Louise was called to give her evidence at 10:16. She told the court that Morgan used to call her, her mother in law. She said her professional background was as a midwife.

C: You’ve kindly provided a statement for the purposes of this inquest dated 27 February 2024, is that correct?

LH: Yes, it is

Louise confirms that the facts are true and there is no further information she wishes to add. The coroner asks her to read her statement.

Louise told the court that she describes herself as Morgan’s mother in law, as she is Dominic’s mother and her grandson’s, grandmother.

She told the court she had been a midwife for 30 years. She said that she worked in community antenatal care, including mental health and trauma informed practice.

She described liaising with mental health services, attending child protection meetings and network meetings and providing evidence in court proceedings.

She tells the court she is not a mental health professional, but she has significant training in mental health and safeguarding. She said she also had experience of working with mentally unwell women, like Morgan.

She said she also thinks that it is important to make clear that prior to February 2023 she had never been part of the journey of entering the care of mental health services or an inpatient environment.

Louise said that she met Morgan shortly after she became pregnant in 2020. By the time she met Morgan she said everything she had been told about her was negative. She was involved in the Child Protection process as she was being assessed for special guardianship of the then unborn baby, if needed.

When she met Morgan she was taken aback by the Morgan she met and grew to love. She told the court that Morgan was very gentle and quiet and what she would call a prim lady. She said she had planted primroses in memory of her and that she always gave her Cath Kidston bags as they seemed to suit her personality.

She said that Morgan struggled with life, but hated to draw attention to her struggles.

“She [Morgan] worked so hard day to day to make a lovely calm, happy life for her and [her son]. She bought everything second hand, didn’t ask for anything from us, and learned everything she could about breastfeeding and caring for a baby, so that she could be the best mother she was able to be.

I was a bit worried it might not live up to her expectations, but she was a dream to look after in early labour, a calm and relaxed new breastfeeding mother, and the most devoted and patient mum to [her son] as he grew and developed, despite the sleepless nights alone and the horrendous pressure of the child protection process”.

Louise told the court that Morgan knew she should sing rhymes to her son, and she sang them endlessly, never once expressing frustration or irritation with him.

She said Morgan put her son’s needs entirely first and it was a quiet, happy little home.

“Morgan was quiet and gentle but also inwardly brave and determined. She fought her struggles like a lioness for [her son] until the end”.

Louise said most of the time Morgan coped without fuss, she tried to access help from the GP and community teams when she felt there was a deterioration in her health.

She said it had been mentioned yesterday that Morgan tried to access GP support. She said that she also tried to access community health visiting support but she was allocated no health visitor, which she said as a health professional she found “unfathomable” as in her professional experience that would have been the person who could help Morgan a lot.

“We, that is the wider family, generally wouldn’t find out about episodes of struggling or feeling low until later”.

Louise told the court she would have liked help more with accessing care and support. She said Morgan expressed guilt and shame about her life and the way she was perceived. Louise said that Morgan wanted to manage and be normal like any other teenager.

She told the court about a dog walking business Morgan had set up when [her son] was very young. She had distributed flyers and put them through people’s doors. Louise told the court about a local social worker who needed help with her puppy and “grew to love Morgan, as most people did”.

When Morgan worked at McDonalds Louise said she would undertake a half hour walk across town to get there, before an 8 hour shift, and she later started working at the Premier Inn as it was closer to her home. She said that Morgan was well liked as a colleague and employee, and that even though she found social interactions difficult, other people warmed to her.

“She told me whenever she found an interaction difficult she’d remind herself that she was doing it for [her son]”.

Louise tole the court that Morgan put up shelves with power tools and constructed by herself a large Ikea wardrobe. She said that when Morgan was becoming really ill she painted their entire flat, and stencilled [her son’s] room in an attempt to distract from the voices she was hearing.

“Her efforts to help herself when she was deteriorating in her final weeks were nothing short of heroic”.

Louise said that Morgan set herself high standards and was often hard on herself when she didn’t achieve them. Louise tried to reassure her that her difficulties were due to the lecturer strikes and teacher absence having an impact on her, but she had plenty of time to develop her knowledge and practice. She said Morgan had set her sights on a BA in Architecture at Portsmouth University, which Louise considered was perfectly achievable for her.

She said that Morgan accessed counselling support at college, unbeknownst to them, and was making efforts to keep herself well.

“Morgan had a very strong sense of right and wrong, she saw everything in black and white … world needed to be secure… she often sent complaint letters, such as when her neighbour smoked cannabis and she smelt it in the hall”.

Louise said that Morgan often said that she couldn’t deal with authority, but what she thought she really meant was that she couldn’t cope with injustice. She said Morgan dealt very well with authority but she struggled when she saw others not being treated well by authority.

She said Morgan had been a good student at her school and was well liked by her form tutor who came to her memorial service after her death, with some colleague, even though it was three years after her death.

She said Morgan had “generally positive and productive working relationships with Children’s Services, who mostly treated her with dignity and respect”.

Louise told the court that the “vast majority of the time we had Morgan in our lives there was no drama, no crisis, no breakdowns” she said that life was that as any other young couple with a baby.

“Just to say, the reason I say that, for the vast majority of the time, I feel that when Morgan had so many issues underlying that it can appear she was continuously in crisis or having interaction with health teams, the vast majority of the time in Morgan’s life she was a normal student, a normal daughter, a normal daughter in law and a normal college student. The crises were crises”.

Louise told the court that the only time she saw Morgan lose control, was the night she had to move into the Mother and Baby Unit which terrified her. She said that she was 9 months pregnant at the time. She described what happened, that Morgan was fixated on taking a small chest of drawers with her, that she wanted to keep all her baby things in. This request was refused, even though her support worker begged them to facilitate this. Morgan barricaded herself into her flat with furniture, the police were called by her support worker who explained she might be a risk to herself. Louise described that the police talked kindly to Morgan, explained they would not be breaking the door down and Morgan just needed time to calm down. Louise said that in the morning Morgan coped with the move, her third in 6 months, even though transitions were difficult for her.

She described the last Christmas Eve that she had spent with her husband, Dominic, Morgan and her grandson. She said that she remembered thinking really clearly that Dominic and Morgan would be at her death bed “and that would be such a comfort, but that wasn’t to be”.

Louise told the court that she had suspected Morgan was autistic from the first interaction she had with her. She gave some examples of why, mostly related to Morgan’s communication style. She said that she would “often hear my own words and phrases parroted back to me” and she understood Morgan “communicated by storing other people’s words and phraseology, particularly older women’s”.

She said Morgan made great efforts to communicate but it did not come naturally to her. Louise said that she soon learnt Morgan was masking, mostly successfully for most of the time, but that was “very tiring and stressful for her”.

Louise gave some examples from large family gatherings where Morgan struggled. She said that Morgan evidently struggled to make sense of the world. She said that her and Morgan would go to see plays and Morgan would remark “I enjoyed it but I couldn’t really follow it or understand it”. Louise said that she “soon realised this was true of Morgan in the rest of her life… she just couldn’t understand it”.

She said that Morgan would write many lists, journal entries and planners. She had a huge white board for life planning. Louise described this as “a template to structure her life which made her feel secure”.

Louise said that Morgan was very similar to other autistic patients she had seen in her clinic. She said that she was “not an expert in autism” but that she had attended training courses for neurodiversity and cared for autistic mothers. She told the court that she found if she accepted Morgan was autistic their communications were more positive and beneficial. She said that they “developed a lovely and very real friendship”.

Louise told the court that prior to February 2023 she had not experienced any prolonged period of knowing Morgan when she was suicidal. She said throughout February and March, Morgan would constantly express the need to die. Louise said that she didn’t allude to feelings, she just said them and it was very hard to hear. She said Morgan would refer to being suicidal in nearly every conversation they had during that period.

“That was Morgan in crisis, she wasn’t like that all the time, before February most of the time she was a great planner and motivated to do things for herself… she had ideas for her future and [her son’s] future”.

Louise said that there was never a point her suicidal thoughts and plans had gone by that point. She said that she recalled that “not being liked by those with control over her was very difficult for Morgan to manage” and she believed that this was a “strong contributor to her suicidal ideation in the end”. Louise told the court that Morgan felt misunderstood by health professionals and therefore she lost hope.

Louise said that she would go on to talk about Morgan’s contact with the police and health services. She said that she visited Morgan in St Richard’s A&E on Sunday [?] February. Louise said that she was shocked by Morgan’s self-harm. She said Morgan “talked about how she felt” and that she said it “was horrible to feel how she did”. She said Morgan was desperate for support and therapy whenever she came out of hospital.

Louise said that Morgan was agitated and wanted to leave the room. She described the feeling of wasps buzzing around her. Louise said that she looked terrified. Morgan was clear about being suicidal. Louise said that it was evident she’d been heavily sedated on the day she saw her, and that Morgan was distressed at having to be watched in the toilet. Louise said that it was agreed Dominic, herself and security could accompany Morgan to the bench outside for air.

Louise told the court that she would have liked to have spent longer talking to her. She said unusually for Morgan she gave her a long and tight hug as she left. Louise said that she was “shocked at her rapid deterioration”.

Louise considered that the staff at St Richard’s were doing their best in tricky circumstances. She said they would have welcomed family support meeting at the earliest opportunity as they could have offered more support to staff, and to Morgan.

Louise moved on to talk about Morgan’s time in Meadowfield. She visited her on 17 February 2023. They met in the ward visitors’ area and chatted for a while about autism and difficulties with life. Louise told the court Morgan “still couldn’t see a way forward other than suicide”.

Morgan asked Louise to arrange for Dominic to become a joint tenant so when she was dead he could live in the flat with [her son]. She said that Morgan was frustrated there were no opportunities for therapy or even to discuss therapies, whilst she was on the ward. She said that Morgan was pleased with herself for setting up an art therapy group on the ward, which other patients appreciated.

Louise said Morgan was receiving PRN [as required medications] to help her feel calm. Morgan said she needed a lot of them, which worried Louise as she knew a careful plan would be needed to be made for her to withdraw or safely use them once she was discharged.

Louise said that she was made aware of Morgan’s imminent discharge when Dominic called her on the afternoon of 21 February. He said that Morgan was coming home. Louise said she was shocked, that it was not remotely anticipated, and no one had contacted Morgan’s mum Tanya, or herself.

Louise said that she was extremely concerned Morgan had been on sedative medication and without these she was worried she would be back to square one.

“I was extremely concerned Morgan, Dominic and [their son] would be alone in a small flat together, it was a huge burden of responsibility for Dominic as [their son] was going through a tricky phrase with tantrums, Morgan was unstable, and as Dominic raised yesterday he was unwell, and has now had a diagnosis”.

Louise told the court that Morgan was “absolutely not well enough to care for [her son] in my opinion but in my naivety I assumed they’d assessed that as part of discharge planning”.

Louise described being confused and conflicted as she drove down to pick Morgan up as Dominic said she was going home in hospital transport “which is basically a taxi”.

On their journey home Morgan told Louise that she would work with Children’s Services, get any support she was offered, and she was looking forward to seeing her son.  

“I settled her in at home and told Dominic to call any time day or night if he or Morgan needed help .I should add I would have liked to stay, it was a very small flat, Dominic & Morgan at that point didn’t feel they needed me to stay, so I told Dominic to call me any time of day or night”.

Louise told the court that Children’s Services visited Morgan the next day.

“To the best of my recall, they later told me that Morgan had presented as very unwell still and not really present”.

Louise said that on 27 February she was visiting her sister in Nottingham when she received a “desperate message” from Tanya saying that there had been a serious incident at Meadowfield.

Tanya described to Louise that alarms were sounding, there was chaos in the background. Tanya told her she called the ward back.

“When she called back she was told Morgan had assaulted members of staff. Tanya told me the nurse she spoke to sounded angry. Tanya said she begged the nurse not to let Morgan leave as she knew the danger she would be in and the state she would now be in, mentally. However, the nurse did let Morgan leave, as Tanya was speaking to him”.

Louise said that her and Tanya both knew Morgan would be alone, very distressed and “almost definitely suicidal”. They knew that there were trees in the hospital ground and a busy road.

“I messaged Morgan telling her we loved her and asking her to stay with us”.

Louise said that Tanya was finding it difficult to get a response from emergency services, Tanya lived 35 minutes away from Meadowfield and Louise was in Nottingham.

“It did feel as if it was a race against time, so I tried to send Morgan messages of hope and love to give her mum time to get there. I received no response to my texts. In all honesty I thought Morgan was probably dead or dying”.

She told the court Tanya eventually messaged her to let her know that Morgan was in police custody and she had been told staff were going to press charges for assault.

“I have never been so shocked in my life.

To clarify, I don’t know if staff pressed charges for the assault, but that’s what we thought at the time.

I just couldn’t comprehend that a young, autistic, mentally ill mother in crisis, would be held in a police cell”.

Louise told the court Tanya messaged her and it seemed at the time the police would release Morgan, she had been told by Meadowfield that she didn’t need to be detained. She said fortunately it became clear how unwell Morgan was.

“I think it is important I say something about the way Morgan has been characterised as a violent and aggressive individual.

As well as knowing Morgan, I had also read a huge amount about her in the context of the Family Court proceedings and prior to February 2023. I had contact with a number of professionals involved with her.

Absolutely nothing I read or heard about led me to believe Morgan was a violent person … the opposite was true. Throughout all the difficulties and extreme stress of the events in the ante-natal and post-natal period … Morgan remained her gentle self-deprecating self, despite her significant internal struggles”.

Tanya said that she had never been told what happened on Maple Ward.

“I do not excuse violence towards my NHS colleagues, in any setting. But I am aware from my own work it does happen, particularly when a patient experiences overwhelming fear and anxiety”.

Louise added that was why staff were trained in trauma-informed care and de-escalation of conflict. She said until that point no professional had ever told them that Morgan was violent towards them. Louise told the court that the staff in Chichester A&E said at times Morgan was agitated and needed restraining, but the staff were very compassionate about this.

Louise told the court that no staff at Meadowfield spoke to them about anything. She said they did not ask for context or triggers for Morgan’s previous agitation or aggression, so that they could manage and de-escalate Morgan for the benefit of the staff or for Morgan’s benefit.

Louise said it felt very much as if Morgan was just labelled a violent, volatile person without considering the wider context of her trauma and her PTSD diagnosis. Louise said she had significant knowledge of how trauma effects people.

“PTSD and trauma responses are a primary survival response or very exaggerated fight or flight. They manifest in extreme loss of control or aggression, completely uncharacteristic of the individual. NHS England documents describe how some women with a history of trauma may experience escalating anxiety and flashbacks”.

Louise told the court Morgan usually felt the need to flee when expressing these primary responses. She said Morgan would ask to leave or try to self-discharge even when it was not in her best interests, adding that was how she dealt with severe anxiety.

“Given her PTSD was likely triggered or exacerbated by an event when she was stripped in police custody aged 15 due to being agitated and suicidal, I think it is likely the loss of control and aggression evidenced at Meadowfield was a consequence of the disturbance and shouting in the neighbouring room which she heard and which she explained later had frightened her, and induced flashbacks. Being restrained would have further exacerbated this, as would sirens and alarms”.

Louise said in her professional experiences there were lots of strategies that could be used for managing traumatised, aggressive and agitated patients. She said she didn’t know how that was dealt with as she wasn’t there, but she felt noise, shouting, bright lights and alarms would not be effective.

“Given Morgan had autism with sensory issues and PTSD she was evidently at high risk of fleeing, withdrawing or losing control”.

She said Morgan required skilled and compassionate evidence-based care.

“In summary my concern for staff and Morgan herself following the dreadful events of that day, was that she was losing control in an entirely uncharacteristic way, likely through fear and feeling unsafe but was subsequently told she was not mentally unwell, could leave at any time and she had no definable mental illness and she was therefore treated as a criminal.

This compounded her feelings of hopelessness, and also shame. As evidenced in her texts to me”.

Louise told the court she made it her mission to improve communication between Morgan, the professionals and ourselves. Louise described the autism tool they used to try and attempt that. This went alongside the letter she wrote, and the “vastly improved verbal communication we were afforded at the Woodlands Centre in Hastings, where we felt Morgan was treated with compassion”.

“During that time I was desperate to find help from anywhere to allow us to communicate with whoever was looking after Morgan. To help them keep her calm, to de-escalate where needed and help them communicate and build trust with her, to enable the therapeutic process to take place”.

Louise told the court that she spoke to a number of people she knew with relevant expertise in both mental health and safeguarding. This included a friend who was a senior manager in a learning disability team in Sussex Partnership Foundation Trust.

This friend was part of the trust wide on-call rota and was able to advise Louise on strategies to use with a young autistic person in a healthcare setting, such as using the traffic light system to manage anxieties.

“As a midwife, I understand the system doesn’t always work, that standards can vary but most people are usually doing their best within the resources they have … it is often important to be aware of the fact that you might need to advocate for a patient.

I was increasingly keen and desperate to try and find a way to navigate the system Morgan was in.

Despite working in the NHS I was struggling to know how to raise issues about Morgan’s care. As a family we were incredibly worried about the fact that Morgan had been moved between various settings and discharged from an inpatient ward twice, without there appearing to be any proper discharge planning, and despite the risk she posed to herself”.

Louise said this was why she wrote the letter to Meadowfield. She said they were desperate, wanted to flag their concerns around discharge, and flag the risks of Morgan’s suicidal ideation and recent suicide attempts. She showed this letter to her friend and asked if it was reasonable, given families are encouraged to be partners in care and raise concerns when necessary.

“Even at that time I didn’t want to put anyone’s back up. This might feel strange given in my own Trust patient feedback and family concerns are strong drivers for care”.

Louise said she had worked with a few people who would take criticism personally and she knew if this happened, with Morgan being so low and further traumatised by being back in police custody, would be worst of all worlds.

“She needed to be kept safe at that time because she was experiencing an acute crisis and she had not improved, having had little time in one therapeutic setting to really do so.

However, were she to be met with hostility or lack of empathy in a supposedly therapeutic environment, I knew this would break her. As it would any young mother as sick and despairing as she was”.

Louise said that was why she showed the letter to her friend, who agreed it was reasonable, and delivered it by hand to Meadowfield on Louise’s behalf on 2 March 2023. She told the court that Morgan was not an inpatient at that time, but she knew there was a chance Morgan would go back there.

Louise said she also emailed Richard Lee at Sussex Partnership Foundation Trust a copy of the letter. She was told he was the Carers Lead at SPFT at the time. She said the email was exhibited to her statement and the subject line read: Morgan Betchley Urgent Safeguarding Information.

Louise told the court at that point her friend also began working on a more personalised communication tool with them as a family, that would allow Morgan to alert staff at an earlier stage, when she was beginning to feel out of control.

Louise was told by Morgan there would be a Mental Health Act Assessment at Worthing Hospital on 1 March 2023. Louise arrived as the multi disciplinary team gathered in Morgan’s room at A&E. Louise told the court she provided a copy of the letter she had sent to Meadowfield, as background to Morgan’s last few weeks. She said she thought this was when she first showed Morgan a copy of the letter and explained to her she hoped it would improve relationships with professionals.

Louise told the court that the people assessing Morgan that day left the room with the letter, and all took the time to read it. She said the psychiatrist asked the usual questions of Morgan who stated she was frustrated that her previous attempts to end her life had failed, she therefore concluded she’d made plan that would definitely work. Louise says the decision was made that Morgan should be detained under section.

“Morgan was very relieved to be sectioned as it made her feel secure again”.

Louise said she was extremely relieved as it was very clear how acutely unwell Morgan was. She felt the assessing team properly considered the letter and had taken it seriously without being defensive. She was very grateful for that.

“Following the meeting Morgan became very anxious, disturbed and agitated. I had not really seen her like that before. The police agreed we could all take her outside for some air, as the room was very hot and she was panicking and saying that she could feel the wasps coming and hear them all around her.

I observed in her behaviour that she really did feel this was the case, rather than just a way of describing her anxiety”.

Louise thought that Morgan’s anxiety was causing sensory symptoms which were then “massively multiplied in intensity due to her autism”. Louise said she was able to help Morgan calm down by using calming techniques she knew from her job.

Louise said when they went back inside she spoke to Morgan about how she was young and things would change with her mental health as she grew older. She said Morgan listened to this, but said she didn’t think they understood how she felt and “she was sure she couldn’t get better”.

Louise said Morgan was transferred from the Woodlands Centre in the early hours of 2 March and had a further Mental Health Act Assessment on 3 March. Louise said that she was interested in the questions the psychiatrist asked Morgan.

Louise said Morgan made it clear she was experiencing suicidal ideation and the voices were getting ever louder and difficult to ignore.

“She stated her wish to be detained and kept safe”.

Louise told the court the psychiatrist asked Morgan if the voices were external, coming from somewhere in room, or internal and inside her head. Morgan said that they were inside her head, they were very real and she couldn’t turn them off. Louise said the psychiatrist asked the question several times in different ways, it felt like the main line of questioning.

“Upon clarifying her answer, he stated she therefore didn’t meet the criteria for detention under the Mental Health Act. Which upset Morgan, who then asked that we be allowed to speak up for her as her advocates.

I knew she was worried about not feeling safe. She truly wanted to live and get well. She wanted help and felt frightened that the voices caused her to feel out of control so I asked the clinicians to explain to Morgan how they could still help her and keep her safe, although she would not be under section’”

Louise told the court a male nurse explained there would still be a plan in place if Morgan felt compelled to flee or leave.

“The Consultant Psychiatrist said to Morgan although she couldn’t see any hope for herself, there was hope for the future and she could get better.

These two seemingly small interactions were kind, reassured me that Morgan was cared for and are a comfort to me even now to this day”.

Louise was becoming more and more upset as her statement went on. The coroner checked that she was ok to continue, she said she was.

Louise told the court when Morgan was in Hastings she text her about the autism tool. She said Morgan responded to thank her, expressed her anxiety, her guilt, and sorrow “for the mess she made of everything”.

She said her sister, who is a nurse, had visited Morgan for an hour or more. At times Morgan had said to her people would be better off without her as there was no treatment, but at other times in that conversation she spoke about her desire to get better and discussed what that would look like in terms of caring for her son.

Louise said they were aware there were difficulties managing Morgan in Hastings, partly around the issue of going to toilet and being observed. Morgan told Louise she was trying to hold everything in which Louise believed was making her very uncomfortable. She said staff liaised with Tanya and they were able to resolve matters.

“We were relieved staff were proactively communicating with Tanya as she could advise and discuss Morgan’s care and help to avoid conflict.

Morgan had by this point been in so many different institutions in the space of a month, that we ourselves were at a loss as to how she would ever get better as her trauma had been compounded”.

Louise added that they felt Morgan was receiving quality professional nursing care in Hastings. She said they were invited to a discharge planning meeting, some days down the line, while Morgan was in Hastings, but before that happened she was transferred back to Meadowfield once more. Louise said she had feared this might happen as Hastings were very busy, but she didn’t actually think it would happen.

“She was extremely anxious about going back and how she might be received”.

Louise said she was shocked when Morgan was returned to Meadowfield. Morgan messaged her on the journey to the hospital and shared her increasing anxiety.

“She asked me if I had given them my letter and I said I had. She also said she was going to fill in the autism tool and was very grateful for it”.

Louise told the court she saw Morgan briefly at Meadowfield on 4 March as she went to collect Dominic, who had been visiting Morgan.

“I took a copy of my letter and this is when I had handwritten a few lines at the end which very much focused on the autism tool, flagging it had been completed and emphasising that we wanted to make the admission work for Morgan”.

She told the court she marked the letter for the attention of the psychiatrist and the matron. She handed it to the male nurse working on the ward that day.

Louise then told the court about the meeting on 7 March that she attended by phone. Tanya and her had kept in regular contact and were concerned Morgan wanted to discharge herself as she felt staff did not like her and she said the psychiatrist had been horrible to her.

“We were very worried as we did not have a robust plan in place … Morgan hadn’t had any treatment, she was still suicidal and we were fearful about what would happen if she was discharged.

At that stage, I assumed Morgan was possibly being sensitive and thought it was unlikely anyone had been horrible to her”.

Louise said she knew they had to make sure Morgan stayed in hospital until they had a robust plan in place to provide her with care in the community. She sent Morgan messages encouraging her to stay and she agreed to this. She also messaged Dominic asking him to persuade Morgan not to discharge herself.

Louise was at work when the meeting happened and joined on the phone.

“It was an extremely difficult meeting to witness.

The psychiatrist Dr Julia, immediately started talking very rapidly and without displaying any empathy.

She did not allow any breaks for Morgan or us to speak.

Dr Julia said Morgan would not be able to go home that day as the crisis team couldn’t come as they had no appointments and if Morgan did go home then she would be considered to be discharging herself against medical advice.

Tanya explained that Morgan had been preparing herself to go home and so this was likely to be difficult for Morgan to process. I remember Tanya saying something along the lines of you have made it clear that there is no treatment here for her and no benefit to her staying and Tanya explained for Morgan this felt like a catch 22 situation where Morgan felt unwelcome and hopeless with regard to treatment at Meadowfield, but she was being told she had to stay in hospital for other reasons”.

Louise told the court that Dr Julia seemed annoyed by Tanya’s intervention. She said she remembered willing Tanya to speak up to advocate for Morgan, and she did.

Louise said Tanya did not state she or the family wanted Morgan to leave the hospital, she was trying to get the staff see things from Morgan’s point of view, and elicit some empathy.

“The psychiatrist spoke in a very abrupt, rapid and apathetic manner, which personally I found very distressing as I was very aware that this would further traumatise Morgan”.

Louise told the court that Dr Julia had referenced the letter Morgan had written to staff, her apology letter, as an example of why there was no benefit for Morgan being there.

“She said it was considered by staff to be insincere and not good enough.

She repeated this several times, despite Tanya interjecting to say Morgan was very sorry. Morgan was visibly crying about this”.

Louise said that at this point Dr Julia referenced the letter that she had written to the Trust, as another example of how relationships had broken down.

“This horrified me because my letter was a desperate attempt to improve relationships for all, and was now being used in front of, and against, the very vulnerable young woman I was trying my hardest to protect.

She continued to bring it up, she was like a dog with a bone, until I heard Tanya and another female suggest we move on”.

Louise told the court she considered this to be “incredibly unprofessional behaviour” and that she was seeking to work as team with Morgan, with all staff part of that team.

“I believe Dr Julia took offence at my letter and Morgan suffered as a consequence.

It is something I find hard to reconcile or forgive myself for.

I do wonder what would have happened if I had not written that letter. I know how that meeting left me feeling and I am a hardened professional with 30 years of frontline work”.

At this point Louise became upset and paused.

She continued by telling the court when she spoke with Tanya after the meeting, she told her Morgan was distressed and crying.

“Tanya said she had apologised to Morgan as she had previously brushed off Morgan’s description of feeling distressed by Dr Julia’s manner … we always sought to try to get Morgan to see the positives so we would say things like I’m sure that wasn’t her intention and there are other staff you can talk to if you feel anxious.

On this occasion Tanya told me that she had said sorry, I can see you were right and please don’t let one doctor ruin your chance to get better for [her son], don’t give them that power, talk to other staff if you feel anxious”.

Louise told the court she was physically ill following that meeting and she immediately told two colleagues that “Morgan was likely to feel more suicidal and hopeless”.

“My fear was that Morgan would be so traumatised and hopeless by the time she left hospital that we wouldn’t be able to pull it back.

Naively, I didn’t think she would be able to take her own life in an NHS hospital and so my fear was focused on what would happen when she was discharged”.

Louise told the court she didn’t have any contact with Morgan on the 7 and 8 March as she was looking after her grandson, while Dominic visited Morgan.

“Morgan’s autism had a significant impact on her care and her experience of care as an inpatient … Morgan struggled with nuances and reading non-verbal communication such as facial expressions and gestures.

In common with many other autistic people she also struggled to comprehend the nuances or grey areas of language so would need information and explanations to be sensitively delivered, particularly when she was stressed or overwhelmed.

It would also be important to explain things carefully in different ways and to check understanding, particularly in a healthcare setting, in order for Morgan to remain calm and not exacerbate her anxiety”.

Louise told the court they saw examples of good practice, in Chichester A&E, in Worthing A&E and in Hastings.

“Morgan’s experience at Meadowfield was that she felt some staff communicated in an abrupt, dismissive manner, which was insensitive to her needs as a young mother with a neurodiversity.

Morgan herself could be abrupt, as she saw things in black and white and didn’t always tune into social niceties. She was obviously also very distressed and anxious”.

Louise said Morgan also experienced sensory issues.

“Bright lights, noise and being physically handled by others would be felt very much more acutely, leading to autistic overwhelm or what many call meltdown.

Morgan would generally deal with this by retreating to a very quiet calm place, usually her bedroom if possible. She would also benefit at those times from a calm, compassionate voice and assistance with breathing techniques”.

Louise told the court that Morgan felt when she became upset or agitated or stressed the staff at Meadowfield were annoyed with her. She did not feel she could communicate with staff at Meadowfield and this compounded her feeling of not being understood.

Louise said at one point she noted mention of reference to a community autism service. She said she looked into this and discovered the waiting list was more than a year long, and she said she was reliably informed in any case the service was running on a shoestring and was unlikely to be able to help Morgan with her acute suicidal ideation and mental health crisis.

“Morgan also made reference to some staff not even believing she was autistic, despite her diagnosis.

This is why we made the tool to assist communication for all involved, as an example of good practice. However, for it to be useful it would have to have been seen as a trusted tool and actually used by staff”.

Louise said Morgan found it difficult to deal with change, and she needed structure and familiarity.

“The number and frequency of changes in environment, staffing and routines which Morgan had to navigate in an extremely short space of time would have been traumatising for any well person.

Morgan being already distressed, suicidal and agitated, had to continuously re-orientate herself, not only to new hospital environments but also to a police cell”.

Louise said Morgan had been diagnosed with PTSD prior to this acute illness.

“There is no doubt that this roundabout of admission and abrupt discharge, followed by almost immediate readmission, transfer, sleeping on temporary beds, back to A&E and finally back to the place where staff had wished to press charges following a distressing incident, retraumatised Morgan exponentially”.

Louise told the court that in her view Morgan was “sadly and tragically let down by her treatment and lack of treatment”.

“She was not provided with the care a young autistic traumatised mother should receive in order to recover.

She was re-traumatised by a horrific merry-go-round of admissions and discharges.

We, her family, were never given any inkling of appropriate therapies we could seek to help her, or of any path towards healing in the community.

In fact, until we jumped up and down to try to make ourselves heard, we were not spoken to, listened to or included at all, even though we were very concerned for [her son] as well”.

Louise said that perhaps the most difficult thing to face is the lack of compassion and empathy that Morgan experienced by some key staff, as she and other members of Morgan’s family witnessed.

“The way individuals in crisis are spoken to and listened to is not a small element of mental health care.

It was in Morgan’s case crucial to her ability to believe she could get better and trust medical professionals to help her do so.

Knowing Morgan well as I did, I have no doubt this hostility contributed in no small part to her decision to end her life in the small hours of March 9”.

Louise concluded her statement by saying although she is a health professional she had no direct experience of any mental health inpatient process before the events she’d described.

“I just thought Morgan would be admitted to hospital and in my naivety, she’d be there until she was better … and there was a safe support package available to her in the community.

I can now see quite clearly that Morgan was pretty well for a lot of her life and that in February 2023, she was suffering an acute crisis.

I didn’t believe that Morgan would ever be able to take her life in an inpatient facility. It genuinely never occurred to me.

When the police came to tell me what happened, I assumed she had escaped and hurt herself whilst in the community.

All the time that Morgan was in hospital, I thought at least for today she is safe. Clearly, I was wrong.

Thank you for listening”.

The coroner thanked Louise and then said she had a few questions that she would like to ask her.

C: Thank you. I know it’s been very difficult for you and thank you for your assistance in the investigation. I have a few questions I’d like to ask.

You discussed about Morgan being discharged on [missed the date] did Morgan discuss that discharge with you?

LH: We had a half hour journey in the car because I picked her up

JE: Sorry ma’am, you’re talking 27 February, after the incident on Maple Ward?

C: The second discharge

JE: When Morgan left hospital and found the park

LH: She didn’t discuss it in detail… all she’d say, we discussed in Worthing and in texts when in Hastings, very much along the lines of I’ve just screwed up big time, I’m so ashamed, um she did say that she didn’t understand what had happened or how it had happened.

She didn’t describe in detail to me what was happening on the ward at that time. I still don’t know what happened on the ward, she was absolutely mortified, I think that was the word she used.

She said well I’m in a police cell again. I said to her that the police could see very well when she was in the police cells how poorly and sick she was. In fact the police with her at the time, she was watched by police in Worthing, also reassured her from their notes, as soon as she got to Worthing A&E it was very obvious how sick she was.

Conversation along lines of trying to reassure her there was understanding from other professionals, that individual was part of her trauma or part of her illness. Didn’t go into detail about the what’s, whys and wherefores, who was responsible and how it happened

C: She didn’t discuss with you who discharged her?

LH: She didn’t discuss who discharged her no, not to me

C: Did she discuss the incident in Meadowfield, the conflict management used at that point?

LH: No. I do recall actually when she was in Worthing A&E she did say she had been un-sectioned prior… couldn’t understand in the middle of this chaos someone had come along and un-sectioned her. In Worthing she had gone to police custody, they’d sent her to A&E.

She couldn’t understand in the middle of all this, chaos was the word she described, in the middle of this someone came along and un-sectioned me and said I could just go.

C: But was no name?

LH: No person, no

C: The meeting on 3 March and meeting at Hastings, paragraph 45 of your statement, don’t know whether you want to refer to that?

LH: Yes, got it

C: You have a discussion with a professional at that point, did you discuss Morgan’s autism diagnosis at that point?

LH: OK that meeting was attended remotely, on 3 March, was a Mental Health Act Assessment so no I didn’t discuss anything about her autism, we weren’t invited to. The meeting ended after the Mental Health Act Assessment.

Discussions between professionals happened after that point with Tanya, during that meeting I don’t even think, I think it was just us staying on the phone with one of the professionals from what I remember, because Morgan was upset she wasn’t detained.

I think from recall Morgan said I think my mum and Louise would want to speak, but the meeting officially was over.

The psychiatrists left and the nurse at that point was with her and I said at that point she’s feeling unsettled because she’s not sectioned, she feels safer when she’s sectioned, this is going to be really unsettling… so briefly yes, there was that, a brief conversation and then he said that they were going to talk about it and he said to her there’s other ways we can do this, we will keep you safe and make a plan with you.

So it was brief but was mentioned, I wouldn’t call it a meeting in which we were invited to have a long conversation, after that point Tanya had contact with the nurses involved.

C: At that point can you advise me what they’d told you at that point, they’d assessed Morgan at that point and conclusion was?

LH: They didn’t tell us at that point, they just said you don’t need to be under Section and they left the room.

We were listening in, it’s difficult to interrupt a psychiatrist when doing a formal review… that’s why we asked them to stay on the line.

Very minimal, no one advised us anything particularly, we knew she would stay there or wasn’t being discharged at that point but didn’t really know what would happen next.

We didn’t ever really know what would happen next.

The coroner has no further questions. There are no questions from Ms Agnew or Mr Berlevy.

Ms Elliott said she had a couple of topics and suggested that might be a convenient moment to take the first break.

The coroner told Ms Hodgson she was still under oath and she couldn’t discuss the hearing with anyone else.

Court was then adjourned for a 10 minute break at 11:26. When we retuned it was Ms Elliott for Morgan’s family to ask questions of Louise.

JE: thank you ma’am. Good morning, I thank you for your evidence, just four topics I want to cover, quite short ones. First the discharge on 21 February…. can I check if this sounds right? Morgan went into A&E right at the beginning of February, then comes out, is a Crisis Team visit whilst she’s at home

LH: Uh hum

JE: She goes back into A&E with Strep A, has attendance then back home, Crisis Team, then goes into place called The Haven, that was a 24 hour thing, leaves The Haven, police were contacted, she returns home. Little period at home, Dominic’s birthday is around that time, early February there is a family dinner?

LH: Yes

JE: Then 9 February she overdoses at home and goes back into A&E, at this point the timeline really begins. She spends 4 nights in A&E and put on a section then. Does that fit broadly?

LH: I wasn’t aware of the very beginning of the timeline, Dominic and Morgan were trying to manage that with health professionals, didn’t want to bother people, that was the way Morgan was. They were trying to manage as best they could and thought they’d get health professionals’ help and she’d have her medication. But certainly from the point of Dominic’s birthday I got involved.

JE: So, beginning timeline there were a few A&E visits, on 9^th goes into A&E for 4 nights, she absconds, suicide attempt and she’s put under Section. What interest from A&E just see. Lines up in chronology on 13 February she goes into Rowan Ward for the first time, 2 admissions on Rowan Ward. Note she’s on Rowan Ward for 8 nights, was discharged home on 21 February. That was the one when you went to pick her up, you’re with me where we are?

LH: Yes

JE: On that discharge Tanya and Dominic discussed yesterday, their concerns, not knowing discharge happening, no involvement, was too early. … had you been invited, had you had an opportunity to express your views, what sort of things you might have wanted to raise with staff?

Before I put to you will read one note at the end of that admission… ma’am I’m reading from 21 February risk assessment, don’t have page number in your bundle, can say one done on 21 February just before discharge. If it helps can get page number for the court during the lunch break. It was completed by Cherno … number of risk assessments completed over time, the document gets built up and up as different layers added, 21 February is in middle of bundle. Shall I follow up on that?

C: If you can

JE: Louise I’m reading from the risk assessment… Morgan’s risk at discharge, number of sections, first risk to self said Morgan is risk to accidental harm or death due to impulsivity, misadventure and maladaptive coping mechanisms, said Morgan engaged in various deliberate acts of self-harm during her admission [she lists, I’ll withhold].

It does note Morgan is really missing her son and wants to go home and no incidents of self-harm since Monday, that’s yesterday, the day before, when Morgan was informed about discharge.

She’s happy to work with the Crisis Team. Self-neglect, says high risk, Morgan is at times restricting diet during her stay on Rowan Ward, vulnerability, high risk due to mental state. At point discharged to Dominic and [their son] this is the summary of risk done by the ward…. To give you an insight.

Had you been involved by the ward in this discharge, can you help the jury with what sort of concerns you might have, before Morgan was sent home? What you’d have expected?

LH: I’d have expected to be involved by the ward and expect Dominic and Tanya to be involved by the ward too.

Would have expected a discharge planning meeting involving Children’s Services as well, that was an A1 priority because another small child is involved in this scenario. Would expect discharge planning meeting to take place with all agencies.

Other questions would ask and expect to be informed of was what risk assessment had been done, that you’ve just read to me, that I’ve never heard before.

That should have been made known to us for the fundamental reason Morgan was coming out into our care, during the day, during the night. They had access to that risk assessment. They knew what the risks were. They sent her out into the night to us, who were not aware of the risks or the risk assessment that had just been done.

My plan, such as it was, just had a call from Dominic to say Morgan was being discharged. That had no forewarning about, priority was to get there as soon as possible so she didn’t go home in a taxi.

Would have wanted to know what risk assessment was, what medication she had been on, what the plan was to reduce that medication and keep her from severe withdrawal symptoms. What those symptoms might be, would have wanted to know what the plan was for a crisis.

The crisis that would, and did, occur following the discharge. OK, we’re taking her home what do we do if something happens in the night, who do we call, what do we say, have you got a letter to hand to them so we don’t have to cobble it together… that actually was a different trust, A&E were different trust to SPFT so wouldn’t have had access to clinical notes as they don’t share systems, so every time she presented to A&E wouldn’t have known how she presented at Meadowfield in any detail, would have only had family’s detail.

Would want to know if she was a risk to her son, that did cross my mind… know she would never have deliberately harmed him, absolutely not, but I’m a midwife and know in the first few years of life with serious mental health and psychotic episodes, it can be a risk to a child for various reasons.

JE: I understand. So you wanted to be in the picture?

LH: Yes, they didn’t let you in the door. She was outside waiting with her bag when I got there.

JE: Could you speak to anyone when you arrived?

LH: No, I couldn’t get through the main doors or ward doors, she was just outside.

JE: Do you feel it was the right time for discharge or could Morgan have benefitted from a longer period in hospital? Are you able to answer that?

LH: It absolutely was not the right time. On discharge she was definitely as clinically unwell and as unstable as she had been when she went in.

There was no improvement, obviously the interactions we had with her and communication I had was when I went to see her, and through Tanya and Dominic.

I was planning to make an evaluation whilst she as in the car with me, she was clearly still high on benzos at the time, which was a big concern. And I think we were all just shocked, we’d had no indication of any significant clinical improvement and she was still persisting in her suicidal planning, as opposed to just ideation. Her planning and her very definite expressing of that being the only plan. I could see she’d be missing her son, of course she was, she was a wonderful mother.

JE: That is documented

LH: Yes, she just needed some compassionate interactions to deal with that

Ms Elliott said the next topic she wanted to ask Louise about was Morgan’s working diagnosis on the ward.

JE: The next topic I wanted to ask about was Morgan’s working diagnosis on the ward. At this point you hadn’t received any communication, but we know now what psychiatrists were considering something called Emotionally Unstable Personality Disorder, EUPD. Do you have any experience of that in your professional life?

LH: Yes, I worked with some of my patients in the mental health team I worked in had been diagnosed with, or went on to be diagnosed with EUPD. I am not a mental health professional, but I know what the NHS signs and symptoms of EUPD are, according to NHS guidelines.

JE: So, you have some experience.

LH: Yes, I do

JE: it’s noted in the records psychiatrists were planning to obtain family views of whether EUPD was the right diagnosis. It didn’t come to that. Can I ask, if you had been asked whether Morgan was a fit for EUPD, what your views would be?

LH: Is interesting, because we were present with the psychiatrist. EUPD had been mentioned to Morgan by herself. It would have been a good idea if they mentioned it to us on 7 March, because then we could all have talked about it together.

Very surprised they were considering that as diagnosis. It is characterised by unstable relationships and emotional instability and Morgan was very much the opposite.

Was very unusual for a 16, 17, 18, 19 year old girl to have a long term quiet calm happy relationship with one person, especially with all the pressures she was under, and they both endured during that time.

There was never any drama, there was never any arguments. It was quite remarkable really, and that was also characteristic of other relationships in her life.

Yes she found difficulties with friendships but not arguing, shouting, drawing attention difficulties, just being anxious about something or somebody, she’d misread people.

In terms of her relationships with myself and my own children, they’re much more volatile than she was. She was the calm one… absolutely completely not.

One of the key parts of diagnosis, inability to keep relationships… short time over the top, or constant drama and conflict. That was not Morgan … other things as well, she was, I think one of the parts of the diagnosis is people behave impulsively.

Morgan there was an element of impulsivity, when she was acutely unwell in that she obviously we believed she impulsively took her own life.

However, what characterised most of her life was almost the opposite. She was very ordered, made lists, she needed order, she journaled, she ordered her flat, knew what was happening in X weeks time, she got it all organised.

She didn’t act spontaneously, she wasn’t the sort of person who didn’t know what she’d do one week to the next, she was very much the opposite … she lived a very simple life.

JE: Thank you, that’s helpful

LH: And I was very shocked by the diagnosis. If they’d engaged with us it would have been helpful … I feel that was just another way of trying to get her out of hospital in all honesty.

There are other symptoms of EUPD again she didn’t have. We could have easily had that discussion with them but it was never raised.

JE: So worried would affect whether she remained on the ward?

LH: Absolutely … it’s fine to have a working diagnosis but you can’t discharge someone because they might have something you’ve not discussed with family and haven’t any evidence of. No. You work on the basis this is a suicidal person with PTSD and depression…

JE: PTSD, depression, autism?

LH: And PMDD as well. She was autistic, we know that, she certainly had PTSD from what I saw, and what her struggles were, she’d experience flashbacks and she had trauma in her life.

She’d always had anxiety and depression, and she managed that and that could be managed, like a lot of people it’s up and down but its manageable. The PMDD is the hormonal part of it, unfortunately for Morgan she was extremely sensitive, probably to progesterone, and made it thousands of times worse, sensory experiences would be heightened because of her autism.

They were complex, really complex. It would take a psychiatrist to work with her, would have taken time and expertise, but the expertise should be there.

JE: And a full diagnosis process. I see.

LH: Absolutely

JE: Briefly on hormones, others mentioned Morgan’s periods … during the time you knew her hadn’t many … do you know when she had her last period on this timeline?

LH: No

JE: You don’t, may need to put that in evidence ma’am.

On diagnosis, it’s fair to say the jury heard evidence when Morgan has got into difficulties where Morgan does seem emotionally dysregulated, out of control. Do I understand from your evidence that wasn’t her in general, but when she was in difficulty or crisis?

LH: Yes, when I first started to know about Morgan I was told about all the difficulties, so it feels like that’s all that happened, nearly all the time I had with Morgan was normal life, very quiet life, very ordered life.

Equally, from what I heard, read, got to know through the child protection process, everything that happened previously was very intermittent, it wasn’t all the time, most of her life was normal … most of the time, like her teacher said on the video, she was quiet, at the back of the class, writing poetry. She wasn’t a person trying to get attention and who needed crisis.

Only time I knew of crises, and gosh was she under pressure, was night before she went into the mother and baby home, and she was so, so anxious about that, and understandably and about to have a baby, she was nearly full term at that point.

JE: Yes in which case can take very quickly, Dr Julia mentions dissocial traits of EUPD.

LH: I’ve heard of it

JE said for the record she’d read the ICD10 definition of how that was characterised.

“Personality disorder characterized by disregard for social obligations, and callous unconcern for the feelings of others. There is gross disparity between behaviour and the prevailing social norms. Behaviour is not readily modifiable by adverse experience, including punishment. There is a low tolerance to frustration and a low threshold for discharge of aggression, including violence; there is a tendency to blame others, or to offer plausible rationalizations for the behaviour bringing the patient into conflict with society”.

LH: Morgan blamed herself with everything

JE: Does that fit with Morgan?

LH: Is the furthest from Morgan you could possibly get.

JE: Next question, you covered Morgan bonding with her son, and motherhood, very moving passage of your statement. Jury will hear evidence in the risk assessment that Morgan felt disconnected from her son at that time, he was no longer a protective factor for her. What do you say about Morgan’s risk at that point?

LH: At the time I didn’t know how severe the disconnect was. She had no doubt unbonded from her son… we should have been informed of that and it discussed with us and Children’s Services.

I would have had every confidence with treatment, she was so bonded with her son, she absolutely adored him. As a health professional I have worked in peri natal mental health … unbonding or lack of bonding, failure to bond but particularly unbonding is literally the highest red flag you can possibly have for mental health crisis and suicide. It’s more than a red flag if a mother does that.

The health visiting service has a health visitor specialising and trained in that… could have been contacted by SPFT… they were never called.

She didn’t have a health visitor at all, not even a basic one. If that happened in my job at any point, maybe even, occasionally seen with someone having baby and toddler who’s two, its indication its very serious, very serious mental health decline.

JE: Last thing I want to come to is your letter. The jury heard number of references to your letter, at this point I would like the jury to hear content of letter so they know what’s being discussed

LH: Yes

Ms Elliott asked Louise if she had a copy of it with her. The coroner’s officer passes it to her.

JE: This is a 1.5 page letter, the one you have there has handwritten additions on the back?

LH: Yes

JE: You said you drafted one letter, then when you knew Morgan was back on Rowan Ward you added some hand written notes?

LH: Yes, I hastily added some hand written notes, one letter was hand delivered by my friend on 2 March, but when she was going back I scribbled some additions to do with the autism communication tool

JE: We were talking 21 February discharge, really didn’t go well, home visit from the Crisis Team, went almost immediately back to A&E, stayed 3 nights in A&E, then admitted to Maple Ward, which is the same hospital as Rowan Ward, Meadowfield. We then discussed how it ended with a violent incident and the discharge you’ve talked about.. then Morgan is in police custody and A&E in Worthing, where you saw her?

LH: Correct

JE: Is that where you saw Morgan experiencing the wasp phenomena, if I can call it that?

LH: Yes

JE: You saw that yourself?

LH: I did yes

JE: She is detained in A&E under a Section 2. She then goes to Woodlands?

LH: In Hastings

JE: Yes, where you hoped she’d stay… it turns out she goes back to Rowan Ward, quite a lot happened as you say… you saw her in Worthing and Woodlands?

LH: I didn’t see her in Woodlands, was at the meeting on the phone and we text afterwards.

JE: It was around that time you wrote this letter, after her discharge?

LH: I wrote the letter immediately after the discharge, when she was in police custody I think

JE: Yes, the date is 1 March

LH: Yes, but it wasn’t delivered that day, was delivered by my friend, was basically delivered twice to the hospital, one with the handwritten was delivered by me, original by my friend

JE: So, we know they had it when Morgan got back on Rowan Ward?

LH: Yes, they had it before then.

JE: Can I ask you first to read down to the end of the third paragraph.

LH: Dear matron/manager, I am writing to express my grave concerns about the treatment, management and care of Morgan Betchley since she became unwell recently. I am a senior midwife with specialist experience in safeguarding and mental health. I am also the grandmother of Morgan’s child and mother of her partner, Dominic.

Morgan has been twice admitted and discharged from Meadowfield Hospital in recent days.

JE: Just pausing there, so first when you drove her home, second when there was the incident.

LH: Both discharges were abrupt, inexplicably unsafe, with no communication with any of Morgan’s family, despite all of us having grave concerns about her level of risk and the fact she’d made multiple attempts on her own life [I’ll not publish the detail that follows].

Immediately following the first discharge, she was noted by both the Crisis Team and Children’s Services to be very unwell and she returned to A&E.

JE: Thank you, we covered that in the chronology. Can you carry on with the next 2 paragraphs please.

LH: There will be a detailed complaint formally raised at the highest level regarding both discharges … [missed] She was in the bushes in the dark, and none of her family were informed, Children’s Services were not informed. The police, called by us not the staff, found her fortunately alive, we thought she was probably dead.

JE: Next paragraph

LH: [missed start] Morgan has been a stable, loving, gentle parent for two years, despite having previous mental health episodes prior to pregnancy. I know her extremely well and have been part of the support network requested by Children’s Services.

JE: Pausing there, you mention you will be raising a complaint. So this wasn’t a complaint letter, what were you hoping do with this letter?

LH: Enhance communication. The reason I said about the complaint was it needed lodged in the complaints department, but we’d do that anyway if people were saying will complain.

I wanted this seen by people at the top, the psychiatrist, the matrons, so that’s why I said that I felt for sake of mental health services in general I would make a complaint about those discharges, but that wasn’t my priority. My priority was let’s do this properly… we need be quite serious now and get our heads together.

Ms Elliott asked Louise if she felt Morgan being a gentle parent might have been missed.

JE: The ward were not aware of Morgan’s usual presentation?

LH: I could only assume that, well not assume, Morgan had said that she felt even at that point she definitely said to me she felt there was some hostility from some staff, maybe hostility isn’t the word, she didn’t feel it was a very therapeutic environment and I…

JE: Wanted staff to be aware of her background?

LH: It’s a fact I felt all the way through, the fact she was a mother, a young mother was nowhere.

I don’t know if it was in the notes, if it wasn’t in the notes I wouldn’t even be shocked. It’s sort of self evident, how would you let someone that age, that distressed, with that recent history, go out into the night into the trees by a very busy road?

I’m certain if she’d got to that road she’d have [withheld]. How would you do that if you really, really understood this was a vulnerable young mother with a little boy who depended on her, and loved her?

JE: That makes sense, and fits with yours and Tanya’s evidence [think she said]

LH: There was no evidence of a personality disorder, no volatility, no mood swings, no inappropriate behaviour or language at any time, she made friends which was hard for her, prioritised her son, she’d given him a calm routine and environment. Children’s Services noted that also [more, missed, apolgies].

JE: You’re confirming you don’t see any evidence of EUPD. By that stage she’d mentioned it to you?

Louise said that she thought she had found this out when it was mentioned to her by Tanya.

JE: So you’re trying to share your views here?

LH: I’m trying to give them a person, the real person.

JE: Can you read to the bottom of the page

LH: I feel she’s been failed and cast as some kind of monster … she’s now in police custody… she was obviously depressed but also told me she had horrible intrusive thoughts…. She asked me to get Dominic on her tenancy so he could live there once she was dead… Morgan has recently been diagnosed with autism, I always knew she was autistic … couple things happened would have been manageable if she was neurotypical but tipped her over the edge. I strongly believe this is a breakdown caused by her autistic struggles and anxiety … she was not able to access an appointment at all with her GP… concern chaos of discharges was compounded by the fact she was prescribed benzodiazepines… should have been a plan for her to reduce slowly with support and care, not abruptly discharge her without them, into the night.

JE: That’s what you discussed with the coroner, the sedating medication Morgan needed when discharged from hospital?

LH: Yes

JE: To the end of the letter please

LH: I’m also concerned Morgan’s mum has been blocked from giving any input … Tanya is very close to Morgan and offers great emotional support and practical help, she also knows Morgan’s extensive history very well… Morgan has encouraged staff just to talk to Dominic. I fully understand the law but this continued even when Dominic took himself off as next of kin. They said he was nearest relative, he is not. Tanya can calm Morgan and assist … please ensure the psychiatrist assessing Morgan has this available … it is in all our interests with services so impossibly stretched, that we make the best decisions to prevent this endless bounce around the system, taking up valuable time and resources. I am grateful for your time in reading this and your care of Morgan while she is with you.

JE: The last paragraph, sounds like you’re asking to work together?

LH: Yes, it’s not in their interests to have Morgan leaving and coming back or going to A&E… not in interests of NHS and certainly not in Dominic or Morgan’s interest

JE: So, 3 March, postscript can you read that out?

LH: Morgan now re admitted to Rowan Ward, colleague with autism expertise … passport… Morgan filled it out… please ensure circulated and clearly visible for all staff… please ensure all communication is carefully communicated and understood by Morgan, for example when doctor said not got a mental health problem that requires you to be under Section, she heard you’re not unwell and we can’t help you.

Lastly any discharge plan must include Children’s Services, Morgan’s family and Community Teams. There absolutely must not be a repeat of recent events. Then the last sentence is cut off, I don’t think was much more.

JE: Yes, can see one line not captured, but again what were you hoping staff would do with this information?

LH: Was hoping it would help them, autism tool given when Morgan admitted Meadowfield but it wasn’t used, autism passport… Morgan said they don’t use it, they don’t do anything with it.

My friend devised, top tips of ways you can help me, really was top tips of ways we can help staff. Who wants to deal with escalation on their ward, with patient feeling very traumatised and fighting back?

What we all want is not to go from green to amber to red, traffic light system broken down, this is what happens to me, how you can help me is such and such, which is why I said would like it put on the wall, hoping Morgan could have good relationship, could start again and feel help for her. And she could speak to staff about her feelings of hopelessness and what was in the future.

JE: I understand and know this is difficult, you’re aware the treating psychiatrist Dr Julia, this letter was received as a breakdown of relationships and a reason for Morgan not to be on ward. Did that surprise you?

LH: In the Trust I work for which is an outstanding trust, that wouldn’t be received like that. I’m not just surprised, I am shocked that letter would be received like that.

JE: Negatively?

LH: Yes

JE: Thank you ma’am, those are my questions.

The coroner said that the jury may have some questions and asked the jury bailiff to check.

They do.

The coroner read them herself, before asking for clarification of one of the questions from one of the jurors.

C: I don’t understand the question you’re raising

Juror: Shall I go into it?

C: Yes please

Juror: There was talk about the dissociative behaviour she was exhibiting, witness said she was aware of it quite late, but who of the family were aware of it?

C: We have to keep questions regarding who, when and where Morgan came by her death, so that’s not an appropriate question.

JE: Ma’am may I ask a question on that point? What is described as dissociative behaviour, is that related to the phenomena of wasps, stinging, feeling out of control? Could I clarify that.

C: Question I understand it, is how far before Morgan’s treatment, who knew about it, so not directly related to her death.

JE: I see. If it is about the behaviour referred to as her loss of control when she’s experiencing difficult symptoms, in our view it is relevant, because it affected her treatment in the last couple of weeks, the interpretation of that presentation, so I’ll make you aware I will return to that tomorrow.

C reads jury question: One of the questions raised by the jury is did you discuss with Rowan Ward the autism diagnosis on the 13 February? If so, what was the response from the staff at that time?

LH: 13 February, you’ll have to remind me

Ms Elliott asks the coroner to take Louise to the chronology, the coroner passes her a copy of the chronology document.

C: Question is, admission on 13 February, did you explain to Rowan Ward about Morgan’s autism at that time?

LH: OK, that was her first admission to Rowan Ward. Rowan Ward wasn’t speaking to any of the family so we weren’t explaining anything to anybody.

It would have been, was assumed they were aware because it was in all the notes from Chichester A&E, but no they didn’t speak to us, and efforts by Tanya to contact the hospital were fruitless, she wasn’t allowed to speak to them.

C: So, to clarify your answer is you didn’t?

LH: No we didn’t, because we couldn’t speak to them

C reads another jury question: I think the jury would like to have some clarification as to what words were used for you to consider at the meeting with Dr Julia, that you considered were lacking empathy and lacking care?

LH: I don’t think it was for me to consider, I can’t even describe how traumatised I was, and we were all were after that meeting.

It wasn’t just the words, was the manner, the rapidity. It was brutal.

It was the way she spoke, very, very fast, angrily. She was angry that Morgan wanted, as soon as she said, she walked in the room and said well you won’t be able to go home because the Crisis Team can’t see you tomorrow they haven’t got any availability.

It was as blunt as that, she knew we were trying to keep Morgan there as Morgan was upset staff weren’t talking to her. She bound in straight away, not good morning how are you feeling, I know you’ve been upset Morgan, as you would in any professionals meeting.

You meet that person at the end of their life, lets face it even if you didn’t know she was going to commit suicide, you had a good sense of how near she was to that.

She didn’t put her at the centre of that meeting, she did the opposite. She talked over all of us.

She was cross when Tanya said can you explain this, was upsetting for Morgan, who wanted to go home. She said if you go home you’re self-discharging. I’d have expected sorry, I know you were looking forward to going home Morgan, do you want me to explain a little about it.

The words about the letter, staff don’t feel you’re sorry, it doesn’t seem sincere, the letter doesn’t seem sincere. Even though Morgan is sitting in front of her crying, saying I’m sorry. It hasn’t been taken like that and for that reason staff cant engage with you. There isn’t any treatment for you here, this isn’t the right place for you.

I think manner in healthcare is extremely important, I don’t think I’m waffling when I say that, if someone is on their death bed how you speak to them, it won’t change the outcome, but it matters.

When I say I was physically ill afterwards, I vomited. It was brutalising.  I’ve been a midwife for 30 years and have never had an experience like it, it was brutalising

To continuously reference my letter negatively, even when Tanya asked her to stop referring to the letter, to keep referencing it, ignoring Tanya, keep barrelling on when Morgan is crying audibly louder and louder, is not just unprofessional.

C: Thank you. There’s a question relating to Dominic being unwell.

LH: Yes

C: Was Morgan aware of that?

LH: Yes

C: Did that cause her increased anxiety?

LH: Morgan was really good around managing things, I’d have thought the difficulties they had generally from the child protection process, to Dominic doing his A levels during this and trying get into university, which he did get into university, she managed really well.

So yes, Dominic was unwell and I did say to Tanya at the time and afterwards do you think that made a bigger difference, but we know Morgan was quite matter of fact about Dominic’s illness, we were trying to get to the bottom of the diagnosis, it’s a complex auto immune one.

I think it didn’t help her in that Dominic is ill, she’s mentally unwell, she had a baby, yes he went to nursery and we were available but we don’t live in the same town, we have jobs. It was harder because they were managing the day to day between them, but I’d say she managed that as well as she could, she’d alert us, once in the night she contacted me and said there was a problem, Dominic has become quite unwell, she knew we were going through processes, albeit privately of trying to get a diagnosis.

So, yes and no. She was strong, on a practical level as Dominic was really quite physically unwell, but at that point it would have been hard for her.

C: If we go back to the timeline chronology was that around the time she was first admitted?

LH: Illness is more longer term, in terms of the scope of the enquiry, yes around the time she’d be admitted, Dominic was poorly and he was consistently poorly for some time before that. He was poorly around the time she was admitted to hospital as well.

C: Thank you. Thank you very much for your evidence today and your involvement with the investigation, again, as yesterday I’d just like to pass on my sincere condolences to you. You are now released.

Louise was released at 12:39.