The coroner called Dr Juliá at 14:40 on Day 4 of Morgan’s inquest.

She took an affirmation and the coroner asked her to take a seat. She also checked that she was pronouncing her name correctly, she was.

The coroner told the court she had two statements from Dr Juliá, one from April 2024 (?) and one from April 2023.

Dr Juliá confirmed that was correct, that she’d seen her statements in advance of the hearing, that all information in them was correct and nothing had changed since she made the statements.

Asked by the coroner to give her name and professional background, she told the court she was Dr Pilar Juliá and that she was a Consultant Psychiatrist. She qualified in Spain and has been working as a Consultant Psychiatrist since 2014, and in the UK since 2016.

She told the court she had spent most of her professional career on acute psychiatry wards. She worked in Birmingham in 2016 and moved to Brighton in June 2022.

C: Thank you, if you could go through your involvement with Morgan please

PJ: I was the Responsible Clinician for Morgan during two of her admissions, the first from 13-21 February 2023 and the second started, was a transfer on 3 March 2023

C: Can you go into more detail, happy for you to go through your statement, so the jury and court are aware of what happened during these admissions and your involvement with her

PJ: During the first admission, was Morgan’s first admission to an acute psychiatric unit as an adult …  CAMHS had admitted… services at the time made every effort to prevent admissions, given difficulties adapting to the environment.

The admission came after a period of Morgan presenting with suicidal thoughts, initially described without intent or plan and (?) behaviours.

Long standing issue for Morgan, started self-harming at 11, this was a coping strategy regarding difficult thoughts.

After few attendances at A&E and contact with the Crisis Team, was felt she couldn’t be kept safe in the community, admission organised, admission through Section 2 of the Mental Health Act.

[missed chunk]

Due to incidents of absconding from The Haven and A&E, was considered a section was the least restrictive way to offer treatment.

I first saw Morgan 14 February, which was the day after her admission, in the ward review on Rowan Ward, usually my colleague as Dr Ahwe explained, take place twice a week on Monday and Thursday.

First thing in the morning every day have handover with nurses who had handover from previous shift, go through the service users we already have, and admissions with background and context about admission…. Which helps us, as obviously we do try to review the service user as soon as possible after admission. With Morgan admitted weekend, wanted to see her Monday but other reviews on the day…

I believe we reviewed Morgan towards the end of the day… as Rowan Ward is a teaching hospital and we have junior doctors to learn how to work in acute wards… review initially led by my junior doctor at time… done with me supervising the meeting so I can assist at any point and take over if aspects not appropriately covered, which was the case in the review with Morgan.

I am probably the author of the ward review entry as I was typing while my colleague does the review.

Morgan presented as quite an eloquent young lady… able to tell us she experienced suicidal thoughts since she was 11 years old, she did say even though she was able to express herself, expressing her feelings was harder… she said last few months things becoming more difficult, thoughts there long time but becoming worse… identified triggers recent, trying to go to college, she mentioned teachers were teaching her wrong things and she was struggling with this aspect, also able to acknowledge was challenging being a mother. Morgan was a young mother, if at some point, if will assist can go over assessments during her pregnancy. Was excited to be a mother but teams seeing her at the time felt she was not understanding the magnitude of having a baby with a history of trauma ….

She explained to us she had recently received diagnosis of autism spectrum disorder, which was trigger. She explained to us hadn’t had any support after diagnosis was made. At the time Morgan wasn’t open to mental health services. Seems she was given a report and no help to come to terms with that diagnosis.

Previous admissions with  CAMHS team who had seen Morgan on 10 September 2020. Morgan had expressed she didn’t necessarily feel she had autism but was happy to engage with that assessment. The formulation from that team was mainly developmental trauma.

Morgan was aware this diagnosis had been given, at time not open to services so we didn’t know who had done assessment, who had done referral at the time.

We asked Morgan if she had the report to share with us and she said she would speak to family to access it [think she said], at time difficult to access.

Ms Elliott asked to confirm what Dr Juliá had just said.

PJ: She said she’d look into it and ask her family.

Since admission Morgan gave us a significant list of diagnoses given to her since contact with mental health services, and going to private psychiatry.

PTSD in the context of a sexual assault in the past, binge eating disorder, [listed lots, at speed, sorry missed], oppositional defiance disorder and specified trauma and stress related disorder.

As Morgan was assessed under Section 2 of the Mental Health Act, that’s used for patients without formal diagnosis or not known to mental health services, our role to untangle a little but those were diagnoses.

A lot of them not mutually exclusive, similar presentations … the diagnosis Morgan didn’t mention that was on her notes was developmental trauma. Her team from CAMHS had longer contact with Morgan including 1-1, was developmental trauma. Possibly when someone before being born is in high level trauma and abuse, can have impact on development, as it was with Morgan.

At this point Ms Elliott said there was a point she wished to raise without the jury present. She said it was not Dr Juliá’s fault.

The jury were taken from court. There was a discussion amongst the legal teams and the coroner, and then the court adjourned for an afternoon break.

The coroner asked for the jury to be returned to court at 15:21.

C: Thank you for retiring for a moment jury, it is now 15:20 so what we will do is go to 16:15 this afternoon, just so we can get some of the evidence of Dr Juliá.

Dr Juliá, I’m sorry about the interruption, but if I can ask you to continue with your evidence.

Dr Juliá recapped the evidence she had given before the break, I’ll not repeat it.

PJ: Morgan was again quite eloquent, especially when she talked to us about her diagnosis of oppositional defiance disorder … also mentioned to two colleagues on admission about her significant difficulties dealing with boundaries and restriction… very eloquent, she told us she lacked respect for authority and struggled with the restriction of the inpatient environment.

To be fair is a very restrictive environment… during that ward review Morgan also identified using self-harm as a coping mechanism and we explored what coping strategies she had to deal with stress…

Morgan was then able to identify a lot of coping strategies at time, suggested meeting with a clinical psychologist, can be useful to explore triggers.

Morgan identified multiple reasons her mental state may be triggered… Morgan declined to speak to the psychologist, said she had before… didn’t want revisit events from the past…

Also suggested meeting the occupational therapist, they could do a lot of work on Morgan’s sensory needs, organisation of the day, routine and… Morgan did say she might meet with the Occupational Therapist, but not just yet, said she felt she needed to be more settled before she could engage.

At that stage I took over the review as complexity was a bit above what my junior doctor had at the time… asked Morgan about the impact of her autism.

Morgan agreed she didn’t understand diagnosis, made her feel somehow there was something wrong with her which was difficult to process.

I suggested first task was to complete an autism passport to facilitate communication with the team…

Which was something we do with any patient with or without diagnosis of autism if identify if they may have those difficulties [I believe she said in communicating/expressing].

Also, the About Me traffic light system, patients with autism or many other diagnosis, talk about might be difficult expressing feelings. Traffic light system is way can facilitate communication with patients… so can show us in a chart. Traffic light system, green, amber and red, what happens when feeling that way, associated to them, what we should do.

Discussed doing this with Morgan, that she said she’d do later in day. Shall we read through that?

C: Yes

PJ: Morgan identified green, smiley chatty talkative, kind caring, rational [missed lots] approachable, calm and collected, open and honest.

When she’s in amber. Starting feel bad… reserved, quiet, expressing a problem, hiding or rubbing her face or eyes, pacing, might engage in head banging, might feel tearful. Help, offer distractions or calming techniques.

The whole idea of traffic light system is support service user who might really struggle, escalate their emotions, not escalate to red and empower them realise they’re getting to that point, not relying on others… is a really helpful strategy.

Ms Elliott asked to look at what the document Dr Juliá had looked like so that she could locate it.

PJ: Red, this is what happens when feel very angry and out of control, shouting, crying, self-harming, severe head banging, spiteful … please offer PRN if appropriate, and distraction techniques.

This was completed the same day as the ward review. Also worked on autism passport, again has traffic light system at beginning, not documents use in isolation, goes little more in depth about communication needs, how to support, what support getting on day, who is important to contact about more information, other people involved in her care, which Morgan documented.

Morgan was referred to TCAT, autism specialist team service. Talked to key person, admission and discharge [missed – talks at speed – can’t catch].

Its expanding more on those communication themes, triggers … keeping me safe, what can be done… things might worry or upset me… Morgan very aware she found it really, really difficult to deal with authority… other was positive wellness plan, which again my colleague Dr Ahwe already talk about, challenges of admission for patient with autism or emotionally unstable personality disorder.

Every clinical guidelines that exist recommends short admission to minimise harms of admission.

[missed]

Reality treatment of acute inpatient unit is just beginning of a journey… Morgan would have needed long term support through therapy, understand her diagnoses. We want to set from the beginning her journey and her pathway.

That was discussed with Morgan in first admission, don’t complete in ward review, not right place to do it, 1-1 intervention with named nurse, that was completed after the ward review.

Asked Morgan how support her needs with her autism… we used everything we had to support her understand her better, her feelings… she was aware of a lot of thigs that would be helpful for her.

Discussed referral to Transforming Care Autism Team (TCAT which she agreed to. Again, would like to be in place as soon as she’s on the ward, but it’s a fairly lengthy process for referral and patient to get accepted.

One of first thing needed is for Morgan to be on the national register, Morgan wasn’t on that register, however did as for report and contacted team to see if they could support…

As do in ward review. Discussed medication, Morgan felt medication never worked in past, PRN to manage distress and anxiety had been helpful.

No licenced pharmacological treatment for any of Morgan’s diagnoses in any case, might use different prescriptions to try manage presentation…. Talked stress …high level anxiety… explored anti-psychotics… need be mindful providing benefit from them.

[Missed chunk]

Tried [withheld], second generation anti-psychotic, but higher risk of weight gain and metabolic syndrome. Also tried [withheld], no help with voices and had caused her to feel restless.

[Missed]

[Withheld] has effect as mood stabiliser, has sedative potential help with issues of sleep, restlessness or distress… can help with hallucinations can call them intrusive thoughts or voices…

[Missed]

That was end of that first ward review … tried to explore what Morgan wanted from the admission … find way to decrease the distress, understand better diagnoses, and have long term support and care for her difficulties.

In her entries through CAMHS, when Morgan was in foster care was supported with care of her newborn baby, lots of difficulties when Morgan in those placements, really struggled to have supervision and advice on how to look after herself and her baby.

Over the following week had ups and down on ward… engaged well… had PRN or more than one occasion… did autism appropriate paperwork… used safety traffic light system and tried let staff know when struggling… so I agreed to prescribe Section 17 leave with partner and family on hospital grounds… she expressed was finding ward environment very triggering.

The coroner asked what date the Section 17 leave was first granted.

PJ: I cannot remember off the top of my head, probably assess safety first few days, understand her difficulties dealing with acute ward… overall ethos in acute ward as much as we can is positive risk taking… colleague already alluded to NICE Guidelines, risk of patient being locked in hospital and take away any skills to manage their distress or safety… main rationale why admissions not recommended, because risk dynamics… do our best to not be excessively restrictive.

Often nurses assess risk, formal review weekly basis, doesn’t mean care stands still until the next medical review.

Someone might feel safe to go on leave today, but not tomorrow… communication system to build rapport with service users.

[Missed lots more]

Reviewed Morgan on the ward review on 20 February, this was formal review on the ward. Have morning handovers, Morgan had had periods of struggling little bit and engaged in self-harm behaviours, but that is to be expected.

Morgan told me she was using ground leave safely, she presented brighter in mood that day, said fewer intrusive thoughts and she thought [withheld] was helping with voices.

Night before agitation and disruptive behaviour. Had broken some therapeutic tools on the ward, I think games.

Again identified inpatient environment was not supportive for her needs, she wanted to try outpatient. Said not having any hallucinations since admitted. Also mentioned like to engage again with [missed] centre which she had done in past. She would really like to be discharged.

I assessed during that review Morgan was able to make decisions about her time in hospital… identified triggers relating to the environment. Weighing pros and cons … concerns about patients with autism very often becoming more distressed with higher risk in inpatient environment.

Going back to 2012, the care transforming review, concerns about patients with autism and patients with learning disability, in inpatient units.

Care treatment review meetings are meant to happen before hospital admission, because its acknowledged very detrimental environment.

Multiple cases where leads to increase risk… and not resulting any positive benefit… taking that into account, and Morgan’s choices. … felt important to empower Morgan … she was willing to engage with community team, felt that was the most appropriate step to take at the time.

Again consideration of [can’t hear]. Not reasons keep in hospital, but reasons to provide long term input. Didn’t think met criteria of Section 2 of the Mental Health Act.

Earlier question what display to be released off section, should be used as least restrictive option… should never treat patient under section when have ability, capacity and willingness.

Discussed how manage treatment, Morgan said happy give month of medication because her partner keeps medication safe at home.

Agreed referral to Crisis Team, Morgan not been previously been open to mental health services in the community.

She didn’t have a Lead Practitioner, referred to community mental health services by us, they hadn’t had time to allocate anyone just yet, so we felt really relevant for Crisis Team to provide input.

Crisis Team role can be to prevent admissions, to minimise risk and provide support. Can be involved with early discharges with people with ongoing risk, work together on crisis management plan.

If Crisis Team feel risk too high to manage, they will decline the referral.

Other interventions, we seem to like traffic light systems, so they have that for level of risk… Immediately on discharge from hospital said to be in red, when Crisis Team assess not at that risk they’re downgraded to amber….

Can be peer support networks, referral to peers with similar experience, can be 1-1 with nurses, can be social prescription to some extent to support service users engage with community.

Overall felt best step at time for Morgan. She was assessed by the Crisis Team. Morgan was happy to engage with them. Safety plan was transferred [missed]

Between ward review and discharge 24 hours, I believe Morgan’s mother in law picked her up from the ward.

On reflection it might have been helpful to have family involved, but Morgan was an adult… family didn’t raise any concerns at time.

After discharge Crisis Team usually do a 72 hour follow up, usually done day after, when Morgan seen by Crisis Team was experiencing being home very overwhelming, found quite difficult and thoughts again about taking an overdose. I think she went to A&E, absconded and took an overdose, was decided again to detain Morgan under Section 2 and she was admitted to Maple Ward. I wasn’t involved with admission to Maple Ward.

C: No we’ve heard, if you can just confirm what you knew about your involvement with Morgan.

PJ: I had no involvement at all as I am not the Responsible Clinician for that ward. What I know is what discussed were concerns about her aggression, she was discharged from section, police found her close to hospital, arrested her, have read the entry, can’t remember the date, when Morgan was in place of safety where indicates police investigating those assaults, wait until Morgan back in local area to interview with staff. That’s as much as I know.

I know from place of safety Mental Health Act assessment was requested again… at time Morgan in place of safety Morgan become quite agitated, hostile, had hit and kicked staff, the trigger

JE: Sorry ma’am I don’t have a record of Morgan hitting and kicking staff, I have a note of a headbutt, the witness wasn’t there, I may well be missing something?

PJ: Morgan verbally abusive and challenging… was informed staff there removed… lash out at other staff… [reads at speed from record, can’t catch apologies] patient unwilling to work with staff… put on friendly hold. Kicked staff, therefore legs held… Morgan then headbutted nurse in charge [during a restraint]

JE: Yes, that was my understanding ma’am, thanks

PJ During her stay on Abbey Ward Morgan was reviewed very often… I do believe she was brought there on the 2 March and on 3 March was an MDT where Morgan was assessed to have capacity, she had by then calmed down.

I think Morgan had reported some remorse about assaulting staff, she said she was sorry for her behaviour.

Note from Nurse X [missed] Morgan said voices told her to hurt staff… escalated as wanted private toilet and did not want to be on camera… team engage with Morgan.

Ward review 3 March 24:40 with doctors [she lists names, didn’t catch]

Morgan very articulate, able express herself well, had identified the triggers, talked about psychotic phenomena but attributed to stress. Reported self-hate around yesterday’s incident with staff, said arousal levels go from 1-100 quickly. Feels she is wasting time and is a burden.

Was discussed, they felt she didn’t need detention. She was willing to work with the team either to move forward in her recovery. Discussion also held around her ability to prevent leaving if she feels at risk.

Asked whether she’d mind going to Rowan Ward if bed availability, she said she would be happy to. Positive experience before.

Advised further violence to staff member would result in discharge from unit… then the behavioural contact that my colleagues from Abbey Ward did.

Dr Juliá asked whether the coroner wished her to read the behaviour contract. [She did, at speed, I missed lots of it, apologies. Please take this report as partial, I can not keep up with the speed at which this witness speaks/reads].

PJ: 3 March, prior to transfer to Rowan Ward. Decision to remove your detention. Due remain in hospital as informal patient. Always strive work in best interests and least restrictive manner…

Made aware using traffic light system is beneficial to you… as noted you find it difficult to initiate conversation… As team build positive strategies and techniques as we progress with working with you…

[missed lots]

You have been working with team in identifying in when agitation starts increase… first step… agreed try use PRN medication and ….

You will be an informal patient and therefore deemed to have capacity…if engage risky behaviour the team can place you under section…

Understand if you were to be aggressive to others this could result in your discharge from hospital.

Morgan would like her mother and mother in law fully involved in her treatment.

Agreement signed by Morgan

[Missed]

Have agreed will not cause intentional harm to myself, nor harm others…

[Missed]

The coroner asked her to confirm the date that behaviour contract was signed, she said 3 March 2023.

PJ: I do believe that was a Friday, and was the day Morgan was transferred to Rowan Ward after 5pm, so out of hours.

Morgan was in the ward throughout the weekend. She, from my recollection, managed well on the ward with no further incidents of agitation or risk. She was informal, could use leave freely.

[Missed]

We came back to work on 6 March 2023, Monday … first thing handover meeting, updates of patients… discuss new admissions.

In that meeting we found a handwritten letter from Morgan’s mother in law addressed to the matrons. At the time the matron, Patrick Fenton (?) wasn’t there. As it was left in the handover room we thought it was relevant to us, to read.

That letter expressed lot of concerns of family regarding discharges from Meadowfield. Bit difficult to identify what applied to Rowan Ward, what was Maple Ward, both admissions a little bundled in one.

Overall gist of the letter was they felt team hadn’t provided enough support. Family not sufficiently involved and would like family to be involved.

Was unusual for letter just to be left in the handover room. Usually, formal complaints go through PALS. Highly unusual for this letter to appear in the handover room.

Obviously, we were mindful the family had some concerns about care provided, difficult to say, but overall in Meadowfield.

Even though the review in Abbey Ward, where Morgan and her mother in law were present, she said happy for her to come back to Rowan Ward. Which was a bit contradictory.

Also aware of several incidents of assault on several members of Rowan Team. We thought discuss with matron whether Rowan Ward was appropriate or if another acute ward where no incidents of assault, no pending police investigations… thought had to discuss with matron as well as with family. Even though felt some things could be improved, different options could be provided if felt Morgan had to be in hospital.

Also raised in handover the team feeling really triggered to some extent not knowing how to react to a letter Morgan had written to the team about the incident, or assault, that took place in Maple Ward. That letter had been handed over to staff throughout the weekend

Staff expressed during handover, expressed found it really difficult to react to that latter. It did not feel to them was an apology, Morgan was bringing up repeatedly in 1-1, staff avoiding the subject as thought would lead to conflict with Morgan if addressed.

Think might be at [gives page reference, missed, she says she’ll read the letter]

Dear staff members included in the altercation on Maple Ward with myself,

I don’t believe that I owe an apology for experiencing a psychotic episode and believe I needed to escape the ward, but I am sorry for causing any injury (if I did) to anyone involved.

I know that when someone is apologising, excuses should not be added into the mix, however I will outline a bit of background just so you might be able to have some insight as to what was causing me so much distress at the time.

Firstly, I have autism. For me this looks like socially being unable to connect and sensory overloads amongst other symptoms.

My mental disorder, whatever that may be, had me believe I had wasps crawling up my back which were stinging me and were only inside the ward. This was why I was trying so desperately to escape.

The garden wasn’t good enough because I wanted to run far away from the danger. While being restrained that was an awful sensory overload for me, alongside the episode I was having. I was going to do everything in my power to escape.

The consequences of having autism and mental health issues meant I was arrested, spent the full 24 hours in police custody, had a Section 136 and was watched while I showered. Had to then stay in a 136 suite for two days and I will be going to the police station again in a few months to find out my punishment.

Another consequence for me is the hatred I have towards myself and please rest assured I have become more suicidal and will get what I deserve once I leave Meadowfield. Think of it as the death penalty. I really am sorry.

It was difficult for the team, especially those involved in the restraint. They stayed professional… this letter was very challenging for the team.

At the MDT we decided to try move away from the letter. Morgan will struggle to accept how understanding was interpreted by others. Decided try not to address it and move on to something else.

Also decided check with matron and family if Morgan was better placed in another ward, obviously a lot of issues had taken place.

Also organise review with every professional in Morgan’s care later in week, wouldn’t have time do on Monday, to support everyone in meeting… That was the outcome from that morning.

JE: Sorry ma’am, decision made in the MDT?

PJ: In the handover, not to do discharge, meeting, in first review to ensure review with everyone there. Trust policy supported this… Morgan was not a new admission, was transfer, seen by the Responsible Clinician on the Friday, so didn’t need to be reviewed within first few days of admission… had already had significant input from senior clinician.

As Mondays go, usually start ward reviews around 10:30. We see a higher volume of service users on the day. Also a 17 bed unit, see 9 on Monday, 8 on Thursday and ad hoc in between if have been any new admissions.

When visiting the ward review, colleague Jessica Archer, ward manager Rowan, had been in handover meeting, told me Morgan was very unhappy would not be reviewed on Monday, said waited whole weekend to see a consultant, wanted to be seen that day.

Jess tried to explain rationale, almost impossible to meet both requests, have meeting on day and everyone to be there and structure.

Practice with people with autism is to give specific times, not when can at short notice, to give them time to prepare.

[missed]

Fairly confident could keep supporting Morgan with interventions until could arrange a meeting with all professionals involved. Morgan was not happy with this. She called her mother and said might self-discharge if she wasn’t seen.

Jess asked me see Morgan that day which I did. Again meant couldn’t bring any other professional to that meeting. Discussed possible therapeutic break .. wouldn’t be appropriate to ignore assaults.

Thought important to address those concerns. Morgan said she wasn’t sure, yes had damaged the therapeutic relationship, said she had some doubt staff still wanted to work with her.

We reassured Morgan that wasn’t the case. Said as team remain professional and happy to work with her, however could understand might have an impact and if she wanted moved to Chichester, ward closer to home, could continue with admission.

Morgan said could have been option but struggled with change so didn’t think best thing to do. Morgan quite appropriate, Morgan was appropriate during review, able to express her views. Morgan again brought up letter.

As Responsible Clinician, and knew team struggling. If any place to address letter and put to end… Morgan clearly expecting response from team that they not able to provide. I thought was safer environment to discuss.

I reassured Morgan regardless of content of letter, or assault, we would be happy to support Morgan. We did express letter not taken as apology by the team, but we would support.

This caused a lot of distress of Morgan and she left the room. We give her space.

Shortly after that Morgan’s mother contacted the ward, she said Morgan was distressed and wanted to leave.

In that… Tanya said she didn’t think hospital was the best place for Morgan and expressed she wanted to take Morgan home. Jessica suggested a professional meeting take place and make plan to ensure safe discharge.

Organised professionals’ meeting for day after, understanding level pressure Morgan wanting to leave ward and family wanting to take her home.

Again, I wish this move quicker but it’s difficult to get all professionals in the same room, busy diaries and agendas. Think we invite mother, mother in law, we invited the Crisis Team, the Lead Practitioner, I do believe we invited the Social Worker.

The Lead Practitioner couldn’t attend, sorry the Crisis Team couldn’t attend. Don’t think we got a reply from the Social Worker. But again thought relevant to move on with review, Morgan and family requesting themselves.

I thought was a really productive meeting. Went into a lot of detail of the difficulties Morgan was experiencing in hospital. Family expressed again. Think mother in law took part, joining by telephone.

[Missed]

Family expressed hospital not necessarily a helpful environment. We agreed given her diagnosis of ASD and …. wasn’t supportive environment for her recovery.

Morgan’s mother expressed views like Morgan managed in community and support with family. Said the family come up with strategies, happy put in place to support Morgan.

One was to move in with her after discharge to avoid stress of being with her child, which we thought was appropriate measure to take. Morgan expressed whole situation was bitter sweet. She said grudge held by professionals. She was reassured again was not the case… our goal to support her to achieve her goals.

Objectively Morgan and her mother said experienced as caring and helpful. No evidence of staff …

Morgan talked about never really needing hospital and asked our views. Sadly, is not black and white answer about someone with Morgan’s difficulties being in hospital.

Went through, all options explored. Morgan remained on ward… at time had Lead Practitioner allocated now and would move into community. Did explore option go home with some level support. Did explore again if Morgan felt needed still be in hospital would explore going to Chichester, would be her local area.

We were as explicit as possible. Understand someone with autism struggles when not clear. We were clear.

[Missed]

Also quite clear were conversations regarding what we’ve already discussed multiple times… deskilling and Morgan’s own difficulties adhering to boundaries and restrictions and inpatient wards not supportive environment for people with autism. They’re away from their routine, sensory management at home… the wards do have bright lights. Food will not meet sensory needs of someone with autism.

We get incredible array of diagnosis on ward… including patients with severe and enduring mental illness… [lists examples, missed].

As a whole it is not an environment which is helpful for people with autism. My colleague mentioned CTR for when people with autism are struggling, not putting them in hospital and what support in local community environment.

Lead Practitioner said would chase up with Transforming Care team, TCAT. We discussed autism report, still not got yet.

[Missed]

TCAT would provide support come to terms with autism spectrum disorder. TCAT not team that takes on a patient with autism, supports teams. Helps them build skills and assess patients then hand over to community team and Lead Practitioner to keep working on.

We also discussed use of PRN in home environment, if needed, was an oversight from first discharge from Rowan. Shortly after discharge Morgan brought [withheld] over the counter… Morgan identified having PRN at home would be helpful.

Also discussed alternative to inpatient admission in moments of crisis. Haven wasn’t safe because Morgan absconded several times.

Discussed when risk does not come to needing locked environment, lots of crisis plans can be used… crisis cafes, not formal intervention, just safe environment where one can have coffee and talk little about how feeling. As well as crisis houses in community. Family was very happy with that. Family identified safe words and would use traffic light at home.

Morgan at time was very determined to take her own discharge after this meeting. Morgan’s mother and mother in law suggested rushed discharge wouldn’t result in positive outcome and encouraged Morgan to remain on the ward.

Crisis Team had not been able to attend. Not able to tell us when they would assess Morgan.

Again, we listened to what Morgan wanted and the family wanted and tried to explore how can support Morgan… explored use of overnight leave, whilst she remained open to us, ASD patients could spend nights at home to minimise distress and come back to the ward for Crisis Team assessment.

Morgan wasn’t keen on this option, then agreed to extended leave over the following days until assessment by Crisis Team, booked on 9 March 2023.

During admission Morgan very eloquent, demonstrated capacity to make decision about her treatment, very helpful having family involved… safety planning… very insightful about how she was feeling at the time, not in best place to be around her child so deciding stay with her mother… one of main drivers wanted to work on spending more time with family and her child.

Based on that plan over the following days Morgan continued to utilise leave with family and partner, which went well until the events of the 9 March.

At this point, 16:25 on Thursday, the coroner decided to adjourn for the day, warning Dr Juliá she was under oath and must not discuss her evidence with anyone. She said on Friday morning questioning of Dr Juliá would start.

[Court was not sitting until 11am on Friday. There was some housekeeping discussions between the legal teams and the coroner before the jury were brought into court shortly before midday, at approximately 11:50. As I only report what is heard in open court in front of a jury, when a jury is sitting, I will not report those discussions].

The coroner said prior to asking the first witness, who was still under oath from yesterday, to come to the witness stand she wanted to give the jury an updated chronology. She checked all jurors had it.

Dr Pilar Juliá was called back at 11:54. The coroner reminded her she was still under oath and asked her to confirm her name for the recording. She does.

C: you recall yesterday you provided an overview of your involvement with Morgan. I have a few questions for you then the questions will be raised from legal representative from the family, the council and also from Sussex Partnership Trust.

Please have some water and make yourself comfortable, I’m sure you’re going to have lots of questions.

PJ: Thank you ma’am

C: From your evidence yesterday, you confirmed you first saw Morgan on 14 February is that correct?

PJ: That’s correct, yes

C: At that time she was seen with your junior doctor?

PJ: Yes

C: the junior doctor’s name?

PJ: Emmanuel O [missed fuller name]

C: How was Morgan? Was she calm?

PJ: She was able to express her views, not experiencing agitation at time, able to articulate well how she’d been feeling over last few months… she clearly expressed her significant distress and difficulty in understanding the diagnosis of autism… did express feeling really lost about that diagnosis.

Her speech want pressured at any point… [missed] … able engage well. Was likely a long review, first time meeting her, and in context junior doctor starting the review and me stepping in when needed.

C: Prior to that you’d taken time to read her notes, so you had history of Morgan?

PJ: As mentioned a few times having morning handover, takes place each morning between 9 and 9:30 or 10am.

In that handover get information from nursing staff there for change of shift about any event might happen over weekend, presentation of patients, how engaging with team, any risk behaviour, anything need to know including handover new patients, usually name, age, diagnosis and reason for admission.

Is brief, trying to discuss 17 patients and all events of the weekend … when have new admission, especially when as junior doctor lead on review, have little time reading, mainly Mental Health Act paperwork and assessment summary that I believe read yesterday by my colleague Dr Ahwe, that is done by clerking doctor on ward when patient arrives, that’s most information at that time.

C: You said Morgan could articulate how she felt?

PJ: Yes

C: You mentioned yesterday about her triggers

PJ: Yes

C: Could you confirm what they were?

PJ: Morgan mentioned 3 main triggers over recent months, one was her college course… she also expressed being a mother even though incredibly rewarding also had its stressors which wouldn’t surprise anyone, had weight on way Morgan was feeling, and one of main differences was her processing and understanding of recent diagnosis of autism given 2 months before. Because that done in private practice, my understanding is Morgan did not have any follow up or sessions to understand what diagnosis meant to her in context of the report, she was struggling to make sense of it.

C: Diagnosis of autism was done in private setting?

PJ: Yes, can give more background as mentioned before. Morgan was under the care of CAMHS between July 2020 and July 2021 and during her pregnancy… formulation colleagues had done, Morgan was at the time working diagnosis of developmental trauma but wanted to rule out diagnosis of autism at the time.

As lot of the symptoms we could describe in someone with developmental trauma were met by that diagnosis, absolutely no reason someone could not have both diagnoses, so team thought appropriate for Morgan to get that assessment.

That was referred while Morgan was under their care, I believe due to waiting lists at time did not happen while Morgan still under the care of CAMHS.

Do believe that’s the main reason why mental health services did not have access to that report. When we refer for assessment of neurodiversity… report will come back to the referring team… [missed] team will do screening tools and make that referral.

Because Morgan discharged from CAMHS and wasn’t open to any mental health services, when that assessment finally took place in December 2022, was no identified mental health team for that private provider to send that report to.

Unfortunately, also meant at time Morgan didn’t have any support from mental health professionals to help her understand this report.

C: Thank you, so in the meeting that you had with her on 14 February, she was able to articulate. What was discussed with her at that point?

PJ: If I might go back to my report on the notes, we discussed her personal history and dealing with suicidal thoughts, quite often when get young people admitted to our care … when already open to CAMHS, do have long standing chronic history of self-harm …. Morgan experiencing suicidal thoughts pretty much ongoing since she was 11 years old, expressed last few months become worse due to triggers just discussed, she explained what plans had made… she felt being out of control…. Understandable…. also expressed she had diagnosis of oppositional defiance disorder and her words were she was lacking respect for authority and struggling with inpatient environment…. very common… [missed chunk]

Unfortunately, they develop self-harm behaviour as way coping with distress… initially have attempts to regain some self-control but unfortunately they become a maladaptive strategy where people lose control…

Morgan was very aware that was one coping strategy that she had. We explored meeting with clinical psychologists… thought being in college probably bit of trigger… she explained lot comes with role of mother and diagnosis of autism. I thought meeting with clinical psychologist would be helpful space.. I think my colleague did a good description of how ward review room looked like…. [missed]

Not right environment to sit down and open up with difficulties… so always think offering appointment with clinical psychologist in these cases is really helpful, much more private quiet space…. Where service user   can explore more triggers led to admission and hopefully start processing some of those difficulties

C: but Morgan wasn’t when you suggested that to her, she wasn’t amenable to that?

PJ: No. Morgan expressed she had had therapy before, if I remember correctly from notes received CBT when she was in school, was referred to Life Centre when disclosed being victim of sexual assault… not comfortable discussing that incident with SPFT staff… Morgan did express she didn’t want talking therapy and she couldn’t accept or forgive what happened in the past, was a reason not to accept this.

As mentioned from college identified at time some lecturers not turning up on time… upsetting for her… need for structure.

C: She was keen to explore the autism?

PJ: She was keen to understand more her diagnosis of autism, again why suggested psychology good space to explore that. As Morgan wasn’t keen we also explored occupational therapist… OT already done lot of work around autism… [missed] Morgan was a bit more open to possibility of engaging with occupational therapist but also felt needed a little more time feeling settled on the ward before exploring that.

Very keen work on passport to explore how we could communicate with her better, which she did over following days with some team members. Also happy be referred to TCAT… not able refer without confirmed diagnosis of autism and service user being in the national registry, which was why we asked for the report

C: At that ward review, Morgan was able to articulate to you the oppositional defiance disorder?

PJ: Yes

C: That she had and advised you she lacked respect for authority and struggled with the restriction of the inpatient environment. Is that correct?

PJ: Yes I can go back to the specific review… I think my report is exactly as possible, I’ll go to specific entry just to make sure I’m not missing any information.

C: I’ve taken those words from your statement

PJ: Yes that’s from my statement, I’ll just. What I documented at time, I think I’m the author of that entry, or was it my colleague Dr Lake? Not sure, if Dr Lake was present, was likely typed by Dr Lake.

JE: From electronic records is Dr Lake

PJ: Thank you. States she explains she is now upping the ante as the overdoses haven’t worked, states feels out of control, given her autism being in control is really important, also explains oppositional defiance disorder, therefore struggling in this environment, states cope with self-harming, doesn’t want help just wants to jump off bridge… asked any coping strategies, likes drawing, she drew a lily in her notebook yesterday and also uses PRN

C: Thank you, and in this meeting you discussed medication she was taking?

PJ: Yes… we explore medications [missed] … any of the diagnoses Morgan given at some point… to make clear medication, think about pyramid, is just the tip of the pyramid. Medication in this diagnosis not aimed to resolve difficulties but aim to support with managing symptoms and allow patient engage with other intervention… as spoke NICE guidelines and Royal College of Psychiatrists regarding long term therapeutic input

C: OK   

[There was then more discussion of what medication Morgan was on, I’m withholding that so wont report. This evidence is largely a repeat of her evidence she gave yesterday].

C: How quicky would the [withheld] start taking effect?

PJ: Anti-psychotics and anti-depressants all medication has some time to take full effect, usually 6 weeks, but in this case we’re not using to treat psychotic symptoms but for calming effect, which would take place almost immediately.

C: So between 14 and 20 Morgan was working with staff would you say?

PJ: Overall yes, were some peaks of risk which is to very much be expected with Morgan’s long standing history of suicidal thoughts and self-harm behaviour, especially on acute environment, one of reasons why acute admission not recommended. Very often we see patient risk to themselves might increase when hospitalised, due to nature of environment

For example, when Morgan at home her suicidal attempts was overdose, and she reported to family, no history of her tying ligatures, which was the behaviour that emerged on the ward. … again, adopting maladaptive strategies from other service users… sees service user, might self-harm through scratching and cutting, they develop other self-harm behaviour that they were not presenting with before

C: On 20th you provide Section 17 leave

PJ: Not sure if 20^th but will be in notes.

She says she thinks it was before and the coroner asks if it was granted.

PJ: Was granted before the review, we don’t wait until the review to reassess someone’s needs, that’s point of morning handover… check not just putting blanket restrictions on someone.

I should have looked yesterday at notes… sorry about that, at some point we thought Morgan was engaging with team, she was struggling with inpatient environment, we thought would be beneficial for her to have leave with staff or partner, so we prescribed that leave

C: On 20th she explained using leave well on the grounds?

PJ: Yes

C: She was agitated the night before?

PJ: She had had an episode of agitation the night before, I think she had damaged some games on the ward… didn’t lead to any harm to staff, or to other patients, or herself but she had become distressed the night before

C: And she had asked, she herself had said the environment wasn’t assisting her and requested outpatient therapy?

PJ: That is correct

C: So is it positive that a patient takes control?

PJ: It is, they have a role in mental health services, we’re not here to take people away and make them better, we’re here to support and walk with people on their recovery… empowering them… often see in young people with a history of mental health services, particularly with admission in teenage years, thankfully not Morgan’s case, they lose any goal or role outside being a mental health patient.

Am sure we can all imagine how difficult it is to deal with self-harm if one doesn’t have any idea of how wants their life to look like or what a good life will be… main goal work with them while build recovery pathway

[Missed]

C: So you discuss with Morgan regarding her discharge?

PJ: Uh hum

C: At that time, we’ve heard jury have heard from others evidence about capacity. Did you consider Morgan had capacity at that time?

PJ: Yes

C: What factors did you consider when determining she had capacity?

PJ: As explained already, happy go over it again, acid test for capacity ask 4 questions, always decision specific. Can someone understand the information, can they retain information, can they use and weigh information to make decision, and can they communicate their views.

Clearly documented Morgan able to do all that during that review [missed]

C: Thank you. At time of discharge was Morgan given medication to take home with her?

PJ: It wasn’t given to Morgan, had been agreed day before partner was happy to carry medication, on day discharge I believe person collecting Morgan was mother in law, so indication would be give medication to mother in law, would have been usual policy to follow.

C: Once she was at home became overwhelmed very quickly, we’ve obviously head from Dr Ahwe. What happened next? You weren’t involved in that. Just have few more questions regarding Woodlands. She went into Woodlands on 1 March?

PJ: I wasn’t involved in that either

C: My question was when she came back to Rowan Ward on 3^rd, her section had been rescinded and she was admitted back to Rowan Ward as a voluntary patient?

PJ: Yes, was really excellent MDT review that took place on the 3 March where Morgan’s mother Tanya and Louise were present, she was seen by [lists 3 names] where they discuss everything that happened, how she was feeling, section status discussed, team felt currently did not need formal detention as more than willing to work with team to work forward in her recovery. Discussion held about ability to stop her leaving at time of risk… Morgan asked whether she would mind going to Rowan Ward, think really relevant question to ask as she’d recently had admission with us… was a bed available, would be closer to her family support network, she has said happy to go as she’d had a positive experience there before.

C: Thank you

PJ: That’s where my colleague suggested if remain informal patient would be relevant to have a behaviour contract

C: Thank you, so she was back on Rowan Ward on 3rd on voluntary basis?

PJ: Yes

C: Until you saw her on the 6^th?

PJ: Yes

C: What were her observations? We’ve heard lots in evidence about observations. What were Morgan’s observations at that point?

PJ: I can’t remember, I’ll just look into our ward review. Usually when patient gets transferred, usually remain on same observations on other ward unless team have specific concern and need place patient on 1-1 which I don’t believe was case… [missed] informal patients more likely to be on general observations, high level observations can be very restrictive… the ward review from that day, 6 March indicates at time on general observations, which is hourly, lowest level of observations we have on an acute ward

C: Then you in your evidence confirm that you saw the letter from Ms Hodgson?

PJ: Yes

C: Did you, I didn’t take a note of it, did you say this was found in the MDT meeting room?

PJ: Yes, in handover meeting on Monday morning get usual handover over what happened, explained Morgan readmitted with us after transfer from seclusion in place of safety Abbey Ward. We were told letter had appeared in MDT room, wasn’t clear what source of that letter, was addressed to matron. Matron wasn’t there and as left in MDT room we thought relevant to us read letter and discuss as and MDT… [lists who in MDT team]… that’s where we read the letter out loud. As mentioned, it was, it raised concerns about the decision to admit Morgan at Rowan Ward. Obviously, the family had expressed concerns about previous discharge, which initially would be reason to consider another ward for admission to prevent difficulties with the team.

The family mention a lot of events what were difficult to follow, which refer to admission to Maple and which to Rowan. Did feel however had to discuss this with Morgan and her family.

We cannot do that when someone in seclusion room, if help court, seclusion room looks like. Use seclusion when presentation of risk to others of level cannot be supported in less restrictive environment… only service user is in inside, is cameras to monitor their safety and their behaviours, staff usually go in with more than 1 member of staff to ensure safety. We do our best to use as little as possible, is challenging and difficult to be restricted in room, with no one to talk to and not access to items.

[Missed]

It is not a comfortable environment, so we consider maybe as bed identified on Rowan was felt level of pressure to come to that bed to move from seclusion room, completely understandably, so thought would discuss with family their concerns and with Morgan how she felt working with the team.

C: Thank you

PJ: Again, if I might add one thing the letter indicated very quickly, was family not happy with level of involvement had so far, as said yesterday Morgan was adult with capacity was able to make those decisions, but we made decision at next review had to be with everyone. Family wanted be involved, which was why we initially postponed review until everyone was available to attend.

C: You refer yesterday to correct procedure, letter should have gone to PALS. Can you explain what PALS are please?

PJ: Across the NHS is formal system to log complaints to get properly investigated, then outcome and family have response, is usual procedure if anyone needs raise concerns, usually trigger safeguarding concerns and policy not followed. Is the right procedure to do it, to ensure those concerns are appropriately addressed

C: PALS, what does the acronym stand for?

PJ: Patient advice and liaison service, I think.

RA: Correct, patient advice and liaison service.

C: My last question, the observations Morgan was on on the 8 March was general observations?

PJ: I honestly cannot remember, I think she was throughout the second admission, her observations were not formally changed from general at any point

JE: Ma’am if I may, they were on intermittent on 8 March, don’t know when changed, but we have those lists.

PJ: Apologies, I don’t know that. Would it help to explain how observations take place?

C: Yes please

PJ: We do try assess risk in dynamic way and not impose restrictions… try to make as least restrictive as we can… as discussed yesterday positive risk taking… morning handover really good place where nurses would advocate for observations to be reviewed and reduced if feel service user   doesn’t meet that level of observations. The increase of observations can be done at any point of day or night, talking about potential increase of risks don’t need to discuss can just go there, but to reduce risks need discussion… [fuller answer, missed]

Unfortunately, that means at times that is not formerly documented I’m afraid I do believe my colleague Jess Archer will talk about that, a lot of work been done on the ward to make sure is documented… I do believe in this case some changes did not have a rationale documented, but I do believe that’s an outcome… [missed]

C: Thank you. Meeting you had with Morgan and her family on 7^th

PJ: Yes

C: Morgan’s capacity at that point, what did you assess it to be?

PJ: I did not feel her capacity had changed at any point… when comes to capacity again as consultant and clinician trained to be constantly checking with ourselves is someone retaining and understanding information we are giving to them… is constantly on some subconscious assessment, check is someone understanding and able to weigh up information.

Capacity is assumed unless significant reasons assume someone lack capacity. Had seen Morgan day before, seen by my colleague 3 days before, at that point nothing changed

C: Thank you, I don’t have any further questions, if you could just stay there now you’ll be asked questions by the representative for the family Ms Elliott

JE: Thank you ma’am, good morning Dr Juliá. Thank you very much for your evidence to the court, will go back over some of this. Understand your first contact was on 14 February ward round?

PJ: Yes

JE: You’ve read in some detail to court, will go straight to family concern. You know family have concerns about their involvement, does start right at this initial ward round. Why no contact had come to them once Morgan arrived on Rowan Ward, we don’t see any evidence of that is that right?

PJ: Yes

JE: You have good understanding of policy, very much focused on involvement of families and carers, [Ms Elliott lists policies that talk about involving families] … involving all aspects of care and providing high quality information…

You’re familiar with this, the jury have heard about consent. Nurse Jallow suggested at one point consent was taken and Morgan declined on 17 February, at this point we don’t see any records consent was checked.

PJ: I think consent was checked with me.

C: Ms Elliott could you confirm the page number

JE: Of care plan, yes

PJ: This is not explicit consent, but on her autism passport Morgan identified her boyfriend Dominic and her mother Tanya for information to contact for more information about her

JE: Yes, that’s exactly my point [gives coroner the page reference] was started on 14^th but that meeting aborted. Nurse Jallow did care plan with Morgan and uploaded that day.

One point on 17th didn’t want family involvement, she does give phone numbers for more information, she does say on her assessment very important to her, even on the care plan with 4 things that are important, family are 3 of them. Given that, why do we not see family invited to this ward round?

PJ: Morgan was admitted on 13th, we saw her 14th which meant we had no time to organise review with family at that point… try to assess the patient as soon as poss. She’ll be medical reviewed within first 72 hours… that’s reason family not invited to first review, is matter of timing.

JE: That is a concern for the family. In Woodlands she was only there one night but family was involved with that ward round, received a link, they said they received a Welcome Pack. She’s on the ward 24 hours but enough time for someone to make a phone call surely? Why had no one said she’s been admitted, short notice but can someone attend the ward round?

PJ: Ideally yes, one reason is review organised by our clerk on the ward, go through list patient, send emails and make sure everyone is coming. Clerk doesn’t work on weekend, ward team might be reluctant to offer review if not available… much more detrimental to invite family to be there if appointment is not available… that’s something that has been reviewed, processes we follow who needs come ward review and ensure doesn’t fall to someone who doesn’t work weekends… Trust are working on it, allocate specific staff member, ideally my PA, my medical secretary have access to my diary and they can book in when I’m available to see patients, however I don’t have a PA or medical secretary, we’ve been discussing this for some time. Falling to team members without structure. Having identified that now identified member of staff happy to work as point of contact to families, other agencies, myself… as well as go to records… service user might not be able to give us information, so this person is taking on the role of gathering all that information and making sure that’s available.

JE: That’s the case now, thank you for that evidence. What you’re saying is the time Morgan was there, there was problem if came in on weekend and ward round next day, was no procedure to get family there.

PJ: If family had expressed wished to attend, yes

JE: Of course, but onus is on the ward… they don’t know when the clinical contacts are for them to engage

PJ: Again, as I mentioned we put things in place to improve. At the time if someone admitted they’re always contacted by the ward to let them know arrived safely, so that should have been done. Patient may express want family here on review, in those cases as passed over in morning… I fully agree and acknowledge the ward also needs to be looking into those things.

JE: Proactively seeking engagement of families, it really becomes an issue when talking discharge meeting but even at early stage, the concept of triangle of care means family could give more information on issues you discuss with Morgan. You’d accept that?

PJ: Yes

JE: You gave additional evidence about Morgan’s autism report… we don’t see document but you have recollection you asked Morgan. The family concern, first question is this document was commissioned by SPFT and why do SPFT not have it? You said today is question of referring teams, are you not aware any ability to search the system?

PJ: This is not an SPFT document

JE: It says SPFT on the front of it

PJ: Was commissioned by SPFT, but assessment not done by SPFT and wasn’t on record when we first met Morgan

JE: If not available on records, Morgan got lot going on at that ward review, Dr Lake notes still in period of crisis, feels unable to communicate or utilise coping strategies. The concern is giving administrative task to Morgan, while trying to adjust to the ward is not a safe route to get this document, is it?

PJ: Part of the outcome of family, was to contact family, part of outcome Morgan would contact family, but also we’d contact ourselves to get that

JE: Indeed, surest route would be to go to the family, who you could be relatively sure had that document, but we don’t see a call out to the family either for the autism assessment, or to attend the ward round, or review at next ward review. We don’t see any of that do we?

PJ: Unfortunately, no record of communication with family. We know the family communicated with the team and visited on the ward.

JE: Sorry what do you know about the family communicating with ward from 13^th?

[Missed]

JE: I don’t think we’ve seen the Section 17 leave form, it must have existed, but we don’t see a call to family to advise them

Dr Juliá said no, adding that the “documentation is lacking”.

PJ: Do completely accept and acknowledge there is no written documentation of that.

JE: No, and family do visit and go on leave with Morgan in that first admission, somehow functioned, otherwise viewed from family, one really important matter, most significant when come to discharge, when comes to Morgan’s child, his interest is legally paramount, safeguarding of a child is legally paramount that’s right isn’t it.

There has been a safeguarding raised in The Haven, raised on 7^th, so really you had all information there in that ward round to know there was a safeguarding issue live, but we don’t see any discussion about that. We don’t see an invitation to social services to come and engage, not then or at any point the admission do we? You’re nodding, for the tape.

PJ: Yes sorry, we reflected on second admission to ensure we had that… were some omissions in terms of inviting professionals who were relevant in that first admission.

JE: And indeed, in terms of family perspective of this crisis for Morgan, I don’t believe you were in court for their evidence?

Dr Juliá confirmed that she wasn’t.

JE: Broadly speaking in terms of the crisis, certainly from Mr Goddard, Morgan’s partner was his evidence was he’d not known Morgan in a state of crisis… since becoming mother not known her to be in crisis, was very, very serious concern for him…. That context is what family are trying to ensure is there for the ward.

You’re nodding, for the remote attendees and the tape?

RA: I think some more direct questioning might assist the witness

JE: The witness is nodding, I’m trying to ascertain if she agreed input of family is beneficial and benefit of them being there. Have to summarise what heard previously and the medical records. Dr Juliá was answering and was nodding, it’s just it’s not recorded, and those listening in are not able to hear.

C: If you could repeat your question?

JE: sorry ma’am I’d scrolled on, yes family views of levels of crisis Morgan was in, that’s something they could have provided if they’d been invited to the ward round?

PJ: Some of those views recorded in contact with Crisis Team and A&E already had access, I do agree more access with family would have been helpful, on other hand had to weigh up Morgan’s view and her difficulty of the admission, and the consequences of not respecting her views at time… I’m speculating what might happen… we do recognise we should have included the family and Morgan was keen for this to happen. We invited them much more in the 2^nd admission, in 1^st admission decisions made on Morgan distress in inpatient environment, her ability voice her views… [missed]

JE: First of all you’re right, she’d been to A&E and Crisis Team, but again these professionals are seeing Morgan in her crisis once she’s suicidal and need help. That’s correct isn’t it?

PJ: Not sure what your question is?

JE: Professionals you said, had information about her level of crisis?

PJ: No, we had information about family views

JE: You don’t have the family views that you’re able to ask about and able to record as part of the assessment on Rowan Ward?

PJ: Have family views on crisis and reason for admission documented in A&E and Crisis Team

JE: That ward round 8 or 9 patients you’re seeing, catch up with everyone after weekend, the idea you take time go back through and select family view, from the many records of the Crisis Team and A&E

PJ: It was a week long of context, so not a huge amount of information to go through

JE: Well from 2 February, so 2 week period

Dr Juliá said that the information was in the admission summary.

PJ: We made an improvement on this, did take on board in second admission that helpful to have more input from family

JE: Thank you, comes to 20 February ward round, as I understand it this was not a formal discharge meeting according to policy? This is ward round where questions of discharge came up, and you made a decision?

PJ: Was ward round, observed Morgan throughout week, she had communicated multiple times to staff how distressing the environment had been

JE: Do you have any of those notes? She does say in the ward round… where does she make repeated references to not finding benefit, would like some assistance to where those records are? Perhaps over lunch?

PJ: I definitely at least have one… there is multiple

JE: I’ll look over lunch ma’am if I can’t find will ask for assistance. you said she’s mentioned it repeatedly, would be grateful to see where those repeat references are.

I wanted to clarify was a ward round, not a discharge meeting, but you ended up making a decision on discharge?

PJ: Tried to asses Morgan views… she was vocal finding ward environment detrimental to her recovery, very keen to go home. Missing her child, said brighter in mood, medication had helped, she talked about how struggling with eating and onward [reads from note]

I explained community mental health team approach and how could benefit her… Morgan states hasn’t heard voices since admission, thinks new medication really helped… states really wants engage with therapy in the community.

[Missed]

We agreed on discharge the day after with the crisis team…

JE: I agree the question of discharge comes up during discussion and a decision is reached.

Ms Elliott asks to take the witness to the discharge policy.

Ms Agnew gives the reference for the ward review note.

JE: Yes Dr Juliá, and I do very much want to talk about her presentation, but in terms of procedure around discharge, I want to understand what that policy says.

Operational policy sets out around discharge. Says the Named Nurse and Lead Practitioner, you’re not the lead practitioner?

PJ: No at the time Morgan did not have a Lead Practitioner allocated yet

RA: We heard Becky Orr’s evidence read to court

JE: Yes, later in the timeline, no Lead Practitioner, the named nurse we understand was on holiday for most of her admission, were you aware of that?

PJ: Named nurse figure on ward is person working on document, doesn’t mean when that person is on annual leave the rest of team isn’t engaging, fact named nurse on holiday at time wouldn’t make any difference with regard to discharge planning for any service user.

JE: Were you aware he was on holiday for most of her admission?

PJ: I don’t remember

JE: That’s fine, please do say if you don’t remember.

Policy says Named Nurse and Lead Practitioner are pivotal for planning discharge process… discharge care plan including crisis planning etc

Two figures and talks about liaison there, what we’d expect, clear community system assist flow of information…. CPA discharge care plan. So clear information for everyone involved?

PJ: Yes

JE: What’s CPA discharge careplan?

PJ: Care programme approach

[Missed]

JE: Said must be care plan approach meeting chaired by consultant or nominated deputy at which service user and family/carers are invited to attend, CPA all those in contact with… other health services and social services?

Where possible MDT identify discharge date as soon as is practical after admission, thinking discharge at earliest point in admission… far enough in advance necessary arrangements be made and required meetings take place… throughout admission discharge and discharge planning discussed

Understandably it’s a thorough process, involving everyone to ensure right network around patient on discharge. The moving on policy…

PJ: Apologies, I understand the Moving on policy is mainly applied when patient is struggling to leave hospital, applies to those cases

JE: OK, doesn’t really add to what I read to you, is a structured approach to discharge care plan meetings, interests of any child at home is paramount.

Ma’am I’ve got to the end of what policy is, now have question about discharge.

Ms Elliott checked if the coroner wished to break for lunch before more questions.

C: If you carry on with those questions then we’ll take lunch 13:30 to 14:30

JE: Of course ma’am. Given policy, it’s not a discharge meeting, but it effectively becomes one.

PJ: When think about policy and how implement, also have to take each case on individual basis. Mentioned yesterday when becomes related to discharge someone from section… law states patient should not be kept under section… Morgan did not meet criteria for detention any longer… willing work with services in community, future oriented… based on that my duty as clinician is to discharge Morgan from Section 2.

Now we move to Morgan wishes and views, what wanted from that review…. Really strong wishes to leave hospital as soon as possible… once informal can express wishes and request happen as soon as possible. That was Morgan’s request, so less time to deal with it.

At the time we did our best, Lead Practitioner had been requested but not allocated, beyond our power. Discussed with Morgan safety planning, her views and wishes, how she felt on safety and go back to her child. Also made referral to Crisis Team that serves role when Lead Practitioner is not allocated, of liaising with family and building on discharge.

If look at assessment Crisis Team for supporting discharge, had discussed with partner discharge and management of medication. States partner agreed lock medication up, they discuss event led to admission, presentation and the crisis.

They do best they can on ongoing planning.. [missed] It is very important we’re clear this was not a discharge without any planning or reflection of Morgan’s needs, this is patient with capacity, very eloquent, very clearly stating remaining on acute ward is increasing her risk, would like to leave as soon as possible. It’s important we do our best to support that.

JE: Dr Juliá, is important you express evidence you wish but may need you to focus on individual questions. The issue that arises here, prior to what becomes a discharge meeting, there has been as I can find it no documentation of discharge, no discharge planning, no consideration of discharge before now, is that right?

PJ: As team would have been happy to support Morgan longer on the ward if she would have wanted.

Ms Elliott interrupts Dr Juliá’s reply to repeat her question.

PJ: I can’t reply to your question without giving context

Ms Elliott repeats her question

PJ: [Missed start] Morgan not voiced her wishes before meeting so unable to consider discharge planning beforehand… would be happy to continue to work with Morgan, she doesn’t think would work, she very eloquently tells us how distressing it is for her to remain on the ward.

JE: The policy says where possible acute MDT should identify suspected discharge date for service user as soon as is practicable after admission. That task on MDT but we don’t see this happening before this meeting, that’s what policy requires so don’t have situation you’re talking about.

Policy is more about following length of admission date [missed] It did happen on 3 March, was given estimated discharge date then, of course it didn’t come to it.

PJ: It came after professionals meeting with family, listen patient and family views… come to date… very distressing for patients to start discussing discharge in that first meeting, often date identified, doesn’t mean there’s any significant planning before it, or date is an aim.

JE: Accept technical date not really sticking to, but another opportunity to think have we got in touch with family, have we got in touch with Children’s Services, have we got in touch with services Morgan is open to, care leavers. Are patients present at the MDT?

PJ: Patient present at ward review but not MDT meeting on Tuesday

JE: So MDT is professionals thinking about discharge as early as possible, I see you’re not going into ward round saying Morgan we’re thinking of discharging you, it comes up in discussion, but point of the policy is as much in place in advance to make sure this is safe, but we don’t see prior to this meeting services have been contacted, that family contacted, that the safeguarding referral for her son has been followed up.

PJ: Some tasks took place, contact TCAT and made referral… had contacted ATAs and requested Lead Practitioner to be allocated, so even though no date for discharge, I need to insist we’d have been happy for Morgan stay longer and we thought would be beneficial to us but we’d taken steps to ensure support in community. Agree some not done yet but making steps.

JE: Dr Juliá, I agree the TCAT referral was made, I’m talking about existing network, prior to involvement with Morgan’s care, Children’s Services, family and care leavers. You’re not disputing they weren’t contacted prior to this ward round?

PJ: I’m not disputing that.

JE: Then comes to this [missed] she feels she’s ready to go home, I’m not going to challenge you on that, is picture of improvement while she was on ward.

What I went through with Nurse Jallow, were you in court for his evidence?

Dr Juliá responded that she wasn’t.

JE: Do say if you need records, what we went through with Nurse Jallow was risk events happened over Morgan’s time on the ward. You said to the coroner yesterday some periods struggling and self-harm behaviours and that was to be expected.

Nurse Jallow 14-19 March, said Morgan had the following incidents, not documented in risk assessment form, only rarely, on care notes:

Banging walls injuring fingers, scratching, ligature in her room, ligature in phsyical exam room [missed] query nosebleed written die on the floor in blood, hadn’t been eating for at least 5 days, ligature in the garden.

Night before that ward round she’d had really quite the episode of distress, she’d ligatured [withheld], head banging, tried break out ward and repeated expressions of suicidal thoughts.

Does that fit with what you reviewed on the notes?

PJ: Does fit with notes and what Morgan already told us about how she manages her distress and what she’d do if particularly distressed, went through some yesterday in About Me, when Morgan feeling upset or angry was likely she’d headbang, when very angry out of control she would self-harm, shout, crying, head banging again.

Those again are the main reasons, Morgan was very eloquent on this, these triggers were made on context of being on ward.

When have to consider right time for discharge, is balancing all those factors and Morgan views and needs and the amount of evidence we had of how distressing and triggering Morgan was feeling the environment on ward was.

JE: Will have to go over evidence at lunch, can I ask ligatures, as you told the coroner, this was relatively new for Morgan. Is views of family if they’d been invited, is not in Morgan’s history, she’s made 4 ligatures on ward, sometimes takes off, sometimes hands over sometimes doesn’t want hand over… this is surely someone expressing still significant amount of suicidal risk, if theses ligatures keep appearing?

PJ: As expressed before very often when someone admitted to an acute ward is risk taking on self-harm … ligatures used…. We were highly concerned about Morgan being on ward because this behaviour of risk she’d never expressed in a home environment, so this reason we look into how helpful or safe for Morgan is to be in inpatient environment

JE: Morgan has made these ligatures, is relatively new behaviour for her, what you’re saying if I understand it, is this could be copying other ward patients and indicative she should come off the ward?

PJ: Saying frequent concern, patients use self-harm as coping strategies, being in environment with other service user using self-harm to cope with distress can be very unhelpful … behaviours taken on by being in acute admission, one of many reasons … one of many factors we need to weigh in when decide if someone is benefitting from inpatient admission, is bottom line what trying to do.

JE: Surely one needs to look at the other side of reason her making ligatures? That she’s still actively suicidal, and she’s not safe

PJ: Morgan said very clearly way she coped through self-harm … ward environment was increasing her distress, so not leap there to understand incorporating these behaviours in ward… often found she’d taken ligature off … this is considered alongside all other evidence already read about, paint overall picture

We see patient overall responsible with medication, overall trying work with team, able identify copying strategies, willing work with team in community but also letting us know environment is causing distress.

JE: I’ll ask one more for my clarity, are you unwilling to accept Morgan tying repeated ligatures on ward is indication of her suicidal risk?

PJ: Morgan had long-standing suicidal thoughts and suicidal risk… very often assess at risk of suicidal behaviour, self-harm behaviours. We also know Morgan had multiple sessions where reporting bright in mood, feeling better and wants to leave hospital. Never say suicidal risk gone, could never be goal of admission, but she was willing to work with community team … and cope at home…. if crisis team assess and think not ready… not able safety plan and ongoing risk, they will not accept the patient under their care.

JE: Were you aware this first ligature in this episode, family concerned new presentation for her, her first ligature was on A&E when she absconded?

PJ: Yes

JE: Not then a question of simply imitating other service users… can we assume that was indication of actual suicidal risk?

PJ: Don’t know, wasn’t there to assess her, probably assume patient with ASD found environment in A&E was incredibly distressing

JE: She was assessed under the Mental Health Act assessment where they took view risks so severe couldn’t be managed in community. That’s right isn’t it?

PJ: That’s right

JE: Other point, are you not concerned ligatures as imitating patients on ward? Are you aware if anyone ever checked with Morgan why ligatured, is it because imitating?

PJ: Not saying she was imitating other patients, saying she experiencing high level of distress and one of the ways she coped was ligature, behaviour not at home, but present in hospital… Morgan confirmed she was able to communicate with the Crisis Team if she couldn’t keep her safety, which she effectively did.

JE: Can we explore… you’ll understand why I’m focusing on these ligatures given the events we discussed. In ward round says introduction made, asked how she feels last week been, Morgan states utilising ground leave without issues, utilised well… conducted a therapy group, never run a group before, check whether wants be peer support worker. Asked about yesterday evening… significant distress, talks context of her eating, encouraged eat meal, became very upset, she did it to come across as stable.

I don’t see in that review of previous week ward round has noted the ligatures, noted the self-harm or explored with Morgan what going on for her. I don’t see it noted there.

PJ: [missed start] She said this environment doesn’t support her needs very well and outpatient would be more suitable for her [reads note at speed, couldn’t catch it]

I would agree it’s not explicit discussion about these but paints picture of a patient willing to engage with support in the community and who feels she’s able to keep herself safe there

JE: It’s not in there, the jury has heard the note a number of times, you agree?

I really do understand Morgan is feeling better, family believed and hoped would happen when contained on ward environment, and you saw improvement in Morgan didn’t you.

My concern is as the professional, Morgan says she wanted to come across as stable, that’s written in this, so she ate a meal in order to come across as stable. She’s trying to present as balanced, job of professional is to take this overall picture of risk into account and see if she’s ready for steps that follow that she’d discharged next day

PJ: Done by Crisis Team, Morgan clearly able safety plan and say she’ll contact them if she needed support from them, and she did… believe shows she was able to manage… those are all thought process factors that influence decision to try support Morgan access in community.

JE: Don’t believe crisis team have explored all these ligature events either. We know from Nurse Jallow they weren’t captured in the risk assessment, so how can we be sure those responsible for discharge and taking into account her risk on ward?

PJ: Don’t agree… they document good self-care, good contact… [reads] Morgan described her mood as feeling stable, improved appetite and good sleep… [missed most] she denied harbouring any active thoughts of suicide… said thoughts much reduced… stated able to calm herself using techniques from ward, said 2 year old son protective factor… [missed]

Morgan told staff planning self-referral to Life Centre discussed last MDT [reads at speed – missing lots]

I think Morgan very clearly talked about not having suicidal plans and intent and engage in community

JE: Thank you for reading that out, is no indication in there Crisis Team were aware of multiple ligatures on the ward, most recently the day before her discharge conversation with you. I know you assess that day, her risk events and ligature on ward is not there.

PJ: Policy of Crisis Team referral is risk assessment must be updated … that would have been communicated before referral made to the Crisis Team

JE: The risk assessment is updated?

At this point the coroner indicated it was time for lunch. She sends the jury out and reminds Dr Juliá that she is under oath and not to discuss her evidence.

The jury returned to court at 14:35. The coroner welcomed them, gave permissions for remote access and said she had a new coroner’s officer with her.

She then asked Dr Juliá to come forward to the witness stand.

JE: Just one matter not asked about in the last line of questioning, I think you said the Crisis Team should have a risk assessment available to them when doing their assessment

PJ: Yes, that’s correct I think helpful if I explain basis on which Crisis Team accept a referral… phonecall from nurse… explain indication of that referral, give verbal risk assessment, then Crisis Team request that risk assessment be updated on the system

JE: Crisis Team assessment says to be completed by ward staff, ward staff made aware, that’s what you said?

PJ: Yes

JE: [missed] So this document says risk assessment not completed yet?

PJ: Think indicates risk assessment handed over not fully documented … appreciate is a 17 bedded unit… Crisis Team works in same hospital as us, do review notes before accepting any referral…. [fuller answer, didn’t catch]

JE: It was really just to cover what was said in the document, thank you Dr Juliá. Morgan’s presentation want to touch briefly on family side of things and what problems their lack of involvement causes from their perspective. Family unaware until the discharge that discharge was happening, that’s right isn’t it?

PJ: Not sure can agree with that, policy is family should be contacted after the ward review… noted partner happy give medication, think that noted day before.

JE: That’s in the Crisis Team assessment. Family say unaware until day of discharge, Children’s Services were unaware, jury heard evidence from Helen Green that they were not aware and she gave evidence they would expect to be. Is that right? Children Services were not aware of discharge?

PJ: No, they were not

JE: In your understanding Mr Goddard was to lock up medication, part of safety plan for Morgan going home.

PJ: My understanding was ongoing thing and was common practice for them to do.

JE: So that’s Morgan’s view, no one had taken Dominic’s view until day of discharge, noted in Crisis Team, 1 month medication given and her partner has agreed to lock them up. Mr Goddard’s evidence to the coroner was he received a call to say Morgan coming home, he was to lock up medications, take her to A&E if any incidents. Didn’t ask if he was OK   with plan or any questions about Morgan’s son… no discussion…. He thought not safe, not practical, he was working so wouldn’t be home to care for her, didn’t feel any significant change in her mental state.

So carer who not home, he’s working, also primary carer of son, jury also heard he was not well at the time.

PJ: None of that information was relayed to the inpatient team, which makes it difficult to take into account.

JE: Yes, because he wasn’t invited to the ward, there was no contact the  family

[Missed}

JE: He was phoned up when plan to discharge Morgan and told he needed to lock up medication, that’s what his evidence is, we’ve covered that.

Because of how late it was there was no chance for other family members to step in or provide support. That’s a problem with telling the family on the day of discharge isn’t it?

PJ: What’s the question?

JE: Problem with not telling family is they can’t make arrangements can they?

PJ: Not necessarily… they could tell us and we would consider…. [missed] … based on Morgan’s wishes and wants of being discharged from ward, if at any point family mentioned to us they were uncomfortable with discharge or not available, would be reviewed, that didn’t come across at any point

JE: 3^rd issue think in your evidence to the coroner you accepted, Morgan taking significant PRN at time, was no plan for titrating down in the community?

PJ: Don’t think used significant amount, she used PRN helpfully … acknowledged was oversight in discharge planning, had to get [withheld] over the counter

JE: On amounts, medication charts [withheld 1] on 13th, 14th, again 14th, 15^th, 16^th, 17^th, 19^th, 20^th and again 20^th and [withheld 2] on 14^th, 14^th, 15^th, 15^th, 16^th, 18^th, 18^th and 19^th  

That was what she had whilst on ward [withheld] is an over the counter anti-histamine, some sedating effects but [withheld] is a benzodiazepine, stronger of the two…. She didn’t have any?

JE: That was an oversight, would have been ideal to consider that on discharge

JE: Dr Juliá taking all these together, the family concern is this didn’t have any hope of being a successful and safe discharge. Was too soon, discharge process not followed, family unprepared, agencies unprepared, Morgan did not have right medication package to take home, no surprise that as soon as she gets home she ends up going straight back into hospital?

PJ: In hindsight lots to consider… at time… best in patient’s interests, were steps taken to ensure follow up in community… was appropriate care and support provided by Crisis Team, which also as a team are able to prescribe medication if needed.

JE: Just for clarity, jury may think she went straight back into hospital so not much break, but unfortunately for Morgan she had to go through process again, can’t go back on ward, had to go to A&E and be assessed, it takes time doesn’t it?

PJ: Don’t know off the top of my head how long it takes.

JE: The jury have the chronology. Won’t take you to matters in between. Your next involvement, Morgan back on Rowan Ward on 3 March, a continuation of her previous admission to Woodlands.

PJ: Yes considered transfer, follows slightly different policies in reviews and how soon patient needs to be reviewed. Also in terms of observations levels, patient just admitted on ward would be on 1-1 observations level, … but on transfer its usually the level of observations being managed in previous placement, previous ward.

JE: That’s helpful thank you, now your first not clinical contact, but first considering her case is 6 March MDT

PJ: Not MDT, the morning handover meeting. Specifics of terminology, MDT happens in same space, same staff, slightly longer meeting have on Tuesdays go into little more detail of plans for person, might need done, documented on system, the Morgan with the handover meeting has same staff, discuss what happened, not formal MDT meeting and not documented as such

JE: Did you say MDT meetings are documented?

PJ: Generally documented by ward clerk, is a table.

JE: Like a handover sheet?

PJ: No usually on CareNotes, usual practice be documented

JE: For clarity, have you seen any MDT notes for Morgan’s admission?

Dr Juliá told the court she doesn’t know.

Ms Agnew said she would check.

JE: The only thing I wanted to confirm, in your statement you said on the morning of 6 March 2023 there was a letter in the handover room, I read this letter to the MDT?

PJ: MDT, apologies, terminology is confusing, meaning is multidisciplinary team, used to describe professionals and the formal meeting where discuss care and plans … when talk MDT staff members, all members of team present, Ots, ward manager, nursing staff, junior doctors, myself

JE: Yes, two issues, major issues for this admission, will cover at the start. First is Mrs Hodgson’s letter you have spoken about, in your statement you say I read this letter to the MDT as Morgan’s family expressing significant dissatisfaction with Morgan’s discharges from Rowan and Maple… agreed escalate to Matron to see if admission to Rowan may not be indicated given dissatisfaction?

PJ: Yes

JE: Seems your primary reaction to Mrs Hodgson’s letter was to consider actually whether Morgan should be on the ward at all, because the family raised concerns, is that main thing, your thinking?

PJ: No, main thing to understand family position, highly likely therapeutic relationship damaged with family and Morgan. It can occur… usually when complaint by family or patient or ongoing police investigation, most often bed management avoid admitting to ward … quite understandably, because they want that matter resolved before patient is readmitted on that ward.

The Trust is wide, different wards, thought explore with family and Morgan if therapeutic relationship was broken. As mentioned, a lot of the letter mixed between events happened on Maple Ward and Rowan… we agreed discuss with Matron, following normal policy not admitting patient  to ward where have ongoing investigation following formal complaints or police investigation, then discuss with family and Morgan.

JE: Yes, you say “if admission on Rowan was indicated”, so straight away considering if she is staying on the ward?

PJ: Yes, consider if more appropriate for Morgan to continue her admission on another ward where therapeutic relationship is not damaged

[Missed]

As MDT we made decision in best interests of Morgan to support family and other agencies to attend, to review Morgan not on Monday.

JE: I see, so you don’t have a copy of the letter?

PJ: No

The coroner’s officer provided a copy of Louise Hodgson’s letter to Dr Juliá.

Ms Elliott said that the letter was 1.5 pages of text, that she wouldn’t read it all out but she invited Dr Juliá to add any parts she missed if she wished to do so.

JE: Well, I’ll tell you the concern straight up that the family have, a lot of this letter is trying be proactive, ensure positive changes in care, that discharge is safe, to help the ward help Morgan.

Looking what have contained in here, Ms Hodgson says she is writing to express her grave concerns. She provides her background and her role in the family.

You’re right the first paragraph discusses recent discharges being unsafe, and you’re right she bundles them together.

She says she’ll raise a complaint formally, this isn’t a formal complaint.

Few other things, she says, in paragraph 5:

I am very clear that it should be documented that Morgan has been a stable, loving, gentle parent for two years, despite having had previous mental health episodes prior to pregnancy. I know her extremely well now and have been part of the support network required by Children’s Services.

She’s trying give the ward background to Morgan’s presentation, that is clinically relevant isn’t it?

PJ: Yes, of course

JE: Next paragraph talks about personality disorder, it says:

She has evidenced no symptoms of any kind of personality disorder, no volatility, no mood swings, no inappropriate behaviour or language, at any time.

She makes clear she has only known Morgan since she’s been together with her son. Her account.

She has made friends, which was always hard for her. She has always prioritised her son and given him a lovely calm home and routine. Children’s Services have noted the same at all visits. [Her son’s] nursery has a very good relationship with Morgan as she is working with them to get him assessed also for mild autism. She has neighbours in her block who are desperately missing her and worried about her.

So, the ward is considering EUPD, is right isn’t it as a diagnosis for Morgan?

PJ: Mixed personality disorder in the context of autism and trauma

JE: I think what’s written in the formulation is EUPD

Dr Juliá read an extract from her statement.

JE: Yes, but that 14 February ward round is documented impression was EUPD, agreed?

PJ: I think I went over that yesterday. When have patient who comes to us with up to 9 or 10 diagnoses, we do quick assessment based on that contact… at times Morgan displayed difficulty with emotional dysregulation, could be in context of EUPD, that’s not a formal diagnosis.

JE: No, it’s not a formal diagnosis and Dr Ahwe made diagnosis of EUPD in his evidence, did you hear that?

PJ: Yes

Ms Agnew interjected to say that she thought Dr Ahwe’s evidence was that it was emerging, that he couldn’t diagnose EUPD without Morgan’s family inputting.

JE: Yes, without views of family. Did you document EUPD in the second admission?

PJ: I can’t remember

JE: No, forgive me, let me briefly look at the ward round, because Nurse Archer when she makes note of speaking with Morgan’s mother, says “environment can be difficult for patient with EUPD”. Seems from all admissions EUPD was the working diagnosis being considered?

PJ: No, I wouldn’t necessarily agree with that. Morgan came to us with an array of diagnoses… a lot with overlapping features… a lot fall within autism… in first admission how approach Morgan and her difficulties, try provide care that’s person centred, understand her needs, her triggers, what brought her into hospital and understand her within that complexity.

This may be known but might be helpful to give wider understanding of autism and its complexities. One thing can never do is provide blanket care, is understood as spectrum, was understood as spectrum, now people use metaphor of spiky profile… can accept many different aspects of life, functioning, communicating with others, processing information and how spiky profile can be different one day to another… [missed]

All recommendations made were as applicable to someone with diagnosis of Emotionally Unstable Personality Disorder, as someone with diagnosis of autism. Try understand all aspects of her personality… and base diagnosis on that

JE: Thank you Dr Juliá. Just going back to my question, only clarify because I wasn’t expecting it to be controversial.

Ward round 6 March diagnosis stated to be EUPD, autism with difficulty regulating mood. 7 March meeting is the same… can’t find mixed personality disorder anywhere and wondering whether it comes from… whether you diagnosed in hindsight?

PJ: That’s in my statement

JE: Yes, written after

PJ: I refer to some of Morgan’s difficulties with authority and oppositional defiance disorder in one of my entries.

JE: Yes, you do mention oppositional defiance disorder in your note on 7 March.

PJ: If I can finish, has an impact on diagnosis, when talking diagnoses in mental health and psychiatry, would be very poor clinical practice to establish diagnosis on few short contacts with someone… [missed] fact some working diagnosis can be in place doesn’t necessarily change the approach… [fuller answer – missed]

Note CAMHS, takes time person with history trauma, abuse, rejection… would be very reductionist to just one thing, good practice keep open mind when comes diagnosis and frequently review…

JE: The only diagnosis mentioned in ward round formulations just read out to you is EUPD, which is new for these admissions, and autism.

You’re considering personality disorder for Morgan, appreciate not made diagnosis, at no point have family views being sought on this.

What Ms Hodgson is trying to do is give you her views on personality disorder, its clinically relevant isn’t it?

PJ: Yes, didn’t dismiss, read letter out in MDT…

JE: When family come to the discussion 7^th, was their evidence what was discussed was how relationships had broken down, absolute focus of this letter and Morgan’s letter.

PJ: Would disagree, documentation doesn’t reflect that, was listening to family, their views, the plans they’d made, how they feel from previous admission, how fix that.

Of course, looked at therapeutic relationship, I am concerned it’s an issue of contention. It wouldn’t be realistic to consider health professionals are not human… wouldn’t have situations where assaulted or harmed… reflective practice helps process emotions.

Same with families or patients who felt care not appropriate at time… would be incredibly poor practice to ignore that situation and not address issues. Fully aware Morgan was angry about the incidents of assault, about being arrested.

JE: Where was Morgan angry about the assault?

PJ: In the letter I read out… she was angry about assault… we were aware… wanted to review suggestions, incredibly poor clinical practice to ignore reality of damage in clinical relationships.

JE: You received Morgan’s letter as her being angry?

PJ: Shall I read it again?

JE: Will come onto it when you discuss with Morgan, comes up in ward round. Jury have heard the letter, you do accept it contains clinically relevant information, seen handwritten notes at bottom talking about Morgan’s autism.

PJ: [Missed] Trying be very, very explicit and clear without shade of doubt… reassure Morgan help is available, no professional was holding a grudge, explicitly discussed with her…

JE: All you write in your statement was you read letter out and needed to consider whether admission indicated. There was nothing about the positives in the letter, proactive actions, Ms Hodgson wants to work with the ward to make things better. Your primary reaction is to consider whether Morgan has a place on this ward.

PJ: No. Immediate reaction is consider whether care Morgan needs might be better provided on [another ward]

JE: You gave evidence yesterday. Just to understand… another thing you raised, team were feeling really triggered in relation to the incident that had taken place on Maple Ward. Letter handed to staff… Morgan bringing it up repeatedly.

You say understandably was a really difficult letter for the team to deal with. They wanted to keep their behaviour professional. Raised in all 1-1s, as an MDT decided to try move away from letter … decided not address it. You said another reason wanted check with Matron whether Morgan’s care was better provided on another ward. Have I understood that right?

PJ: Yes

JE: Two matters. You say your team were triggered, what team members had been involved?

PJ: Two team members I think, at the time Patrick Fenton was Matron

JE: Just want to understand who were the team members who were triggered?

PJ: General feeling of the team, handover the weekend, had been difficult for staff to read that letter and difficult to know how react to Morgan who was seeking repeatedly some reassurance about that letter and asking how staff taken it, how they felt about it… staff trying redirect conversation, move into different subject and not focus on that letter. Was very challenging as Morgan was fairly clearly she wanted a certain reaction from that letter.

JE: Will talk about letter, but who was involved on Rowan Ward and triggered by it, Chloe Patrick received injuries aware of that. Patrick Fenton was involved but not assaulted, he was Matron, no clinical contact with Morgan at all.

PJ: No, not suggesting was feeling, can’t specifically remember what members, was general feeling of whole team.

That was handover in morning, was feeling of finding it really difficult to address those, any team members knew response to letter could trigger Morgan.

JE: So, although we only see Chloe Patrick having any clinical contact with Morgan, that we see on Rowan Ward, the whole team you say, had adopted feeling of awkwardness and difficulty around this apology letter?

PJ: That was what was communicated, yes

JE: Isn’t it for you to explore why the whole team feel upset about it, to manage that?

PJ: [missed] Team keen to support Morgan, wanted do that but thought would be challenging to openly discuss letter with Morgan … so said avoid letter.

JE: Will see how that bears out… you say repeated 1-1s she is bringing it up. Can we look at the notes, I’m getting confused by the timeline… p201 Dr Juliá we’ve got a couple of notes to look at, do you feel able to do what the Coroner’s Officer is doing, or do you need the Coroner’s Officer with you to help?

PJ: I think it’s helpful if she can stay

The coroner suggested that she might like to take a chair to sit on and checked that she was happy to assist Dr Juliá.

There was then a discussion about where in the bundle they were going. Ms Elliott and the coroner discussed when would be natural opportunity to take a jury break. The coroner said court had only been sitting for 50 minutes so should continue.

JE: [reading from note written by Chloe Patrick] Morgan came to clinic this morning for her medication, one of other nurses came into clinic so did not have to engage with Morgan, Morgan asked if she hurt me in the incident, I said yes, she said sorry I was having a psychotic episode, later on Morgan approached me with letter … uploaded on correspondence tab of CareNotes.

Looking at that note, I do see Chloe having difficulty, trying take herself out of the situation. Don’t see Morgan fixatedly going on and on about the letter and trying to get some response from Chloe?

PJ: Also in my statement referring during the day Monday happened a few times, was communicated team finding it difficult to know how to respond to that letter. Discussion how team felt about providing good clinical care which was agreed they could, then moved onto plan.

JE: I read your evidence, you said Morgan bringing up repeatedly…. Raised in almost every 1-1… you’re talking about that meeting on Monday, you said agreed move away from that letter.

In all shift notes note Morgan polite on interaction, able make needs known… only mention is she’s handed in letter and note from Chloe about that. No mention of her going on repeatedly about that and making things difficult for staff.

PJ: Didn’t say making difficult for staff

JE: No, challenging. You didn’t say that.

PJ: Yes, challenging… at no point did think Morgan was doing to make things difficult for them… if that was case would raise concerns about ability care for Morgan.

In following days was brought up, know happened more than once

JE: You specifically raise this in terms of decision making at MDT, she was bringing up repeatedly, almost every 1-1 was really challenging, we see interaction with Chloe Patrick and don’t see a single other reference to this letter.

RA: The witness has answered repeatedly.

C: She says in her statement she’s saying during the day

JE: But she’s talking about the decision making at the MDT. I’ve put my point.

PJ: Decision making at MDT is not just letter… was based on the understanding was a challenging conversation to have with Morgan, staff didn’t feel would go in a positive way. As a team we decided move on …

JE: You accept as far as notes go, is not documented anywhere else before that meeting?

PJ: Was in verbal handover I believe

JE: Can we go to the ward round please.

PJ: Before we discuss ward round, important we did not intend have ward round on that day… you mentioned positives from letter, we did take on board, needed more time follow advice, involve family… need more than 4, 5 hours in morning to organise that [missed]

Taking all that positive advice on board we agreed not to review Morgan on that day but do in later meeting… not documented either, because part of morning handover but that was my recollection.

Felt in Morgan’s best interest, policy of Trust reviewed once a week, Morgan seen senior clinician Friday, assessed her mental state, utilising leave…

Unfortunately, Morgan wasn’t happy about this. Morgan called her mother… My colleague Jessica Archer [Dr Juliá is re-reading parts from her earlier evidence, I wont repeat]

JE: I don’t challenge was a request to have it that day, you went ahead with the ward round that day.

What I do want to ask about is this breakdown of therapeutic relationship and how that was dealt with, with Morgan, especially as an autistic person…. In your statement you said you asked Morgan if relationship was damaged… Morgan wasn’t sure if she felt that, yes been some therapeutic damage, and she had doubts staff wanted to work with her… reassured staff would work with her … is that your evidence to the coroner yesterday?

PJ: Yes

JE: It fits with what your evidence is?

PJ: Yes

JE: My concern from evidence family have given to the coroner, is this idea of relationship breakdown was handed to Morgan from the ward, was a decision taken by the ward.

Looking at records, Dr Lake’s note of the ward round says Dr Juliá explained we’d be worried she might not find the environment … [missed]

Dr Juliá explains this might be a damaged therapeutic relationship. It is documented you are saying to Morgan this relationship might be damaged.

PJ: Asking if she felt that way

JE: We can only go off the note. It says, is documented, you explain relationship might be damaged.

Dr Juliá responded to tell the court that when doctors take notes they summarise.

JE: Yes, that’s how he documented it.

Wanted reassure Morgan the team happy to work with her, would be in professional capacity, would explore very evident effects of significant incidents of assault had affected staff on ward and family feedback on admission.

Morgan says in text to her Personal Advisor [from the Care Leavers Service]: “Consultant said therapeutic relationship between myself and staff is damaged and I’m very unlikely to make progress here”

PJ: I have no recollection of that … family say Morgan taking of information was not always accurate… I never said to Morgan she can’t make any progress on ward, talk clearly what can do on ward…

[fuller answer – missed]

JE: That’s as may be, next thing in ward round notes is asking Morgan if she’d like to move to another ward.

Ms Agnew interjected and asked the full paragraph be read for completeness. She then reads it.

RA: Dr Juliá explains we’d be worried she, Morgan, might not find our environment helpful on this occasion, given her and her family didn’t find helpful on last occasion. Dr Juliá said might be damaged therapeutic relationship. Asks how she would feel going to ward in Chichester, is ambivalent, says could be a good idea, but doesn’t like change.

JE: Thank you. Your evidence to the coroner yesterday was she struggled with change, so might not be best thing do for her. She really struggled due to her autism with change didn’t she?

Dr Juliá responded that that doesn’t mean that she shouldn’t give Morgan options.

JE: You know when she was on Woodlands she asked to come to Rowan Ward?

PJ: No. She didn’t ask when on Woodlands, that was when she was on Maple… was asked if wanted go Rowan Ward…. Was taken in context of the letter the family handed over.

Think is concerning you don’t think have address difficulties in therapeutic relationships… unfortunately sometimes breakdown in relationship, good practice to assess if can be provided somewhere more conducive to recovery [fuller missed – missed]

JE: Of course Dr Juliá, I am not suggesting it’s not an issue that needed dealing with on the ward.

PJ: Seems imply Morgan would take as rejection, that’s where you’re coming from? That is why done in context of ward round, with team to support Morgan… again understanding someone with autism might struggle to understand things, very explicit, happy continue working with Morgan

JE: On the question of moving ward, would you accept would be a difficulty for Morgan given the sheer number of moves she’d had, not saying shouldn’t offer, but very difficult for her to tolerate?

PJ: That’s why we ask Morgan, she tells us her views, we respect them

JE: Seems the apology letter comes towards the end?

PJ: Don’t think so, Morgan wasn’t able to engage after brought up… as team agreed moved on from letter.

Letter started by saying don’t think need to apologise which team found difficult to work with… in my assessment at time having heard what happened during day thought likely keep repeating itself, most appropriate try to close, reassure Morgan happy work with her… document lot detail in my entry day after, I might read from that.

Morgan make several comments about staff feeling sad or holding grudges against her… objectively Morgan and mother stated, during professionals meetings, Morgan had expressed she experienced team as caring and professional…. Morgan worried care and professionalism may not be genuine … Morgan written letter…. Letter states does not believe she should apologise… Morgan also state experiencing psychotic episode that led to assaults. Assessment indicated Morgan to have capacity and not experiencing any psychotic symptoms… Morgan seems determined to receive some praise or gratefulness from staff after writing this letter… Morgan has brought up letter in different spaces and became angry and frustrated when not receiving praise she was expecting… appears Morgan family may be reinforcing… some family psycho education and support around family dynamics may be beneficial.

JE: Thank you Dr Juliá for reading that out. It really does seem clear from that, you don’t see anything positive about Morgan’s attempts to write apology letter, your only indication is negatives

PJ: No [fuller answer – missed]

JE: This is reflected in your ward round with Morgan. The only note that exists about it “Morgan explains wrote letter to say sorry, Dr Juliá said didn’t read that way, Morgan leaves”.

Understand you say that’s brief, but you said to the coroner you wanted to shut this down, didn’t want to discuss it with Morgan

PJ: Aware causing… this was something likely impact negatively on Morgan ability to engage with staff, was really difficult situation would concede that, challenging… move on from letter but in same context reassure Morgan team happy to assist her… reason said that in ward round was in controlled environment, however Morgan found difficult tolerate that, left room without addressing ….

The intention of this I think I cannot really, my clinical statement, rationale at time is fairly clear, don’t think can add more to that. Not about not seeing anything positive on letter. Is acknowledging complex clinical situation, letter was causing distress for Morgan when not receiving response she wanted from the team. Important to close on that… and give her informed choice and ability about where she wanted to continue her healthcare, in what setting.

JE: All we have is you saying doesn’t read as apology, Morgan is upset and leaves. High risk when communicating with someone who is autistic… saying doesn’t read as apology is going to cause distress for Morgan?

PJ: At some point was going to come up, in situation less safe than ward review. Was in safe environment in acute inpatient setting with other staff able to support and engage with Morgan… if Morgan able remain in that room… that was plan to do it… part of Morgan’s autism care plan, lot information about how she process information, needs to take time to process information, at time felt appropriate thing to do. In next encounter reassure, be explicit, regardless of letter happy deliver care.

JE: [missed] at no point did anyone discuss the positives with Morgan, she says understands excuses not wanted, tries to explain not her intention to cause harm, explains role of autism, ends by saying she’s really sorry. Seems very odd decision of ward, is it doesn’t need talked about.

RA: The doctor has answered repeatedly and expressed in her clinical opinion was important to move on from the letter.

JE: Only other account I have of Morgan talking about this apology letter is what happened in the ward round.

Nurse Archer attends as Morgan is packing her belongings. Said wanted to go home, Morgan said unable to build therapeutic relationships with staff here and wanted to leave. Then talks conversation with Morgan’s mum, which we’ll go into with her.

Says Morgan fixated on conversation had in ward round, Dr Juliá questioned letter as didn’t feel like much of an apology…. Said at time of assault thought wasps were covering her… she doesn’t want to wait to tomorrow and is packing her bags.

What Morgan is reporting is the stress of what happened on ward round, she’s fixating, she feels her apology has been rejected… is a risk isn’t it?

PJ: Not sure what question is?

JE: Your plan was to shut down this apology letter?

PJ: Our plan was to move on because any discussion would lead to this exact reaction… whenever Morgan was not getting response she wanted was increased risk factor…

At times, yes of course we were fully aware would cause level of distress in Morgan. What did here was work as multidisciplinary team, don’t work in isolation, was helpful and relevant engage with Morgan, have debrief how she was feeling… give them time to process information, give them time to manage their behaviour….  I was again included in my clinical, I feel I’m repeating the same thing.

JE: Morgan’s mum in her evidence to the coroner said Morgan was very upset, told letter she’d written was not genuine and relationships were damaged… she saw as another example of how staff viewed her negatively. Morgan left with the feeling the ward viewed her in negative light.

PJ: I disagree with that… knew some distress after … but meeting with Jessica Archer…. understandable going to be level of distress when someone has really harmed someone and reaction to them, even more in patient with long history struggling with rejection.

However doesn’t mean from therapeutic point of view should avoid having conversation. We thought ward was place could address that as part of therapeutic… to offer reassurance and statements explicitly about level of care can be provided, and involve Morgan and her family in professionals meeting… [missed lots, apologies]

I just feel we’re just going over my clinical statement and judgement, over and over, don’t have anything to add to that.

JE: Well Dr Juliá that family concern is what’s behind this discharge was this dynamic on the ward….

PJ: I strongly disagree no evidence of that [positives] lot of 1-1 when Morgan interacted with staff, she talked how positive traffic light system

JE: Dr Juliá, I do have to interrupt, you’re giving lots of evidence to the jury, we have to track… ward round 6 March… Morgan asked display on door… saying in that interview ward perhaps not equipped deal with her autism. So, its mixed picture with autism.

PJ: We also offered psychology appointment, again might take bit if go through every entry after that meeting, evidence Morgan was offered intervention from staff… actively reassured team happy with her, supported leave with her family, listened to family concerns, organised professionals meeting,… all that evidenced in following days.

I think you’re reducing one difficult interaction, which we anticipated would be difficult, which I think is inaccurate and unfair

JE: It’s because what the family say, and what Morgan says, Morgan says in her messages, day after ward round messaging her Personal Advisor… leaving today because they have made me feel unwelcome… made me feel like I don’t deserve their treatment…. Veronica asks have you told them, she says I told them and tried to apologise, they’re holding a grudge… Veronica says should be treating you with compassion and support… [Morgan] says making awkward, pressured atmosphere around me, I can’t cope with it… consultant says I’m unlikely to make progress here.

An autistic suicidal patient, treated over a month, in and out and back to hospital. This is how she’s left feeling on the ward. It should have been handled differently shouldn’t it Dr Juliá?

PJ: Lots of interactions to make Morgan feel welcome, both Morgan and her mother said in professionals meeting their interaction with staff was positive and caring.

Not a black and white picture here, lots of grey, again feel I’m repeating. Did understand difficult conversation to have, did everything in our power. Made explicit statements… understand difficult process for someone with autism and fears rejection… offer what available to allow her and family make decision, to move on. As clinicians were aware some difficulties in that relationship, ignoring would lead to higher level distress, we address it…  

C: Ms Elliott?

Ms Elliott says that she is just taking instructions, she won’t ask any further questions on what has been discussed so far. She wants to check with Morgan’s family that they are content. They are.

Ms Agnew says that she has a couple of questions, she wonders if she can ask them before the break but recognises the coroner should ask Mr Berlevy first.

Mr Berlevy jokes that he doesn’t have 400, before saying he has no questions for Dr Juliá.

C: Ms Agnew?

RA: Some brief clarifications, one document taken to, Section 17 leave form from 16 February, 5107, can you confirm whether that is the Section 17 leave form you completed?

PJ: Yes, that’s it

RA: Thank you. Then in relation to that first admission when that Section 17 leave was given of course, was not disputed by Ms Elliott and totally accepted Morgan, I’m going to be really simplistic here for expediency, interrupt me if misunderstood, that Morgan wanted to be discharged, wasn’t in dispute. As I understood your evidence you were working with her to do that, and continue care in the community with the crisis team?

PJ: Yes

C: When you say first admission?

RA: First admission to Rowan Ward that started on the 13 February.

C: From 13th to 21^st?

RA: Yes. Just thinking generically, overall are there circumstances where a patient says I want to be discharged, and you don’t act in accordance with their wishes?

PJ: Yes, might make decision is not safe and we’d use the Mental Health Act

RA: Did any of those apply? [fuller question, didn’t catch, apologiues]

PJ: No grounds for detention, always least restrictive measures, when patient has capacity, willing work, then discharge from section

RA: Just thinking role of Crisis Team, so jury are really clear, had some evidence from Dr Ahwe this week about the Crisis Team, being high level intensive care to allow for care at home, highest level of intensive care at home. Is that correct?

PJ: Yes

RA: If I understand your evidence if Crisis Team didn’t agree with discharge they could say no, don’t think is safe, wont accept discharge?

PJ: Yes, does happen at times and leads to joint meetings

RA: And reformulation of the plan I imagine?

PJ: Yes

RA: Two ward reviews, first 6 March, second admission in Case Lines 303? This is 6 March one just had some discussion, I read out paragraph where you were explaining the worry about not finding the environment helpful and potential transfer to Chichester. Just going to read the rest of that entry in notes, MDT discussion

Explanation of how traffic light system works, including Morgan needs to show to staff, Morgan disagrees explaining ward might not be properly equipped to deal with autism. Can you explain what that means?

PJ: Yes, my recollection based on comments Morgan made to Crisis Team when discharged from Rowan Ward. Morgan mentioned team not using traffic light, not coming to her to check how she was.

Contrary to traffic light system, is to empower service user to show how they are feeling… traffic light system does not work well if patient is passive on using it.

Would require staff constantly checking on this… is way co-producing care and not relying exclusively on team… Morgan had made that comment that traffic light not used. We tried to help Morgan understand goal of traffic light system is to help her to let staff know

RA: Is this akin to walking beside patient and empower them in their recovery

PJ: Yes [fuller answer, missed]

RA: Then goes on, explains can go through autism passport again and update what we have whilst working with her, that’s your recollection?

PJ: Yes

[Missed Ms Agnew’s question but it related to a note referring keyrings on the ward]

PJ: Think at the time was project to support service users to be more self-sufficient in coping strategies, not relying on 1-1 interaction with staff or organised activities on ward.

Have activity worker on ward and OTs, have timetable, but obviously they’re adults we’re working with so not every second of every day is filled up with an activity….

We know coping strategies are as unique for the service user as the service users. … we don’t have blanket coping strategies work for everyone, key is exploring all of them. Project was about having accessible suggestions or coping strategies on ward in a key ring [fuller answer – missed]

RA: Thank you. Then goes on Morgan explains she uses ice packs on occasion which she found helpful, you Dr Juliá suggest apps to identify more coping strategies Morgan says already does this, you encourage look  through app when not at peak of anxiety. Then Morgan explains would like to see psychologist, that’s a change?

PJ: It is, it’s a quite positive change

RA: Asked what her goal would be, like to talk about what is going through her mind, Dr Juliá suggests having space to talk about her new diagnosis of autism. That was the plan to support Morgan at that time on 6 March?

PJ: Yes

RA: Thank you.

C: Just going back to point Ms Agnew made regarding the Crisis Team …if they hadn’t thought was appropriate for Morgan to be discharged, she’d have remained in hospital?

PJ: Yes

C: Thank you, long two hour questioning, we obviously have questions from jury to raise with Dr Juliá. Think it’s appropriate now to have 5 minute break. Can I ask jury bailiff whether possible carry on a little longer than 4:30 this afternoon. So could get their questions and Mr Traynor’s evidence.

Court was adjourned at 16:05. The jury returned to court at 16:23 and the coroner asked Dr Juliá to return to the witness stand.

The coroner thanked the jury for agreeing to stay later. She also thanked them for consolidating their questions during the break.

C: Dr Juliá questions raised by the jury. First is, should hospital policy always be followed?

PJ: I think, like with many things we do with mental health services, or overall in healthcare, policies are there to provide guidance of best options to take, however your care, amount of patients, many other factors can mean policy not followed as indicated. Doesn’t necessarily mean care not good, usually clinical reasons behind it.

C: So policies are best practice?

PJ: Yes

C asks jury question: Are staff trained on what hospital policies are?

PJ: Yes. Overall understanding of policies, distributed when new policy comes in place, then team meetings where discussed

C asks jury question: So, what are acceptable reasons to ignore policy?

PJ: No one has the right to ignore policy, based on different clinical scenarios, situations, requests patient, their views… decision might be made to not follow every step of a policy

C asks jury question: Dr Juliá mentioned few times, Morgan said multiple times during the week she wanted to be discharged. She also said Morgan only brought up wanting to be discharged on 20^th. Can she clarify what she means?

PJ: I don’t recall saying Morgan wanted to be discharged during the week, had said Morgan mentioned several times she was finding the ward environment challenging

C asks jury question: Thank you. You mentioned systems have been reviewed since this incident. Does that meant systems in place at the time Morgan was in hospital care were not sufficient, and not in best interests of Morgan?

PJ: No, I don’t think we can make that statement. As health professionals always reviewing our practice and considering care we provide. Sometimes unfortunately incidents happen, and we look at ways of improving. That doesn’t mean the care prior wasn’t appropriate or was inadequate.

C asks jury question: Thank you. So is medicine, some more information, filed on any system. Pharmacy information filed? What prescriptions Morgan will be taking?

PJ: Yes those are documented on the CareNotes, usually in ward review any chances medication done documented there. Currently not electronic prescribing system, kept in folders in clinic where written and crossed out when not needed any more.

C: So would there be a record of medication patient sent home with when discharged?

PJ: Yes, included in discharge summary when patient leaves, first thing do to obtain medication send them home with is complete list [more missed]

C: So the medicine, drugs Morgan was sent home with, discharged on 21st would have been on the discharge summary?

PJ: Yes

C asks jury question: If you were aware of Morgan’s autism and made adaptions, why were there no steps taken to help prepare and support Morgan with her transition during the first discharge? Why only a day?

PJ: Think we addressed provision we made, referral to Crisis Team, high intense support team. Rational at time Morgan desire leave hospital and her distress being in hospital was causing… best decision for her was to listen to how she was feeling and support her wishes.

C asks jury question: Was Morgan’s confusion with her autism diagnosis noted on her care file in CaseNotes system?

PJ: I’m not sure I understand that. That came up when I met with Morgan several times. In first review she brought up she didn’t understand her diagnosis of autism, which was documented on ward review

C: So it was documented in CaseNotes?

PJ: Yes

C asks jury question: Should the care plan which a patient is sent home with, be logged to the system?

PJ: Discharge planning depends what team go with… part documented Crisis Team of intensive support Morgan having on her discharge home. Usually record what decision made, what referral made, what steps taken… can include requests to GP, for example to follow up on various things, overall how risk managed and how assessed.

C asks jury question: Is there a hospital policy relating to this?

PJ: Yes, discharge summaries have to be completed and finalised before the patient leaves the ward.

C asks jury question: When did you find out about the violent outburst of 27^th?

PJ: I think I heard from team, the next day, next working day I was on the ward

C asks jury question: Next question is were you surprised it happened, but I think is outside scope of the inquest

PJ: Yes, I think difficult to answer that

JE: Not necessarily given this witnesses knowledge, did it fit with her clinical presentation?

C: That’s not what the jury member asked

JE: Maybe we could check whether in context of clinical knowledge of Morgan?

C: Was it in your clinical knowledge?

PJ: Had seen before discharge Morgan had violent distress, that came with knowledge she might struggle at times.

JE: Am sure Dr Juliá didn’t mean to infer otherwise, the violent outburst you’re referring to, no one was injured at that time?

PJ: No, I don’t think so, no

C asks jury question: Did Dr Ahwe seek your opinion of Morgan’s case when she was admitted to Maple Ward?

PJ: No

C asks jury question: Did you seek Dr Ahwe’s advice on Morgan’s case after her readmission to Rowan Ward?

PJ: No. If I may expand answer, have access and can read colleague’s reviews. Obviously we’re next to each other, can consult if need something, but most often documentation provides enough.

C asks jury question: Morgan first created ligatures during her first stay on Rowan Ward. When were the family notified about this new behaviour?

PJ: I can’t answer that question

C asks jury question: Do you think your phrasing ‘it doesn’t read much like an apology’ comes across as antagonistic, rather than putting the issue to bed and move on from it?

PJ: In hindsight, challenging to do, at time my views and what tried to do was explain to Morgan and give her reassurance we’re there to support her and close this with letter.

C asks jury question: Following incident on 27th a member of Maple staff telephoned the police to press charges, given this was an open case against Morgan why was she readmitted if it is policy not to when there’s an open case?

PJ: I don’t know, I can’t reply to that

C asks jury question: Prior to ward review of 14^th did you have access to, and review, Morgan’s full medical history going back to childhood?

PJ: No, I didn’t do that, would be hard do that, only have partial access to GP records, Morgan had moved recently but didn’t have access all her historical medication.

C: Second part is, did you just have notes taken during the admission?

PJ: Yes, and Morgan’s own statements, she could identify what medication, one helpful, one unhelpful

C asks jury question: Dr Ahwe assessed traumatic incidents in childhood, and dealt with restraints, how she should be dealt with before his ward round on 17^th. Did you do the same on your ward round, and if not why not?

PJ: Had access to the [admission?] assessment summary that includes part of history, medication history and access to crisis team. I applaud my colleague being able to review more than 5k entries in that period of time

C asks jury question: Thank you. Is there reason things discussed in handover meetings aren’t document in MDT meetings as more about patients discussed, so surely should be documented?

PJ: MDT meeting weekly, go into much more detail in that meeting, whole point of handover is different shift and staff members, is important we’re consistent and carry on that information… any admissions, increase or decrease in risk

C asks jury question: Thank you. If procedure was to send the letter to PALS, why was the letter on the table in the MDT meeting room?

PJ: I don’t know

C: Was it ever sent to PALS?

PJ: That’s not something we do as team, is done by person wanting to make a complaint

C asks jury question: Following a violent incident is support to staff to avoid negative bias against the patient [my paraphrase/didn’t catch exact wording, apologies]

PJ: Yes, is [missed] and that’s why we try to be reflective in our practice and address things, not leave things unsaid… if staff felt unable to work with a patient that would be taken into account

C asks jury question: Given Morgan’s communication challenges was Morgan’s letter viewed as a positive effort to engage with staff?

PJ: Think really difficult to comment on that, feel talking for whole team how understood, experienced. As clinician for team, made decision based on that

C asks jury question: Outside letter’s content would this positive intention be communicated to Morgan?

PJ: Yes, and we reassured Morgan in professionals meeting that team was supportive, were happy keep working with her [missed]

C asks jury question: Is it normal procedure to confirm a safety plan with any third party that is included in the safety plan, before discharge is made?

C repeats the question and adds that she thinks it is referring to family.

PJ: Yes, yes. One would expect the feedback from family on agreement or disagreement on that, that’s why those conversations take place

C asks jury question: What were the factors that led to leaving the Section 2 in place for so long with the first admission… Section 2 was in place for a period of time when Morgan first admitted to the ward, until she left on the 21^st. That first time was quite a long period versus subsequent sections removed quite quickly.

PJ: OK. Section 2 can last up to 28 days, is period considered sufficient to allow assessment, as mentioned before if clinician thinks is no longer appropriate they can remove it. In this case just met Morgan that Monday, thought gave stability, thought more appropriate have time to assess how she could work with team, how coproduce coping strategies… removing section before we could test that wouldn’t have been appropriate

C asks jury question: OK. Were the staff in the ward actively using the traffic light system?

PJ: Yes, from my understanding they were

C asks jury question: On 27^th would you agree Morgan was red on the traffic light system?

PJ: I wasn’t part of, would be speculating

C asks jury question: The heading of these questions say may be better placed to a nurse. What steps were laid out to de-escalate Morgan from red stage, according to the traffic light system?

PJ: I wasn’t involved

C: She had written it out, does Morgan mention?

PJ: Yes, when struggling, PRN if appropriate and distraction techniques

C asks jury question: Next question is, what is PRN?

PJ: As required medication, don’t prescribe regular to take on daily basis, is one of many coping strategies have to support patients manage their own distress. Ideally advise PRN not used at any sign of distress, highly addictive medication, if use on daily basis develop tolerance… is one of many tools in kit one might have

JE: Sorry ma’am a clarification … what document?

PJ: The About Me traffic light system

At this point Mr Berlevy indicates he is leaving court if the coroner is agreeable. She is.

C asks jury question: Are there situations where therapy is mandatory?

PJ: Umm the nature of therapy itself makes it quite challenging if mandatory decision, definitely not in general remit of adult admissions… cannot force someone to engage in therapy… therapy is space through many different strategies [lists types of therapy] patient alongside clinician develops ways to understand situation of distress, understand trauma or deal with grief. If patient is not willing engage in that process its jut not successful.

C asks jury question: If so, is guide place someone on it?

PJ: No is not such a thing

C asks jury question: After requesting outpatient therapy, did Morgan receive it or have it scheduled in?

PJ: Was part of the package of care with Crisis Team, if remember correctly Crisis Team indicated couple mechanisms, one DBT and coping skills, another peer support [missed] Peer support intervention is really beneficial one, someone who has been through the same pathway.

C asks jury question: When Morgan was first discharged did you expect her to be back in care so soon?

PJ: No

C asks jury question: The topic of Morgan’s apology letter, why do you think staff had a hard time coming to terms with it?

PJ: That would be speculation which I don’t think I can do

C asks jury question: Also did you feel you had to resolve discussions about that apology letter in that one single meeting with Morgan and her family?

PJ: No wasn’t my plan to bring that letter in ward review or her family, but brought up so would have been poor clinical practice to ignore it… [fuller answer – missed]

C asks jury question: What would be minimum time from patient expressing they want to be discharged, and actually occurring?

PJ: In a couple hours, if patient is informal and expressing they want to leave the ward and no legal grounds for detention they can leave immediately. We would not recommend that.

C asks jury question: Asks in your own words, describe your mood and manner to Morgan when addressed apology letter

PJ: Can’t recollect that, know Morgan felt uncared for and family having same feelings, was curious to explore her views about her care, whether she wants care somewhere else… as professional understanding that’s something can happen [damage to therapeutic relationship]

C: Thank you those are the last of the jury questions, appreciate you have been on the witness stand for a very long time. Thank you for your assistance in the investigation.

Dr Juliá was released at 16:50

PJ: I would like to express my sincere condolences to the family, hope I’ve done everything in my power to assist in getting an outcome from this.