Once the jury were out, the coroner heard evidence from Mr Alistair McGrory of Sussex Partnership NHS Foundation Trust relating to the Serious Incident Investigation conducted following Morgan’s death and the action plan that emerged from it. This was to address the coroner so she could decide if there were any outstanding matters in terms of Prevention of Future Deaths.

I won’t report all the discussion but what follows was the coroner’s decision when she returned from considering the evidence she’d heard.

C: Obviously, we’ve got our checklist of things we’d be grateful if you’d come back to us on

AMcG: Yes

C: Having considered all of those, my question is, is there a policy on the guidance to staff to assess the risk posed by fixtures and fittings supplied by the Trust?

AMcG: Mmm, I’m not sure if there’s a specific policy but I know that there is a ligature risk assessment process, um, but as I don’t use it personally I’m not familiar with its structure. Umm, yeh that’s as far as I can go with that really

C: I ask that, partly for the family’s point regarding the collapsible bin, also in evidence nobody could address whether or not a bed sheet should be considered as a ligature risk and there was Nurse Archer did mention about the curtains, but you know, my concern is obviously I haven’t heard evidence that that guidance is in place.

So before I make my decision I’d like to hear whether or not there are any submissions from Ms Elliott?

JE: Yes ma’am our understanding of evidence when Nurse Archer gave evidence is any material would be a ligature risk… [missed] was an uncertainty there, Nurse Archer said was her expectation [that bed sheets should be removed] but it’s not in any policy. It goes to the family concern, what happens when ligature risk items is taken from room, how is it addressed, how is it returned.

The most we saw was in the observation policy it says items may be removed, but it speaks to a lack of policy.

C: Yes not just in respect of bed sheets, duvet, curtain. It goes towards the bin point

JE: Yes it does because that can be used in a ligature event, clothing, other material, what is the policy and procedure?

C: It is also relating to what fixtures and fittings are supplied by the Trust itself

Ms Elliott checked what the coroner meant and she confirmed it included curtains and other furniture items that were removable.

JE: Yes removable items, that was concern of jury as well in relation to curtains. Not only what risk assessment should take place, but what do you remove when there is a ligature risk, what is the procedure?

C: Thank you. Mr Berlevy, do you have any points?

KB: I don’t thank you

C: Ms Agnew, do you?

RA: Yes ma’am, what I’m hearing is you’re interested in additional policies the Trust have regarding ligature risks… are other guidance and policy the Trust have that I’m aware of… obviously Mr McGrory is here today as a non clinician. I’d be grateful if I can have the opportunity to do written submissions to you in respect of this point to give you assurance and the policies you’re interested in.

I know there’s a ligature anchor point reduction policy and know there is other guidance… which include the clinical assessment of risk policy, that’s not the full name. I don’t even know whether it’s in the bundle.

But again, would welcome the opportunity to do written submissions to you in relation to that as this is a point Mr McGrory would not be able to fully cover as he’s not a clinician, as he’s quite honestly said to you.

C: Thank you. Ms Elliott do you have any further submissions in respect of the Prevention of Future Death report?

JE: All I can say ma’am is from the family perspective it needs addressing, how you address it is a matter for you. [missed] It is your duty to make a report where it may impact on future deaths… there is uncertainty there… after inquest you are functus officio, you have no role, even though it does happen [I think she said].

All I say is as a family, the evidence was unclear. I note there’s a ligature anchor point reduction policy, we’ve not seen that, we haven’t been able to question witnesses about it.

Would seem strange to us if we’d explored what is the policy and procedure around removing ligature items and staff didn’t refer to it.

All I can say is that does remain our concern, and we do think it needs made safe. Thank you.

C: Thank you, so Mr McGrory, you are no longer a witness so you are released, I will just deal with the point of Prevention of Future Deaths, thank you for your assistance

Mr McGrory left the remote court link at 15:55.

C: Firstly, I’d like to explain the test that is required, under paragraph 7 of schedule 5 of the Coroners and Court Act 2009 and Regulations 28 and 29 of Coroner’s Investigation Regulation 2013, where an investigation gives rise to a concern future deaths will occur, and the investigating coroner is of the opinion action should be taken to eradicate the risks of deaths.

The coroner must make a report to the person she believes may have the power to take such action. These reports are known as Prevention of Future Deaths reports.

So, I consider that in respect of the points listed by Ms Agnew, who very helpfully explained she was going to get back to me, I would ask you return to me within 21 days regarding the autism training, the presentations for girls and the Green Light Toolkit. To clarify the time regarding the safety huddles in place, the time when it is. The prevention and management of violence and aggression implementation of the trauma, check what policy says regarding prevention and management of violence and aggression regarding trauma training. The removal of items policy, and the complaints policy relating to the clinical information and the complaints information.

If I can ask you get back to me within 21 days with regards those points.

My main concern is regarding items in the room and what fixtures and fittings supplied, and the assessment. Staff clearly from their evidence did not understand there was this policy in place.

So I haven’t had sufficient evidence today for me not to be concerned regarding that. So I do intend to make a Prevention of Future Deaths report in respect is there a policy on the guidance, and staff are aware of the risk posed, by fixtures and fittings supplied by the Trust.

I will write Ms Agnew, I will write to you with details of all the information required within 21 days and a Prevention of Future Deaths Report will be prepared in respect of that point.  

I understand from the jury bailiff that the jury should be ready shortly, so I’m going to adjourn now and wait for them to confirm that. I don’t think there are any other housekeeping points?

Ms Elliott confirmed they were going to ask whether arrangements could be made for Monday but wont be required if jury are due back imminently.

Court was adjourned at 4pm to await the jury’s decision.