At 16:52 on Friday 15 November, Day 5 of Morgan’s inquest the coroner asked Nurse Traynor to come to the witness stand.
He gave an oath, confirmed his name was John Traynor and that he was a Registered Mental Health Nurse.
C: Thank you, and you’ve provided a statement for the purposes of the inquest. Its dated 15 September 2023, could you confirm that the information within that statement is accurate, that there are no changes to that statement since you made your statement in September 2023
JT: Yes, that’s correct
C: Would now be grateful if you could just confirm your involvement with Morgan, more than happy if you’d like to paraphrase your statement.
JT: So my involvement in reviewing the day before during morning handover meeting, review observations, fluid [?] charts, observation charts and discuss if still needed that day
Morgan was reviewed and downgraded from 15 minute observations to general. The general consensus between staff that morning was no longer needed, incident free for ligatures for week at that time, couple of superficial scratches a few days beforehand.
She was due to be discharged at that point the next day, so good practice take her off observations prior to discharge. So, we asked question and removed observations.
C: So, your involvement with Morgan was between 3-8 March?
JT: I was off the week before, so that was one of first shifts I worked with her
C: OK, you’re referring to the downgrading of the observations, was on 8 March is that correct?
JT: Yes
C: So you are in a MDT team meeting at approximately 9am?
JT: Yes
C: Then Dr Lake advised you to review the observation level for Morgan, is that correct?
JT: No. I asked question if these still needed, then team review, is a team decision.
C: So document, and you physically filled out the form?
JT: Yes, afterwards person taking observations on ward at time, took observation sheet off, reviewed after MDT discussion, put in scanning tray to be scanned onto record, informed rest of staff about decision made, yeh
C: Thank you, I don’t have any further questions. Ms Elliott is the legal representative for the family, she is asking questions
JE: Just a few about that one decision, is important to the family. Do you have a copy of your note you made?
JT: The retrospective entry?
JE: Yes, the retrospective entry, that’s right, p179 [?] of the bundle. I’ll just read that out so jury can hear it.
Says note entered retrospectively, looking at times, says 9 March 2023, time 15:38 in afternoon. You’ve filled that in the afternoon after Morgan has died, is that right?
Ms Agnew asked for it to be read out.
Ms Elliott agreed but first checked that Nurse Traynor was aware of Morgan’s passing by the time he wrote it.
He confirms he was. Ms Elliott asked him to read the note he wrote after Morgan died to the jury.
JT: Note entered retrospectively, discussing Morgan asking Dr Julia and Dr Lake if observations still required, normal practice, always reviewed level of observations on daily basis. All agreed back to general observations, hadn’t tied any ligatures… informed nursing staff no longer on observations.
JE: Thank you. I don’t have that observations chart to hand, regarding it. Jury heard, long list of times, that just notes what Morgan is doing at the time?
JT: Yes, staff on write a sentence about that time
JE: So when you regard, just write regarded?
JT: Discuss MDT, in handovers then [missed] would have wrote an entry in the notes as well, which is why did afterwards, wrote retrospective entry, wanted information to be available.
JE: Notes on the observation chart just says regarded, doesn’t give reason, that’s what note is meant to be?
JT: Yes
JE: I see, just going to your witness statement [gives reference]. You say last sentence paragraph 3, I’ll read out, you’re talking about the morning handover, morning MDT meeting, you said “when we got to Morgan’s enhanced observations I asked Dr Lake if still needed, Dr Lake said due to be discharged following day so good idea take her off enhanced observations before she was discharged”. You remember writing that?
JT: Yes
JE: That’s a specific memory you have?
JT: Yes, that’s why I wrote in my statement
JE: So Dr Lake’s view is more looking forward to discharge, not what is happening on the ward?
JT: Shouldn’t go from enhanced observations to discharge
JE: That’s my question, shouldn’t it be based on risk level, not just impending discharge? You have memory Dr Lake saying taking off as due to be discharged?
JT: [can’t hear]
JE: I’ll be absolutely clear what I’m asking, concerned at idea someone comes off enhanced observations because they are due to be discharged, your memory is Dr Lake said that, so I’ll ask him
JT: Yes
JE: Just policy around reducing observations, will read out what believe is relevant. Engagement and observation policy, says:
“Reduction in the level of observation levels must follow a formal process to ensure that a team decision is made which is based on a current mental health and risk assessment whilst taking into account the views of the patient and carers”.
We’ve heard the MDT doesn’t involve the patient, is that right?
JT: Not in morning handover, no
JE: Doesn’t seem from your note Morgan’s views were sought on that reduction?
JT: No. At that time of morning she’d be asleep…. Usually patients aren’t involved with it, most of them might not be awake yet.
JE: It then says:
Evidence of positive change or any other acceptable criteria for the reduction in level must be agreed by the two or more professionals [lists possible people, doctors and nurses] referred to and documented by one of them.
That is the procedure you’re familiar with?
JT: Yes
JE It says staff reducing observations reassess current risk, taking into account the views of the nurses on duty, the patient and family, other members of the MDT. You are familiar with that being the process?
He is. Ms Elliott asks the coroner’s officer to sit with the witness so she can take him through the medical records.
JE: 5 March we have 2 notes, morning note p201 written by Chloe Patrick, dealing with apology letter, we didn’t see any risk events on 5 March.
There were no risk events documented there, we’ll look at the note, p201
Note Chloe Patrick recording Morgan came in for meds, Nurse Patrick didn’t feel able to engage, didn’t have any further engagement with Morgan. Morgan gave her a note, are you happy there are no risk events there for Morgan?
JT: No risk events?
JE: No self-harm, no ligatures
JT: From that note?
JE: Just have to confirm, I’m not trying to catch you out, the jury don’t have the note.
JT: Nothing about risk events in that note, no
JE: Day shift Sharon Mays p202, do you have that? Saying how Morgan been on the day, informal patient nursed on intermittent observations due to new admission… polite on interactions, able make needs known, handed letter into staff about incident on Maple Ward… went out with mother for several hours, returned ward without issue… no ligatures, no self-harm, nothing of concern there. Finally 5 March, night shift note, as we track how Morgan is doing p200
This is documented on morning of 6 March, night shift note tends cover everything from 8pm previous evening, is that right?
JT: Yes
JE: Morgan remains informal, nursed under intermittent observations, due to aggression and self-harm… visible communal areas…. Spending time with peer TS, a friend on the ward presumably, reported struggling with flashbacks, advised write down or draw them, compliant medications… so, flashbacks but again no self-harm or ligatures at this stage.
Going onto the 6 March long note p197, will read so don’t have to do it again, only 1 or 2 notes.
Note Rudy Mills entered, sorry that’s call with Morgan’s mother, don’t need to worry about that.
Know is ward round, p193 please this is an encounter with Jessica Archer, Jessica Archer says was reported to me Morgan was packing her belongings, saying wanted discharge herself and go home.
I spoke to Morgan about this, said unable build therapeutic relationships with staff here and wanted to leave… Morgan very fixated about conversation just had in ward round where Morgan wrote apology letter to staff and Dr Julia questioned and said “didn’t sound like much of an apology”… I kept steering away from this conversation said wanted discharge her safely, wanted discharge self today and said her mum would pick her up… told Morgan arranged discharge planning meeting for 4pm next day, [her mother] said didn’t want Morgan discharged but felt backed into corner…
We can see there Morgan had ward round, she’s upset after the ward round, wanting to self-discharge. As yet we don’t see any self-harm or ligatures?
C: [missed]
JE: Yes ma’am, but decision made by MDT because view taken to reduce her observations
C: Nurse Traynor didn’t make decision, was clinical decision at ward meeting
JE: He was there
C: We’ve heard from Dr Julia today and was have Dr Lake [to come]
JE: very reasonable, was proceeding all three were involved in this decision. Given time pressures happy to take up with Dr Lake
C: Why cant you ask Dr Lake?
JE: I can ma’am, I need to take what presentation was, happy to do that with Dr Lake.
No further questions from Ms Elliott.
JE: 5 March we have 2 notes, morning note p201 written by Chloe Patrick, dealing with apology letter, we didn’t see any risk events on 5 March.
There were no risk events documented there, we’ll look at the note, p201
Note Chloe Patrick recording Morgan came in for meds, Nurse Patrick didn’t feel able to engage, didn’t have any further engagement with Morgan. Morgan gave her a note, are you happy there are no risk events there for Morgan?
JT: No risk events?
JE: No self-harm, no ligatures
JT: From that note?
JE: Just have to confirm, I’m not trying to catch you out, the jury don’t have the note.
JT: Nothing about risk events in that note, no
JE: Day shift Sharon Mays p202, do you have that? Saying how Morgan been on the day, informal patient nursed on intermittent observations due to new admission… polite on interactions, able make needs known, handed letter into staff about incident on Maple Ward… went out with mother for several hours, returned ward without issue… no ligatures, no self-harm, nothing of concern there. Finally 5 March, night shift note, as we track how Morgan is doing p200
This is documented on morning of 6 March, night shift note tends cover everything from 8pm previous evening, is that right?
JT: Yes
JE: Morgan remains informal, nursed under intermittent observations, due to aggression and self-harm… visible communal areas…. Spending time with peer TS, a friend on the ward presumably, reported struggling with flashbacks, advised write down or draw them, compliant medications… so, flashbacks but again no self-harm or ligatures at this stage.
Going onto the 6 March long note p197, will read so don’t have to do it again, only 1 or 2 notes.
Note Rudy Mills entered, sorry that’s call with Morgan’s mother, don’t need to worry about that.
Know is ward round, p193 please this is an encounter with Jessica Archer, Jessica Archer says was reported to me Morgan was packing her belongings, saying wanted discharge herself and go home.
I spoke to Morgan about this, said unable build therapeutic relationships with staff here and wanted to leave… Morgan very fixated about conversation just had in ward round where Morgan wrote apology letter to staff and Dr Julia questioned and said “didn’t sound like much of an apology”… I kept steering away from this conversation said wanted discharge her safely, wanted discharge self today and said her mum would pick her up… told Morgan arranged discharge planning meeting for 4pm next day, [her mother] said didn’t want Morgan discharged but felt backed into corner…
We can see there Morgan had ward round, she’s upset after the ward round, wanting to self-discharge. As yet we don’t see any self-harm or ligatures?
C: [missed]
JE: Yes ma’am, but decision made by MDT because view taken to reduce her observations
C: Nurse Traynor didn’t make decision, was clinical decision at ward meeting
JE: He was there
C: We’ve heard from Dr Julia today and was have Dr Lake [to come]
JE: very reasonable, was proceeding all three were involved in this decision. Given time pressures happy to take up with Dr Lake
C: Why cant you ask Dr Lake?
JE: I can ma’am, I need to take what presentation was, happy to do that with Dr Lake.
No further questions from Ms Elliott.
Then it was over to Ms Agnew, who started by asking Nurse Traynor what his understanding of Morgan’s presentation was.
JT: General consensus amongst staff, I’d been off beforehand, general consensus she was incident free for a number of days so plan take her off as planning for discharge as well
C: To clarify, with regards taking off observations before discharge, you said she couldn’t go from observation level she was on straight to discharge, had to be some removal of the observations?
JT: Yeh good practice to step down before discharge rather than enhanced level of observations to immediate discharge. Test it out, see how it goes beforehand.
C: See how it goes, test how it was before discharge. Ms Agnew, I didn’t mean to step in.
RA: No, thank you, it’s helpful. One final question, we’ve heard about least restrictive practice and importance of that, is it your understanding a reduction in observation levels is least restrictive practice?
JT: Yes, with observations should review at all available times to have least restrictive practice… good practice to review as often as possible
C: What is your understanding of least restrictive practice?
JT: With the view of patient, family view if possible, working with patient to downgrade these steps… always try use least restrictive practice and get down to general observations as soon as possible… otherwise being checked on constantly all the time can cause some issues…
C: Ms Agnew’s question was did you think was correct observations for Morgan at that particular time?
JT: Yes
RA: One follow up question
C: I did jump in on your question
RA: Not problem at all, subsequent to reduction of observations did you become aware of any immediate concerns thereafter?
JT: No, was no issues for rest of that shift
C: Do the jury have any questions?
JE: Ma’am I think is helpful to make clear I do challenge these answers, but will take with Dr Lake. The family does not think reduction was appropriate but I’ll raise with Dr Lake, are you content ma’am?
C: Yes Ms Elliott, I’m not trying to restrict your questioning but the questions may be more appropriate to Dr Lake
JE: Ma’am yes, I think that’s fair. Good point same questions both witnesses, just don’t want it accepted because I haven’t challenged this witness I think it’s appropriate
Coroner asks jury question: Can you confirm the date for the reduction to observations?
JT: Was 8 March
Coroner asks jury question: The 8th. Do you remember whether there was a traffic light indicator on Morgan’s door, and if so what it was set to?
JT: I can’t recall that I’m afraid
Coroner asks jury question: When you came back from sick leave, did you pick up on any tension or concern regarding Morgan and the incident on Maple Ward amongst fellow staff?
JT: No
C: So, thank you very much, are there any other questions from the jury?
There aren’t.
The coroner thanks Nurse Traynor for his participation into the investigation into Morgan’s death. He was released at 17:20
C: Members of the jury, as I said earlier, it was very helpful we were able to run over today, thank you very much. I understand the family and representatives for Sussex Partnership Trust are really happy we were able to have the evidence of Mr Traynor this afternoon so he can go back into his clinical role.
May I wish you all a very good weekend, just to remind you of the warnings given at the beginning of the inquest, you’re only to consider the evidence you hear in this court room when making your decision.
Have a lovely weekend and please return for 10am on Monday.
The jury were released at 17:21.
[I am unable to be in court Monday to Wednesday next week. I hope to be able to report on the coroner’s summing up and when the jury returns but I’m unsure if that will be possible. Whatever happens I will report the conclusion of the jury in due course. With thanks to everyone who is funding, reading, sharing and commenting on my reporting].