A healthcare assistant has said sorry to the parents of a girl who died while at the unit where he worked, describing her as a gentle soul.
Joel Davies was giving evidence on day six of the inquest into Molly-Star Kirk, a 20-year-old woman who was found dead in her room at Farndon Unit in Newark on May 29, 2022.
It was revealed the necessary checks had not been carried out on Molly before her death, despite her observation sheet being completed to say they had.
Coroner Laurinda Bower told the hearing at Nottingham Coroner’s Court that Molly had been in long term care from 2017 until her death.
During that time, she attempted suicide several times and was admitted to a number of hospitals across the country including Milton Keynes, London, Maidstone and Northampton. She became an inpatient in Newark in October 2021.
Joel Davies, a health care assistant bank at the facility at the time of Molly’s death was called to give evidence because he was working on the day before Molly’s death and the day.
At the end of his evidence he apologised to Molly’s family, saying “a gentle soul she was. Despite the challenges, she was a person I had a lot of compassion for. I am sorry.”
Mr Davies worked at Farndon Unit from December 2019 until June 2022, employed by Elysium, the company operating the mental clinic.
Like a previous witness, Karma Dele Oluoje, he told the hearing didn’t have access to any log-in details for the computer system, which would have given him access to patients’ records, their risks and needs and medical history.
His training was provided by Elysium, however, he wasn’t guided through any documentation and his mental and physical health observations training was mainly shadowing other staff members.
The hearing was told Mr Davies hadn’t heard about Molly’s constant seizures.
On the day before Molly’s death, Mr Davies spent the majority of the day with Molly, accompanying her to Spar shop, where she had her first seizure when returning to the bus.
When both arrived back at Farndon Unit, Molly had a second seizure on the floor and a third one less than an hour later, between 1pm and 1.55pm.
Mr Davies previously described Molly’s seizures as pseudoseizures, which can imply that a person is pretending to have a seizure – “a way of Molly communicating and expressing her needs as she did it often and for attention, ” he told the court.
As he didn’t have access to the patient’s mental health plans, he was mainly updated on the patient’s status at the handover at the beginning of each shift, which lasted about 15 to 20 minutes, allowing him to get brief details about the patients rather than all the relevant information.
Around 1.55pm Molly used the phone to contact 999 to report about her seizures and ask for help. The phone was then taken away from her by a staff member.
The emergency services were told on another call soon after not to send an ambulance.
She told Mr Davies that there was something terribly wrong with her and that she needed to go to the hospital, however, that wasn’t reported nor was Molly taken to the hospital.
After lunch, Mr Davies said Molly’s “behavioural disturbance continued in full force.”
Molly was described as being very distressed, including banging her head on the walls several times, to the point of having to be restrained in holds and given medication.
The medication given to Molly caused rapid tranquilisation, which would increase the need for observation of the patient, however, the staff wasn’t aware of or trained in the rapid tranquilisation policy.
Mr Davies didn’t report any of Molly’s seizures or distressed behaviours, which the night staff would not be aware of.
On the day of her death, May 29, Mr Davies was set to observe eight patients, including Molly, between noon and 1pm.
Molly was meant to be checked 12 times an hour, the equivalent of once every five minutes, which the observation sheet shows to have been completed, however, CCTV footage revealed that only six checks were completed.
Some of the checks meant to have been completed by Mr Davies were done by other staff members, who didn’t carry the observation sheet.
Throughout the day, none of the staff members on shift conducted the right observation policy, filling the sheet as if 12 checks were performed.
Mr Davies said that it was the culture at Farndon Unit to not conduct all the checks and just fill the observation sheet in blocks, not only at the Aster ward but in all of them.
He admitted to not being able to confirm if Molly was dead or alive during his final checks.
“I didn’t exercise my individual responsibilities,” he said at the inquest and added that the observation sheet would be completed with “usually generic and standard” information.
The inquest continues.
