I was not available to report Days 6, 7 and 8 from Morgan’s inquest this week. I am grateful to the court for allowing me to attend remotely for the coroner’s summing up and the conclusion of the inquest.

Most of today was spent waiting or observing legal submissions between the coroner and the counsel for the Interested Persons. I won’t report any of those discussions before the inquest is concluded.

We heard the jury had been waiting in court since 10am, when the coroner asked for them to be brought into court at 3pm.

Lisa Milner, the Assistant Coroner for West Sussex, Bright and Hove welcomed the jury back and thanked them for their patience.

She introduced herself for the sake of the recording.

C: So, after considering everything overnight, I know I said to you yesterday we have heard all the evidence.

When dealing with my directions, and summing up to you, I feel there are certain documents you still need to hear that we have in our bundle.

The coroner then asked her Coroner’s Officer to swear an oath (she had not previously assisted this inquest) and read the relevant paragraphs from the policy she had in front of her.

She swore an oath and did so.

CO: I’m reading from Therapeutic Engagement and Observation Policy and Procedure. The highlighted sections read as follows.

C: Before you start, these are from the policy about observations

CO: On page 3 Observation is a minimally restrictive intervention of varying intensity in which a member of healthcare staff observes and maintains contact with a service user to ensure the service user’s safety and the safety of others (NICE 2015 p15)

JE: Sorry ma’am, those are where I asked for the paragraphs to be read together

CO: This involves a two-way relationship, established between the patient and the member of staff, which is meaningful, grounded in trust and therapeutic for the patient (NMC 2008).

Observation also provides an opportunity to collaborate with the patient in managing their risks. It should not be delivered in a way that is, or is perceived as, custodial or punitive.

Paragraph 1.2.2 NICE (2005) has defined four levels of observation.

For the purpose of clarity within this policy, any observations beyond the frequency of general observations will be classified as enhanced.

• General observation

• Intermittent enhanced observation

• Within eyesight enhanced observation

• Within arms length enhanced observation

Following onto the next page under detailed description of 4 levels of observations, following [missed section]

At times, it may be necessary to search the patient and their belongings whilst having due regard for the patient’s legal rights. The Trust’s Searching patients and their property policy will be followed.

In some circumstances it may be necessary to temporarily remove belongings that could be used to inflict harm.

Within Arms Length Enhanced Observation. This level of observation is for patients assessed to be at the highest level of risk of harming themselves or others, who need to be supervised at close proximity (NICE 2005). The patient must be at ‘arms length’ of the observing nurse at all times, day and night.

Within Eyesight Enhanced Observation. This level of observation is for patients assessed to be at the highest level of risk of harming themselves or others but who can be safely supervised within eyesight. The patient must be kept within sight at all times, day and night.

Intermittent Enhanced Observation. This level of observation is appropriate when patients are assessed to be potentially, but not imminently at risk of suicide or potential risk of harm to others. The care team must agree the maximum time period between observations. This can be between 15 and 30 minutes.

General Observation. General observation is the minimum level of observation for all inpatients, it means we will check the location of the patient every hour.

At paragraph 1.3. Principles. Observation is a dynamic therapeutic intervention through which patients needs will receive ongoing assessment and intervention. Any risks relating to personal safety, or risk to others should be managed consistently by the multi-disciplinary team. It is important that the level of observation is matched to the risk identified and is reviewed regularly.

The primary function of observation and engagement is to maintain patient safety. However, the process of observing patients gives staff the opportunity to assess behaviour, symptoms, physical wellbeing and interactions.

Paragraph 2.2 The decision to increase or decrease the level of observation must be underpinned by an assessment of risk which must be clearly documented.

Paragraph 4.7.1. All levels of observations will be reviewed by the nursing team on a shift-by-shift basis.

Paragraph 4.7.3. Changing the level of observation must be dependent on the patient’s requirements for care and safety and not on the availability of the full multidisciplinary team to make decisions.

Appendix 2 Information for patients, relatives and carers. The highlighted section is:

How are Levels of Engagement and Observation Decided? It is important that support is tailored to each patient as an individual, so staff will assess their mental and physical health care needs on a regular basis.

Staff will also bear in mind any other factors, for example, medication changes and patient history.

This finishes the highlighted sections ma’am, thank you.

C: Within the investigation into Morgan’s death there has been two toxicology reports … dated 11 April 2023, a subsequent report dated 1 March 2024, then a witness statement from Robert Moore who is the toxicologist.

The coroner then asked her officer to read the results and comments made from both reports.

I’ll not report them, bar saying that the first report found nothing except Morgan’s prescribed medication in her blood and urine.

The toxicologist had added that the toxicology results showed that the “Indicated medication was not present in excess, no other drugs were detected by the screening”.

The statement from the toxicologist explained that the first report was as a result of standard testing, the second has been after a retrospective targeted analysis.

Both reports showed Morgan had nothing except her medication in her blood or urine and nothing in excess of therapeutic levels.

C: So, this now concludes the evidence that has been obtained in respect of the investigation into the death of Morgan Rose Betchley

What will happen now is you will hear from me and receive documentation, that will provide you with the summing up and also the directions to you to enable you to make your decisions.

Firstly, jury bailiff could I ask you to provide the [missed]

CO: Got them here ma’am

C: Thank you. You have now received a record of inquest, I will go through the document to explain how this document needs to be prepared, I’ll also provide you with directions and a summing up in respect of the evidence you have heard.

The summing up will be in two parts, first I shall give you directions of law, tell you the law, what the law is and the purpose of this inquest. You must take from that and me and apply it to the evidence you have heard.

Secondly, I shall review the evidence in the case and remind you of the important [missed] although in the end up for you to consider the important evidence that matters.

It is upon that evidence and only your evidence that you come by your decisions.

If I appear to express a particular view about the evidence, you must ignore it, unless you agree with it. I do not intend to express a view.

The Summing Up will be in two parts. First, I shall give you directions of law. I shall tell you what the law is for the purposes of this inquest and you must take that from me and apply it to the evidence which you have heard.

Secondly, I shall review the evidence in the case and remind you of what is important, although in the end it is what you consider to be important in the evidence that matters. It is upon the evidence and only the evidence that you come to your decisions. If I appear to have a view about the evidence, ignore it unless you agree with it. I do not intend to express a view. I must also tell you that the evidence is now closed. There will be no more evidence.

The evidence which you have is the evidence of the witnesses who gave evidence from the witness box, the statements of witnesses which were read and the documentary evidence. All of that is evidence for you to consider.

As I have said to you before, ignore anything which you may have heard or read about the events surrounding Morgan’s death. Just concentrate on the evidence which you have heard and seen here in the hearing.

Everything else is irrelevant. Also ignore any feelings you might have of sympathy for anybody or prejudice you might feel against anybody. Come to your decisions coolly and calmly on the evidence. Your duty is to find the facts and come to a conclusion – from the evidence.

In order for you to decide the facts, you must make an assessment of the evidence. It is up to you what you make of each witness, in terms of their credibility and reliability. What evidence do you accept and what evidence do you reject? That is a matter for you. It is open to you to accept one part and reject another part of a witness’s testimony.

As said previously, if I appear to express a particular view about the evidence, you must ignore it, unless you agree with it. It is your view of the evidence that matters.

I must remind you this is not a trial; it is an inquest into a death, a fact-finding inquiry to find out how Morgan died.

It is not a method of apportioning blame. There is no indictment, no criminal charge. It is simply a way of establishing facts.

The evidence has been directed towards answering four questions. Who was the deceased? When, where and how did Morgan come by her death? You must also reach an overall conclusion about the death. You must not express an opinion about other matters or make recommendations.

You have heard in evidence a comprehensive serious incident report was commissioned by Sussex Partnership Foundation Trust. You have heard extracts from that report.

As coroner I’m required by law to consider whether as a result of that report I should be making a Regulation 28 of the Coroner and Justice Act 2009, I should make a report.

Therefore, I will have evidence from Mr McGrory … on witness list at the beginning of the inquest… I will hear that evidence tomorrow…. it’s not for jury to make that decision with regards to Regulation 28 report.

Once you have made your findings in relation to the four questions and reached a conclusion you must record these, and sign one copy of the Record of Inquest. You have copies of this form in front of you and must complete all the sections. I shall give guidance as to how you approach individual sections.

I shall deal with this first.

These are the details which are required for the death to be formally registered. In this case there is no dispute about them and therefore those details are straight forward.

I shall set them out for you and you shall enter them into the form.

The coroner then directed the jury what particulars to enter into the Record of Inquest including Morgan’s date and place of death, her name, sex, date and place of birth, her occupation and her usual address.

The coroner checked with Morgan’s family members whether they wished for her occupation to be recorded as “mother” but they said student.

She then told the jury that in Section 2 they had to record the cause of death.

C: You are required to determine the medical cause of death. You will recall from the evidence of the pathologist, Dr Appleton, that the correct format for recording this is to show the disease or condition directly leading to death i.e. the immediate cause of death, under 1(a) with underlying conditions in sequence under 1(b) and 1(c).

In this case there are no underlying conditions.

This has not been subject to a dispute in this case and therefore I direct you to record at 1a) hanging.

Section 3 This is where you should record when, where and how the deceased came to her death [missed]

Your conclusion should be brief, neutral and factual [missed]

You must not use language such as carelessly, recklessly, breach of duty… since they imply a criminal or civil judgement.

You may however come to a judgemental conclusion and describe acts or omissions as failures, in such words as failure, inappropriate, inadequate, omission, insufficient or lacking etc.

What you write down in section 3 is a matter for you.

The coroner then listed a number of aspects that the jury should consider including Morgan’s multiple admissions and discharges from hospital and her diagnosis [there were more, I missed them I’m afraid].

C: You may include other issues you consider important, provided they are relevant to the circumstances of the death.

At Section 4 you are required to record your conclusion, should not be considered until you have agreed factual foundation for it in Section 3.

You are required to record your conclusion in Section 4. I shall now direct you as to what conclusions you may consider.

In the Chief Coroner’s Guidance it is recommended short-form conclusions are used where necessary, where possible. In this case a narrative conclusion is the most appropriate conclusion… a short brief account of how a death came about.

In 3 and 4, You are required to record how, when and where Morgan came by her death. Suggested follow structure below, setting answers out on a separate piece of paper which your foreman can hand to me when you return and have reached your conclusions.

Include recording the facts of what happened including the timing and place.

[Missed]

I direct you as a matter of law, you may not record a conclusion that Morgan probably would not have died on basis of the issues set out in paragraph 35 below.

Subject to this, your conclusion is a matter to you.

You may wish to consider the following. These are the directions to you the jury. You may consider:

a) on 9 March 2023

1. Did Morgan deliberately carry out an act of self-harm which caused her own death and
2. In doing so did Morgan intend to take her own life?

b) When considering intent your answer should be on the balance of probabilities and [missed] may be that

1. Morgan intended to do so
2. That she did not intend to do so
3. That it is not possible on the evidence to determine whether she intended to do so.

c) Whether there was adequate consideration given to Morgan’s family in Morgan’s care and treatment

d) Whether adequate consideration was given to Morgan’s diagnosis of autism

e) Whether the safety and management of Morgan’s discharges from Rowan Ward on 21 and Maple Ward on 27 February was adequate?

f) Whether management of Morgan’s therapeutic relationship with staff during her last admission to Rowan Ward was appropriate?

g) Whether Morgan’s risk assessment and management, including her observation level on the night shift of 8/9 March 2023 was appropriate?

Members of the jury you will receive a copy of these directions.

These questions can be considered as part of a narrative conclusion. You can add to these as you feel appropriate. You can ignore matters you do not feel are relevant to your enquiry.

Narrative conclusions must be directed to the issues which are central to the cause of death.

Individual acts or omission may possibly contribute to death if contribution was more than minimal, negligible or trivial.

And if contribution was real rather than fanciful i.e. more than speculative.

You may record any act or omission if it is possible it has caused or contributed to the death, making it clear in your conclusion we consider it possible that… [missed]

May not be the only cause but must have contributed in way that is more than minimal, negligible or trivial.

You may use language such as, directions are as follows:

If applicable any act or omission that you find such as defective, unacceptable, inappropriate, inadequate, omission, unsuitable, insufficient, lacking, failure etc

You may not use words that imply civil or criminal judgement such as carelessly, negligently, recklessly, foolishly, reprehensively, guilt, tortious, breach of duty, breach of duty of care.

I’m going to go back and say the words you may use as I said them very quickly, may not have written them down.

You may use words such as defective, unacceptable, inappropriate, inadequate, omission, unsuitable, insufficient, lacking, failure. They’re not the extent of the words you may use but are an example of words you may use.

If you consider any matters listed above are not relevant to the question of how and in what circumstances Morgan came by her death then you should either not refer to those issues in your narrative, or state in your narrative the issue is not relevant to how or in what circumstance she died.

You may record any other central issue which you deem is relevant to the circumstances of her death… should record is relevant to death but you cannot conclude the issue caused or contributed to the death having occurred.

Standard of proof you should apply is balance of probabilities, that is more likely than not.

When coming to your conclusion of facts you consider to be relevant, should consider factors known or ought to be known to individual at the relevant time, you should not apply the benefit of hindsight.

When first you retire you should decide which evidence you accept, which evidence you reject. Do this before you consider conclusions or determinations.

Then, and only then, should you go on to reach your conclusion.

You have probably all heard of majority verdicts. At this stage I must advise you I can only accept a conclusion which is one which all agree, a unanimous conclusion.

Should the time come when I’m in a position to accept a conclusion that is not unanimous I will ask you to come back into court and I will further direct you.

You are under no pressure of time.

If you have not already done so, you should when you retire choose a spokesperson to speak for you. They will be required to stand up and read out the record of inquest when you have made your determinations.

If you want further directions on law or evidence send a note to my bailiff, the court will resume and I will provide you with them.

When the court officer has sworn, I will ask you to retire to your findings and conclusion.

So, over the past 2 weeks, nearly 2 weeks you have heard lots of evidence form different witnesses. I shall now provide, those should still be in your mind, I will now provide you with a summary of that evidence.

Morgan Betchley was a lady, a 19 year old young lady who lived with her partner Dominic and their young son in Chichester.

She juggled motherhood, a loving relationship, a job and a college course.

She was well loved, inspirational and a determined young lady.

She had no mental health history prior to the age of 11 when she first became unwell. Her mother Tanya Betchley considers that her initial struggles had correlation with her menstrual cycle.

There were notable incidents historically where Morgan’s mental health [missed].

Tanya Betchley advised as a result of an incident when Morgan was 15 she was taken into care to obtain appropriate treatment.

Morgan received a diagnosis of autism in late January 2023.

Morgan’s mental health deteriorated early in February 2023 and she had multiple admissions and discharges from hospital.

Heard Morgan verbalised her triggering factors related to money worries, college, being a mother and not understanding her autism diagnosis.

Morgan’s provisional working diagnosis was that of Emotionally Unstable Personality Disorder, EUPD. Albeit Louise Hodgson, Dominic’s mother, does not consider Morgan presented with traits of this diagnosis.

We have heard from Dr Ahwe that acute mental health wards are not conducive with autism patients, although allowances are made to care for autistic patients’ individual needs.

Morgan attended A&E at St Richard’s Hospital on 1 February 2023 reporting auditory hallucinations and suicidal ideations… she was discharged with follow up from the Crisis Resolution and Home Treatment Team, which I’ll refer to as the Crisis Team.

After attendance Morgan was physically unwell and diagnosed with Strep A.

Morgan has further contact with mental health services on 6 February 2023 and is admitted to The Haven at Millview Hospital on 7 February where she discharges herself against medical advice.

She is visited at home by the Crisis Team on 8 February.

On 9 February Morgan is admitted to A&E at St Richard’s Hospital, Chichester after taking an overdose [withheld] assessed liable for detention under Section 2 of the Mental Health Act 1983.

Dr Julia confirmed Section 2 allows for a person to be admitted to hospital for up to 28 days to assess whether they are suffering from a mental disorder.

At this point the coroner asked Ms Elliott if there was an issue. Ms Elliott responded that there was a query about the overdose but she would return to it.

C: At this stage she was not detained as there were no beds for Morgan.

On 13 February Morgan was admitted to Meadowfield, where she stayed for 8 nights.

Dr Julia was the responsible clinician during this admission. She assessed Morgan on 14 February. Morgan was assessed as having capacity. Morgan’s autism diagnosis was discussed and Dr Julia requested a copy of the report Morgan had received from Psicon.

She discussed with Morgan completing an autism passport and a referral to a psychologist. Morgan declined this referral but subsequently completed the autism passport.

Morgan disclosed to Dr Julia she had Oppositional Defiance Disorder, which meant it was difficult for her to be detained.

They discussed medication and Morgan’s medication was amended and she was prescribed [withheld].

Dr Julia advised the admission went well, although as expected Morgan’s mental health fluctuated. Over the following week Morgan engaged in some 1-1s and accepted medication and some therapeutic activities… completed her autism passport…

She expressed on different occasions she was finding the ward environment triggering and distressing.

[Missed – reference to the traffic light system]

Dr Julia prescribed therapeutic Section 17 leave to enable her to the hospital grounds with her partner and staff.

Section 17 leave is leave granted under the Mental Health Act 1983 and allows for certain patients who have been detained under the Mental Health Act to be granted leave of absence from the hospital in which they’re detained for …

A risk assessment was completed on 14 February 2023.

You heard evidence form Dominic Goddard relating to the autism passport and the fact the staff did not take sufficient notice of this.

Dr Julia reviewed Morgan during her ward round on 20 February 2023. Morgan told her she’d been using her grounds leave without any issues or risk, stating she had used it well and was helpful… Expressed she was ready to be discharged home with her son.

Morgan had episode of agitated behaviour in night before this conversation but indicated the inpatient environment was not supporting her needs well and asked to try an outpatient approach with therapy, that Morgan expressed would be more beneficial to her.

Morgan expressed she had not experienced any hallucinations since admission and felt [withheld] was helping.

[Missed]

Agreed engage with Crisis Team. Also expressed wanted to consider with Crisis Team for therapy. Dr Julia asked the team to refer, team to Crisis Life Centre for therapy.

A discharge plan was put in place for Crisis Team to visit Morgan in the community.

As Morgan was an adult there was no involvement of family regards this discharge.

Dr Julia advised process put in place to contact relevant services in regards to Morgan’s son.

You heard in evidence from Morgan’s family they were not contacted, they were not involved regarding this discharge and did not feel this discharge was appropriately managed, and feel it was very abrupt.

A further risk assessment was completed on the 21 February prior to the discharge.

Unfortunately when Morgan was assessed by the Crisis Team at home, it was considered Morgan was not in a safe place in the community, further admitted to A&E at St Richard’s where she stayed for 3 nights awaiting a bed.

On 24 February Morgan absconds from A&E and makes a suicide attempt and is sectioned under Section 136 of the Mental Health Act, which is a power given to the police to remove a person from a public place to a safe place when they are suffering from a mental disorder.

Morgan was assessed 25 February and detained under Section 2. She is then admitted to Maple Ward at Meadowfield Hospital.

She is assessed by Dr Ahwe at approximately 2pm on 27 February. Dr Ahwe is aware she tied a loose ligature on the 25 February. Dr Ahwe provided evidence form records in Morgan’s mental health notes that Morgan had experienced trauma at the age of 11 and 15 when she had experienced abuse.

He further advised she also experienced further trauma which resulted in PTSD when she was incarcerated at the age of 18 after an incident with her mother and she was restrained by the police.

After the assessment Morgan expressed a desire to be detained. He authorised therapeutic leave under Section 17.

Morgan asked to leave the ward at approximately 3pm. While staff were ascertaining status regards leave, Morgan became agitated and attempts to escape.

The coroner went on to say that Morgan damaged the ward door when attempting to escape. She said assistance was required from other wards and Chloe Patrick answered an alarm, attending from another ward.

C: Morgan refused to calm down or take any calming medications… then restrained by 5 members of staff, and then agrees to take calming medication [missed but the coroner indicated that members of staff were hurt in this incident].

Tanya was called during this incident.

The family are talking, can I say the jury need to concentrate on this.

JE: Apologies

C: Tanya telephoning during this incident and could hear Morgan in the background, she begged a member of staff not to let Morgan leave. After the incident Morgan discharges herself from the ward, despite Dr Ahwe attempting to reason with her in a meeting at approximately 4:20pm to have a more controlled discharge.

Dr Ahwe states his management of Morgan at this time, was with consideration of her autism diagnosis. Dr Ahwe requested Morgan sign a behavioural contract, which she refused.

Upon discharge, in the hospital grounds Morgan ties a loose ligature to a tree in view of workmen and staff. Morgan is arrested and taken to Worthing Police Station and stays overnight in custody. In the meantime Tanya called 999 as she knew Morgan would be at risk.

Morgan is then admitted to A&E at Worthing Hospital and detained under Section 136, where she stays for 1 night.

Morgan is assessed and detained under Section 2 whilst in A&E.

She is then admitted to Woodland’s health based place of safety.

After this incident Morgan explained to Tanya she was having a psychotic episode and was being attacked by wasps and needed to escape.

You will have heard evidence from Nurse Archer who confirmed in her evidence there was no psychosis identified in Morgan’s presentation.

On 1 March 2023 Morgan is detained under Section 2 of the Mental Health Act whilst in A&E.

On 2 March 2023 Morgan is admitted to Abbey Ward at the Woodland’s Centre in Hastings. She stays for 1 night.

After assessment it is considered appropriate for Morgan’s Section 2 to be rescinded and she is transferred to Rowan Ward as a voluntary patient on intermittent observations.

The family’s experience with Woodland’s Centre was positive and collaborative.

Whilst at a meeting with Woodlands Tanya identified potentially they did not have the Psicon report regarding Morgan’s autism.

On 4 March 2023 Tanya encouraged Morgan to complete the top tips for me which had been provided by Louise Hodgson.

This is a document that identifies how professionals could assist Morgan, and categorised a red, green and amber state of mind.

On 2 March Morgan was admitted to the decommissioned 136 suite on Abbey Ward.

On 3rd her section was rescinded as Morgan expressed a wish to work with the nursing team. She signed a contract stating she understood she’d be discharged if there were any further periods of violence.

She was then transferred to Rowan Ward on the 3 March.

On 4 March she was able to walk off the ward with her boyfriend and returned appropriately. She had been more settled.

On 5 March she’d superficially scratched her hand which was dressed. Also on 5 March Morgan left the ward for several hours with her mother without issue.

She was expressing remorse for incidents on Maple Ward where the staff were hurt.

Whilst on Rowan Ward on 6 March Nurse Archer received a telephone call from Tanya and Morgan’s mother was saying she wanted to move Morgan into her home and wanted Morgan out of hospital as it was not the right environment for her.

Morgan’s mother Tanya disputes the contents of this conversation and said this was not what she had discussed with Nurse Archer.

Nurse Archer set up a discharge planning meeting. Due to complexities was suggested professionals should be in attendance.

Professionals meeting was organised for 4pm on 7 March 2023. Unfortunately, the Crisis Team were invited by unable to attend at short notice.

Morgan attended, Morgan’s mother Tanya, and Louise Hodgson, Morgan’s mother in law attended by speaker phone. Also in attendance was Morgan’s Lead Practitioner.

Shortly after speaking to Tanya’s mother, Morgan stated she wanted to discharge herself from hospital.

Overnight leave was then offered to Morgan at the planning meeting… stated last resort action. Tanya then rang the ward and said she’d managed to persuade Morgan to stay till the next day.

On morning 6 March 2023 a letter was placed in the handover room written by Morgan’s mother in law.

Dr Julia read this letter to the multidisciplinary team meeting as Morgan’s family were expressing significant dissatisfaction with Morgan’s discharges from Rowan and Maple Wards, and the care received.

The team discussed and agreed to escalate this to Matron to assess if admission to Rowan was appropriate given the families views and dissatisfaction.

Staff also discussed the letter Morgan had handed to the team following the incident of assault in last admission.

Dr Julia reviewed Morgan on 6 March 2023.

Morgan explained she was unable to use her coping strategies on discharge.

Was able understand why seclusion was used after incident of assault.

Later that day Morgan was found self-harming with [withheld]. She asked to leave the ward but was persuaded from doing so.

Dr Julia discussed the letter [with Morgan] and asked whether she thought the therapeutic relationship was damaged.

Dr Julia explored whether seeking bed in a hospital closer to her family was [missed]. Morgan was said to be ambivalent about this but told Dr Julia it could be a good idea, but she didn’t like change.

Morgan presented as calm and appropriate, able to articulate her thoughts, with no evidence of thought disorder during this review.

She abruptly left after not receiving the expected result after she asked about the letter handed to staff.

[Missed]

… was discussed current presentation in hospital being potentially unhelpful environment for her given her diagnosis of ASD, as well as missing the supportive environment from home.

Tanya requested she’d like support from services for Morgan to be managed in the community and be supported by family, who came up with different strategies.

Discussions had about Morgan moving in with Tanya for time being may be option… Morgan expressed some ambivalence regarding admission and whole situation feeling [missed] given how much therapeutic relationship had broken down.

Explained she thought was grudge held by professionals, she was reassured this wasn’t case and that regardless of incident of assault that the care she received from team would remain, and their goal would be always to support her in recovery and achieve her goals.

The benefit of a hospital admission was discussed with Morgan and Dr Julia advised this was on a case by case basis and always assessed on situation by situation basis.

Morgan confirmed she’d be happy return home and engage with the Crisis Team. Put in place following risk management.

You have heard evidence that from Louise Hodgson, that the amounts of transitions and discharges would have been very difficult for any person, even without having autism.

Dr Lake also confirmed the pattern of behaviours on these discharges would be difficult.

At the meeting of the professional’s. On the 7 was professionals meeting and clear discharge plan was outlined which included the Crisis Team following her up.

Tanya’s evidence is at this meeting Morgan was withdrawn, low in mood and appeared sedated. She was concerned people wouldn’t be able to help her.

From outset of the meeting the approach of hospital was Morgan should not remain in hospital. She was very concerned for Morgan but she was under the assumption that as Crisis Team agreed to attend on 9 March that this discharge would not be approved.

As result of that meeting on 7 March Louise Hodgson’s evidence is she came away from that meeting shocked and sick.

[Missed]

Found lightly banging her head in the Garden Room on 7 March due to flashbacks.

We heard evidence from Nurse Patrick, who was in charge of the ward on 8/9 March.

As nurse in charge that night she was responsible for running the shift, ensuring staff were allocated to do necessary tasks and completing them appropriately.

She was also responsible for managing situations as they arose and maintaining the safety of the ward.

She discussed how she managed her engagement and therapeutic care to Morgan, particularly after the significant assault she was party to on Maple Ward on 27 February 2023.

She explained as team cared for Morgan by utilising those staff members with whom she had the best rapport.

She confirmed Nurse Amosu had a good rapport with Morgan.

She recalled seeing him talk to Morgan in the ward social area. They appeared to be a in a good, engaged conversations.

She confirmed the ward in general on 8/9 March was unsettled as result of a highly intoxicated patient, whose behaviours were disruptive for most of the evening.

Whilst the disruption was ongoing Morgan went in and out of her room but was mainly in communal areas.

Morgan was pleasant and polite with no signs of distress throughout the night.

Remembers Morgan stood in communal area at about 2:30 and recalls she was asked to go to her bedroom or the TV room whilst they were restraining the patient, which she wholly cooperated with.

She remembers saying the other patient had her vape, as Morgan had kindly given it to her. Nurse Patrick said she would obtain it back for her.

Nurse Patrick advises is nothing in this conversation to suggest any upset whatsoever. Standard practical conversation around the return of the vape.

Once the intoxicated patient had been removed from the ward. Nurse Patrick came back to the ward at approximately 2:30. She did not see Morgan again until she attended alarm.

Nurse Patrick was not aware of Morgan’s personal items being removed by Nurse Amosu.

The family consider the therapeutic relationship between Nurse Patrick and Morgan had broken down, and did not feel this was approportionate.

Nurse Traynor confirmed in morning handover on 8 March Morgan’s observations were reduced form intermittent to general, which are hourly observations.

Nurse Amosu is an agency registered mental health nurse, had a good relationship with Morgan, had known her from previous admissions. Confirmed 8 March approximately 7pm he had a conversation with  Morgan and she was calm. She had no suicidal ideations. She explained to him that a trigger had been combination of money worries, college, being a mother and not understanding her autism diagnosis.

Katie Mills, who is a healthcare assistant, was approached by Morgan at approximately 9pm.

Katie advised Morgan seemed agitated. Karen had a 1-1, sorry, Katie had a 1-1 with Morgan.

In this meeting Morgan confirmed her protective factors were that of her family and son and expressed concerns of coping in community… she expressed ideally she’d like to remain longer.

Karen Mills referred her to traffic light system and advised how could be used in the community.

Advised Morgan expressed no suicidal ideations.

Katie undertook further observations of Morgan and Morgan seemed calm at this point.

Katie in her evidence said she could not recall whether she spoke to Morgan at this time.

Confirmed during evening Morgan was sat in communal areas engaging with other patients, in particular an intoxicated patient that had been admitted.

Nurse Amosu had a conversation with Morgan at 22:20 and took her observations. Due to her verbalising slight agitation she asked for medication to assist with sleeping. Considered charts and gave 2mg [withheld].

Nurse Amosu was not concerned about Morgan’s immediate risk but at that time was aware of unexpected disturbance on the ward, so as a precautionary measure collected Morgan’s belongings from her room, with her consent, packed up previously on 6, and asked her to sit in the communal areas.

At approximately 2:45pm [the coroner referred to pm throughout, but I’m assuming this should be a.m. as it refers to the night into morning when Morgan died] Morgan requested a duvet and wanted to take one from another patient.

To avoid infection risk just before 3pm Nurse Amosu collected Morgan’s duvet from the store on his way to another patient.

Nurse Amosu said she was calm, settled and able to communicate.

Confirmed she did not look agitated, confirmed he’d assessed Morgan dynamically on an ongoing basis.

When Karen saw, Katie saw Morgan at 3am to undertake her observations Morgan was in her bed with her lights off looking at her telephone.

At 3:15 pm Morgan had conversations with various members of staff when she came out her room to ask her telephone to be charged.

First spoke to Nurse Amosu, who was doing eyesight observations for another patient. Morgan asked if he could help her charge her telephone. He said he couldn’t leave the patient he was with and suggested she go to the office and ask someone to charge it, which she did.

At 3:30pm Karen Mackley noticed was some irregularities with Morgan’s door.

[I’ll withhold the detail but Morgan was found at approximately 3:30, an alarm was raised]

C: Alarm raised, Nurse Patrick came to assist. At this time Morgan had a pulse but unfortunately did not survive.

Tanya gave evidence she was surprised so many incidents of self-harm were not documented, therefore unable to establish true level of risk.

You heard from the observation policy in evidence… that is what the best practice would be to assess risk by 1-1.

Policy also requires risk to be minimally restrictive and observations are dynamic therapeutic interventions.

Dominic’s evidence is he considers Morgan’s act was impulsive.

You have heard read evidence from DI Alchin-Gadd confirming Morgan did not leave any suicide note.

The medical cause of death provided by Dr Appleton is that of hanging.

[The coroner then provided some evidence from the post mortem examination that I’ll not report].

C: That concludes the summing up of the evidence you have head during Morgan’s inquest.

I will now ask the jury to retire and provide a conclusion into Morgan’s death.

JE: ma’am there’s one legal matter if I may, once we’ve got the jury out please

C: Yes

The jury left court at 16:24. Legal discussions followed for approximately 10 minutes and then they returned to court.

C: Members of the jury you have been very patient. One technical point has been raised by the family, will address you on that tomorrow.

Bear in mind what you’ve been given today… pleas return 10am when you’ll work together on a conclusion into the death of Morgan Rose Betchley.

The jury were released at 16:37 to return tomorrow morning.