I am grateful to the Horsham Coroners Court for facilitating remote attendance for Day 4 of Morgan’s inquest.

I was not in court yesterday when the court heard from a mental health nurse, Cherno Jallow, and the start of the evidence of Dr Anthony Ahwe.

When I joined on Day 4 the coroner, Lisa Milner, had taken Dr Ahwe through his evidence in chief and Ms Elliott, for Morgan’s family, had started asking questions.

The jury returned to court this morning at 10:12 and the coroner welcomed them and said there were a couple of housekeeping points before we proceeded.

She said that she was reminding them that they are hearing the evidence in this inquest and they must answer four questions from it, who, when, where and how Morgan came by her death.

She also reminded the jury of the warnings she gave them at the beginning of the inquest on Monday and stated that “does also relate to blogging” reminding them that they need to make their decisions based on the evidence they hear in the court room and nowhere else.

The coroner then asked Dr Ahwe to return to the stand, welcomed him and said she would hand over to Ms Elliott.

Ms Elliott’s first questioning was around events on 27 February 2023. She said she would park that for a moment but first wished to turn to the Sussex Partnership Foundation Trust policy on managing aggression and violence.

Dr Ahwe confirmed he was familiar with the policy, and agreed with Ms Elliott’s suggestion that it was regrettable that such a policy was required, but that it was in place as violence does happen on wards.

He agreed that it dealt with management techniques, with restraint and de-escalation and what to do after an incident. Ms Elliott took him to the section on Post-incident support and management.

Ms Elliott said that the policy dealt with support for staff, but she would not take him to that, instead she wished to look at support for service users after these events.

JE: The heading is Understanding the reasons for behaviours of concern. Behaviours of concern is the term used in this policy to describe aggressive and violence, is that right?

AA: Yes

JE: What it says is that “It is important to understand the root causes of behaviour and recognise that many behaviours of concern are assumed to have a purpose and communicative meaning for the person”.

AA: Yes

JE: The paragraph below “Staff must be aware of how their own behaviour, communication (verbal and non-verbal) and actions can impact the behaviour of others. Factors which may contribute to a person’s distress or behaviours of concern which should be considered within the risk assessment and care plan are described in Appendix 3- Framework for explaining behaviours of concern”. Could we go to Appendix 3 please and look at that document.

The coroner’s officer brings up the record for Dr Ahwe to read.

JE: It’s entitled Framework for explaining behaviours of concern, at the top is the person, then there’s a flowchart, the jury can’t see so I’m describing, there’s a grid with headings, historical factors, current presentation, environmental factors and situational factors. There are various items considered within this framework?

AA: Yes

Ms Elliott said that she just wanted to introduce that and would return to it shortly, before then she wanted to finish what the policy said. She asked for Dr Ahwe to be shown the policy document.

JE: thank you, just that section 4.3 7.1 [the numbers are slightly different to the policy currently online so I assume the court are working to the version in place at the time of Morgan’s admission] Post incident support for Service Users. I want to read what the policy expects, it’s a couple of paragraphs.

“Those in charge of clinical areas following an incident should ensure that at an appropriate time, the service user involved has the opportunity to discuss the incident in a supportive environment with a member of staff or an advocate or carer. This is called a post incident review.

The person should be given a choice as to who they would like to discuss their experience with, wherever possible. If the person is able and agrees to discuss the incident which led to the use of restrictive intervention, their understanding and experience of the incident should be explored”.

Restrictive intervention could be something like restraint?

AA: Yes

JE: “Their understanding of the incident should be explored. The aim is to explore what led up to the incident, what aspects of the intervention helped, didn’t help and might be done differently in the future to try and prevent a similar incident from happening again.

Staff can offer the service user the opportunity to write their perspective, feelings, anxieties or concerns of the event in the notes.

People with limited verbal communication skills may need support to participate in the post incident review. If new information is collated the individual’s PBS / care plan should be updated”.

Just over the page “Service users should be reminded that they can record their future wishes and feelings about which restrictive interventions, or any other aspect of care, they would or would not like to be used in an advance statement”.

This policy envisages a service user is given after incident support to work out what happened, what there experience was and what to do moving forward?

AA: That’s correct

JE: The concern I want to explore is that’s not what happened for Morgan in that meeting with you… we discussed one aspect yesterday… first let’s look at timing of when you went to see Morgan.

The policy says post incident support should be done at an appropriate time. Can I check your note please, time entered is 16:08, would you like to look at your note?

AA: I think I can remember it

JE: It has a date of 27 February, time 16:08, entered 27 February 16:08. Is that the time you entered your note into the system?

AA: Yes that’s the time, that note was [can’t hear]

JE: You’ve done it quite contemporaneously, which is helpful, we know you had a meeting with Morgan by 8 minutes past 4?

AA: Sure

JE: We don’t have much on timing but do have observation sheet, will tell jury what that is, do we have any way of sharing the medical records?

There was then some discussion as the record was found and shown to Dr Ahwe.

JE: Do you see that intermittent observation sheet on the screen?

AA: Yes

JE: Long list of staff recording brief observations of where Morgan is, earlier in day garden lounge listening music… that’s what should be seeing, track of where she is and what doing, gives time… see consistently by 14:28 she is noted to be hitting a cupboard door, into fire door, the incident has started, she’s kicking the ward door, consistent with what we know?

15:30 notes ongoing hitting floor, very upset.

15:45 (?) standing by door in room

We know by 4 o’clock Morgan is with staff in doctor’s room. So, sometime roughly after 15:45 this meeting began, is that fair?

AA: That’s correct

JE: By 4pm she’s with you in the room … fair to say you’re talking about 20 minutes from when that meeting starts then?

AA: Yes, if I recall

JE: This is first concern about the meeting, in terms of all decisions reached there … capacity assessment… discharge…  post-incident support [missed some] there’s just really not enough time in this encounter with you, to go through all the things in the policy and make those significant clinical decisions is there?

AA: The clinical decision I made was based on the risk behaviours at the time, which was supported by policy guideline… I’m aware of what the policy is, so I didn’t have to go through that policy before making my decision.

JE: You said to the coroner you were trying to explore the reasons for Morgan’s behaviour?

AA: That’s correct

JE: In that meeting, and you made decision about her section, and capacity assessment. That’s quite a lot you’re doing in that meeting?

AA: Yes

JE: Key concern how soon that is after the episode, or indeed whilst it is ongoing. 15:30 she’s described still very upset, your meeting started earlier than 15:45, you said Morgan was still verbally aggressive during that meeting?

AA: That’s right

JE: We know from Morgan’s mum’s evidence, she is on phone in this incident, that Morgan left in a very heightened state… Morgan has not had a chance to calm down at this point has she Dr Ahwe?

AA: By the time I saw her she wasn’t physically aggressive, that happened before I saw her, she was just verbally aggressive. By that time if I remember she’d had Lorazepam

JE: She did, it’s documented at 10 or 15 minutes past 3, about that time

AA: Yes

JE: She’s had lorazepam, it doesn’t seem to have lot of affect. She was verbally aggressive to you?

AA: She wasn’t physically aggressive, so it had some effect

JE: Yes, I understand that, but she’s not been able to calm down, gather her thoughts and get through this incident before you make decisions

AA: She was calm enough for me to make that decision, she was verbally aggressive but understood what was going on. She understood her behaviour and didn’t want to take any responsibility for her behaviour when I talked to her about it. She showed no remorse, she was communicating with me but she wasn’t taking any responsibility for her behaviour.

JE: I know that’s your note, I’m concerned about the state Morgan was in, she walks straight out of ward into a suicide attempt… you say she’s calm but verbally aggressive, is very difficult to see how this close to an incident which you know is a new presentation for Morgan, this level of violence on ward we’ve not seen before have we?

AA: About her leaving the hospital and go to hospital ground and tying a ligature, I don’t believe she actually wanted to end her life at that time, I think in that situation it was a cry for help. She did that in hospital grounds in front of many members of staff including members of the police, so when staff approached her she then became aggressive again.

So, I don’t think at that time she actually wanted to end her life, I think was a cry for help… other incidents where engaging self-harm behaviour, she’s taking [withhold] … she is I think, she’s intelligent enough to know those tablets she’s taking was not going to kill her, I think she’s also looked at research and knows what quantity of tablets will cause fatality.

JE: Dr Ahwe, I don’t necessarily challenge you on that, my questions is more going to the question of Morgan’s state and whether she was in a state to participate in these very important decisions of her care…. She walked off the ward, tied a ligature, assaulted a member of ward, runs off to the bushes, ties another ligature… how could she participate in decision to discharge her section, leave the ward? How could she engage in remorse, questions, background? It wasn’t possible.

AA: She had Lorazepam, we had calmed her down, was able to engage in a conversation with me, could assess her capacity and understanding. She refused to take any responsibility for her actions.

JE: No-one else was in that meeting … will move on to what you’ve said now and to [missed] about Morgan’s reasons for what she did and remorse. You say simply, she refused to show any remorse?

AA: That’s correct yes

JE: That’s the reason I raise the line of questioning about giving Morgan a chance to calm down. The records show she would have been able to show remorse.

Police record after the arrest… in quotes it says the detained person, that’s Morgan, happy to accept what is being said was a true reflection, stated had a lot of guilt and regret about the situation.

The police confirm that in an email to the ward … she’s admitted her offences and apologised for her behaviour.

The next agency she is with is the police, at no point does she deny… says she has guilt and regret and she apologises for what happened.

Same thing in Woodlands, is that correct, there is an incident in Woodlands, a headbutt when she thought cameras were talking to her?

AA: Yes

JE: Same… next day Morgan was remorseful for yesterday’s incident, noted says has no control when reaches certain level of agitation… I can’t challenge you on what she said in your meeting, am saying if she was given time to calm down and put the event behind her we see she is capable of expressing regret, but she didn’t have time.

AA: I’m not saying she didn’t express regret but at time I saw her she showed no remorse for that behaviour … she went to custody hours later and expressed regrets, it’s not unusual for patients to change the way…

JE: Yes quite, isn’t that exactly the point, this short interview in the middle of an incident was not giving Morgan the chance to reflect and digest?

AA: She was fighting the system. You need to understand. Almost rebelling, she was angry towards doctors, she was angry to staff, she wasn’t remorseful, earlier wanted to leave and the staff declined. All this she was expressing her anger at that time… she just did not show any remorse, she didn’t regret what she did.

JE: I suggest she had very little chance given the time of that interaction. At any point in this interview did you consider what impact Morgan’s autism might be having on her ability to express regret?

AA: Yes, that was partly what led to my decision to rescind the section as well, because I knew she had this diagnosis of autism.

Guidelines on how best to manage patients with autism, I’ve got some evidence here if you allow me to read out, will make you understand how we managed the autism as well.

JE: I don’t want to go again through what we did yesterday, place for that evidence would be your second statement, what you were taking account of in the clinical decisions you made.

AA: I’m not talking about yesterday, NICE Guidelines and other bodies of evidence which talks about patients not being, patients, not allowing patients to be detained in hospital, reducing the amount of restrictions, restraints on this type of patient because it leads to a negative outcome. All this side of things was looking at when managing, not just autism but this behaviour.

JE: You say in a 20 minute interview you took into account guidelines on autism?

AA: [missed]

JE: This was before the ward round?

AA: Yes, I read everything about Morgan, I looked at autism diagnosis, looked at the emotionally unstable personality disorder, have all that in mind and took into account before I saw Morgan for the first time.

JE: Would like to keep with this interview with Morgan at 4pm. If you have further new evidence to give your counsel will probably take you to it… the reality is Dr Ahwe you say you read about her autism and taken into account but your plan was to keep her on section, keep her on the ward with 2 hour leave, and see her mum the next week … you were expecting to see her on the following ward round, so I don’t see how that changes as a result of this event?

Can I ask you, my question was when considering remorse … lets remind the court what you say in your note about this, forgive me while I find the page myself, 748 please.

In terms of factors looking at remorse and opportunity for Morgan to explain, all that it says on this topic is discussed her anti-social behaviour and Morgan won’t take any responsibility for her action.

That’s your note at the time, no mention taking her autism into account, no mention you even asked her what the reasons for her behaviour was. There’s none of what you’re saying in your evidence today.

AA: Just because it’s not there doesn’t mean I didn’t ask her. Was a short period of time, she became aggressive, lots happening at the same time. At the same time we had to keep her safe because of aggressive behaviour.

JE: Yes Dr Ahwe, that’s my point. It’s a short period of time where she’s aggressive and volatile, and you’re saying not expressing remorse… there is no mention of taking her autism into account, it just says she shows no remorse for her behaviour. That’s what it says.

AA: That’s correct, yes

JE: In terms of explanation we looked at document in Appendix 3, can go back there, it gives some things to think about, let me find the page number

The coroner provides a reference.

JE: Sorry, no that’s the post incident support. Let me go back, 5322 please? Do you have it Dr Ahwe?

AA: [cant hear]

JE: Just looking at a few of these things, one can immediately think would be relevant for Morgan, under situational it says to consider inability to communicate effectively or feel understood, that was directly relevant to Morgan’s autism wasn’t it?

AA: [can’t hear – think he doesn’t have the page] The Appendix 3?

JE: Yes, this is the framework for explaining behaviours of concern, directly relevant to what might be going on for someone, flowchart, then has precursors, how person might present before behaviours of concern emerge, then behaviours of concern at the bottom. Framework for trying to understand what has gone on for service users. There’s a couple that might seem really relevant for Morgan …  inability to communicate effectively or feel understood, Morgan’s autism directly impacted her ability to communicate didn’t it… even without her saying would know it was relevant in times of stress.

AA: Despite her autism she was able to communicate effectively, her autism I wouldn’t consider as severe.

JE: You’ve conducted your own autism assessment of Morgan?

AA: No. Talking to her through the time she worked with us, she’s able to communicate effectively.

JE: The jury are aware there was a very detailed report about Morgan’s autism… a 22 page report… went into detail about her communication difficulty and difficulties… one of the things it said as a woman with autism she was able to mask communication difficulties… you didn’t have the report, will go through with other witnesses… you needed knowledge of how that presented in Morgan.

AA: As I said ,I knew she had that diagnosis of autism in December 2022, through my interaction with Morgan I took her autism diagnosis into account. As I said she was able to communicate with me, I didn’t need to use any non-verbal cues when I spoke to her.

JE: Sounds as though you rather minimised it. It said she wasn’t severe and she was able to communicate, that’s not what we see.

AA: Patients with severe autism cannot communicate verbally, have to use non-verbal cues …

JE: Of course, I’m not suggesting she was non-verbal, I am saying this was a high stress event, when Morgan engaged with you, when she was still really in the middle of it. She has autism, the report mentions sensory factors, communication deficits, and my point to you is we don’t see it taken into account.

AA: It was taken into account. I knew about the diagnosis of autism, I took that into account.

JE: [missed start] distressing hallucinations, experiencing voices to tell her to run away, hurt herself, hurt others… in the Mental Health Act assessment after this, it says hearing voices telling her to hurt everyone.

She describes distressing voices frequently throughout her admissions… she reports was having phenomena of having wasps stinging her, that she needed to get away from. She consistently reports in police custody and A&E, we don’t see any consideration of what role that might have been playing for Morgan, in your note.

AA: Morgan was on the ward for just 2 days. Throughout her interaction with staff there wasn’t any evidence of her experiencing voices or seeing things or having this body sensation… I know she said before she came and after she left hospital and went to Woodlands.

When these symptoms are challenged they would not be true hallucinations that we find in patients with schizophrenia. Morgan had said so herself. It’s not uncommon for patient with autism or emotionally unstable personality disorder to be experiencing, we call it pseudo psychosis… [fuller answer, missed]

JE: I’m not putting to you this is a formal psychosis. Morgan reports she was experiencing a very distressing sensation. Her sense was she was being stung by wasps, and she was highly distressed. My point to you is there’s nothing about this in the notes … her trigger was not explored by you.

AA: I don’t know where in the notes she mentions she was experiencing this

JE: She mentions it to her mother, who reports it to the police, straight after events.

AA: During that time on Maple Ward, where did she mention it?

JE: During her time on Maple Ward, Dr Ahwe, first of all you told this jury you read all of Morgan’s notes so you would have been aware this is part of her history would you?

AA: Yes, but where does she report these symptoms?

JE: She doesn’t have a chance on Maple Ward… she reports the experience of wasps was part of what caused her to engage in violence. I’ll take you to that [gives reference] you have that police document?

He doesn’t

JE: I’ll read it out to you, police record called at 16:32 by Tanya Betchley, reporting 19 year old daughter absconded from Maple Ward where she was attending due to suicide events… Tanya says shortly before leaving she assaulted staff and left shouting and screaming… [missed] … she said she was hiding in a bush in the hospital and was under attack by bees.

Morgan states was in hospital under Section 2 after being detained on a Section 136… she stated having episode where she thought wasps were chasing and stinging her, she wanted to escape so she kicked the door… she admits flailing around and kicking out.

That’s Morgan’s account… Morgan’s consistent account is part of what triggered this event, you called a pseudo hallucination, happy to work with that, she had this event where she was being stung by wasps… I don’t know if she wasn’t asked, but she doesn’t get the chance to explain to you.

AA: It would have been ruled out when she came to the ward, that’s what we observe, we observed for psychosis symptoms… if there was any evidence she was responding to unseen stimuli this would have been picked up while she’s on Maple Ward.

JE: Are you saying she’s making it up?

AA: No, I’m not saying that but if described subjectively, objectively we will then illicit any signs.

Patients could say they are hearing voices for instance, that’s a subjective experience, then if patient is responding to voices by talking to themselves or becoming destructive, these are things that would be picked up by staff during observations…. During the hours she was on Maple Ward there wasn’t any evidence objectively she was experiencing any form of pseudo psychosis.

JE: I agree with you on that, no evidence it happened until this point which caused the episode. That wasn’t explored.

Agree we don’t see earlier in this admission, 10 February response unseen… at other points hears voices or sees her cat… I do agree nothing was documented on Maple Ward.

Morgan’s repeated account of the event is she was experiencing this phenomena but she didn’t get a chance… this wasn’t something you explored with Morgan.

AA: I ruled out psychotic symptoms, I ruled out mood disorder as I said in my capacity assessment. I sent an email to Helen.

JE: That’s right

AA: I said no evidence of mood disorder or psychotic symptoms

JE: That’s another thing you’ve done in this 20 minute encounter? You rescind the Section 2, assess that, says no remorse, assess capacity, assess her ability to leave the ward… you rule out psychosis and mood disorder, but I don’t think you make a note of that at the time. You don’t

Miss Agnew interjected to say the witness had said he’d noted that in an email.

JE: But it’s not in his note at the time. You mentioned capacity, say she shows no remorse for her behaviours and has capacity. Do the Trust use a capacity assessment form?

AA: Yes, a capacity assessment form for specific decisions, depends what assessing.

JE: Did you use the form?

AA: The form wasn’t used, this was a discussion with Morgan herself, I made decision

JE: So, you didn’t go through all the elements of the Mental Health Act?

AA: I went through all of them and at the end I concluded she had capacity.

Ms Elliott ask what decisions Dr Ahwe was making.

AA: Her treatment, others about her discharge… the initial assessment regarding admission to hospital and treatment, then the other was the capacity regarding her discharge.

JE: Yesterday I think you mentioned to the coroner capacity in relation to her behaviours, is that another one?

AA: Yes, that’s all included. Capacity regarding her admission, behaviour and discharge.

JE: You’re right, as part of the Mental Capacity Act each one needs to be assessed separately… whether Morgan could understand information, use or weigh information …

AA: The assessment I made was following my initial ward round, for some reason I can’t remember who did the ward round documentation which is not there. I can’t remember if it was the junior doctor that time, if no junior doctor then staff do documentation. There were two staff with me who saw me with Morgan, one of them normally she’d have done that ward round documentation.

JE: Are you saying this capacity assessment happened in the ward round?

AA: Yes, was done in the ward round

JE: So, you didn’t assess her capacity at the time of these events, this violence?

AA: No. I assessed her capacity when I saw her on the ward round. Capacity regarding treatment.

JE: Right

AA: Second capacity when they called me because she was becoming aggressive. That was capacity regarding discharge and behaviours.

JE: You say 3 capacity assessments that day. None of them we see documented?

AA: That’s correct

JE: We see no capacity assessment forms… when you say she had capacity on the ward round, you didn’t discharge her from Section 2 then?

AA: No. She remained for brief periods of time, that was the plan.

JE: You said you’d see her mother next ward round, so a week at that point?

AA: Yes. I saw her Monday 27

JE: Dr Ahwe, I have to suggest to you it was very unlikely you had time to do a proper capacity assessment of Morgan …

AA: I did do a capacity assessment for Morgan, we have to do capacity assessments for all patients we see for the first time

JE: I can’t challenge you about the ward round, we just don’t have a note about it.

You mentioned the ward round a number of times, you never mentioned the capacity assessment. I can’t challenge you on it.

What I’m saying is it seems very unlikely you could do a full capacity assessment in that 20 minute meeting.

AA: It doesn’t take long to do it, just [missed one] understanding, retain information, weighing up and communicating. It doesn’t take long.

JE: It’s a serious matter isn’t it Dr Ahwe, reason to take Section 2 away?

AA: I did record she had capacity, but … my staff was oversight.. it was completed [apologies missed some of that]

JE: I think I’ve asked my questions on that.

Brings me back to the decision to rescind Section 2. That’s what results in Morgan leaving the ward, if you hadn’t she’d have been staying on the ward, that’s right isn’t it?

AA: She’d be staying on the ward and that would be more detrimental to her health… I think I need to bring up some evidence for you to understand … autism

JE: More evidence?

AA: Yes

JE: Evidence for autistic patients?

AA: Yes, for autism and for emotionally unstable personality disorder, is why being in hospital detained is detrimental to their wellbeing.

JE: Dr Ahwe whatever evidence you show me, my questions to you will be the same.

You had the opportunity on the ward round, where you had working diagnosis of EUPD not confirmed with family, you knew had autism…

Any decision of whether appropriate staying on Section 2 should have been made on the ward round. You didn’t discharge her then… whatever evidence you show me, why didn’t you assess based on that in the ward round?

AA: When first come to the ward we assess risks, when I first saw Morgan she was calm and engaged with me…  she requested leave and I wrote her up for leave. I don’t usually give leave for patient I’ve seen straight away… with Morgan she had this autism diagnosis, the ward environment can be toxic for patients like that… wanted her to spend more time outside the hospital, that was the plan. And for mum and social worker to attend the next ward round to get more information. That was the initial plan.

However following my review she became quite aggressive…. When she assaulted a number of staff, when I next saw her I tried to engage and talk to her about those behaviours, she had no remorse.

I felt detaining her in hospital is only going to become more counterproductive. When she left the ward, after she left the ward, she was picked up by the police, she was taken to custody, seen by mental health support worker in custody. She told the mental health support worker she wanted to return to the hospital on a voluntary basis.

JE: She didn’t say on a voluntary basis. She said she wanted to return to the hospital.

AA: Yes, she said wanted to return to hospital, if for instance I was called by the bed management team about Morgan coming to hospital I’d have been more than happy for Morgan to return. I hadn’t discharged her, she discharged herself….

That damaged the relationship with all staff. It was felt returning to Maple Ward would not be appropriate…. Even if she had returned to Maple Ward can swap patients from Rowan Ward….

JE: I’ll cover when she gets back, what I’m concerned about is the Section 2 decision at that time.

I understand you want to refer to EUPD Guidelines, those are in your statement, and autism guidance. Want to ask why someone comes off Section 2? People are put on Section 2 because they meet statutory criteria aren’t they?

AA: That’s right

JE: That doesn’t refer to capacity, is about the seriousness of mental disorder and ability to keep safe, broadly speaking?

AA: That’s correct

JE: We know why Morgan was put on Section 2 [lists reasons] outcome of that meeting the day before she came to the ward. She presented low in mood, hopeless, plans to end her life, poor sleep, hearing voices commanding suicide… [lists more].

The view was her risks were of very serious and imminent nature, in Dr Chloe’s opinion could not be managed safely in the community. She was admitted under Section 2 to keep her safe from these risks. That’s right isn’t it?

AA: That’s right, yes

JE: Your decision to rescind did not look at her risks, no assessment of her mental state, her suicidality. We see no assessment of whether she meets criteria of Section 2 in first place. It’s not in your note is it?

AA: Decision about rescinding section, we have many patients under Section 2 or Section 3. When they come to hospital, for assessment it could be rescinded. It doesn’t mean they have to be on Section 2 for all the days.

JE: I understand that.

AA: When she left custody after she was discharged from Maple Ward, she was taken to Woodlands in Hastings on 2 March. The consultant in Hastings looked at the evidence and felt that a section wasn’t needed, so her section was rescinded the following day and because she agreed to remain in hospital on a voluntary basis and signed a behaviour contract. That’s exactly what I was trying to do on Maple Ward.

From Woodlands she went to Rowan Ward on a voluntary basis, was no aggressive behaviour, no violent behaviour, no suicidal behaviour. That makes the point, for this group of patients the more you detain them, the more you restrict them, they become more rebellious, aggressive, fighting the system.

The evidence shows, which I have here, you give, you empower this group of patients. You give them control so that they can help in their own safety planning.

When you restrict this group of patients, yes, lots of negative consequences, and I think there’s somewhere where I read Morgan doesn’t want to be touched, I read it somewhere …

That’s another reason why I rescind the section so staff will not be restraining her giving her injection against her will, was causing her to be more distressed given trauma she’s already gone through, was just retraumatising, that’s why this section was rescinded.

JE: Dr Ahwe, it’s just not conceivable you went through all that process and rationale in this interaction with Morgan, in 20 minutes

AA: As I said before I see any patient I will look at their care notes, their care records. I had 2 or 3 hours before I saw Morgan, that was handed over to me… [can’t hear] I think around 2pm, I had lots of time to look at her background, before I saw her. I didn’t just go to the room, to the ward round.

JE: You’re saying you reached one plan on the ward round, safe to stay on the ward, she wanted to stay on the ward, Section 17 leave escorted, she wasn’t allowed off by herself.

Then you completely change that plan after this episode of violence. If I understand, you’re saying she’s had an episode of violence, can’t restrain…

All that evidence you’re giving to the court now features nowhere in your note, nowhere in your email to Helen, 95% doesn’t feature in your statement, it’s just not plausible that all featured…. [missed]

Ms Agnew said that he mentioned Emotionally Unstable Personality Disorder in his statement.

JE: Yes, that’s why I said 95%. What Morgan said in her diary notes uploaded to her care plan, she says, the doctor was un-sectioning me so I could leave unless I wanted to behave. Doctor presented angrily with me, at this point I was still hallucinating… doctor stated if she wanted to be there she’d have to behave, if she didn’t want to be there then leave.

We heard from Helen Green yesterday, your email a couple of days after the event, she found it angry.

AA: In what response?

JE: She said you seemed angry, in this email you put block capitals bold text at the bottom. Morgan says you were angry, and Dr Ahwe I have to say that seems very likely from your note, from the circumstances…

AA: Angry about what?

JE: Morgan says the doctor was angry with me….

AA: That was her perception at the time. When I saw her at the beginning was good rapport, she engaged well, was a plan, she wanted to go to Rowan Ward

JE: She’s not saying you’re angry during the ward round, she’s saying you were angry when you took away her Section 2, and I’m saying that’s likely in the circumstances, were you angry?

AA: I wasn’t angry, if I was angry with that level of violence and aggression the first thing I’d do was contact the police. I didn’t do that despite her showing no remorse, no regrets. I said to her I’d arrange for her to go to Rowan Ward, if I was angry I’d have said to staff please call the police… I wanted her to be seen at the next ward round with mum and the Children’s Social Worker. There wasn’t any plan to discharge her, she discharged herself.

JE: She walked off the ward, and you didn’t think to stop her? Why didn’t you use your Section 5 powers?

AA: I had just rescinded the section.

JE: With a plan for her to stay on the ward and receive treatment, if I understand your evidence?

AA: Yes

JE: And then she walked off. She’s at risk.

AA: She had capacity

JE: What about risk? There is no risk assessment at all.

AA: Following that incident, she started running off, that’s when staff contacted the police. Staff did not contact police immediately after she left the ward.

JE: That is correct. They contacted at that point. What you felt about this incident is captured in your email, the passage Helen Green referred to… patients will be discharged immediately if they cause serious harm to staff unless of course they’re deemed to lack capacity. That’s what you say 2, 3 days later. They will be discharged immediately. That’s what you felt about this event?

AA: Discharge immediately, but it doesn’t apply to Morgan. Morgan wasn’t discharged immediately, the section was rescinded, she agreed to remain in hospital on a voluntary basis. After I finished talking to her I continued my ward round, then was this violent behaviour. I didn’t discharge her.

JE: I accept your note didn’t say discharged, but you took away her section, she left the ward. You say to Helen Green who was asking what happened, violent patients will be discharged immediately [reads]

AA: I didn’t discharge her. I said under normal circumstances a patient with capacity would be discharged. Morgan was the exception, I didn’t discharge her. I said despite you not showing remorse I’m happy for you to remain in hospital.

JE: In the circumstances that’s relatively technical. She said you were angry, you took away her section, and she left the ward.

Ms Agnew mentioned the “behaviour point”.

JE: Yes, unless she behaves.

AA: Yes, if you look at the Woodland, staff rescinded the section the next day, was asked to sign a behaviour contract and she did.

Rescind the section is what we did, behaviour contract she agreed, and went to Rowan Ward then.

JE: What happened on Woodlands was a ward round with multiple staff, attended by family… the family evidence was it was compassionate and caring.

Totally different situation to this interview, you conduct in the middle of an incident, in heightened state.

AA: Was no time here on Maple Ward, she was becoming distressed, she’d assaulted a number of staff. She was becoming very aggressive, I felt the only way to diffuse this situation is to rescind the section and give her time to reflect. That was the plan. I wasn’t trying to, I felt restricting her was just making things worse for her.

JE: Dr Ahwe we’ve been through it. Where I’m left at the end of this evidence is the policy should have been followed, she should have been given space to calm down and proper procedure followed … reasons explored

AA: She was given space to calm down, response team called when she was becoming aggressive and violent. Intra- muscular injection was drawn up… staff … there was time to talk to her and try diffuse the situation. She wasn’t restrained or given an injection against her will.

JE: I’ve not suggested that to you, I’ve asked question on why she was not sufficiently calm … I say it should have been managed on the ward, her Section 2 should not be rescinded … no reasons recorded in the notes … all that’s happened since the ward round was an episode of violence, an escalation of risk surely?

RA: Ma’am the witness mentioned a couple of times Morgan was calm enough for him to make a decision.

C: I agree

JE: Those are my questions.

Ms Elliott says she’ll turn her back before confirming she has no further questions.

Mr Berlevy for West Sussex County Council had no questions for Dr Ahwe.

Ms Agnew had questions but asked for a comfort break first.

Court adjourned at 11:22 and the jury returned at 11:36.

The coroner asked Dr Ahwe to come back to the witness stand.

C: Thank you, you’re now going to be asked questions by Ms Agnew, who is the representative for Sussex Partnership Foundation Trust.

RA: Dr Ahwe I just want to firstly start by enabling the jury to understand what information you would have had access to… we heard from Nurse Jallow yesterday about the CareNotes system. We’ve heard that evidence. Do you have access to CareNotes?

AA: Yes, I do

RA: Is it fair to say CareNotes captures clinical information from all services that Sussex Partnership Foundation Trust deliver?

AA: That’s correct

RA: The jury will get an updated chronology at some point which shows which services are covered by Sussex Partnership, if I run through them with you so we have in evidence what those services are.

Firstly, mental health liaison team service at St Richard’s, is that?

AA: Yes, that’s by Sussex Partnership, yes

RA: So information by liaison service in St Richards would be on CareNotes?

AA: Yes

Dr Ahwe confirmed that the Crisis Team were also part of Sussex Partnership Foundation Trust.

RA: Just to assist the jury… is it correct to say they are utilised as a hospital at home, as opposed to an inpatient setting

AA: That’s correct

RA: Then The Haven at Millview, is that Sussex Partnership?

AA: That’s correct

RA: So, information is in the records

AA: Yes

RA: Then Rowan Ward, Maple Ward at Meadowfield, so all included in CareNotes records?

AA: Yes

RA: Then Sussex Liaison and Diversion Service, heard reference to them being in the police station

AA: That’s right

RA: Is that Sussex Partnership

AA: They have access to the CareNotes of Sussex Partnership

RA: Then we heard about Woodlands, and Abbey Ward. Is that also Sussex Partnership?

AA: In Hastings, yes

RA: So, you’d have access to all that information, is that correct?

AA: Yes

RA: Additionally heard in evidence about CAMHS, is that also Sussex Partnership?

AA: It is correct

RA: So, you have historic information on records as well?

AA: Yes, the record I had access to dates back to 2018, when I saw the first entry on CareNotes about Morgan

RA: You just gave evidence to Ms Elliott you had 2 to 3 hours to review information before the first ward round. Is that correct?

AA: That’s correct

RA: Your evidence to the coroner was you’re a consultant with 20 years’ experience?

AA: That’s correct

RA: And of course getting to consultant takes bit of time… [missed exact question but believe Ms Agnew asked him about his experience with autism, emotionally unstable personality disorder, trauma}

AA: OK, so emotionally unstable personality disorder is a disorder that occurs in early adult life, dating back to childhood young adult, whereby is chronic feelings of emptiness, emotional dysregulation, impulsivity, self-harm behaviours. You could also have patients who have difficultly forming an attachment or have fear of rejections, you also have patients who have associated binge eating behaviour or patients who engage in substant misuse.

So, we see a range of disorder, starting before adult life which can go on to adult life. You don’t usually make a diagnosis of emotionally unstable personality disorder before the age of 18. You have to allow a patient to undergo full developmental state in their life. Before you can see patient having traits of emotionally unstable personality disorder, but you cannot make a diagnosis before 18. By the time they turn 18 will be able to make a diagnosis of emotionally unstable personality disorder.

After obtaining information from people who knew the patient well, in this case family members, before make a diagnosis of emotionally unstable personality disorder. That’s why when I saw her, was a provisional diagnosis on evidence I had before me.

That diagnosis was going to be confirmed after I’d spoken to family, it might have been confirmed after speaking family. That’s really EUPD.

RA: In your working experience of more than 20 years, working with patients I think you referred to as emerging emotionally unstable personality disorder… that’s something with which you’re familiar, what is the range of patients within current inpatient setting, so jury have a context of the types of patients within that setting. You’d be treating and considering emerging?

AA: Yes, at any point of time 17 bedded ward, any given time we’d have some patients who had emotionally unstable personality disorder. Most of them are female but interestingly is commoner in men but men don’t present so obvious as women. I think a third of the patients we see are patients with emotionally unstable personalities.

RA: Yes, thank you. Just going through some practicalities of how when come onto the ward… we heard yesterday one of the junior doctors does admission assessment, is that how it works?

AA: Yes

Ms Agnew took Dr Ahwe to the admission assessment completed when Morgan was admitted onto his ward.

RA: Do you have that in front of you doctor?

AA: Yes

RA: The clinician completing it by the name of Eleanor Trout on 25 February 2023, would it be ok if I just read that, for the jury’s benefit.

She reads: I clerked Morgan on 13 February. Just pause there, jury remember they heard was the same junior doctor who clerked when Morgan went into Rowan Ward on 13 February… Please see previous assessment. She cross refers, pausing there for a moment is it right junior doctors can clerk on both wards? Heard some evidence yesterday was separation of ward staff, although some crossover in emergency circumstances. Is it right junior doctors can clerk on both wards if on duty at that time?

AA: Yes, that’s right… Eleanor Trout used to be my junior doctor in training. I think this time around Morgan wasn’t admitted, ok I think Morgan was admitted to Maple Ward I think.

RA: Yes she was admitted to Maple Ward, but she’s referring back

AA: [missed]

RA: She clerks Morgan in on 13^th, she notes that on the 25th when she did again… says regarding current admission she, Morgan, says discharged Rowan Ward feeling positive about plan for discharge. Discharged under care of Crisis Team… told them her mental state was deteriorating therefore sent her to A&E as a place of safety, absconded A&E, attempts to [withheld]. Tells me she made her partner aware of her plan. Found by police, taken back to A&E… also told me she took [withheld] in A&E. Is this what you are describing in laymans terms as the cry for help?

AA: Correct

RA: From here transferred to Meadowfield under Section 2, partner and parents aware admitted, says her son being cared for by them. Denies recent alcohol or drug binges, says compliant with medication. That information relayed to your clerking doctor by Morgan when she comes onto Maple Ward?

AA: Yes

RA: Then let’s go to 14 February, Dr Trout’s previous assessment, that’s page 2097 do you have that doctor?

AA: Yes

RA: We can see its same form again and by Dr Trout, says confirmed by Dr Lake is that another doctor?

AA: Yes

RA: We’ll hear from Dr Lake in evidence later.

AA: He was the doctor working on Rowan Ward. Clerked by Dr Trout, confirmed by Dr Lake

RA: We’ve got in evidence already, don’t intend to go through in totality will just take down to forensic history, actually for jury headings presenting concerns… part we’ve had in evidence already, then sections on personal history

AA: Yes

RA: As clerking doctor do they just go through this form, is that how it works?

AA: Yes

RA: With the patient, in front of them?

AA: Yes

RA: So, they have a computer with them and they’re putting it in?

AA: Yes, and sometimes carers or family with patient

RA: Family history then [missed] then forensic history, suggested to you yesterday your knowledge of trauma and how knew… had involvement with police due to mental health crisis… April 2019. Would you have read this document?

AA: Yes, I saw this and the same history by another doctor, and also by a mental health professional

RA: What Morgan had said to various people had been very consistent about what took place.

AA: and those traumas and [missed] sexual abuse traumas yesterday as well

RA: You refer to EUPD Guidelines and put that in your statement, mentioned repeatedly when discussing trauma

AA: Yes, that’s correct

RA: Can you explain historical trauma and EUPD?

AA: Unfortunately, many patients with emotionally unstable personality disorder, can’t remember the figures now 50 or 60% of them will have undergone child sexual abuse or quite severe sexual trauma, is one of the factors disposing them to level of emotionally unstable personality disorder, together with some other factors.

I think in Morgan’s case she talked about being sexually abused at the age of 11. Then she also talked about being sexually assaulted by a former boyfriend.

All those traumatic history was there in the background. Then with the incident with the police where she was down on the floor restrained by 6 or 7 police officers, that was another trauma in itself. In addition to that trauma other contact she’s had with police, mental health services, where she had been restrained on the floor. In my view that brought about traumatic memories of her background trauma history, that’s where the link comes in.

RA: Is it right to say there is a link between trauma and emotionally unstable personality disorder?

AA: There is

RA: You were taken at some length in evidence about your decision making of rescission of Section 2, following the assault. Just want to take you, it’s not your entry, 747, 746, an entry I believe by a clinician called Katie Chambers, can you see that doctor?

AA: Yes

RA: That’s an entry we were referring to yesterday, day to day CaseNote entry, is that correct?

AA: Yes

RA: [missed start] It’s made by a clinician Katie Chambers, do you know who Katie Chambers is?

AA: Yes

RA: Is she a doctor or a nurse?

AA: A nurse, no, a healthcare assistant.

RA: It says at 14:20 Morgan asked a member of staff if she could have leave, while her leave status was being checked Morgan began to kick the main ward doors. Want to ask how leave is granted and how it’s checked. We heard you completed a Section 17 leave form, that’s right?

AA: Yes

RA: We’ve seen that, that was for accompanied leave after the ward review… to enable Morgan to have some time off from what can be a very challenging environment on the ward?

AA: That’s right

RA: Accompanied by a member of staff or her family?

AA: Yes

RA: Leave form has to be checked, is that right?

AA: After the  ward round can’t remember if Morgan requested leave, I can’t remember but I did say I was going to write up the leave and then left the ward, was other things I was doing at the same time. So, I hadn’t completed the leave form which is why the staff had declined.

RA: They have to check don’t they?

AA: Yes

RA: Appears during the checking process Morgan became distressed. Offered verbal de-escalation by multiple members of staff, however no effect. Morgan continued to kick ward doors with such intensity [missed] Morgan offered PRN, however she refused.

She was asked to come away from doors due to level of disruption and go to her bedroom, she refused.

Ms Agnew continued to read from that entry. Including who was present at the time, those involved with Morgan.

RA: Then we’re heading to assault one, can you see that?

AA: Yes

RA: Then decision of assault one, when attempted to redirect Morgan to her bedroom started hitting out at staff, placed in arm hold by [named 2 staff] but kept kicking out… Morgan restrained on floor… kicked staff in head, then went to smash staff against the wall using her legs… assisted by [missed]

Is that other staff responding from other wards to the incident?

AA: Yes, Chloe P from Rowan Ward, a healthcare assistant from Larch Ward

RA: to have more staff and support?

AA: Yes

Ms Agnew continued to read that entry, including the information that Morgan pulled staff hair and tried to bite staff. Staff restrained Morgan on the floor.

RA: She was offered 2mg PRN Lorazepam Oral, at this time an IM had already been drawn up. IM intramuscle?

AA: Intramuscular

RA: … Morgan deescalated enough for staff to disengage from restraint, again ask move away from main ward doors, she refused stating she wanted 5 minutes on her own, which she was given

Does that summary reflect your recollection of what was relayed to you in relation to that incident?

AA: Yes, it does

RA: Then says Morgan seen by Dr Ahwe and her section rescinded, please see note regarding this that’s a reference to your note you were taken to?

AA: Yes

RA: Your evidence is your conversation took around 20 minutes

AA: Yes

RA: To be clear, your evidence was that Morgan was calm enough for you to make the decision you made to rescind Section 2?

AA: Yes

RA: Because you were taken on a number of occasions to be really clear for the jury, was your evidence that you gave consideration to the impact on Morgan of remaining on section?

AA: That’s correct

RA: In the context of her diagnoses?

AA: That’s correct

RA: Then at 16:20 note, Morgan left ward having taken her own discharge against medical advice, although she refused to sign the paperwork… 16:35 alarm raised Maple Ward corridor, a Rowan Ward member alert to patient tying ligature in grounds, outside main corridor.

Again was your evidence, I’m just quoting you, you felt the ongoing detention was counterproductive at 16:08.

We then know thereabouts at 16:20 and 16:36 is further incident where Morgan has left the ward?

JE: Sorry ma’am, it wasn’t noted the detention was counterproductive was noted the admission was counterproductive. Or were you referring to his evidence?

RA: His evidence

JE: I apologise

RA: My note of his evidence to you, you felt the detention was counterproductive?

AA: Correct

RA: And you changed your clinical decision?

AA: That’s right

RA: Is clinical decision for you as RC, responsible clinician in the Mental Health Act, to make that decision

AA: That’s correct

RA: With the support of your MDT

AA: That’s correct

RA: Then 16:20 and 16:25(?) then get timeline subsequent incident outside, would it be too simplistic to …categorise was escalation of behaviours?

AA: Yes

RA: Which of course you wouldn’t know at the time you’re making the decision to rescind the section?

AA: That’s correct

RA: I think it was your evidence that you did not, you expressly did not seek the police to be called at the time you rescinded, following the assault, is that correct?

AA: That’s correct and reason was I knew she had traumatic experience with police in 2019 and I didn’t want it to happen again.

RA: Yes, just been to that on your clerking doctors note … clearly noted that trauma.

Morgan found outside with [withheld] … ligature did not appear to be tight enough to restrict her airway, was that what you were describing in layman’s terms as a cry for help?

AA: Correct

Ms Agnew then described a member of staff approaching with ligature cutters, Morgan kicking her in the stomach area, a second member of staff approaching who Morgan punched in the face, and Morgan then being restrained in armholds while ligature was removed.

RA: It later transpired workmen were going to their van, Morgan caught sight of them, workmen alerted reception as to what was going on.

After ligature was removed Morgan said I’m discharged so can do what I want and walked away from staff, down the hill, and to the carpark.

If give jury understanding of what that means, sounds like the unit is on top of a hill, then walking down hill and understand then there’s a main road there?

AA: That’s correct

Ms Agnew continued reading the entry, which included what Morgan was reading and the fact she had a suitcase with her.

RA: At 16:35 on returning to the ward Katie Chambers contacted police on 999 to advise Morgan was discharged from hospital however likely to come to the attention of the public and they should be aware. Also advice that an assault had taken place and a reference number of the call is noted.

Then 17:20 police attend ward to speak to staff who have been assaulted, it describes staff assault again. All staff completed post incident proforma and Dr Ahwe completed assessment of capacity at the time of the incident.

So, for the jury, an escalation of Morgan’s presentation occurring during that afternoon following your ward round?

AA: Mm

RA: Start of escalation led to you change your clinical opinion, you rescinded the section, then further escalation which led to calls to police because of their concerns?

AA: That’s correct

Ms Agnew says she has no further questions. The coroner asks Dr Ahwe to stay where he is at the moment as the jury may have questions.

The coroner received questions from the jury and asked them of Dr Ahwe.

C asked jury question: Can a lack of remorse be a character trait of autism?

AA: I wouldn’t say yes, sorry, I wouldn’t say a lack of remorse can be a characteristic.

With mental health problems lots of overlap between autism and some other mental health problems, but I know that was also a provisional diagnosis of mixed personality disorder with antisocial personality traits.

Patients with antisocial personality traits can have that lack of remorse.

C: There was a question yesterday, what does MDT stand for?

AA: Multidisciplinary team, involves doctors, nurses, psychologists, occupational therapists. It’s not just staff, different healthcare professionals.

C: Yesterday we heard about MDT meetings. What happens in an MDT meeting?

AA: The MDT meeting is the ward round we have attended by myself, junior doctors, staff, sometimes… invite people from outside, family members, relatives, if there are social workers involved they are invited as well, or probation officers or housing officers

C: What happens at those meetings?

AA: When we discuss patient assessment of their mental health, treatment, we are assessing their mental health treatment and assessing the risk as well and you try to find out, is more or less like a holistic assessment.

C: Thank you. There’s a question around the assessment of Morgan’s notes. For the ward round on 27 February, how many other patients were in the ward, what number would there be, where those notes also had to be reviewed?

AA: There are 17 patients on the ward, we review 5 to 6 patients per ward round. Usually held Monday, Wednesday, Friday, so for that 17 patient caseload, we have maybe Monday see 5 patients, Wednesday 5 or 6 and Friday another 5. So, 17 patients, every patient is reviewed at least once a week.

So, on that day I would have seen at least 5 patients in the ward round, or 6 including Morgan. Every new patient we prioritise, they have to be seen because Morgan came in on the weekend. So, the next ward round would be Monday, on 27^th, that was when she was.

C: If a patient does not, or refuses to sign their self-discharge, are they still considered discharged and no longer the responsibility of the hospital?

AA: Yes, if they refuse to sign behaviour contracts they are still considered discharge.

JE: Sorry ma’am, the behaviour contract is something different to self-discharge

AA: Was it the behaviour contract you’re asking?

C: No self-discharge. If patient does not, or refuses, to sign their self-discharge, are they still considered discharged or no longer the responsibility of the hospital?

AA: Yes, discharged against medical advice form which we give to patient to sign, Morgan refused to sign that form. Behaviour contract was a different form she refused to sign as well.

C asks another jury question: What training do your staff have in restraining patients in violent outbursts? I’m not sure you’ll be able to answer this question.

Ms Agnew said something which I couldn’t hear.

AA: I have an idea, the MVA training which we all have to do every 3 years, more frequently with inpatient staff because they’re exposed to this management of violence and aggression.

C: Thank you, what behaviours would typically need to be displayed by a patient before a Section 2 would be rescinded?

Dr Ahwe asks the coroner to repeat the question. She does.

Ms Elliott wanted to clarify that there were other incidents of self-harm, that she said she would address later.

C: This question goes on to ask is it common to rescind a Section 2 without anyone else present?

AA: Anyone present, you mean family? Morgan’s family members?

C: Yes

AA: You could consult family members but you don’t need to get family consent, but its good practice to inform them

C asks jury question: We heard reference to a behaviour contract, what does a behaviour contract say?

AA: Depends on individual patients, for instance engage with care plan, no aggressive behaviour towards others, sometimes we put not engage in any significant self-harm behaviours. We do not expect patients with long history of self-harm behaviours to just stop straight away so not so relevant, more about aggressive behaviour to others. Not to smoke or take drugs or drink excessive alcohol on the unit. Those are the main behaviours we’re talking about.

Even if break behaviour contract it doesn’t mean discharged straight away, because has to be risk assessment, as dynamic process and risks change.

[missed]

AA: Depends on the risk assessment

C: We heard from Nurse Jallow yesterday moods can change very quickly

AA: That’s right yes

C: This is question already asked, not going to ask this question, related to how you note you’d reviewed Morgan.

C asks jury question: If a patient’s autism diagnosis is reported and reports are not supplied on admission, can this be requested by the ward so they can familiarise themselves with a patients situation before interacting with them? Relates to the PSICON report that was undertaken in respect of Morgan.

AA: Yes

C: We heard evidence yesterday, or this week, it wasn’t on Morgan’s notes, the system. Had you seen that report?

AA: I’d not seen that report, but as I said I knew about the diagnosis of December 2022. Morgan was treated, even though there was uncertainty about the autism diagnosis, Morgan was treated as if she had autism, even though we hadn’t seen the same report.

C: the question here is would you have requested that report to familiarise yourself?

AA: If Morgan was on my ward for longer than 48 hours yes, these were all the things we were planning to do, the autism diagnosis we’d have explored that but because she was just on my ward for 48 hours we didn’t

C: but to clarify Morgan was treated [missed]

AA: I had read in the CareNotes she was diagnosed in December 2022, that’s why I said shortly after admission to Rowan the diagnosis had been made ?? with the autism diagnosis

C asks jury question: This question asks can we get a rough timeline for the day’s events, the assault, meeting, ward round, arrest

Can’t hear

C: That’s been clarified

RA: That’s Katie Chambers

JE: I think the only thing we don’t have is the time of the ward round, think noted in observations. I’ll see if I can find them ma’am.

C asks jury question: Next question is how flexible is capacity? Can it change during episodes?

AA: Yes, it can, it can change during a patient’s treatment journey, so a patient could have capacity today, lack capacity the next day. Patients can have capacity for a specific decision about maybe their finances, but lack capacity about their treatment and care

C: Does that depend, your assessment of capacity would be dependent on your communication with that client, that patient?

AA: Yes

C asks jury question: So, question relates to the meeting you had with Morgan after the assault. It says is there any legal policy or obligations to have a meeting with Morgan, so soon after the assault on staff?

Is there any regulations regarding how quickly need to have a meeting with Morgan after the assault?

AA: After the assault, no there wasn’t. if I remember I think I was still doing, almost finishing ward round for another patient, after that I went back to see Morgan. There’s no time limit.

C: No regulation with regards to how quickly would have to respond to that?

AA: No, do as quicky as we can because of the urgency of the situation

C: And you were the responsible clinician on that day?

AA: That’s correct yes.

C: So was there a reason you were expecting an apology from Morgan, outside the common courtesy, given her mental state?

AA: No, I wasn’t expecting an apology. I was just trying to find out her understanding of the consequences of her behaviour. I wasn’t expecting her to say well I’m sorry I done this. The consequences of behaviour was trying to get her level of understanding

C: To assist your clinical decision making?

AA: That’s correct

C asks jury question: Next question is would you have changed if she were to have given an apology, would your clinical decision be different if Morgan had apologised?

AA: No the apology wasn’t [can’t hear] was assessing her understanding, I just felt being on section, restraining her was what I was trying to avoid. It wouldn’t have changed if she had apologised. That decision to rescind wouldn’t have changed if she apologised for her behaviour, if she’d shown remorse or regret, I’d still have gone ahead to rescind the section.

C: Question heard previously, Morgan then did write an apology letter, did you see this?

AA: I think I yes, I saw entries I think on Woodlands where they talked to her about the assault. She did apologise, I think I saw entries. When it was discussed on Rowan Ward as well.

I wasn’t clear if she was truly apologetic from what I could read, but I know on Woodlands she did apologise.

C: To make clear if she had made an apology or not your clinical decision would be the same?

AA: Yes

RA: This witness didn’t have any involvement after that day

AA: No

C: I think you answered last question, did you believe the apology was authentic? I think you just answered that.

AA: Yes, I think it was authentic from the way she mentioned it.

C: Ms Agnew said you did not treat Morgan after this incident?

AA: the apology was when she left my ward

C: She did make an apology, she then wrote an apology letter?

AA: After she left

C: Yes, but you didn’t treat Morgan after that did you?

AA: No

C asks jury question: Are triggering behaviours of patients communicated to staff as a form of safeguarding healthcare employees and recognising cues in mental health decline of patient? Not sure if that’s a question, or a statement. [She repeats it] It’s not really a question.

JE: Ma’am it might need clarified with whoever asked, way I understand is are triggers for behaviours of concern, are staff aware of that… are staff aware of triggers and behaviours of concern

AA: Yes, if that’s case ABC, is antecedents which is A, what led to behaviour and behaviour itself is B, consequences of the behaviour is C … it’s always ABC, we will talk to patients

C: So staff are aware of the incident?

AA: Yes, the trigger to that incident

C: So there’s an explanation as to why the trigger occurred?

AA: Yes, what happened and what outcome

JE: Ma’am I’m a bit nervous, could we check the jurors question has been answered?

C: Question are triggering behaviours of patients communicated to staff to safeguarding healthcare employees, and recognising cues?

Juror: Ms Elliott understood what I was asking correctly

JE: Ma’am Dr Ahwe just gave evidence was ABC completed, I couldn’t find in bundle, neither could my solicitor

AA: No there wasn’t an ABC assessment, but that is normal process

JE: OK, that’s normal process, thank you

C asks jury question: This question is of two days Morgan spent on ward, how much time did Dr Ahwe spend in direct communication with her?

AA: In direct communication?

C: Yes

RA: Have already asked that, up to half an hour?

AA: Also before that we have handover of patients which happens every day, so each patient are discussed in that MDT handover meeting even before I see a patient in ward round will have had an update about that patient.

C asks jury question: Does sedatives impair the ability to express thoughts verbally effectively?

AA: If you give too much medication that can affect the judgement, so that’s why for Morgan she was given short acting lorazepam we don’t expect the effects of that to be long lasting. As I said when I saw her she was quite compos mentis and able to communicate with me.

C asks jury question: Is there a ward policy outlining a timeline threshold following any incidents of violence or aggression before a patient is contacted? Think we’ve dealt with that question.

RA: Yes, as soon as possible, was the words of Dr Ahwe

JE: Whatever Dr Ahwe said I don’t think he said there was a policy in place that says as soon as possible, what I referred to says at a suitable time

C: Yes we’ve had this question

RA: Yes as soon as possible given the urgency of the circumstances

C asks jury question: So second question is when should this analysis be conducted and who should be present?

AA: As soon as possible

C: As soon as possible

C asks jury question: What time on 27 February is Morgan discharged or did she leave? Timeline for exactly what time she left?

JE: 16:20 [can’t hear]

C: So 16:20

JE: Yes 16:20 in the notes

C asks jury question: There’s a question Dr Ahwe mentioned bright lights and chaos being detrimental to Morgan and reason for rescinding Section 2. Given that violent aggressive outbursts are rare, what did Dr Ahwe mean by chaos?

AA: Chaos am talking about ward environment not autistic friendly to patients with autism, the noise, loudness, over stimulating environment doesn’t help if you’ve got autism, that’s what I mean by chaos

C: So, will read this out, so that everybody knows what the question is but already had in evidence, would Helen Green be contacted by Dr Ahwe as acting responsible clinician prior to Morgan being discharged? Should that strategy [missed]

AA: Would Helen be contacting me?

C: Would Helen Green be contacted by Dr Ahwe as acting clinician, you’re responsible clinician, the process?

AA: Yes, the process involved is when patients are discharged, especially patients with children, the staff contact social services if they’re involved or the family or someone who looks after the child, about the discharge. That is the process involved so any patient with children we would automatically raise a safeguarding when they come to us

C: In this particular situation the process had started?

AA: Had started, Kevin MacMillan the staff nurse was communicating with Helen about Morgan and the welfare of the child. We knew at that time the child was being looked after by partner, and partners mum I think.

C: So if not, why given the known risks and interest social services would have had, due to young children involved, i.e. Morgan’s sister and son. Just explained process was in place to notify Helen Green is that correct?

JE: Ma’am, to be clear, process was in place to invite her to a ward round, Helen Green’s evidence was she didn’t have any notification about discharge, think we should be clear that’s her evidence… questions go more to Morgan having self-discharged.

C: Dr Ahwe evidence is process Kevin MacMillan had contacted Helen

AA: Kevin MacMillan had contacted Helen and Helen in her response said she was about to contact Kevin the same day to discuss Morgan

JE: Yes ma’am, but not after she was discharged, so the timeline is clear. That contact was to say Morgan is on ward, come see her on ward, that’s good practice.

What’s asked about is when Morgan left the ward did anyone contact Helen Green and Helen Green’s evidence was no. She had to follow up herself, is that right Dr Ahwe?

AA: I don’t know, normally contacts if children are involved, I don’t know if any staff contacted Helen after discharge

JE: Helen Green writes an email to try and find out what’s happening with discharge

AA: Yes, I then responded to her

C asks jury question: Thank you. Should a care plan and discharge plan, as well as contacting family and care workers, be done before Section 2 rescinded to avoid chance of leaving before everything in place, or is it standard to rescind Section 2 first?

AA: Can do either way, sometimes when patients on ward round we section and rescind that time, in presence of family members.

With the urgency of her situation we didn’t contact family to let them know she was being discharged. Normally what happens is staff contact family or social workers, in this case Helen, that patient has been discharged.

C asks jury question: Thank you. Was the safety of Morgan’s son put onto the risk assessment discharge paperwork?

AA: That’s correct, safeguarding is raised for any patients with a child.

JE: Sorry Dr Ahwe, I don’t want to interrupt

AA: That is usually practice for every child, we raise safeguarding when we have patient with child, that is normal practice. That was what Kevin was doing when he contacted Helen.

JE: Just to be clear what Dr Ahwe was just saying, there was no discharge risk assessment, and was no discharge paperwork here. Is that right?

AA: I don’t know, I’ve not checked that, normally every patient being discharged has that

JE: I’ll put to you that isn’t right, is no paperwork or risk assessment here

AA: That’s what staff normally do when they’re discharged

C: Thank you, yes

RA: I think Dr Ahwe’s evidence is the urgency in this particular circumstance, I don’t think he can go much further than that.

C: Yes.

C asks jury question: Where should suicidal autistic people turn to get help?

AA: When you look at all the evidence, if you allow me to read, can I? I’ve got it here.

So, this is the National Institute of Health and Clinical Excellence

JE: Dr Ahwe just before you do, if they are coming into evidence we do need to see them, so we know if we have questions on it. Which guidelines are they?

AA: National Institute Clinical Excellence

JE: NICE Guideline?

AA: Sorry which number? Is College Report 2020

JE: What’s the title so we can follow along?

AA: Is what I wrote in my statement

JE: I’ve got them. Thank you, please continue

AA: What it says, guidelines recommends considering acute psychiatric admissions for management of crisis on short term basis due to recognition of unintended adverse consequences of prolonged admission which may have more negative effects than positive ones.

Royal College of Psychiatrists organisation said in their college report autism in itself neither requires psychiatric treatment, nor warrants psychiatric admission, but may be needed for co-occurring disorder. In Morgan’s case she had EUPD.

Ms Elliott asked for the document name that he was referring to. There were a number of attempts to identify a name/reference.  

AA: Royal College of Psychiatrists College Report

JE: On autism?

AA: Yes, college report 2020

[I believe it’s this one]

Dr Ahwe says Morgan’s autism in itself neither requires psychiatric treatment or warrants admissions. The coroner interjects to try again to establish what is being referenced.

C: Dr Ahwe, you’re referring to documents that will be your evidence, that haven’t been provided to the Interested Persons’ representatives. Could you confirm to me what references you are going to be referring to, then in the lunchbreak can look prior to you giving your evidence.

AA: NICE Guidelines, Royal College of Psychiatrists College Report and CQC

JE: Sorry ma’am we need titles, is a number of reports, do you have the titles Dr Ahwe?

AA: I don’t have them

RA: Could it be permitted for me to have a conversation with this witness, will give undertaking not to talk about evidence, to ascertain what the correct documents are?

C: Yes, whilst under oath if you liaise purely with Ms Agnew in relation to the evidence you’re going to give the documents, the titles of the documents so they can be produced to other legal representatives

Ms Agnew checks whether there are any further jury questions, the coroner said there are three more.

C asks jury question: Did Morgan have an autistic passport? If not, why not?

AA: She did have yes

C asks jury question: During the initial violent aggressive incident at 14:20/14:25 was noted staff requested Morgan to come away from the area and go to her bedroom. Given evidence that ward bedrooms pose the biggest risk of ligature use, was this advisable given the training for restraint, violence and aggressive patients?

AA: Yes. During that time Morgan was escalating, there were staff with her, she was not left on her own, there were staff.

C: There were staff?

AA: Yeh

C: Staff with Morgan, they escorted her to her bedroom?

AA: I think so, they would have done

C: So question needs to be answered where should suicidal autistic people turn for help.

Dr Ahwe you are still under oath, we are going to take a lunch break, it is 13:20 if we come back 14:20. You can speak to your legal representative, but only to obtain the references you are going to make in your evidence relating to the question from the jury, which is where should suicidal autistic people turn to for help.

Jury bailiff could you take out the jury please. Thank you for your attention this morning, have a lovely lunch and we’ll see you back at 14:20

Court was adjourned for lunch shortly after 13:20.

The jury were brought back into court at 14:34. The coroner asked Dr Ahwe to return to the witness stand.

C asks jury question: The question from jury posed to you prior to the lunchbreak was where should suicidal autistic people turn to get help? If you could just explain the answer to that question.

AA: Yes, there are places where patients with autism can receive help, is mainly community based in that you also have inpatient specialist units catering for people with autism and other comorbidity in psychiatric unit, mainly private sector like Priory Hospital and Cygnet Hospital, they can cater for people with autism and other comorbidities

In the NHS most acute wards do not specifically cater for patients with autism because most of them are not autistic friendly, so we try to adapt the environment to meet patient’s needs

C: thank you, you referred to a document we’ve now seen during the lunchbreak, could you explain the reference you made to that prior to the lunchbreak?

AA: Can I read from it?

C: Yes

JE: Ma’am sorry, I thought we just agreed we weren’t going to refer to the guidelines because I haven’t had the chance to read them. I haven’t had time to scrutinise them, my submission was is inappropriate to go into them as we can’t challenge them, agree or disagree with anything said, we’re too in the dark.

C: What you just said had summarised what guidelines said is that correct?

AA: Yes, National institute Health Excellence looked at guidelines, also CQC where talk about restraining patients and long lasting negative effects on patients who are restrained

JE: Ma’am it’s not much better to engage with them indirectly, we don’t have resources to engage with them. Dr Ahwe gave his answers within his expertise, I think that’s as far as we can take it, we haven’t had this material.

C: I agree. So, answer to your question where should suicidal autistic people turn to?

AA: Autism patients normally have other comorbid conditions such as emotionally instability or psychosis, when they do have that, yes they come to acute inpatient ward, where they treat other …. the autism is managed with all what I said about autistic friendly approach, in inpatient setting

C: So, you deal with them in an inpatient setting and adapt?

AA: Yes, that’s correct

C: Thank you, I have no further questions, you are released Dr Ahwe, thank you for your assistance, I appreciate it’s been a two day process.

Dr Ahwe asks if he can address the family and the coroner says yes.

He says to them “I’m really sorry for the loss of your daughter… I hope this process you’ll be able to find answers to your questions, I’m sorry”

Dr Ahwe is released. The coroner apologised to Ms Elliott and said she had misunderstood what she’d said.

Then the next witness, Dr Julia was called. Her evidence was part heard so I’ll not report it now.