Most of the morning of Day 10 of Morgan’s inquest was spent in legal discussion and for court administration as the new directions to be given to the jury were agreed.
I made an application to the court for a copy of the directions given to the jury, which assisted this reporting.
The jury were brought into court at 11:52.
The coroner welcomed the jury and gave her introduction. She then read the warnings as this was a hybrid remote hearing and asked those of us attending remotely to confirm that they were in a room on their own and not recording.
C: Members of the jury you will recall yesterday you were provided with summing up and my direction.
The coroner was receiving feedback on her microphone, her officer did something to fix it.
C: Thank you. Apologies was feedback on the microphone. I provided you yesterday with summing up and directions I provided to you.
The representative from the family quite rightly addressed a particular point in the directions, therefore I will re-read to you the directions that have been agreed.
It relates to the fact you are able to make a possible conclusion, or a possible events within the narrative.
So I will now read to you
JE: Ma’am I think you mean probable?
C: Yes, possible wasn’t in there yesterday. We’ve all agreed to these directions, the directions are as follows.
I am now going to sum up to you. The summing up will be in two parts. First, I shall give you directions of law. And I shall tell you 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 give you 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 decision.
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 further evidence.
The evidence that you have is that which was provided by the witness who gave their evidence orally in court and the statements of witnesses which were read out and documentary evidence.
All of the evidence that you have been provided with, is for you to consider.
As I have said to you before, I ask that you do not consider anything that which you may have heard or read about the events surrounding the death of Morgan.
I remind you to concentrate on the evidence which you have heard and seen here in the hearing. Everything else is irrelevant.
It is crucial that you disregard any feelings you might have of sympathy for anyone or prejudice you might feel against anybody.
You must come to your decision coolly and calmly, on the evidence.
Your duty is to find the facts and find a conclusion from the evidence that is believed to be on the balance of probabilities.
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 or reliability.
What evidence do you accept and what evidence do you reject? This is a matter for you. It is open to you to accept one part and reject another part of a witness’s testimony.
If I appear to express a 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 that this is not a trial, it is an inquest into a death. A fact-finding investigation 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.
I shall give you directions on law, which you must take from me, and apply to the evidence.
I am going to give you my direction of law in writing so that you can have then retire and read the record
I shall also remind you of the evidence to enable you to make factual findings that will support your conclusion.
The four questions. The evidence have 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 Review Report was commissioned by Sussex Partnership NHS Foundation Trust and you have heard extracts from that report.
I am not required by law, I am required by law to consider whether a report should be made under Regulation 28 of the Coroners and Justice Act 2009.
I will hear further evidence from Mr McGrory.
The Record of Inquest. Once you have made your findings in relation to the four questions and reached a conclusion you must record these and sign one final copy of the Record of Inquest.
You have copies of this form in front of you and you must complete the sections. I gave you guidance on that yesterday, I shall just give you the guidance again.
Section 5 I shall deal with 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 straightforward here. I will set them out for you and you will enter them on the form.
The coroner then listed the details that needed recording. I’ll not report them. They include Morgan’s date and place of death, her name, sex, date and place of birth, occupation and usual address.
C: You are required to determine the medical cause of death.
You will recall from the evidence of the pathologist that the correct format for recording this is to show the disease or condition directly leading to the death i.e. the immediate cause of death under 1a and that underlying condition in sequence under 1b and 1c.
There are no underlying conditions in this case.
There is no subject of dispute in this case and I therefore direct you to record the following: 1a is Hanging.
Under Section 3 this is where you should record when, where and how the deceased came by her death.
You will see from the wording on the form that you should include the wider circumstances of the death where Section 5/2 of the Coroners and Justice Act 2009 applies.
It applies in this case.
Your conclusions should be expressed in brief, factual and neutral language.
You must not include any indication of criminal liability on behalf of a named individual or an indication of civil liability.
You must in deliberations examine the actions and inactions of individuals and identify those individuals amongst yourselves, but you must, must not use the name of the person on the record of inquest except by reference to their job title, i.e. psychiatrist, nurse, support worker.
You must not use language such as careless, reckless, guilt, tortious, breach of duty, breach of duty of care, since they imply a civil or criminal judgement.
You may however come to a judgemental conclusion and may describe acts or omissions as failures, and use such words as failure, inappropriate, inadequate, omission, insufficient or lacking.
What you write down in Section 3 is a matter for you.
As this is a case where the wider circumstances should be recorded, you should include factual findings on relevant issues specific to this case, about which you have heard evidence.
I suggest that this may include the legal status of Morgan’s admission to hospital, the leave that she was experiencing at the time of her death and her diagnosis.
You may include other issues that you consider important provided they are relevant and related to the circumstances of the death.
So, Conclusions, Section 4 Finally, you are required to record your conclusion in Section 4.
This should not be considered until you have agreed the factual foundation for it in Section 3.
I shall now direct you as to what conclusions you may consider, and in what order.
In this case, the coroner’s guidance determines that there is one possible conclusion in this matter, that is of narrative.
A narrative conclusion is a short brief factual account of how a death came about.
In completing Box 3 and 4 you are required to record a) how, when and where Morgan came by her death, including the date and place.
It is suggested that in giving your answer you follow the structure set out below setting your answer out on a separate piece of paper, which your Foreman can hand to me when you return, having reached your conclusions.
This means recording the fact about what happened, including the timing and place.
The coroner gave an example.
C: A narrative conclusion is a conclusion and should be entered in Box 4.
Where the narrative conclusion includes the answers that would normally be put in Box 3 such as how, when and where you should write in Box 3 “See Box 4”.
As you make your findings, which must flow from the evidence, you must not speculate.
When considering probable causes of death, I remind you that you are doing so on the balance of probabilities i.e. that is more likely than not.
You may also consider possible causes of death if they are sufficient.
This is where an individual act, may have possibly contributed to the death, if the contribution was more than minimal, trivial or negligible and if the possibility is a real possibility rather than a fanciful one i.e. more than just speculation. You should make this clear in your conclusion, for example, ‘We consider it possible that’.
It need not be the only cause of the death but must have contributed in a way that is more than minimal, trivial or negligible.
So, the standard of proof. You must reach all your findings of fact on when, where and how Morgan came to her death on the balance of probabilities and, importantly must be matters that made a material, more than minimal, trivial or negligible contribution to Morgan’s death.
From what I have said it follows that any piece of evidence which goes to meet the balance of probabilities should not be included in the chain of causation.
I would like to remind you that it is not your function to determine what could, or should, have been done with the benefit of hindsight.
Knowing what we now know provides clarity as to what could have been done but whether different paths could be taken it is not possible to say that it would have had and as that is therefore speculation it is not permitted in a coroner’s court.
You should only consider the evidence as to what was known at the time.
Remember, when you complete the record of inquest any person reading your document will not have been, will not have seen any statements, medical notes or reports. Nor will they have heard the evidence. Nor will they had these notes.
You must complete the record of inquest in sentences that are self-explanatory, so the document makes sense to anyone reading it as a freestanding document which explains what happened.
So, subject to this direction, how you express your conclusion is a matter for you but you may like to consider the following issues:
So, these are the issues you were directed on yesterday, which are:
On 9 March 2023
- did Morgan deliberately carry out an act of self-harm which caused her own death, and
- in doing so, did Morgan intend to take her own life?
When considering intent, your answer should be on the balance of probabilities, and as to 2 above may be that:
- Morgan intended to do so, or
- that she did not intend to do so, or
- that it is not possible on the evidence to determine whether she intended to do so.
You may also wish to consider whether there were any adequate considerations and involvement given to Morgan’s family in Morgan’s care and treatment. Sorry, whether there was adequate considerations and involvement given to Morgan’s family in Morgan’s care and treatment.
Whether adequate consideration was given to Morgan’s diagnosis of autism.
Was the safety and management of Morgan’s discharges from Rowan Ward on the 21st, and Maple Ward on the 27th of February, adequate.
Whether management of Morgan’s therapeutic relationship with staff during her last admission to Rowan Ward was appropriate.
Whether Morgan’s risk assessment and management, including her observation level on the night shift on the 8/9 March 2023 was appropriate.
These matters can be considered as part of a narrative conclusion.
You can add to these as you feel appropriate.
And you can ignore them. Sorry, ignore matters which you do not feel are relevant to your inquiry.
Narrative conclusions must be directed to the issues which are central to the cause of death and nothing more, or to the disputed factual issues at the heart of the case.
If you conclude that any of the above may be sufficient you should only record an individual act, omission as probably or possibly contributed to the death, if the contribution was more than minimal, trivial or negligible and if the possibility is real possibility rather than a fanciful one i.e. more than speculation.
You may use language such as if applicable, language that describes any act or omission such as defective, unacceptable, inappropriate, inadequate, omission, unsuitable, insufficient, lacking, failure.
You may not use words that imply a civil or criminal judgement such as carelessly, negligently, recklessly, foolishly, reprehensibly, guilt, tortious, breach of duty, breach of duty of care.
The standard of proof you should apply when considering any findings is that on the balance of probabilities, that is more likely than not.
When coming to your decision as to fact that you consider to be relevant, you should consider the matters that were known, or ought to have been known to individuals at the time and should not apply the benefit of hindsight.
When first you retire you should first decide which evidence you accept and which evidence you reject.
Do this before you discuss conclusions or determinations.
Then and only then, you should go on to reach your conclusions.
You have probably all heard of majority verdicts. At this stage that I can only accept, I can only accept a conclusion which is one with which you all agree, a unanimous conclusion.
Should the time come when I am in a position to accept a conclusion which is not unanimous, I will ask you to come back into court and I will direct you further.
You are under absolutely 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 the law, or evidence, send a note to my bailiff and the court will reassemble and I will provide you with them.
When the court officer has been sworn, I will ask you to retire to consider your findings of conclusions.
Just to make it perfectly clear, these are your directions, not the directions given yesterday. They’re largely very similar but there are other directions which have been given.
You will be provided now with a copy of those directions.
The jury were then given paper copies of the directions.
JE: Ma’am not a matter for the jury to go out, paragraph 44 was a sentence you didn’t read out, rightly. Should the jury be directed to strike that? It’s still in the written directions isn’t it?
C: Yes it is, paragraph 44 jury, is a reference that had been left in right at the end of the paragraph, see Box 4, paragraph 22 of these directions will apply. That wasn’t read out because the numbering has changed in this document so that needs to be struck.
Members of the jury I will ask you to retire and consider your findings and conclusions.
The Jury Bailiff was sworn in and the jury left the court to start deliberating on the conclusions of Morgan’s inquest at 12:21 on Friday 22 November 2024.