: We will go onto Dr Ahwe. Section 2 is not the same as a capacity assessment. What are Section 2 criteria?
JC: Mental disorder of a nature or degree, along with risk to health of person, protection of person and/or others
JE: So that doesn’t expressly mention capacity but it’s all tied up together?
JC: The Mental Health Act, trumps capacity, yes
JE: Thank you, 28 February, jury has heard what happened, admission to Maple Ward, Morgan under Section 2, she’s a formal patient. Jury have not heard much about the details yet, an incident as a result of which her Section 2 was rescinded. You’re aware of that history?
JC: Yes
JE: First of all can we look at the Mental Health Act assessment Morgan had on 24 February 2023 which was paragraph 27 in your statement
JC: Yes, I can see it
JE: We have that Mental Health Act Assessment in records … Dr K (?) and Dr Crow as Section 12 doctors. Dr Crow notes Morgan is autistic with depression and PTSD, low mood … notes absconded A&E, Morgan written suicide notes.
In terms of safety, clearly Morgan is at risk, cannot be managed safely by the Crisis Team. She cannot be kept safe out of hospital. Then the interview with Morgan supports all of that statement?
JC: Yes
JE: We then see bed request, arising out of this for continued/longer period of assessment due to worsening presentation of mental state since discharge 2 days ago. There’s been an assessment, they’re wanting to detain Morgan and for her to go in for a continued and longer period of time?
JC: Yes, it’s for a proper assessment
JE: Given that, was it a surprise to you she was discharged 2 days later?
JC: Yes
JE: You heard from Helen Green or Dominic, not from the ward?
JC: Yes, I was quite panicked to be honest, because of the risk
JE: Surprising in the context of why she’d gone in?
JC: Yes, particularly the arrest was a bit of a shock as well.
JE: Why was the arrest a shock?
JC: It’s difficult, I don’t know further detail of what happened on the ward. It just seemed disproportionate to go from being on a mental health ward to being in custody, especially in light of Morgan, and her background.
JE: There’s a note in the records, clinical note stating what police record said. Suggest AMHP Service escalating discharge as inappropriate through proper channels, however they have asked police directly to protect situation by detaining Morgan on 136.
Was that the feeling at the time? Something had gone wrong with that discharge, it shouldn’t have happened?
JC: Yes. If she had been discharged during an incident, that’s the question mark.
JE: Yes. My next question, will go through this evidence tomorrow with Dr Ahwe. It seems is an incident of violence, Morgan did assault staff in whatever state she was in, a number of staff. She’s then seen by Dr Ahwe shortly after who rescinds her Section 2 as a result of the incident.
What I want to ask you, is are you aware of any policy or procedure of rescinding a Section 2 when someone has been violent?
JC: No
JE: What do you expect to be the procedure when someone is discharged from a Section 2?
JC: Well, you’d have a discharge planning meeting, involve the Mental Health Social Work Team, the Crisis Team, the Lead Practitioner in the community, family, the Nearest Relative.
JE: So, Children’s Services for [Morgan’s son], care leavers for herself, the Family Court’s whole network around Morgan you’d expect to be there?
JC: Yes
JE: So criteria for detaining someone on Section 2, would you expect some check no longer meeting those criteria when take them off?
JC: That’s the Consultant’s prerogative, assessing again, deciding person no longer meets criteria. That can be done by one doctor.
JE: Yes, the doing, but you’d expect some consideration… has the situation changed?
JC: Yes, risk assessing I suppose
JE: So situation we have, there’s been this violent incident, one or two things documented in history, family say this is the first such incident for Morgan, is that your understanding from Case Notes?
JC: Yes. I’m not aware of anything happening prior to that
JE: You mentioned Section 2 is not just risk to self but risk to other people, this new violence could be seen as an increase of risk?
JC: Yes. Would expect it to be considered in relation to the mental health of the person.
JE: Thank you, needs consideration in context of mental health?
JC: Yes
JE: Note communication between you and Helen Green. It does seem between the two of you you’re doing what you can to get Morgan back into hospital?
JC: To keep her safe, make sure she’s safe in the immediate.
JE: You mentioned another Mental Health Act Assessment and she’s sectioned again?
JC: Yes, that was the 3rd time she was a Section 2
JE: Yes, the first was on 10 February?
JC: Yes
JE: For that one Morgan was under Section, bed on 13th, first admission into hospital. The whole admission under Section 2. Then one on [missed] that precedes admission to Maple Ward. Then goes back on, as result of all your efforts as I see it, on 1 March?
JC: Yes
JE: Whilst in A&E in Worthing?
JC: Yes
Ms Elliott said that she would read to Ms Cooper an extract from the report of the Mental Health Act assessment of Morgan conducted on 1 March 2023. She said it was conducted by Dr N, a Section 12 doctor.
JE: Subjectively and objectively depressed … hopelessness about the future … became distressed during ward round, saw wasps stinging her, when restrained attacked staff. Also reported heard voices telling her to kill others.
Clearly the view here is the risk is high, and she needs to be detained. Clinic note she’s presenting as chaotic, depressed, misunderstood.
Also a note of Victor, he’s one of your team?
JC: Yes
JE: He’s trying to safety plan and he’s saying what do we do when patients lack capacity… patient is a massive risk, is his reflection.
We’ve got those two AMHPs and doctors either side of what happened with Dr Ahwe. Is your view the risk changed or had gone away at any point?
JE: No similar risk, similar references in medical recommendations.
The risk increased it seems to me, the risk was escalating if you look at the pattern, the events, we end up using a 140 by the 3rd.
JE: That’s the special urgency bed?
JC: Yes
Ms Elliott checked there was nothing more from the family, before offering thanks to Ms Cooper “from the family for everything you tried to do”.
It was then over to Mr Berlevy, who asked questions on behalf of Ms Cooper’s employer, West Sussex County Council.
KB: Ms Cooper let’s quickly cover a few points. Section 2 of the Mental Health Act is a section where someone can be, or is liable to be detained, removed from the streets and taken to hospital if deemed to fall in section. Have I got that right or wrong?
JC: More or less, for up to 28 days
KB: That’s for treatment?
JC: It’s for assessment
KB: Section 3 is a different power, tell us what the difference is?
JC: Section 3 is for admission for treatment, usually used when known diagnosis and treatment plan, up to 6 months
KB: Potentially a more draconian measure, could be detained for a longer period?
JC: Potentially
KB: A Mental Health Act assessment, you’ve mentioned 2 doctors, so the jury understand that doesn’t mean 2 GPs who walk off the street… one has to be a Section 12 registered professional doctor. Someone with special expertise in diagnosis or treatment of a mental health disorder, is that right?
JC: Yes
KB: But have to be a Section 12 doctor, and A N Other doctor to consider individual and make a recommendation to the AMHP?
JC: They’d make individual recommendations but need for consistency of view amongst the doctors.
KB: Section 136 is a power police officers can use if an individual presents as being in need of taken to a place of safety?
JC: Yes
KB: Up to a 24 hour period where person is taken to a place of safety?
JC: Yes
KB: Just heard about The Haven, is a place of safety for purpose of 136 isn’t it?
JC: No, it has been used on occasion but shouldn’t be used as a place of safety
KB: Could take to A&E?
JC: Yes, A&E is used
KB: It’s not that an officer drops off at A&E, they have to stay with the person?
JC: Yes
KB: For a maximum of 24 hours for assessment under the Mental Health Act?
JC: Yes
KB: Section 2 we heard something about capacity, in your professional experience can they have capacity or do they not?
JC: They could, or it might be variable.
KB: Capacity is a moving feast isn’t it?
JC: Yes
KB: Individual can have capacity 11am in morning not at 2pm the same day?
JC: Yes, it’s decision specific as well, is it about treatment or care or whether go to hospital
KB: Thank you, I hope that’s some help
No further questions from Mr Berlevy. The coroner asked the jury bailiff whether the jury had any questions.
C reads jury question: have a question regarding when patients have special needs, when trying to find a bed, are those considerations taken into account?
JC: Yes, I must state it’s not the role of the AMHP to identify the bed, we might make suggestions, that’s the role of SPFT bed management.
C: So jury question, there is a witness Mr Beynon coming you could ask that question. I have lots of questions here to ask different witnesses, have kept them safe, that will be question Mr Beynon will be able to answer.
C asks jury question: I’m not sure whether you’re able to answer this either, when a patient is violent to staff what is normal procedure to ensure staff aren’t harmed?
JC: That will be a question for health I think, Dr Ahwe. I mean obviously we risk assess when we do MHA assessments, its different for me.
C asks jury question: In your role as AMHP, prior to Section 2 release are historic trends of behaviour considered, or is it solely based on current admission?
JC: When assessing? You consider the history, yes, as well as current presentation.
C: I think you’ve answered this previously, may need clarification. Should a Section 2 release be based on the safety of the patient in care alone, or are also considerations given to safety of staff in the institution?
JC: I think that’s a health question as well
C: Thank you, these questions will be kept and asked to appropriate witness.
Ms Cooper was released at 1504.
Court adjourned for a short break, and on return the coroner said they would hear the read evidence of Cheryl Wiggs.
[I left court at that time. I have applied for a remote link to access the hearing tomorrow, Thursday, but have had no response from the court at present. I am not optimistic it will be granted but if it is I shall report here as soon as I am able. I am also unsure whether I will be able to return in person for the coroner’s summing up and the jury’s conclusion, or whether remote access will be granted, but I will report after the inquest if I am unable
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