Harry’s Inquest

 

A Brilliant Boy’s Short Life

 

Care, Competence and Accountability.

 

 

 

 

 

 

HARRY’S  INQUEST

CARE, COMPETENCE AND ACCOUNTABILITY.

 

Index 2012-01-09

 

1)      Introduction

2)      Pictures of Harry

3)      The Verdict of the Inquest

4)      Press Articles.

5)      Post Mortem and Toxicology Reports

6)      JHR Witness Statements x 3.

7)      Dr Jaydeokar correspondence.

8)      Dr Jaydeokar’s Witness Statement

9)      Dr Prasad Witness Statement

10)  Lola Odukomaiya 's Witness Statement and weight chart.

11)  Drug / Weight chart

12)  Selected  Medical Reports on Harry

13)  Mental Capacity Act 2005- Summary

14)  Three new studies on psychiatric drugsdangerous and no benefit.

15)  Wikipedia excerpts – Adverse effects of Chlorpromazine(CPZ), Citalopram, Zopiclone.

16)  Citalopram warning.

17)  Dr Mitchell broadcast BBC R4

18)  ‘All in the mind’ 4/10/11 – transcript.

19)  Articles by Dr Mitchell.

20)  Experts' Reports:

a)      Dr Clifford

21)  b)Dr Radley

22)  c) Professor Singh.

23)  List of Witnesses at the Inquest hearing 4/1/12

24)  Transcript of Inquest hearing.

25)  Conclusion-Care Competence and Accountability.

26)  Paintings by Harry.

27)  Ref: Harry's Story - A Brilliant Boy’s Short Life.          

 

 

 

Introduction

 

The Inquest on Harry Horne Roberts our most beloved son was held on 4th January 2012. Harry died suddenly in his sleep and without warning on 16th December 2009.

 

Harry was born on 29th June 1989, a most beautiful baby boy. He achieved 10/10 on his Apgar Test scores shortly after birth. We his parents were overjoyed.  There was no cause for concern in Harry's first year, and indeed he was ahead in all his milestones. He crawled early and walked at 11 months. At the same time he acquired a few words of speech-Dada, Mama, Apple, Watch and Ball.

 

Then he regressed and lost eye-contact following an MMR jab given at just under one year; as Jennifer his mother was due to give birth to Francesca, her second child, by Caesarean section in July 1990, and might been called up to hospital at any time. Harry received the MMR jab on 20th June 1990. Afterwards Harry's speech did not develop and he lost  eye-contact. Francesca was born healthy, a beautiful baby girl, and our joy had seemed complete. However it gradually dawned on us that all was not well with Harry's development. We believed he suffered from the effects of his MMR jab, to which he had responded with a very high temperature, and high pitched screaming; soon coming out in large purple spots all over his body. His GP thought he was allergic the penicillin Amoxycillin given to him in response to the adverse reaction to MMR jab, Pluserix.

 

The tragic story of Harry's developing autism, and how we all struggled as a family to bring him up is told in our Book 'Harry's Story a Brilliant Boy's Short Life', which can be found on the internet at

www. trust-for-autism.org.uk/HarrysStory/Home.pdf.

That Book tells the story of the development of Harry's many talents- as an artist, musician, model-maker, film maker and computer expert - despite his terrible disability.

 

In the present Book we tell the even more tragic story of Harry's sudden death in care, where he lived from the age of 18 years and two months because we could no longer keep him safe and because caring for him 24/7 became beyond our powers.

 

Harry always wanted to return home to Cheverton Road, but the heartbreak of our original decision to place him in supported accommodation nearby was compounded by our inability to see him return to our constant care, immeasurably as we loved our darling brilliant boy.

 

Harry made very good progress at the Bridge School where he spent three years  as a 6th former until he was 19, latterly at the fine new school in Carleton Road, Holloway, Islington near where we live .

 

Aged 18 years and two months when he went to live in supported accommodation at Myddleton Road, Wood Green, three miles from where we live,  Harry settled in quite well. He was distressed to leave school a year later, and kept asking us when he could go to 'the new studio school'. He attended the Daylight Day Centre at Highbury Islington for two days a week. Yet for the highly intelligent Harry, though the staff there were so good to him and did much creative work with him,  two days a week was never enough .

 

We took him each Saturday and Sunday to the libraries, museums, the Zoo - all of which he loved;  and on weekdays swimming, trampolining and to the parks, as well as on more library visits. Harry had a wide variety of intellectual interests including natural history, animals, space and the universe, science, geology and the weather and history, and borrowed and bought many CD-Roms and books as well as favourite films, both scientific and children's stories.

 

We kept urging his carers at Hillgreen Care Ltd ('HCL'), Myddleton Road, to reduce his weight. He was a compulsive compensatory eater mainly of carbohydrates. HCL brought his weight down by over 20 kilos; then it began to climb again. We  appealed to them as well as to his psychiatrist Dr Jaydeokar and to GP Dr Prasad to help deal with his problems including especially his weight.

 

When we asked for weight reports his one-to-one carer Dayo would mumble something we couldn't understand. His English was poor but as he was devoted to Harry we did not press him. Keith asked other carers but their language was a barrier in this respect also.

 

Harry was attending art lessons twice weekly at the Hoffmann Art Foundation in Wood Green, paid for by us, with their artist in residence Ian Wilson. He made good progress there and produced original art works. He had some six exhibitions of his work, starting with one at East Finchley Library when he was at secondary school in Barnet. In the summer of 2007 his exhibition of art work was Lauderdale House, Waterloo Park, Highgate, London. A Preview for a joint exhibition with the Hoffmann Foundation  was packed with friends. Harry was always the most loveable boy and many people warmed to him. Other exhibitions were held at London libraries as well those at his schools.

 

Keith and Jennie took Harry out on the weekend of the 12th and 13th December 2009. on Saturday it was the Zoo as usual; and on Sunday we took Harry to High Beech, Epping Forest for a walk. Harry bounded along picking dead leaves from the trees and  from the ground, together with sticks. He seemed well and full of life. Jennie noted with alarm that he seemed to have put on more weight when she put her arms around his tummy to hug him.

 

On the morning of the 16th December came the earth-shattering news that Harry had passed away in his sleep early that morning, apparently from heart failure. Jennie’s world stopped. She had lost her immeasurably loved first born son, the wonderful, brilliantly gifted but injured and vulnerable Harry.

 

Harry had known he was autistic, as the Tavistock Centre told us when he was six. “What’s wrong with Harry's brain?” he would ask and say quite often “Harry is sad” “Harry is crying”.

 

For his short and most tragic life our tears will never cease.

 

St Michael's Church, Highgate, was packed with friends for Harry's funeral on the 4th January 2010. His music teacher Lucy sang his favourite ‘The Snowman  Song’. His teacher Peter and carers Hannelore and Kristin gave fulsome tributes to the boy they had come to love . Keith gave the address. The service   conducted by the Vicar the Reverend Prebend Jonathan Trigg, concluded with the theme tune from the film Hercules – ‘I have often dreamed of a far-off place where a hero's welcome will be waiting for me’.

 

May he rest  in peace in heaven, our most beloved Harry, until we trust and pray we shall meet up with him again .

 

Harry was laid to rest in Michael's Memorial Garden in June 2010 the month of his 21st birthday. A bench to his memory was consecrated there by the Vicar in June 2011. We hope to install a stained-glass window to his memory in the beautiful St Michael's Church, subject to approval by the Vicar and the PCC, following his Inquest which concluded on 4th January 2012.

 

This book tells the story of the Inquest, Harry's Inquest, and the  evidence presented at it.

 

It emerged only after his death that Harry was given Citalopram from October 2008. Jenny was told he was on Citalopram at his Review on 9th March 2009. She was told it was a  tranquilliser for anxiety, which her GP confirmed. As Harry was always very anxious, with episodes of high anxiety once or twice a week this was accepted as benign.

 

Only after Harry's death was it disclosed to us his parents  that he was given Chlorpromazine, a powerful anti-psychotic drug prescribed by his Mental Health Trust  psychiatrist, from 13th February 2009. We were beyond horrified as our researches told us that it could cause sudden death, massive appetite increase and metabolic weight gain. Citalopram too, it has since been discovered, can cause sudden death as well as weight fluctuation. During Harry's time on these drugs his weight had rocketed again by nearly 20 kilos.

 

What follows is the evidence presented to the Inquest, and the transcript of that Inquest, as well as, at the start of the Book,  the Coroner's Verdict .

 

 

 

 

 

Parents’ tragedy as autistic son found dead in Haringey care home

Sarah Collings, Reporter Monday, January 9, 2012 
6.05 PM

The parents of an autistic boy who died suddenly in care have spoken of being “let down” by the multiple doctors and services who failed to prevent the tragedy.

Harry Horne-Roberts was just 20-years-old when he died two years after moving into Hillgreen Care home in Haringey.

There had been no indication that anything was wrong and just days before his death he went walking with his parents in Epping Forest and was his usual bouncy self.

But on December 16, 2009 at 7am he was found face down on his bedroom floor and pronounced dead at 10.30am.

Coroner Dr Andrew Walker of Barnet Coroner’s Court ruled the 22-stone teenager’s death was due to a heart attack linked to obesity at an inquest on Wednesday last week (January 4).

But Harry’s parents, Jennifer Horne-Roberts and Keith Roberts, claimed strong anti-psychotic drugs he was given without their knowledge were responsible.

They claim his three stone weight gain during 15 months in care was due to the drug chloropromazine and that the boisterous 6t-teen was given the drugs without their knowledge.

Before he moved to the care home, Harry had been exuberant and regularly took part in sports and outings.

His parents took the “heartbreaking” step to put Harry into care to increase his independence, but claimed during the inquest they were instead locked out of his treatment with “catastrophic consequences”.

They only learned that he was on the drug when a carer let the information slip in March 2009 and then wrote four letters to Harry’s psychiatrist without receiving a reply.

During the inquest psychiatrist Dr Sujeet Jaydeokar said: “There was a breakdown of communications.”

He added: “With hindsight it would have been better if we had copied you into the letters. We have now changed our practice and now copy all letters to family members.”

Haringey Mental Health Trust acknowledged its failure to implement a dietician-led weight loss programme.

The trust has now implemented new processes to improve the outcome for obese patients with learning disabilities.

Coroner Mr Walker said in a narrative verdict: “What he [Harry] needed was a programme to reduce his morbid obesity. If he had that, he might have had a chance.

“The absence of a dietician-led program to reduce his morbid obesity caused his death.”

His parents, who are both in their 60s and live in Cheverton Road near Archway, plan to publish a book telling the story of Harry’s inquest and to exhibit his films and artwork to keep his memory alive.

His mother, a barrister, said after the inquest: “We feel completely let down by the inadequate policies in place. No-one took responsibility.

“We continue to be devastated by the loss of our darling boy Harry. He was and always will remain our most beloved, beautiful son.”Mrs Horne-Roberts continues to campaign for the withdrawal of the combined MMR vaccine, which she believes caused Harry’s autism.

 Dieting and exercise ‘could have saved obese artist’s life’

Dieting and exercise could have saved Harry’s life, says coroner

Published: 06 January 2012
by PETER GRUNER

IN an historic verdict, a coroner has recorded that lack of treatment for obesity was the likely cause of death for a talented young artist from Upper Holloway who was autistic.

Coroner Andrew Walker said he would consider issuing a nationwide warning to health authorities following the tragic death of 20-year-old Harry Horne-Roberts in a care home.

Recording a narrative verdict at the resumed inquest into the death of Mr Horne-Roberts, from Cheverton Road, Mr Walker said it was his firm belief that the young man would have been alive today if the care home in Haringey had employed a professional dietician and provided a proper exercise regime.

The inquest highlighted the serious lack of capability among care workers in dealing with rising obesity and its effect on young people with learning difficulties, who are often compulsive and “comfort” eaters.

Harry, a popular and gregarious young man, died of heart failure in his sleep on December 16, 2009.

He was 5ft 11in and weighed 20 stone.

A former pupil at The Bridge School in Holloway, he was 18 when he moved to supported accommodation at Hillgreen Care Home in Tottenham, where he subsequently died.

His mother, Jennifer Horne-Roberts, a barrister, and her architect husband Keith questioned witnesses at the day-long inquest in Barnet on Wednesday.

The couple had called for an inquest into the death of their son because of their lack of satisfaction with an earlier coroner’s report in 2010, which concluded that their son died from natural causes.

The court heard that Harry, described as “highly intelligent”, had been given a powerful anti-psychotic drug, Chlorpromazine, to calm him down prior to his death.

The medication had been administered despite the fact that he was not psychotic and there had been no consultation with his parents as was the rule under the Mental Capacity Act.

Despite a high blood pressure reading taken by the care home’s GP, there had been no follow-up readings, which is the normal practice.

Pathologist Professor Rupert Risdon, who examined Harry following his death, found fatty tissue around the heart, a sure sign of obesity.

“I could see, however, no signs of damage as a result of drugs given to the young man,” he said.

“My view was that Harry died from heart disease related to obesity.”

Dr Jane Radley, a consultant psychiatrist at the home, said she accepted that parents should have been consulted before Harry was given drugs, but it may not have made any difference to the outcome.

She added: “We did not notice evidence of significant side-effects from the medication or evidence that it might cause weight gain.”

The home’s GP, Dr D Prasad, said he had looked forward to meeting Harry and was extremely sorry when he died.

“We did discuss his weight with care workers and there were signs it was coming down,” he said.

“I think everyone did all they could. But I agree that someone specifically should have been more responsible for seeing that he maintained a balanced diet and exercised regularly.”

The court heard that Haringey Primary Care Trust had done much to improve facilities in care homes since Harry’s death, including putting more emphasis on diet and exercise.

Speaking after the case, Mrs Horne-Roberts welcomed the coroner’s verdict, even though he had not accepted that the drugs might have contributed to Harry’s death.

“I think it’s over now,” she said.

“His weight did clearly contribute to his death and this should have been monitored.

The fact that his weight was high for so long and nothing was done about it shows what we would call neglect, although it doesn’t fulfill the legal definition.

“We can’t bring Harry back and it was a desperate time for us. But we can at least ensure it doesn’t happen to other people with special needs.”

There is a memorial bench to Harry at St Michael’s Church, Highgate, and his name will be included on a stained glass window. He had exhibited his work throughout London.

A new e-book, Harry’s Story, has been written and the Horne-Roberts are planning to write about the two inquests into his death.

Mr Horne-Roberts said that, with autism on the increase, there is a big concern about what happens to young people with special needs after they leave school.

“When Harry left school it was like he fell off a cliff,” he said.

“He loved Bridge School and was very engaged.

There was very little to do after he left.

All he had was a day centre in Islington for two days a week.”

Harry’s Story – A Brilliant Boy’s Short Life is on the internet at www.trust-for-autism.org.uk/HarrysStory/home.pdf.

Parents’ tragedy as autistic son found dead in Haringey care home

Sarah Collings, Reporter Monday, January 9, 2012 
6.05 PM

The parents of an autistic boy who died suddenly in care have spoken of being “let down” by the multiple doctors and services who failed to prevent the tragedy.

Harry's parents Jennifer Horne-Roberts and Keith Roberts with some of Harry's art work. Picture: Nigel Sutton

Harry Horne-Roberts was just 20-years-old when he died two years after moving into Hillgreen Care home in Haringey.

There had been no indication that anything was wrong and just days before his death he went walking with his parents in Epping Forest and was his usual bouncy self.

But on December 16, 2009 at 7am he was found face down on his bedroom floor and pronounced dead at 10.30am.

Coroner Dr Andrew Walker of Barnet Coroner’s Court ruled the 22-stone teenager’s death was due to a heart attack linked to obesity at an inquest on Wednesday last week (January 4).

But Harry’s parents, Jennifer Horne-Roberts and Keith Roberts, claimed strong anti-psychotic drugs he was given without their knowledge were responsible.

They claim his three stone weight gain during 15 months in care was due to the drug chloropromazine and that the boisterous 6t-teen was given the drugs without their knowledge.

Before he moved to the care home, Harry had been exuberant and regularly took part in sports and outings.

His parents took the “heartbreaking” step to put Harry into care to increase his independence, but claimed during the inquest they were instead locked out of his treatment with “catastrophic consequences”.

They only learned that he was on the drug when a carer let the information slip in March 2009 and then wrote four letters to Harry’s psychiatrist without receiving a reply.

During the inquest psychiatrist Dr Sujeet Jaydeokar said: “There was a breakdown of communications.”

He added: “With hindsight it would have been better if we had copied you into the letters. We have now changed our practice and now copy all letters to family members.”

Haringey Mental Health Trust acknowledged its failure to implement a dietician-led weight loss programme.

The trust has now implemented new processes to improve the outcome for obese patients with learning disabilities.

Coroner Mr Walker said in a narrative verdict: “What he [Harry] needed was a programme to reduce his morbid obesity. If he had that, he might have had a chance.

“The absence of a dietician-led program to reduce his morbid obesity caused his death.”

His parents, who are both in their 60s and live in Cheverton Road near Archway, plan to publish a book telling the story of Harry’s inquest and to exhibit his films and artwork to keep his memory alive.

His mother, a barrister, said after the inquest: “We feel completely let down by the inadequate policies in place. No-one took responsibility.

“We continue to be devastated by the loss of our darling boy Harry. He was and always will remain our most beloved, beautiful son.”Mrs Horne-Roberts continues to campaign for the withdrawal of the combined MMR vaccine, which she believes caused Harry’s autism.

 WITNESS STATEMENT:

 

Jennifer Horne-Roberts, Barrister, of 81 Cheverton Road London, N19 3BA the mother of Harry Horne-Roberts will say as followers:

 

1. Harry was born on the 29 June 1989 after a normal pregnancy, a most beautiful baby boy. He achieved 10/10 on his Apgar tests after birth, and made excellent progress in his first year. He was ahead on all his milestone.

 

2. Friends and relatives would remark  what a particularly beautiful boy he was. I exhibit a picture of Harry as a baby. 

 

3. Francesca was born on the 24th July 1990 also a beautiful baby. Our joy might seem complete. Shortly before that, on 20th June 1990, Harry's GP approved  that he had his MMRjab, as I was going into hospital shortly before Francesca's birth. There was a measles scare on.

 

4. Harry had a very bad reaction to his MMR jab, with high-pitched screaming and very high temperature. Doctor gave him Amoxycillin. Soon after large purple spots appeared all over his body. His GP thought he must be allergic to the amoxycillin which is penicillin based. This turned out not to be the case as future doses of penicillin revealed.

 

5.After that Harry lost the few words of speech he had  had "apple, watch, ball". We gradually noticed that his eye contact was poor also. Francesca progressed normally; she was as the paediatrician said at her birth "perfect". When he was two years two months the health visitor expressed concern when Harry did not respond to her calling his name. Tests followed which revealed Harry to have some of the symptoms of autism. The Tavistock Centre confirmed however that Harry was imaginative and highly intelligent. He was not classically autistic but had regressive or late onset autism.

 

6. US expert doctors confirmed in recent years from extensive bio-testing of Harry that his Autism was they believe caused by the MMR jab he received aged one year.

 

7. Harry went to special schools after a brief spell at St Michael's London N6 a  mainstream primary school, attended by Francesco also.

 

8. He went to Moselle primary school N17 then Oak Lodge secondary school N3 then the 6th form of The Bridge School in Islington these were all SEN schools. He made good progress there. At Oak Lodge his ICT, music and art especially flourished. He got an entry-level GCSE in art, and had several art exhibitions at London venues. We exhibit the notice of his art exhibition at East Finchley Library in 2006, as well as examples of Harry's art work. Harry had very lively intellectual interests and collected books and visited libraries to get CD-Roms and DVDs on natural history, dinosaurs, and space and the universe, nature science and history; and loved films including Disney films. Indeed five years ago he taught himself to make  films on the computer at home, using some of his own graphic images as well as music he composed in addition to other favourite images and sound tracks. He made 15  four-minute films.  Harry was also extremely good at model-making.

 

9.When Harry left The Bridge School his final report and music report were good. I exhibit these.

 

10. Harry was a handful at home and Keith his father and I had to sleep in a shift system so that one of us was awake and alert whenever Harry was up at night or late or early as he often was. Autistic children are extremely challenging and difficult to bring up, and Harry was no exception in this respect.

 

11.He would try to escape as he was adventurous. Once we had an air-sea rescue of  Harry from the cliffs at Hastings where my late mother lived. We had wonderful holidays with the children there eight times per year until 2004 when my mother moved into care. After that we took the family holidays at Rye Bay.

 

12.Francesca was very good with Harry and made excellent progress despite the difficulty of growing up with an autistic sibling. She is now a scholar at Leeds University.

 

13.On one occasion of the 10 or so when Harry escaped from home over the years, he was found trying to swim across the Thames near Waterloo wearing pea jacket and trainers. He was fished out of the Thames by the river police and kept overnight in St  Thomas's Hospital. We were not aware where he was until the next morning. We were beside ourselves with worry.

 

14. When Harry was over 18 we very reluctantly agreed he should go into Supported Accommodation nearby, with us taking him out 4 or 5 times a week, which we always continued to do. I attach the Schedule of our outings with him throughout his time at Hillgreen. We had made the decision because Harry had been able to outrun us and we could no longer keep him safe 24/7. Also he needed to prepare for a life when we were no longer there to care for him as we thought. At Hillgreen Care Harry had a young fit strong one-to-one carer and staff on duty and awake 24/7.

 

15.My Bar practice and Keith's architecture practice had suffered from the need to be constantly at home for Harry. From an early age no child carer could cope with autism. One of the cases I did was the US/Omnibus MMR/Autism cases, in 2007-2008. I advised on expert evidence in the cases generally from the UK. We won some of these cases lost others. An expert witness in one of the lead cases Dr.Bradstreet of Florida, examined Harry's bio samples in the US and concluded that Harry’s regressive/late onset autism was caused by the MMR jab. He recommended small nicotine patches which he said would help calm Harry, improve his speech and make him less inclined to run off. Harry was on these from September 2008 and they seemed successful. Harry was due to have more tests done this year.

 

16. The worst feature of Harry's condition had always been his extremely high anxiety,  which is a common feature of autism. He became slightly calmer after adolescence and with the effect of the patches.

 

17. We had been planning for an expert US doctor to come to the UK and treat Harry and others. Some young people with regressive/late onset autism had been cured in the US. We hoped that Harry, who everyone agreed was a brilliant boy despite his autism, could be cured and perhaps lead a more independent life as an artist, musician,  and computer buff eventually. He had talents in all these fields. He could read and write and speak very well and had extensive vocabulary its use limited only by his condition.

 

18. Apart from his anxiety Harry was the most gentle sweet natured lovable boy, as all his teachers and carers confirm. Lola his housemother at Hillgreen Care referred to him as "our little darling" as he was so loved by staff there. We attach the testimonial to Harry written after his death by Dayo, Harry's one to one who was greatly attached to him.

 

19. We attach the letter written by Dr Hagen, Harry's dentist for many years.

 

20. Harry had a very restricted self-limiting diet that was mainly carbohydrate based. Although he would eat chicken nuggets, pepperoni, apples nuts and raisins, attempts to get him to the fresh meat fruits and vegetables regularly met with little success. When very young we worried that he ate so little. He gradually put on weight becoming a somewhat compulsive eater of the diet including toast and Marmite, pepperoni pizzas cereals and crisps and other carbohydrates.

 

21.In the last few years of his life Harry who was 5ft 11 inches tall with a large frame was over 20 stone in weight. We were extremely concerned. We and Hillgreen were addressing this by limiting his intake as best we could; with limited success. He should never have been prescribed anti-psychotics which increase appetite and weight. Also he was never psychotic certainly not manic only anxious which is a common feature of his regressive/late onset Autism. While he lived with us he was on no medication; apart from two weeks in 2006 when he was adolescent and troubled by extremely hot weather when he was prescribed Risperidone by his then psychiatrist Alex Sales, of the Northern Health Centre in Islington. His agitation at that time was resolved successfully.

 

22. We were always very actively involved in Harry's health care including his therapy at the Tavistock Centre during his primary school years several times weekly. We asked to be fully involved in his medical and dental care when he was at Hillgreen and sometimes attended the dentist and his GP with him and his carer. However we were not always told about visits so could not therefore attend. We visited his psychiatrist Dr Jaydeokar with Harry in December 2007.  Keith told the doctor then that Harry was not born autistic but became so on his MMR jabs. He was also told later that Harry was on nicotine patches described by US Dr. Bradstreet from September 2008. We did not hear further from the Dr.J. We attended once at Hillgreen during 2008 when the doctor was due to visit in an attempt to see him. He was late and by the time we returned less than half-an-hour later he had left notwithstanding that we had left instructions for us to be contacted on our mobile phone. We never received replies to our letters which we sent in March and May 2009 which we exhibit.

           

23.We were utterly horrified to learn after Harry's death that he had been prescribed anti-psychotic medication Chlorpromazine from February 2009: we never informed or consulted contrary to the Mental Capacity Act 2005. Harry was unable to consent to any treatment by reason of his disability. Also Harry was not tested in any way, including a mental capacity test as required by the Act. Harry's weight further required that he be given heart tests before prescribing anti-psychotic medication. We do not accept the such medication was appropriate for Harry at any time.

 

24. At Harry's Islington Social Services Review on 9th March 2009 I asked about Harry's medication and Lola the housemother told me that he was on Citilopram. She did not tell me he was on Chlorpromazine at any time. I had looked up Citilopram and it did not seem at all dangerous from what I read. After Harry's death we learned from Wikipedia and other sources that Chlorpromazine can lead to sudden death and heart failure which is what happened Harry on 16th December 2009. Harry should never have been prescribed drugs with such risks attached.

 

25. On 13th December 2009 we had taken him on an outing to Epping Forest. He was bounding along picking leaves from the trees and from the forest floor, which was a habit of his: he seemed in very good health. He had only ever had one or two colds in his whole line and no other physical ailments. It always seemed perfectly physically healthy. We were however very concerned about his weight and determined that it should reduce. We often spoke to Hillgreen staff about the need to reduce his weight and they would tell us when his weight came down. However his weight did not reduce in the last months of his life.

 

26. Harry was always most gentle and sweet natured but sometimes very anxious. He was extremely lovable and a brilliant mind behind his autism. He had great talent in art music and computers despite his autism. He is unique and irreplaceable our most darling boy. We have lost our beautiful boy and are totally heartbroken as is Francesca his sister and all our family. RIP Harry.

 

This Statement is true........................................................

 

Dated...................................................................................

 

Signed...........................................................................................

11 March 2010

2nd Witness Statement of Jennifer Horne-Roberts

 

I Jennifer Horne-Roberts, barrister and mother of Harry Horne-Roberts RIP, of 81 Cheverton Road London N19 will say as follows:

1

As regards the Statement of Dr. Jaydeoker of 25th June, 2010 Bundle document No. 2. at page two. St Ann's Hospital assessment was wrong in that Harry was very imaginative see Albert Reid’s assessment of January 1993 already referred to. As regards to prescribing by Dr Sales of Risperidone Harry was adolescent at the time and the weather was extremely hot, which distressed him.

2

As regards his weight we have an open plan kitchen and it was extremely difficult for us to stop Harry taking food when he wanted it. He had a self restricting mainly carbohydrate diet. We were most concerned about his weight and relied on Hillgreen Care to bring it down, which they did until 2008 when he was 125kg (see the weight chart appended to Lola’s statement #48. Once on the  medication, Citilopram, then Zopiclone and Chlorpromazine (CPZ), his weight rocketed. The first of these drugs causes weight fluctuations; the third  increases appetite to ravenous levels and so causes massive weight gain. It was reckless to prescribe these drugs for Harry in view of his weight. It was also illegal under the Mental Capacity Act 2005 as we his parents should by law have been consulted.

Hillgreen Care and Dr Prasad are in breach of the law at in that respect and they too were reckless in his treatment.

3

Hillgreen Care would never answer us whenever in 2009 we asked about Harry's weight. Some of the staff including Dayo his one to one were extremely difficult to understand. They had a duty to care for Harry which they flagrantly breached by allowing his weight to rocket.

4

Dr Prasad said in his statement that the CPZ given to Harry was “a therapeutic dose “ but that is not accepted. CPZ was a danger to Harry's health and heart  both in itself and in encouraging his weight gain. He too was reckless in prescribing CPZ and the other drugs and reckless in not performing Tests before and during administration of the drugs, in breach of Guidelines. He was also in breach of the law in not consulting us, Harry's parents. Moreover we could have assisted with any testing, as occurred whenever Harry was treated while he lived with us for example at the Royal Free Hospital.

5

The Daily Medical Logs kept by Hillgreen Care show his behaviour did not improve on medication, indeed it worsened. See Exhibit JHR’s schedule from Daily Logs. Harry as a late  onset autistic person was always anxious; which is a feature of his condition. He needed careful management to help allay his anxiety not dangerous medication. We had generally managed without medication while he lived with us, apart from two weeks on Risperidone aged 16. He went into supported accommodation to be helped when we could no longer guarantee his safety, not to be chemically coshed.

In reply to our letter to Dr. Jaydeoker of March 2009,  in his letter of 27th March 2009 he stated that Harry was anxious. He made no mention of medication.

6

I asked what medicine Harry was on when medicine was referred to at his  review of 9th March 2009. Lola replied Citalopram when in fact  he was already on CPZ. I asked my GP about Citalopram and she referred to the British National Formulary and said it was for anxiety. I therefore accepted it as benign. I did not know about adverse side-effects of drugs, or that Wikipedia held information about drugs on the Internet at that stage. Only after Harry's death were we advised to refer to Wikipedia, having discovered to our utter horror the dangers of CPZ. We then discovered that all the drugs that  Harry was prescribed have dangerous side-effects. It is a clear inference that the drugs especially CPZ increased Harry's weight thereby killing him and/or killed him directly.

7

Keith had asked staff about medication but never got a straight answer  from the Hillgreen care staff. As Lola says in her Witness Statement I was against any medication for Harry. Did Hillgreen Care deliberately conceal the truth from us  and deceive us on this? Ditto Dr. Jaydeoker.

8

I contend again that Dr. Jaydeoker , Dr Prasad and Hillgreen Care were all reckless in their treatment of Harry, and that the latter two were complicit in the his murder by Dr. Jaydeoker. He recklessly prescribed drugs which killed our beloved Harry. That is murder.

9

Lola's witness statement is a travesty of the truth. She exaggerates Harry's challenging behaviour. He was merely anxious and needed kindness. Three weeks before Harry died she told me all ladies at Hillgreen Care  were smitten by Harry as he was so lovable, and referred to him as “our little darling”.

10

Dayo Harry's one-to-one wrote a Testimonial after Harry's death which is an exhibit to my first witness statement. This testimonial is a true representation of  Harry's loveable and benign nature. His anxiety needed sympathy and careful handling which is what Hillgreen Care were paid very handsomely to provide

11

Citalopram which Dr. Jaydeoker said causes hypomania was we believe the cause or contributed to Harry's behaviour when on Boxing Day 2008  he jumped out of the Zoo into the Regents Canal while with us. We did not know then that he was on any medication.

12

We were never at any time consulted or informed of any of Harry's medication; except on 9th March 2009 at Harry's review when Lola informed me that  Harry was on Citalopram. We never received a Health Care Plan. We asked for Daily Diet Sheets which we never received. We asked that Harry be given brown bread. We suspected he was fed far too much white bread.

 

 

 

13

We exhibit the print outs from Wikipedia on Zopiclone, Citilopram and CPZ. These print outs make clear the dangerous and horrific side-effects of these drugs.

14

Dr. Jane Radley in her Reports of 23rd September 2010 not does not refer to weight gain us as side-effect of CPZ. Her report is a whitewash and ignores the inevitable side-effects which occurred to Harry. DI Welsh told us it was extremely difficult to find an expert to put anything in writing.

 15

Professor Singh's report will say confirms what we say  about lack of testing and the duty to consult us parents. None of these witnesses has any appreciation of Harry's personality or his brilliant talent . (see photos of Harry as a baby and the Exhibits to my first witness statement also including his school reports newspaper articles Music Report and artwork. We exhibit our book  ‘Harry’s Story  a Brilliant Boy’s too Short Life’ where you can see his wonderful artwork.

16

We note from the interview with Dr. Jaydeoker at number 16 of the Haringey Mental Health Trust Bundle that they he had no line manager and that the administration of the trust was totally inadequate. They too are complicit in  our son's death. See the Trust's Action Plan at their Bundle #1 which recognises their appalling deficiencies while Harry was under their care

17

The Trust and Dr. Jaydeoker, Dr Prasad, and Hillgreen Care were not only grossly negligent , they recklessly caused the death of our darling Harry.

18

We wish this case to be referred to the DPP for the relevant prosecutions to take place i.e. the murder of our son also prosecutions under the Mental Capacity Act 2005.

From the Inquest we seek verdicts of unlawful killing of Harry.

 

19.

Further we seek a police enquiry at Kentish Town Health Centre London NW5 into the circumstances in which our son received his original injuries.

 

Thursday, April 07, 2011

 

Medical Daily Log   Harry Horne Roberts 2007 (2007-2009)

 

27/8/07

Left by parents at 53 Myddleton Road. H behaviour challenging

 

28/8/07

H behaviour challenging.

 

30/8/07

H behaviour challenging (its incident report).

 

6/9/07

H behaviour challenging ( incident report).

 

7/9/07

H behaviour challenging

 

9/9/07

H breaks chair

 

11/9/07

H shouting and hits head  briefly in room

 

15/9/07

H challenging (incident report)

 

23/9/07

H a bit agitated

 

7/10/07

Fire extinguisher knob removed by H (see incident report)

 

8/10/07

H  anxious

 

12/10/07

H behaviour challenging and a broken table leg

 

22/10/07

H agitated

 

24/10/07

H behaviour very challenging while out.

 

5/11/07

H challenging behaviour- internet not working.

 

8/11/07

What medicine is prescribed by a GP for higher temperature?

 

9/11/07

Temperature down.

17/11/07

What medication?

 

19/11/07

ditto?

 

20/11/07

ditto?

 

24/11/07

H very anxious K and J and F away for 4 days in the USA – H absconds. H complains of neck and mouth pains (27/11/ 07?)

 

26/11/07

G.P.  prescribes Paracetamol and Deep Heat.

K and J see H at school went there straight from the airport.

 

28/11/07

J & K saw H

 

2911-07

K and J took H to dentist

 

30/11/07

Internet was broken.

 

1/12/07

H  flooded room.

 

8/12/07

H puts things in to sink - blocks the waste.

 

16/12/07

H agitated and Art lessons.

 

20/12/07

H disabled front door opened it and ran out. Brought back by staff.

 

27/12/07

H agitated.

 

31/12/07

H floods bathroom

 

 

Medical Daily Log   Harry Horne Roberts 2008

 

17/1/08

H disables security door and escapes.

 

18/1/08

flooded bathroom

 

21/1/08

H unsettled and shouting

 

25/1/08

H shouting and banging ahead on Wall

 

3/2/08

broke front door alarm glass

 

7/2/08

H review at the unit - and dropped him off at school later.

 

16/2/08

H breaks plastic plate and puts paper in toilet.

 

1/3/08

H a bit anxious soothed by piano playing.

 

8/3/08

H anxious and noisy

 

23/3/08

H agitated at British Museum with parents.

 

26/3/08

H makes noise.

 

6/4/08

H unsettled shouting.

 

18/4/08

H  to GP ringworm?

2/5/08

Harry on holiday at Rye Bay

 

7/5/08

Harry absconds brought at by police see incident report.

 

12/5/08

Harry prepares scrambled egg and toast

 

21/5/08

H flooded his toilet

24/5/08

H anxious

 

26/5/08

H damaged carpet in toilet-restless

 

31/5/08

H put mattresses in shower –Abi tantrum so H anxious

 

7/6/08

H complains of sore mouth –K and J give Bonjela to staff.

 

24/7/08

 H to Daylight agitated and aggressive to staff. Daylight confifm this?

 

1/8/08

H disabled alarm system at Daylight

 

6/8/08

H restless throughout the night

17/8/08

H restless throughout the night?

 

24/8/08

H noisy and anxious at night.

 

4/9/08

H restless noisy at night and bangs head on wall.

 

10/9/08

H feels weak -Trampoline cancelled. H anxious at night

 

15/9/08

H weak swim cancelled

 

21/9/08

H a bit anxious and noisy

 

25/9/08

H a bit anxious.

 

2/10/08

H a bit agitated but calms down.

 

4/10/08

H spends the day with parents

 

5/10/08

mark on H’s leg

 

8/10/08

With Dad  to the Sobel a bit anxious and noisy

 

11/10/08

H  runs  in and out of toilet shouting in his room

 

14/10/08

H put on Citalopram by Dr J. with effect from this date. Parents not advised.

 

16/19/08

Shouting and agitated in the evening medication given

 

23/10/08

H obsessive re toilet and goes to the office to use the internet H’s internet was broken.

 

23/10/08

H escapes through a window

 

24/10/08

H to toilet frequently and anxious

 

25/10/08

H escapes from the unit.

 

26/10/08

H a bit anxious

 

29/10/08

H’s internet working again.

10/11/08

H leg bruised-reported including to parents

 

11/11/08

Dr J  visit to review medication. Parents not advised.

H to art class a bit anxious but calmed down.

 

12/11/08

H fall no injury found

 

13/11/08

H very anxious.

 

16/11/08

H a bit anxious but calmed down later.

 

19/1108

H anxious jumping as when on the Trampoline.

 

24/11/08

H anxious at the class could not do much work.

 

25/11/08

H anxious at dentists and then allows him to check mouth for sores-Bonjela for sore mouth.

 

 

25/11/08

Art class H a bit unsettled.

 

26/11/08

H  wants to escape while in the garden- staff foiled this.

 

27/11/08

H runs off to shop grabbed chips

 

30/11/08

H tries to get mattress from Abi’s room

 

2/12/08

H unsettled at art class shouting ‘escaping boy’

 

3/12/08

H agitated and tries to run away

 

4/12/ 08

H rearranging his room then calms down

8/12/08

H anxious at art class and then calms down.

 

9/12/08

ditto

 

10/12/08

H anxious and noisy

 

14/12/08

 ditto and banging head on wall

 

15/12/08

Harry shouting re escape

 

16/12/08

H slept and did not go to art 3.30-5.00.

 

21/12/08

H a bit anxious staff calm him down

 

24/12/08

H anxious and noisy

 

26/12/ 08

Harry jumps into the Regents Canal from the Zoo while out with mum and dad

 

28/12/08

Francesca (sister) and Will  (brother) visit H with Dad.

 

Medical Daily Log   Harry Horne Roberts 2009 

 

1/1/09

H upset roof incident

 

3/1/09

H upset

 

7/1/09

H anxious

 

12/1/09

H shouting in bed at evening

 

14/1/09

H planned escape did not succeed

 

18/1/09

H agitated waiting for parents

 

22/1/09

H shouting

 

25/1/09

H anxious-neighbour complained of noise

 

29/1/09

Noise in room

 

5/2/09

H agitated as school bus was delayed

 

13/2/09

Dr J prescribes CPZ for H. Parents not advised.

 

5/3/09

H anxious waiting for school bus.

 

6/3/09

H tries to escape

 

9/3/09

J told in answer in answer to question that H was on Citalopram-words unclear on this page of notes.

 

2/4/09

H unsettled said 'escaping boy'.

 

4/4/09

H agitated to go out again.

 

 

7/4/09

H agitated at art class

 

9/4/09

H sick

 

10/4/09

H complains of stomach upset. Parents get Collis Browns medicine.

 

12/4/09

H complains of stomach pains tired and week

 

21/4/09

H a bit anxious

 

30/4/09

H ran to local shop

 

8-11/5/09

Rye Harbour holiday

 

11/5/09

H a bit anxious at art session

19/5/09

H unsettled wanting to escape from art lesson

 

20/5/09

H aggressive

 

24/5/09

H a bit anxious

 

27/5/09

H a bit agitated

 

28/5/09

H anxious noisy

 

29/5/09

H restless at night to bed late up early

 

1/6/09

H agitated

 

3/6/09

H very anxious-makes hole in wall

 

4/6/09

H shouting mimics animals staff say this was very unusual and they had not experience it for a while.

 

 

8/6/09

H agitated and crying and screaming because Abi swore at staff.

 

9/6/09

H bed broken

 

10/6/09

H anxious and hit head on wall screaming at night.

 

13/6/09

H shouting and play acting.

 

16/6/09

H surfs Internet in his room.

 

17/6/09

H complains of toothache

 

18/6/09

H screaming

 

25/6/09

H agitated because another resident was very noisy

 

26/6/09

H a bit agitated

 

28/6/09

H a bit agitated by IMAX film sound track at Science Museum

 

3-6/7/09

Holiday at Rye Harbour

 

9/7/09

H sleepless and shouting

 

13/7/09

Traffic incident H agitated and wanted to run away

 

14/7/0-9

H rips clothes and very anxious

 

16/7/09

H animated and shouting

 

21/7/09

H agitated for a while

 

28/7/09

H ran to corner shop Art class cancelled H agitated for a while

 

 

30/7/09

H bangs head and shouting

 

2/8/09

H noisy and bangs head

 

 

8/8/09

H a bit anxious

 

10/8/09

H 'on his best behaviour'

 

16/8/09

H a bit anxious and shouting

 

21/8/09

H briefly agitated

 

2/9/09

H screened and shouted and hit head on wall

 

4-7/9/09

Rye Harbour holiday

 

10/9/09

H not allowed into lounge. H screaming ‘as he occasionally does’.

 

13/9/09

H a bit anxious and agitated. Shouting and vocalising. Later calmed down.

 

15/9/09

H challenging, hit head on wall, making lots of noise. Art class cancelled as H said ‘escaping boy’.

 

22/9/09

H became agitated. Shouting at top of voice. H hit out at Nathan. H was moved away. H calmed down eventually.

 

29/9/09

H hit Dayo with fist at art class; so art class was cancelled.

 

01/10/09

‘H acting and talking accompanied with some violence’

 

2 to 5/10/09

To holiday at Rye Harbour with parents.

 

19/10/09

H ‘sounds with mouth’ during TV in lounge.

 

23/10/09

H ‘a little anxious’ but later calms down.

 

26/10/09 am

H ‘demanded for assistance in personal care’.

 

29/10/09 am

H ‘approached staff for assistance with his personal care’

 

31/10/09

H to 81 Cheverton Rd (home) for overnight stay at Haloween.

 

2/11/09

‘H claimed his Dad was bringing a wedding cake’

 

3/11/09

H desepate for art class Ian Wilson was running late. ‘H kept going on about wanting a wedding cake’

 

5/11/09

H thought he was traveling today.

 

9/1109

H very agitated so his art class was cancelled. Later H blowing up balloons and singing.

 

15/11/09

H ‘heard at about 10.30 pm shouting in his room as usual’.

 

19/11/09

‘H was a bit anxious but later calmed down’

 

23/11/09

H unsettled at art class

 

25/11/09

H a bit anxious at art class, but later calmed down.

 

 

26/11/09

H a bit anxious

 

27/11/09

H back from Daylight no coat or shirt

 

28/11/09

H to 81 Cheverton Rd (home) for overnight stay

 

29/11/09

H a bit agitated

 

30/11/09

H wets bed

 

1/12/09

H a bit anxious at art

 

6/12/09

'H has been doing fine'

H screamed at night

 

8/12/09

H anxious and unsettled at art class after his giraffe painting.

 

10/12/09

H a bit anxious

 

15/12/09

H refused to stay at art class

 

 

 

 

WITNESS STATEMENT:

 

Jennifer Horne-Roberts, Barrister, of 81 Cheverton Road London, N19 3BA the mother of Harry Horne-Roberts will say as followers:

 

1. Harry was born on the 29 June 1989 after a normal pregnancy, a most beautiful baby boy. He achieved 10/10 on his Apgar tests after birth, and made excellent progress in his first year. He was ahead on all his milestone.

 

2. Friends and relatives would remark  what a particularly beautiful boy he was. I exhibit a picture of Harry as a baby. 

 

3. Francesca was born on the 24th July 1990 also a beautiful baby. Our joy might seem complete. Shortly before that, on 20th June 1990, Harry's GP approved  that he had his MMRjab, as I was going into hospital shortly before Francesca's birth. There was a measles scare on.

 

4. Harry had a very bad reaction to his MMR jab, with high-pitched screaming and very high temperature. Doctor gave him Amoxycillin. Soon after large purple spots appeared all over his body. His GP thought he must be allergic to the amoxycillin which is penicillin based. This turned out not to be the case as future doses of penicillin revealed.

 

5.After that Harry lost the few words of speech he had  had "apple, watch, ball". We gradually noticed that his eye contact was poor also. Francesca progressed normally; she was as the paediatrician said at her birth "perfect". When he was two years two months the health visitor expressed concern when Harry did not respond to her calling his name. Tests followed which revealed Harry to have some of the symptoms of autism. The Tavistock Centre confirmed however that Harry was imaginative and highly intelligent. He was not classically autistic but had regressive or late onset autism.

 

6. US expert doctors confirmed in recent years from extensive bio-testing of Harry that his Autism was they believe caused by the MMR jab he received aged one year.

 

7. Harry went to special schools after a brief spell at St Michael's London N6 a  mainstream primary school, attended by Francesco also.

 

8. He went to Moselle primary school N17 then Oak Lodge secondary school N3 then the 6th form of The Bridge School in Islington these were all SEN schools. He made good progress there. At Oak Lodge his ICT, music and art especially flourished. He got an entry-level GCSE in art, and had several art exhibitions at London venues. We exhibit the notice of his art exhibition at East Finchley Library in 2006, as well as examples of Harry's art work. Harry had very lively intellectual interests and collected books and visited libraries to get CD-Roms and DVDs on natural history, dinosaurs, and space and the universe, nature science and history; and loved films including Disney films. Indeed five years ago he taught himself to make  films on the computer at home, using some of his own graphic images as well as music he composed in addition to other favourite images and sound tracks. He made 15  four-minute films.  Harry was also extremely good at model-making.

 

9.When Harry left The Bridge School his final report and music report were good. I exhibit these.

 

10. Harry was a handful at home and Keith his father and I had to sleep in a shift system so that one of us was awake and alert whenever Harry was up at night or late or early as he often was. Autistic children are extremely challenging and difficult to bring up, and Harry was no exception in this respect.

 

11.He would try to escape as he was adventurous. Once we had an air-sea rescue of  Harry from the cliffs at Hastings where my late mother lived. We had wonderful holidays with the children there eight times per year until 2004 when my mother moved into care. After that we took the family holidays at Rye Bay.

 

12.Francesca was very good with Harry and made excellent progress despite the difficulty of growing up with an autistic sibling. She is now a scholar at Leeds University.

 

13.On one occasion of the 10 or so when Harry escaped from home over the years, he was found trying to swim across the Thames near Waterloo wearing pea jacket and trainers. He was fished out of the Thames by the river police and kept overnight in St  Thomas's Hospital. We were not aware where he was until the next morning. We were beside ourselves with worry.

 

14. When Harry was over 18 we very reluctantly agreed he should go into Supported Accommodation nearby, with us taking him out 4 or 5 times a week, which we always continued to do. I attach the Schedule of our outings with him throughout his time at Hillgreen. We had made the decision because Harry had been able to outrun us and we could no longer keep him safe 24/7. Also he needed to prepare for a life when we were no longer there to care for him as we thought. At Hillgreen Care Harry had a young fit strong one-to-one carer and staff on duty and awake 24/7.

 

15.My Bar practice and Keith's architecture practice had suffered from the need to be constantly at home for Harry. From an early age no child carer could cope with autism. One of the cases I did was the US/Omnibus MMR/Autism cases, in 2007-2008. I advised on expert evidence in the cases generally from the UK. We won some of these cases lost others. An expert witness in one of the lead cases Dr.Bradstreet of Florida, examined Harry's bio samples in the US and concluded that Harry’s regressive/late onset autism was caused by the MMR jab. He recommended small nicotine patches which he said would help calm Harry, improve his speech and make him less inclined to run off. Harry was on these from September 2008 and they seemed successful. Harry was due to have more tests done this year.

 

16. The worst feature of Harry's condition had always been his extremely high anxiety,  which is a common feature of autism. He became slightly calmer after adolescence and with the effect of the patches.

 

17. We had been planning for an expert US doctor to come to the UK and treat Harry and others. Some young people with regressive/late onset autism had been cured in the US. We hoped that Harry, who everyone agreed was a brilliant boy despite his autism, could be cured and perhaps lead a more independent life as an artist, musician,  and computer buff eventually. He had talents in all these fields. He could read and write and speak very well and had extensive vocabulary its use limited only by his condition.

 

18. Apart from his anxiety Harry was the most gentle sweet natured lovable boy, as all his teachers and carers confirm. Lola his housemother at Hillgreen Care referred to him as "our little darling" as he was so loved by staff there. We attach the testimonial to Harry written after his death by Dayo, Harry's one to one who was greatly attached to him.

 

19. We attach the letter written by Dr Hagen, Harry's dentist for many years.

 

20. Harry had a very restricted self-limiting diet that was mainly carbohydrate based. Although he would eat chicken nuggets, pepperoni, apples nuts and raisins, attempts to get him to the fresh meat fruits and vegetables regularly met with little success. When very young we worried that he ate so little. He gradually put on weight becoming a somewhat compulsive eater of the diet including toast and Marmite, pepperoni pizzas cereals and crisps and other carbohydrates.

 

21.In the last few years of his life Harry who was 5ft 11 inches tall with a large frame was over 20 stone in weight. We were extremely concerned. We and Hillgreen were addressing this by limiting his intake as best we could; with limited success. He should never have been prescribed anti-psychotics which increase appetite and weight. Also he was never psychotic certainly not manic only anxious which is a common feature of his regressive/late onset Autism. While he lived with us he was on no medication; apart from two weeks in 2006 when he was adolescent and troubled by extremely hot weather when he was prescribed Risperidone by his then psychiatrist Alex Sales, of the Northern Health Centre in Islington. His agitation at that time was resolved successfully.

 

22. We were always very actively involved in Harry's health care including his therapy at the Tavistock Centre during his primary school years several times weekly. We asked to be fully involved in his medical and dental care when he was at Hillgreen and sometimes attended the dentist and his GP with him and his carer. However we were not always told about visits so could not therefore attend. We visited his psychiatrist Dr Jaydeokar with Harry in December 2007.  Keith told the doctor then that Harry was not born autistic but became so on his MMR jabs. He was also told later that Harry was on nicotine patches described by US Dr. Bradstreet from September 2008. We did not hear further from the Dr.J. We attended once at Hillgreen during 2008 when the doctor was due to visit in an attempt to see him. He was late and by the time we returned less than half-an-hour later he had left notwithstanding that we had left instructions for us to be contacted on our mobile phone. We never received replies to our letters which we sent in March and May 2009 which we exhibit.

           

23.We were utterly horrified to learn after Harry's death that he had been prescribed anti-psychotic medication Chlorpromazine from February 2009: we never informed or consulted contrary to the Mental Capacity Act 2005. Harry was unable to consent to any treatment by reason of his disability. Also Harry was not tested in any way, including a mental capacity test as required by the Act. Harry's weight further required that he be given heart tests before prescribing anti-psychotic medication. We do not accept the such medication was appropriate for Harry at any time.

 

24. At Harry's Islington Social Services Review on 9th March 2009 I asked about Harry's medication and Lola the housemother told me that he was on Citilopram. She did not tell me he was on Chlorpromazine at any time. I had looked up Citilopram and it did not seem at all dangerous from what I read. After Harry's death we learned from Wikipedia and other sources that Chlorpromazine can lead to sudden death and heart failure which is what happened Harry on 16th December 2009. Harry should never have been prescribed drugs with such risks attached.

 

25. On 13th December 2009 we had taken him on an outing to Epping Forest. He was bounding along picking leaves from the trees and from the forest floor, which was a habit of his: he seemed in very good health. He had only ever had one or two colds in his whole line and no other physical ailments. It always seemed perfectly physically healthy. We were however very concerned about his weight and determined that it should reduce. We often spoke to Hillgreen staff about the need to reduce his weight and they would tell us when his weight came down. However his weight did not reduce in the last months of his life.

 

26. Harry was always most gentle and sweet natured but sometimes very anxious. He was extremely lovable and a brilliant mind behind his autism. He had great talent in art music and computers despite his autism. He is unique and irreplaceable our most darling boy. We have lost our beautiful boy and are totally heartbroken as is Francesca his sister and all our family. RIP Harry.

 

This Statement is true........................................................

Dated...................................................................................

Signed...........................................................................................

 

List of Exhibits:

  1. Harry’s Art Work.
  2. Bridge School Reports.
  3. Schedule of Parents Outings.
  4. Letter from Dr Hagen.
  5. Letters from Dr Jaydeokar.

 

Dear Coroner,

Please see below for confirmation that Harry had a clear ECG and Blood Test a very few years before his death.

Both of us clearly recollect this.

Keith and Jennifer.

 

From: Keith Roberts [mailto:keith@horne-roberts.co.uk]
Sent: Thu 22/12/2011 08:48
To: Bramley Val
Cc: Catherine Fox
Subject: Harry Horne-Roberts RIP


Dear Val,
We attach the emails to Harry's GP which you asked for.
Last week we received the medical records from the Coroner. We looked for evidence of the ECG taken a few years ago , which was clear. Ditto a blood test taken at age 18 when he was still at school which was also clear. Unfortunately those records are not with the notes but we recollect them very clearly.
Sincerely Keith and Jennifer

 

Medicines Monitoring Guidelines

Introduction, scope and responsibilities

These guidelines contain the recommended physical health monitoring that is required for somebody taking psychotropic

medication. They do not cover the general physical health monitoring that is also required for people with mental health problems, monitoring of other side effects not associated with physical health or monitoring of medication effectiveness.

The recommendations apply to all people who are prescribed psychotropic medication in whatever setting. The current prescriber of the medication is responsible (in conjunction with the care co-ordinator) for ensuring that the appropriate monitoring is undertaken.

It is important to note that the guidance does not override the individual responsibility of health professionals to make decisions appropriate to the circumstances of the individual service user, in consultation with the service user and/or guardian or carer.

More or less frequent monitoring may be required according to individual circumstances; the reasons for this should be documented clearly. This

may be particularly relevant for children and older people who are more susceptible to medication side effects.

There is growing evidence about the impact that medication may have on the physical health of an individual. If therapy with medication is planned or initiated the following guidance on safe clinical practice around monitoring the physical health of patients taking these medicines should be followed. This is in addition to the general assessment of physical health that should take place before any

medication is prescribed to ensure that medicines are not going to precipitate or worsen a condition.

Should any physical parameter be outside normal ranges or substantially change then further advice should be sought if outside the competency of the prescriber. It is often prudent to re-measure the parameter. If an examination or test is not undertaken the reasons for this should be clearly documented. This could include that the test has been undertaken recently in another setting e.g. primary care or

refused. In the event of a service user refusing an examination or tests, they should be performed as soon as consent is given.

Adverse effects of Chlorpromazine

 

The main side effects of chlorpromazine are due to its anticholinergic properties; these effects overshadow and counteract, to some extent, the extrapyramidal side effects typical of many early generation antipsychotics. These include sedation, slurred speech, dry mouth, constipation, urinary retention and possible lowering of seizure threshold. Appetite may be increased with resultant weight gain, and Glucose tolerance may be impaired.[23] It lowers blood pressure with accompanying dizziness.[15] Memory loss and amnesia has also been reported. Chlorpromazine, which has sedating effects, will increase sleep time when given at high doses or when first administered, although tolerance usually develops.[24] Sleep cycles or REM sleep is not altered by antipsychotics.[25]

Dermatological reactions are frequently observed. In fact three types of skin disorders are observed: hypersensitivity reaction, contact dermatitis, andphotosensitivity. During long-term therapy of schizophrenic patients chlorpromazine can induce abnormal pigmentation of the skin. This can be manifested as gray-blue pigmentation in regions exposed to sunlight.[24]

There are adverse effects on the reproductive system. Phenothiazines are known to cause hyperprolactinaemia leading to amenorrhea, cessation of normal cyclic ovarian function, loss of libido, occasional hirsutism, false positive pregnancy tests, and long-term risk of osteoporosis in women. The effects of hyperprolactinemia in men are gynaecomastialactationimpotence, loss of libido, and hypospermatogenesis. These antipsychotics have significant effects on gonadal hormones including significantly lower levels of estradiol and progesterone in women whereas men display significantly lower levels of testosterone and DHEA when undergoing antipsychotic drug treatment compared to controls.[26] According to one study of the effects on the reproductive system in rats treated with chlorpromazine there were significant decreases in the weight of the testis, epididymis, seminal vesicles, and prostate gland. This was accompanied by a decline in sperm motility, sperm counts, viability, and serum levels of testosterone in chlorpromazine rats compared to control rats. It has been reported that a change in either the absolute or relative weight of an organ after a chemical is administered is an indication of the toxic effect of the chemical. Therefore, the observed change in the relative weight of the testis and other accessory reproductive organs in rats treated with chlorpromazine indicates that the drug might be toxic to these organs at least during the period of treatments. Furthermore, the weights of the kidney, heart, liver, and adrenal glands of these treated rats were not affected both during administration of the drug and recovery periods, suggesting that the drug is not toxic to these organs.[26]

Antipsychotic drugs may cause priapism, a pathologically prolonged and painful penile erection, which is usually unassociated with sexual desire or intercourse. Although this effect is rare it is a potentially serious complication that can lead to permanent impotence and other serious complications.[27]

Even therapeutically low doses may trigger seizures in susceptible patients, such as those with an abnormally low genetically determined seizure threshold, presumably by lowering the seizure threshold. The incidence of the first unprovoked seizure in the general population is from 0.07 to 0.09%, but in patients treated with commonly used antipsychotic drugs it reportedly ranges from 0.1 to 1.5%. In overdose, the risk reaches 4 to 30%. This wide variability among studies may be due to methodological differences. The risk is greatly influenced by the individual's inherited seizure threshold, and particularly by a history of epilepsy, brain damage or other conditions. The triggering of seizures by antipsychotic drugs is generally agreed to be a dose-dependent adverse effect.[28]

Tardive dyskinesia and akathisia are less commonly seen with chlorpromazine than they are with high potency typical antipsychotics such as haloperidol[29] ortrifluoperazine, and some evidence suggests that, with conservative dosing, the incidence of such effects for chlorpromazine may be comparable to that of newer agents such as risperidone or olanzapine.[30]

A particularly severe side effect is neuroleptic malignant syndrome, which can be fatal.[31] Other reported side effects are rare, though severe; these include a reduction in the number of white blood cells—referred to as leukopenia—or, in extreme cases, even agranulocytosis, which may occur in 0.01% of patients and lead to death via uncontrollable infections and/or sepsis. Chlorpromazine is also known to accumulate in the eye—in the posterior corneal stromalens, and uveal tract. Because it is a phototoxic compound, the potential exists for it to cause cellular damage after light exposure. Research confirms a significant risk of blindness from continued use of chlorpromazine, as well as other optological defects such as color blindness and benign pigmentation of the cornea.[32]

Cardiotoxic effects of phenothiazines in overdose are similar to that of the tricyclic antidepressants.[24] Cardiac arrhythmia and apparent sudden death have been associated with therapeutic doses of chlorpromazine, however they are rare cases. The sudden cardiovascular collapse is attributable to ventricular dysrhythmia. Supraventricular tachycardia may also develop. Patients on chlorpromazine therapy exhibit abnormalities on the electrocardiographic T and U waves. These major cardiac arrhythmias that are lethal are a potential hazard even in patients without heart disease who are receiving therapeutic doses of antipsychotic drugs. In order to quantify the risk of cardiac complications to patients receiving therapeutic doses of phenothiazines a prospective clinical trial is suggested.[33]

 

FDA Drug Safety Communication: Abnormal heart rhythms associated with high doses of Celexa (citalopram hydrobromide)

Safety Announcement
Additional Information for Patients
Additional Information for Healthcare Professionals
Data Summary 

 

Safety Announcement

[8-24-2011] The U.S. Food and Drug Administration (FDA) is informing healthcare professionals and patients that the antidepressant Celexa (citalopram hydrobromide; also marketed as generics) should no longer be used at doses greater than 40 mg per day because it can cause abnormal changes in the electrical activity of the heart. Studies did not show a benefit in the treatment of depression at doses higher than 40 mg per day. 

Additional Information for Healthcare Professionals 

·                     Citalopram causes dose-dependent QT interval prolongation. Citalopram should no longer be prescribed at doses greater than 40 mg per day.

·                     Citalopram should not be used in patients with congenital long QT syndrome.

·                     Patients with congestive heart failure, bradyarrhythmias, or predisposition to hypokalemia or hypomagnesemia because of concomitant illness or drugs, are at higher risk of developing Torsade de Pointes.

·                     Hypokalemia and hypomagnesemia should be corrected before administering citalopram. Electrolytes should be monitored as clinically indicated.

·                     Consider more frequent electrocardiogram (ECG) monitoring in patients with congestive heart failure, bradyarrhythmias, or patients on concomitant medications that prolong the QT interval.

·                     20 mg per day is the maximum recommended dose for patients with hepatic impairment, who are greater than 60 years of age, who are CYP 2C19 poor metabolizers, or who are taking concomitant cimetidine (Tagamet®), because these factors lead to increased blood levels of citalopram, increasing the risk of QT interval prolongation and Torsade de Pointes.

·                     No dose adjustment is necessary for patients with mild or moderate renal impairment.

·                     Advise patients to contact a healthcare professional immediately if they experience signs and symptoms of an abnormal heart rate or rhythm while taking citalopram.

·                     Report adverse events involving citalopram to the FDA MedWatch program, using the information in the "Contact Us" box at the bottom of the page.

 

As a result of this thorough QT study, FDA has determined that citalopram causes dose-dependent QT interval prolongation and should no longer be used at doses above 40 mg per day. Important safety information about the potential for QT interval prolongation and Torsade de Pointes with drug dosage and usage recommendations are being added to the package inserts of Celexa and its generic equivalents.

 

 

ALL IN THE MIND –BBC RADIO 4 October 4th 2011.

 

  1. TX  ----What we are really interested in nowadays is our increasing weight and   diabetes as a package. That may explain how patients with serious mental health problems and or diabetes have a serious mortality gap compared to the general population.

 

  1. Mortality gap means that patients actually die up to 20 years earlier than the age matched general population.

 

  1. We thought the mortality gap was due to suicide but we actually know now that death due to miscellaneous clinical conditions outnumbers death due to suicide by at least four to one.

 

  1. One observation of people who have just started their anti-psychotic medication   is that weight gain begins soon after the beginning the anti-psychotic medication.

 

  1. We can notice an effect of weight gain within two to four weeks. This is a good predictor for what weight gain will ensue overall. They (anti-psychotic drugs) are definitely known to have one side-effect, weight gain.

 

  1. Psychiatrists recognise the problem as existing but whether they do anything about it is another question. The problem is that those psychiatrists want to treat the patient with the most effective anti-psychotic drugs and the most effective drugs have what in their perception may have downstream side-effects such as  weight gain.

 

  1. They might think that these could be dealt with later. Unfortunately the literature suggests that the later you intervene the less likely it is that you can offset the weight gain.

 

  1. We looked at two things; whether people were getting monitoring and once the weight gain had been detected whether people were getting the treatment to help reduce weight.

 

  1. In monitoring terms anything that requires a blood test was actually the experience of less than 50 per cent of patients.

 

  1. With mental health patients psychiatrists or specialists are working outside their comfort zone.

 

  1. I personally think the clinician prescribing anti-psychotic drugs should be involved in monitoring the physical health outcomes------.

 

 

Background. Despite increased cardiometabolic risk in individuals with mental illness taking antipsychotic medication, metabolic screening practices are often incomplete or inconsistent.

 

Method. We undertook a systematic search and a PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) meta-analysis of studies examining routine metabolic screening practices in those taking antipsychotics both for patients in psychiatric care before and following implementation of monitoring guidelines.

 

Conclusions. In routine clinical practice, metabolic monitoring is concerningly low in people prescribed antipsychotic medication. Although guidelines can increase monitoring, most patients still do not receive adequate testing.

Received 8 February 2011

 

Adverse effects of Chlorpromazine

 

The main side effects of chlorpromazine are due to its anticholinergic properties; these effects overshadow and counteract, to some extent, the extrapyramidal side effects typical of many early generation antipsychotics. These include sedation, slurred speech, dry mouth, constipation, urinary retention and possible lowering of seizure threshold. Appetite may be increased with resultant weight gain, and Glucose tolerance may be impaired.[23] It lowers blood pressure with accompanying dizziness.[15] Memory loss and amnesia has also been reported. Chlorpromazine, which has sedating effects, will increase sleep time when given at high doses or when first administered, although tolerance usually develops.[24] Sleep cycles or REM sleep is not altered by antipsychotics.[25]

Dermatological reactions are frequently observed. In fact three types of skin disorders are observed: hypersensitivity reaction, contact dermatitis, andphotosensitivity. During long-term therapy of schizophrenic patients chlorpromazine can induce abnormal pigmentation of the skin. This can be manifested as gray-blue pigmentation in regions exposed to sunlight.[24]

There are adverse effects on the reproductive system. Phenothiazines are known to cause hyperprolactinaemia leading to amenorrhea, cessation of normal cyclic ovarian function, loss of libido, occasional hirsutism, false positive pregnancy tests, and long-term risk of osteoporosis in women. The effects of hyperprolactinemia in men are gynaecomastialactationimpotence, loss of libido, and hypospermatogenesis. These antipsychotics have significant effects on gonadal hormones including significantly lower levels of estradiol and progesterone in women whereas men display significantly lower levels of testosterone and DHEA when undergoing antipsychotic drug treatment compared to controls.[26] According to one study of the effects on the reproductive system in rats treated with chlorpromazine there were significant decreases in the weight of the testis, epididymis, seminal vesicles, and prostate gland. This was accompanied by a decline in sperm motility, sperm counts, viability, and serum levels of testosterone in chlorpromazine rats compared to control rats. It has been reported that a change in either the absolute or relative weight of an organ after a chemical is administered is an indication of the toxic effect of the chemical. Therefore, the observed change in the relative weight of the testis and other accessory reproductive organs in rats treated with chlorpromazine indicates that the drug might be toxic to these organs at least during the period of treatments. Furthermore, the weights of the kidney, heart, liver, and adrenal glands of these treated rats were not affected both during administration of the drug and recovery periods, suggesting that the drug is not toxic to these organs.[26]

Antipsychotic drugs may cause priapism, a pathologically prolonged and painful penile erection, which is usually unassociated with sexual desire or intercourse. Although this effect is rare it is a potentially serious complication that can lead to permanent impotence and other serious complications.[27]

Even therapeutically low doses may trigger seizures in susceptible patients, such as those with an abnormally low genetically determined seizure threshold, presumably by lowering the seizure threshold. The incidence of the first unprovoked seizure in the general population is from 0.07 to 0.09%, but in patients treated with commonly used antipsychotic drugs it reportedly ranges from 0.1 to 1.5%. In overdose, the risk reaches 4 to 30%. This wide variability among studies may be due to methodological differences. The risk is greatly influenced by the individual's inherited seizure threshold, and particularly by a history of epilepsy, brain damage or other conditions. The triggering of seizures by antipsychotic drugs is generally agreed to be a dose-dependent adverse effect.[28]

Tardive dyskinesia and akathisia are less commonly seen with chlorpromazine than they are with high potency typical antipsychotics such as haloperidol[29] ortrifluoperazine, and some evidence suggests that, with conservative dosing, the incidence of such effects for chlorpromazine may be comparable to that of newer agents such as risperidone or olanzapine.[30]

A particularly severe side effect is neuroleptic malignant syndrome, which can be fatal.[31] Other reported side effects are rare, though severe; these include a reduction in the number of white blood cells—referred to as leukopenia—or, in extreme cases, even agranulocytosis, which may occur in 0.01% of patients and lead to death via uncontrollable infections and/or sepsis. Chlorpromazine is also known to accumulate in the eye—in the posterior corneal stromalens, and uveal tract. Because it is a phototoxic compound, the potential exists for it to cause cellular damage after light exposure. Research confirms a significant risk of blindness from continued use of chlorpromazine, as well as other optological defects such as color blindness and benign pigmentation of the cornea.[32]

Cardiotoxic effects of phenothiazines in overdose are similar to that of the tricyclic antidepressants.[24] Cardiac arrhythmia and apparent sudden death have been associated with therapeutic doses of chlorpromazine, however they are rare cases. The sudden cardiovascular collapse is attributable to ventricular dysrhythmia. Supraventricular tachycardia may also develop. Patients on chlorpromazine therapy exhibit abnormalities on the electrocardiographic T and U waves. These major cardiac arrhythmias that are lethal are a potential hazard even in patients without heart disease who are receiving therapeutic doses of antipsychotic drugs. In order to quantify the risk of cardiac complications to patients receiving therapeutic doses of phenothiazines a prospective clinical trial is suggested.[33]

 

 

 

Mr Harry Home Roberts (Deceased)
Psychiatric Report Date of Report:
23d September 2010
contact. He was assessed and it was concluded that he had communication difficulties. He had a further assessment in March 1993 when a diagnosis of autism was made. He attended a main stream primary school for 1 year and was then transferred to Moselle Special School, which he attended between the ages of 7 and 11. He then attended Oak Lodge Special School from the age of 11 to 16. He attended Wood bridge School from the age of 16 to 19. In September 2007, when he was 18, he moved from the family home into residential care at 53 Myddleton Road. This is a privately owned residential care home run by Hill Green Care for 5 people with learning disabilities. It is rated 2 star (good) by the Care Quality Commission.
4.2 Professor Murch reports that he saw Mr Home-Roberts in January 1998 at the age of 8 because of gastro intestinal problems. Mr Home-Roberts had loose stools and swelling of the intestinal lymph tissue. He was treated with Mesalazine and improved. In June 1998 he was reviewed and was suffering from constipation. This was treated with laxatives. In January 1999 his dose of Mesalazine was increased. That year Mr Home Roberts was put on a wheat and milk free diet, as there was some research suggesting that this sort of diet may be helpful to children with autism. Subsequently it has been found that there is no evidence to suggest it is beneficial. Around this time his Mesalazine was stopped. When he was reviewed by Professor Murch in July 2001 at the age of 12, Professor Murch noted that he had gained a significant amount of weight. He asked for an opinion from an endocrinologist but he advised that there was no endocrinal cause for this. In 2001 he was treated with antibiotics as this was thought to be of benefit to children with autism. In September 2003 Professor Murch records that there had been reports of a significant worsening in his behaviour which had gone beyond what might reasonably be managed at home. However, he does not give any details of the nature of these behavioural difficulties.
5. PSYCHIATRIC HISTORY
5.1 In October 2006
it is recorded that Mr Home-Roberts had been treated with Risperidone, this was because he had become agitated and was constantly stamping his feet. This medication was reported to be effective and was discontinued after a few weeks.
5.2 In 2007 it is reported that Mr Home-Roberts exhibited violent outbursts when he became anxious. During this he would head butt against a wall, hit himself with his hand or hit out at other people around him.
5.3 In September 2007 Mr Home Roberts moved to Myddleton Road. On the
1st October 2007 he was taken to see Dr Prasad, GP to be registered with him. Dr Prasad notes that Mr Home-Roberts became increasingly agitated as the check-up progressed, trying to self M Harry Home Roberts (Deceased) Page 3 of 7
Our Ref: CSI2O1O/227/JR

Mr Harry Home Roberts (Deceased)
Psychiatric Report Date of Report: 23’ September 2010
harm and hurt himself by head butting walls and throwing himself about the room and on to the floor. Dr Prasad reports that this occurred on every occasion he saw Mr Home-Roberts and that he was unable to examine him or check his blood pressure. Mr Home-Roberts was referred to the Community Learning Disability Team in Haringey shortly before he moved to his new home. Mr Home-Roberts was seen by Dr Sujeet Jaydeokar, Consultant in Learning Disability Psychiatry on the 19th December 2007. Dr Jaydeokar referred him on to a Speech and Language Therapist and Psychologist.
5.4 Dr Jaydeokar was next asked to see Mr Home-Roberts in October 2008. It was reported that he was not sleeping well, he was restless and agitated. He was banging his head on the wall. Dr Jaydeokar considered that he suffered from anxiety and prescribed Citalopram 10mg daily. Citalopram is an antidepressant of the Selective Serotonin Reuptake Inhibitor type which is recognised to be effective in anxiety disorders. He was reviewed on the
11th November when it was reported that there had been some improvement in his behaviour, but as he continued to not sleep well the Citalopram was increased to 20mg daily. On the 6th January 2009 Mr Home-Roberts was seen by Dr Jaydeokar when the staff who cared for him reported that his sleep pattern remained poor and that he was restless and agitated in the evenings he was noisy and banging on walls and he had tried to abscond the Citalopmam was increased to 30mg daily and he was treated with Zopiclone, a sleeping medication. On the 3rd February 2009 he was still not sleeping well and Dr Jaydeokar prescribed Chlorpromazine 100mg at night. He subsequently reported that there was improvement in Mr Home-Robert’s behaviour and his sleep pattern.
5.5 He was seen again on the
23d June 2009 when staff reported that he was exhibiting episodic behavioural difficulties, running around throwing things and enacting a cartoon character. He also exhibited physical aggression towards members of staff. Staff also reported that he had been physically aggressive towards his mother and there had been a deterioration in his sleep pattern. Dr Jaydeokar concluded that Mr Home-Roberts was suffering from hypomania. This condition of over-excitement occurs in bipolar disorder and can be exacerbated by antidepressants and therefore Dr Jaydeokar discontinued his Citalopram. On the 30th July 2009 it was reported that there had been some improvement in his behaviour since the discontinuation of the Citalopram but problems remained. Dr Jaydeokar increased the dose of Chlorpromazine to 25mg in the morning and 25mg in the afternoon and 100mg at night. There was subsequently an improvement in his behaviour and he was not seen again by Dr Jaydeokar prior to his death in December 2009.
Mr Harry Home Robemts (Deceased) Page 4 of 7
Our Ref CS/2010/227/JR

Mr Harry Home Roberts (Deceased)
Psychiatric Report Date of Report: 23’’ September 2010
6. RESPONSE TO QUESTIONS FROM THE METROPOLITAN POLICE
1. What is Autism?
Autism is a developmental disorder characterised by impairments in social interaction and communication and restricted and repetitive behaviour that begins before the age of 3. Children with Autism show less attention to social stimuli than other children. They smile and look at others less often and respond less to their own name. Older autistic children tend not to play with other children but often play with objects in a repetitive way. They are often late developing speech and when they do develop speech it may be unusual in tone, volume or language used. They also have impairments in non-verbal communication. Many children and adults with Autism became anxious very easily, particularly if their routine is disrupted. When anxious they may harm themselves or become aggressive to others.
2. What is the treatment for Autism?
There are no treatments that have been found to be beneficial for the syndrome of Autism itself. Many treatments have been proposed but after proper testing none of them have been found to be effective. However, children and adults with Autism can be helped to learn to improve their communication skills and their social skills. Also the other problems that people with Autism suffer, particularly anxiety, can be helped by medication.
3. What is Chiorpromazine?
Chlorpromazine is a member of the anti psychotic group of drugs. This is a wide and varied group of drugs which are used to treat psychotic illnesses, such as schizophrenia. However, in smaller doses they are also used to treat anxiety. Chiorpromazine is the oldest member of this group, having been discovered in 1950. Many other drugs similar to Chlorpromazine have been produced in the years since Chlorpromazine and some are said to have fewer side effects. The drug which Mr Home Roberts was treated with in 2006, Risperidone, is another member of this group.
4. What are the side effects of this drug and what are safe levels?
Antipsychotic drugs have a wide range of possible side effects, although most are rare. The most common side effects are disorders of movement, including tremor, abnormal face and body movements and restlessness. Other side effects include low blood pressure, drowsiness, fits, dizziness, headache, confusion, dry mouth, constipation and rarely heart irregularities, rashes, jaundice and eye problems. The usual starting dose of Chlorpromazine is 75mg and the doses used to treat anxiety
Mr Harry Home Roberts (Deceased) Page 5 of 7
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Mr Harry Home Roberts (Deceased)
Psychiatric Report Date of Report: 23’’ September 2010
are from 75mg to 300mg. Higher doses are sometimes used in schizophrenia and up to 1,000mg can be prescribed.
5. Have any deaths been directly attributable to the administration of Chiorpro mazine?
There have been cases of sudden death in people taking Chlorpromazine although it is not clear whether these deaths were directly caused by Chlorpromazine or were coincidental. The possibility remains that Chlorpromazine was the cause but these incidents have been rare. Studies of death rates from cardiac causes in people taking antipsychotic drugs compared to people who do not take them show that the use of anti-psychotic drugs leads to an increased risk of death from cardiac causes. The related drug Thioridazine was taken off the market in 2005 because of concerns that it increased the risk of sudden death from cardiac causes.
6. Is Chiorpromazine the correct form of treatment for Mr Roberts’ form of Autism?
As previously indicated, there is no treatment for Autism. However, Chlorpromazine is an effective treatment for the anxiety and agitation associated with Autism and for hypomania. Other antipsychotics are also used for this purpose but it is not clear which is the most appropriate drug. Many psychiatrists prefer to prescribe the newer antipsychotic drugs such as risperidone but there is no evidence that they are safer.
7. Is there any compulsory testing prior to the administration of Chlorpro mazine?
There is no compulsory testing prior to the administration of Chlorpromazine. However, guidelines suggest that it is helpful to perform an ECG (electro cardiogram) to check the function of the heart before using Chlorpromazine and also to carry out blood tests. However, many people with learning disabilities and Autism do not cooperate with these tests and given Mr Home Roberts’ behaviour at the GP’s it seems likely that this would be the case for him. In that situation a decision must be made in the patient’s best interests as to whether the benefits of the medication outweigh the risks of given them medication without these tests. It is the practice of many learning disability psychiatrists, myself included, to prescribe antipsychotic drugs to people with learning disabilities without carrying out these tests where it is clearly in the patient’s best interests to do so.
Mr Harry Home Roberts (Deceased) Page 6 of 7
Our Ref:
CS/201012271JR

Mr Harry Home Roberts (Deceased)
Psychiatric Report Date of Report:
23id September 2010
8. Once Chiorpromazine is administered, are there any compulsory or recommended monitors to be put in place for the person’s health once on this drug?
Again
there is no compulsory testing but it is recommended that blood tests and ECG monitoring is carried out every 6 months or a year.
9. Could Chlorpromazine have contributed to Mr Roberts’ death in the specific circumstances of this case?
From the information available to me it is possible that the combination of obesity and the use of Chlorpromazine both contributed to Mr Home Roberts’ death.
10,
On review of the evidence provided, is there anything that should have been done differently in treating Mr Roberts?
In retrospect the following could have been done differently:
I. The involvement of Mr Home Roberts’ family and other carers in the decision to administer Chlorpromazine. This would have formed part of a ‘best interests assessment’ under the Mental Capacity Act 2005.
II. Risperidone could have been used as an alternative to Chlorpromazine as it was tolerated by Mr Home Roberts in the past. However it is not clear that this would have led to a different outcome.
Ill. An attempt could have been made to carry out an ECG recording prior to the administration of Chlorpromazine,
IV. Once Mr Home-Roberts’ behaviour was settled it may have been possible to reduce or discontinue the Chiorpromazine. However it would be usual to continue the medication for at least 6 months before attempting a reduction.
7. STATEMENT OF
DUTY TO THE COURT
I understand that my primary duty is to the Court. I have endeavoured to be accurate, to cover the relevant issues and to include in the report only those matters in which I have knowledge and experience. The contents of this report are true to the best of my knowledge and belief and include all matters relevant to the issues on which evidence is given.
Dr Jane Radley
Consultant Psychiatrist
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EXPERT WITNESS STATEMENT
Name: Mr Harry Home ROBERTS (Deceased) Date of Birth: 20.06.1989
Statement Prepared By: Dr Jane Radley
Consultant Psychiatrist
St Andrew’s Healthcare
Billing Road
Northampton
NNI 5DG
Date of Statement:
23d September 2010
Statement Requested By: DS Bahader Singh
Metropolitan Police
Critical Incident Team
Tottenham Police Station
398 High Road
Tottenham
N17 9JA

Mr Harry Home Roberts (Deceased)
Psychiatric Report Date of Report: 231c September 2010
1. QUALIFICATIONS
I am a Consultant in Learning Disability Psychiatry at St Andrew’s Healthcare, Northampton. I qualified in medicine from Leicester University in 1985, I became a member of the Royal College of General Practitioners in 1991 and a member of the Royal College of Psychiatrists in 1994, I have worked as a Consultant Psychiatrist for people with learning disabilities since 1997. I am approved under Section 12(2) of the Mental Health Act 1983.
2. SOURCES OF INFORMATION
In completing this report I have had access to the following:
• Statement from Dr Jaydeokar
• Statement from Professor Murch
• Statement from Dr Prasad
• Review of Clinical Notes by Professor Singh
• Root cause analysis investigation report
• Statement from Jennifer Home-Roberts
• Medical administration records and letters from Dr Jaydeokar
• Toxicology Report
• Post Mortem Report
• Integrated Time Line
3. REASON FOR REPORT
3.1 I have been asked by DS Bahader Singh of the Metropolitan Police to provide a report in relation to the death of Mr Home-Roberts. Mr Home-Roberts was a 20 year old man who suffered from autism and morbid obesity and who died on the l6 December 2009. After post mortem the cause of death was given as acute cardiac failure and morbid obesity.
4. BACKGROUND
4.1 Harry Home-Roberts was born at University College Hospital following a normal pregnancy. His birth was induced at 40 weeks gestation and he was born by caesarean section. He was smaller than expected at birth but otherwise healthy. Shortly after birth he developed jaundice, which is common in newborn babies, and treated in the usual way with photo therapy. At the age of 2 he was noted to have communication difficulties and poor eye
Mr Harry Home Roberts (Deceased) Page 2 of 7
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Mr Harry Home Roberts (Deceased)
Psychiatric Report Date of Report:
23d September 2010
contact. He was assessed and it was concluded that he had communication difficulties. He had a further assessment in March 1993 when a diagnosis of autism was made. He attended a main stream primary school for 1 year and was then transferred to Moselle Special School, which he attended between the ages of 7 and 11. He then attended Oak Lodge Special School from the age of 11 to 16. He attended Woodbridge School from the age of 16 to 19. In September 2007, when he was 18, he moved from the family home into residential care at 53 Myddleton Road. This is a privately owned residential care home run by Hill Green Care for 5 people with learning disabilities. It is rated 2 star (good) by the Care Quality Commission.
4.2 Professor Murch reports that he saw Mr Home-Roberts in January 1998 at the age of 8 because of gastro intestinal problems. Mr Home-Roberts had loose stools and swelling of the intestinal lymph tissue. He was treated with Mesalazine and improved. In June 1998 he was reviewed and was suffering from constipation. This was treated with laxatives. In January 1999 his dose of Mesalazine was increased. That year Mr Home Roberts was put on a wheat and milk free diet, as there was some research suggesting that this sort of diet may be helpful to children with autism. Subsequently it has been found that there is no evidence to suggest it is beneficial. Around this time his Mesalazine was stopped. When he was reviewed by Professor Murch in July 2001 at the age of 12, Professor Murch noted that he had gained a significant amount of weight. He asked for an opinion from an endocrinologist but he advised that there was no endocrinal cause for this. In 2001 he was treated with antibiotics as this was thought to be of benefit to children with autism. In September 2003 Professor Murch records that there had been reports of a significant worsening in his behaviour which had gone beyond what might reasonably be managed at home. However, he does not give any details of the nature of these behavioural difficulties.
5. PSYCHIATRIC HISTORY
51 In October 2006 it is recorded that Mr Home-Roberts had been treated with Risperidone, this was because he had become agitated and was constantly stamping his feet. This medication was reported to be effective and was discontinued after a few weeks.
5.2 In 2007 it is reported that Mr Home-Roberts exhibited violent outbursts when he became anxious. During this he would head butt against a wall, hit himself with his hand or hit out at other people around him.
5.3 In September 2007 Mr Home Roberts moved to Myddleton Road. On the 1st October 2007 he was taken to see Dr Prasad, GP to be registered with him. Dr Prasad notes that Mr Home-Roberts became increasingly agitated as the check-up progressed, trying to self M Harry Home Roberts (Deceased) Page 3 of 7
Our Ref:
CSI2O1O/2271JR

Mr Harry Home Roberts (Deceased)
Psychiatric Report Date of Report:
23rd September 2010
harm and hurt himself by head butting walls and throwing himself about the room and on to the floor. Dr Prasad reports that this occurred on every occasion he saw Mr Home-Roberts and that he was unable to examine him or check his blood pressure. Mr Home-Roberts was referred to the Community Learning Disability Team in Haringey shortly before he moved to his new home. Mr Home-Roberts was seen by Dr Sujeet Jaydeokar, Consultant in Learning Disability Psychiatry on the 19th December 2007. Dr Jaydeokar referred him on to a Speech and Language Therapist and Psychologist.
5.4 Dr Jaydeokar was next asked to see Mr Home-Roberts in October 2008. It was reported that he was not sleeping well, he was restless and agitated. He was banging his head on the wall. Dr Jaydeokar considered that he suffered from anxiety and prescribed Citalopram 10mg daily. Citalopram is an antidepressant of the Selective Serotonin Reuptake Inhibitor type which is recognised to be effective in anxiety disorders. He was reviewed on the 1
1th November when it was reported that there had been some improvement in his behaviour, but as he continued to not sleep well the Citalopram was increased to 20mg daily. On the 6t[, January 2009 Mr Home-Roberts was seen by Dr Jaydeokar when the staff who cared for him reported that his sleep pattern remained poor and that he was restless and agitated in the evenings he was noisy and banging on walls and he had tried to abscond the Citalopram was increased to 30mg daily and he was treated with Zopiclone, a sleeping medication. On the 3rd February 2009 he was still not sleeping well and Dr Jaydeokar prescribed Chlorpromazine 100mg at night. He subsequently reported that there was improvement in Mr Home-Robert’s behaviour and his sleep pattern.
5.5 He was seen again on the
23rd June 2009 when staff reported that he was exhibiting episodic behavioural difficulties, running around throwing things and enacting a cartoon character. He also exhibited physical aggression towards members of staff. Staff also reported that he had been physically aggressive towards his mother and there had been a deterioration in his sleep pattern. Dr Jaydeokar concluded that Mr Home-Roberts was suffering from hypomania. This condition of over-excitement occurs in bipolar disorder and can be exacerbated by antidepressants and therefore Dr Jaydeokar discontinued his Citalopram. On the 30th July 2009 it was reported that there had been some improvement in his behaviour since the discontinuation of the Citalopram but problems remained. Dr Jaydeokar increased the dose of Chlorpromazine to 25mg in the morning and 25mg in the afternoon and 100mg at night. There was subsequently an improvement in his behaviour and he was not seen again by Dr Jaydeokar prior to his death in December 2009.
Mr Harry Home Roberts (Deceased) Page 4 of 7
Our Ref:
CSI2O1 0/227/JR

Mr Harry Home Roberts (Deceased)
Psychiatric Report Date of Report:
23id September 2010
6. RESPONSE TO QUESTIONS FROM THE METROPOLITAN POLICE
1. What is Autism?
Autism is a developmental disorder characterised by impairments in social interaction and communication and restricted and repetitive behaviour that begins before the age of 3. Children with Autism show less attention to social stimuli than other children. They smile and look at others less often and respond less to their own name. Older autistic children tend not to play with other children but often play with objects in a repetitive way. They are often late developing speech and when they do develop speech it may be unusual in tone, volume or language used. They also have impairments in non-verbal communication. Many children and adults with Autism became anxious very easily, particularly if their routine is disrupted. When anxious they may harm themselves or become aggressive to others.
2. What is the treatment for Autism?
There are no treatments that have been found to be beneficial for the syndrome of Autism itself. Many treatments have been proposed but after proper testing none of them have been found to be effective. However, children and adults with Autism can be helped to learn to improve their communication skills and their social skills. Also the other problems that people with Autism suffer, particularly anxiety, can be helped by medication.
3. What is Chlorpromazine?
Chlorpromazine is a member of the anti psychotic group of drugs. This is a wide and varied group of drugs which are used to treat psychotic illnesses, such as schizophrenia. However, in smaller doses they are also used to treat anxiety. Chlorpromazine is the oldest member of this group, having been discovered in 1950. Many other drugs similar to Chlorpromazine have been produced in the years since Chlorpromazine and some are said to have fewer side effects. The drug which Mr Home Roberts was treated with in 2006, Risperidone, is another member of this group.
4. What are the
side effects of this drug and what are safe levels?
Antipsychotic drugs have a wide range of possible side effects, although most are rare. The most common side effects are disorders of movement, including tremor, abnormal face and body movements and restlessness. Other side effects include low blood pressure, drowsiness, fits, dizziness, headache, confusion, dry mouth, constipation and rarely heart irregularities, rashes, jaundice and eye problems. The usual starting dose of Chlorpromazine is 75mg and the doses used to treat anxiety
Mr Harry Home Roberts (Deceased) Page 5 of 7
Our Ret CS/201 01227fJR

Mr Harry Home Roberts (Deceased)
Psychiatric Report Date of Report:
23rd September 2010
are from 75mg to 300mg. Higher doses are sometimes used in schizophrenia and up to 1,000mg can be prescribed.
5. Have any
deaths been directly attributable to the administration of Chlorpro mazine?
There have been cases of sudden death in people taking Chiorpromazine although it is not clear whether these deaths were directly caused by Chiorpromazine or were coincidental. The possibility remains that Chlorpromazine was the cause but these incidents have been rare. Studies of death rates from cardiac causes in people taking antipsychotic drugs compared to people who do not take them show that the use of anti-psychotic drugs leads to an increased risk of death from cardiac causes. The related drug Thioridazine was taken off the market in 2005 because of concerns that it increased the risk of sudden death from cardiac causes.
6. Is Chiorpromazine the correct form of treatment for Mr Roberts’ form of Autism?
As previously indicated, there is no treatment for Autism. However, Chiorpromazine is an effective treatment for the anxiety and agitation associated with Autism and for hypomania. Other antipsychotics are also used for this purpose but it is not clear which is the most appropriate drug. Many psychiatrists prefer to prescribe the newer antipsychotic drugs such as risperidone but there is no evidence that they are safer.
7. Is there any compulsory testing prior to the administration of Chiorpro mazine?
There is no compulsory testing prior to the administration of Chlorpromazine. However, guidelines suggest that it is helpful to perform an ECG (electro cardiogram) to check the function of the heart before using Chlorpromazine and also to carry out blood tests. However, many people with learning disabilities and Autism do not cooperate with these tests and given Mr Home Roberts’ behaviour at the GP’s it seems likely that this would be the case for him. in that situation a decision must be made in the patient’s best interests as to whether the benefits of the medication outweigh the risks of given them medication without these tests. It is the practice of many learning disability psychiatrists, myself included, to prescribe antipsychotic drugs to people with learning disabilities without carrying out these tests where it is clearly in the patient’s best interests to do so.
Mr Harry Home Roberts (Deceased) Page 6 of 7
Our Ref:
CS120101227/JR

Mr Harry Home Roberts (Deceased)
Psychiatric Report Date of Report:
23id September 2010
8. Once Chlorpromazine is administered, are there any compulsory or recommended monitors to be put in place for the person’s health once on this drug?
Again there is no compulsory testing but it is recommended that blood tests and ECG monitoring is carried out every 6 months or a year.
9. Could Chlorpromazine have contributed to Mr Roberts’ death in the specific circumstances of this case?
From the information available to me it is possible that the combination of obesity and the use of Chlorpromazine both contributed to Mr Home Roberts’ death.
10. On review of
the evidence provided, is there anything that should have been done differently in treating Mr Roberts?
In retrospect the following could have been done differently:
I. The involvement of Mr Home Roberts’ family and other carers in the decision to administer Chiorpromazine. This would have formed part of a ‘best interests assessment’ under the Mental Capacity Act 2005.
II. Risperidone could have been used as an alternative to Chlorpromazine as it was tolerated by Mr Home Roberts in the past. However it is not clear that this would have led to a different outcome.
Ill. An attempt could have been made to carry out an ECG recording prior to the administration of Chlorpromazine.
IV. Once Mr Home-Roberts’ behaviour was settled it may have been possible to reduce or discontinue the Chlorpromazine. However it would be usual to continue the medication for at least 6 months before attempting a reduction.
7. STATEMENT OF DUTY TO THE
COURT
I understand that my primary duty is to the Court. I have endeavoured to be accurate, to cover the relevant issues and to include in the report only those matters in which I have knowledge and experience. The contents of this report are true to the best of my knowledge and belief and include all matters relevant to the issues on which evidence is given.
Dr Jane Radley
Consultant Psychiatrist
Mr Harry Home Roberts (Deceased) Page 7 of 7
Our Ref: CS/2010/227/JR

E V I D E N C E

Page no

 

          PROFESSOR RISDON sworn

              Examined by THE CORONER…………………………………………… 5

              Examined by MR DOCHERTY…………………………………………… 9

              Examined by MS PASAUD……………………………………………… 11

              Examined by MRS HORNE-ROBERTS     ……………………… 14

              Examined by MR ROBERTS…………………………………………… 15

 

          Statement OF DR SUSAN PATERSON read……………………… 17

 

          DR JANE RADLEY affirmed

              Examined by THE CORONER……………………………………………17

              Examined by MR DOCHERTY…………………………………….. 24

              Examined by MRS HORNE-ROBERTS………………………… 26

              Examined by MR ROBERTS…………………………………………… 32

 

          DR SUJEET JAYDEOKAR affirmed

              Examined by THE CORONER……………………………………………33

              Examined by MR DOCHERTY.…………………………………………43

              Examined by MRS HORNE-ROBERTS………………………….49

              Examined by MR ROBERTS…………………………………………….55

              Examined by MRS HORNE-ROBERTS……………………………58

              Examined by MS PASAUD…………………………………………………62

 

          DR CLIFFORD sworn

              Examined by THE CORONER……………………………………………71

              Examined by DR PRASAD.………………………………………………74

              Examined by Mr DOCHERTY………………………………………… 74

              Examined by MRS HORNE-ROBERTS………………………….76

              Examined by MR ROBERTS………………………………………………78

 

          DR PRASAD sworn

              Examined by THE CORONER……………………………………………78

              Examined by MS PASAUD.………………………………………………85

              Examined by MRS HORNE-ROBERTS………………………….89

              Examined by MR ROBERTS…………………………………………….94

 

          MS LOLA ODUKOMAIYA affirmed

              Examined by THE CORONER……………………………………………95

              Examined by MR ROBERTS………………………………………………99

              Examined by MR DOCHERTY……………………………………………99

              Examined by THE CORONER (FOR FAMILY)………102

 

          DR KARVOUNIS sworn

              Examined by THE CORONER…………………………………………104

              Examined by MRS HORNE-ROBERTS…………………………108          Examined by MR ROBERTS………………………………………….109

              Examined by MS PASAUD………………………………………………112

CLERK OF THE COURT:  Court rise for Her Majesty’s Coroner.

THE CORONER:  Please sit down.  I am now going to resume the inquest touching the death of Harry Horne-Roberts.  The inquest touching that death was opened on 14 January 2010 and adjourned to today’s date.  This inquest, like all others, is an inquiry; no one is on trial, least of all the person who died, and this inquest is to find answers to four limited factual questions.  Who is the person who has died, how, when and where did that death come about?  The question, however, in these circumstances being limited to finding out how the cause of death arose, or to put it another way the sequence of events which directly led to and caused the death.  It is not an opportunity for us to examine the circumstances in any broader detail.  These matters, together with the particulars for the time being required by the Registration Act to be registered concerning the death, these are the matters that this inquest will deal with.

                        Can I just welcome members of the family. You know you have my sympathies at this time.  Ms Pasaud[?], you appear on behalf of Barnet, Enfield and Haringey Mental Health Trust.

MS PASAUD:  Yes, Sir.

THE CORONER:  Mr Docherty, you appear on behalf of Hillgreen Care Limited.

MR DOCHERTY:  Yes, Sir.

THE CORONER:  And Dr Prasad, you are representing yourself today.

DR PRASAD:  Yes.

THE CORONER:  Is that right?

DR PRASAD:  Yes.

THE CORONER:  Thank you very much indeed.  Was there anything else that you wished to say?

DR PRASAD:  Yes, I haven’t taken advice from my legal advisor, Medical Protection yet.  Then last night I spoke to them, and they just said to me to go to see you.  They’re just wanting a witness, so I came here as a witness to give evidence.

THE CORONER:  I’m sorry, there’s a lot of noise from the fan.  Could you just repeat that please?

DR PRASAD:  I contacted my legal advisor, Medical Protection, last night.

THE CORONER:  Yes.

DR PRASAD:  About this inquest, and they said to enter the court and just give accounts of what they are asking you about as a witness.  That’s all I…

THE CORONER:  I see.

DR PRASAD:  Do I have to get involved my medical advisor?

THE CORONER:  Well we deemed that you were a properly interested party because your conduct may have been criticised.

DR PRASAD:  Yes.

THE CORONER: Or might be criticised.  And you will see from the papers that you have the extent of the concerns raised.  That makes you a properly interested party, which means that you’re entitled to ask questions of any witnesses who come to this inquest to give evidence.

DR PRASAD:  Well I’m not prepared for that, but anyhow.

THE CORONER:  Were you aware that we had a number of pre-inquest meetings where we had invited you to attend?

DR PRASAD:  Yes, I received a copy of a report on November or 6 December last time, to attend.

THE CORONER:  The reason for having pre-inquest meetings is so that you can take part and understand where things stand.  And the reason for having these meetings is to avoid what is happening now.

DR PRASAD: Yes.

THE CORONER:  And that is difficulties arising because you say you are not ready.

DR PRASAD:  Not from a medical advisor point of view, but what I have done it, I can reply with my statement which I have given already, Sir.

THE CORONER:  Just so that we make this clear, are you saying that you are not able to properly participate in this inquest?

DR PRASAD:  No, I am able to do it.  Whatever statement I have given I can stand on that, yes.

THE CORONER:  All right.  Oh, well that is very helpful, because if you were not able to properly participate, and you were saying, ‘Well I don’t want this hearing to go ahead today because I’m not ready,’ that’s not what you’re saying.

DR PRASAD:  No, I’m not saying.  I’m ready.

THE CORONER:  No.  You’re ready to go ahead.

DR PRASAD:  Yes.

THE CORONER:  All right, well that is very helpful, thank you very much indeed.  Do take a seat.  When this inquest was opened on 14 January 2010 it was confirmed that Harry Alexander Horne-Roberts was lying dead within the Greater London Northern District, and an inquest was opened touching his death, and the particulars for the time being required by the Registration Act to be registered concerning the death were on that occasion set down, and I turn to those now. 

                        Mr Horne-Roberts was born on 20 June 1989 in London, Harry Alexander Horne-Roberts.  I have no occupation recorded for him.  The address I have is 53 Middleton Road, Wood Green in London, and the date and place of death is 16 December 2009 at 53 Middleton Road, Wood Green in London.  Members of the family, are all those details correct?

MRS HORNE-ROBERTS:  29 June is the date of birth, Sir.

THE CORONER:  29 June.

MRS HORNE-ROBERTS:  Yes.

THE CORONER:  Thank you very much indeed, 1989.  Thank you very much indeed.  Now let us begin by looking at the cause of death that was established following an examination on 18 December 2009, and for that purpose could I ask Professor Risdon, would you be kind enough to step forward.

 

PROFESSOR RUPERT ANTHONY RISDON (sworn)

Examined by THE CORONER

 

Q.        Thank you very much indeed.  And you are Home Office accredited pathologist.

A.        Yes.

Q.        Thank you very much indeed.  Now you undertook an examination.

A.        I did.

Q.        On 18 December 2009 to establish the cause of death, is that correct?

A.        That is correct, Sir.  Could I just say before I start that there are clearly issues surrounding this death that I was not aware of until this morning.  So you need to listen to my evidence in that context.

Q.        Of course.

A.        And I will if necessary make a few comments after that.

Q.        Yes, please do.  If you need to change the cause of death in the light of the material that you now know, then please do so.

A.        Thank you.

Q.        So the examination took place on 18 December 2009.

A.        Yes.

Q.        In Haringey Public Mortuary.  And were you able at that time to establish a cause of death?

A.        Well I thought I was.

Q.        Well perhaps a better question is what do you think now the cause of death is?

A.        Well I think the cause of death now I would probably prefer to put as unascertained rather than what I put there, because I think there are issues surrounding it, which I don’t think can necessarily be answered by the post‑mortem in any case.  What I did find was that Harry was a very – he was very overweight, and when I came to examine – first of all the congestion of his lungs suggested to me that he had died acutely of left ventricular failure.  When I came to examine the heart there were no structural abnormalities of the heart itself, but because of the degree of obesity the heart itself was, as it were, encased in fat that filled the mediastinum.  We recognised that one of the dangers of obesity is that it can have this sort of constrictive effect on the heart.

                        Another thing that I should perhaps make a point is that as we learn more about obesity we find, for example, if you look in terms of the propensity to develop type II diabetes, that some of these people actually have a lot of fat within their thorax and abdomen and not necessarily elsewhere, so that the degree of their obesity, if you just weigh them, is not necessarily apparent.  And I think Harry very much felt into this category because most of the obesity was truncal, if you like, rather than elsewhere. 

                        So my conclusion…

Q.        So just so that – if I have that clearly, the classic picture of obesity is collections of fat.

A.        Yes.

Q.        Around the body which are clearly visible to the naked eye.

A.        That’s right.

Q.        As a person carrying with them too much weight.  But that’s not the case with…

A.        Well I think – he was obviously overweight, but I think that such subjects can be overweight to a degree that you would recognise that they were overweight but perhaps not that they had a dangerous degree of fat collection within their body itself.

Q.        So morbid obesity then in this case wouldn’t apply.

A.        Well I think – I use the term because I think that that’s – at the time that’s what caused – I mean morbid obesity now has a very strict definition in terms of the weight and the height and the rest of the formula.  The other thing, of course, as a young man dying suddenly and unexpectedly, I had to consider the possibility of drugs or whatever being involved, so I asked for toxicology to be done, and the result of that was that no drugs were detected in the general screen, and the stomach contents were blood, and no drugs of abuse were detected in the urine.  So on that basis I was considering in terms of a natural death, which I give as acute cardiac failure to morbid obesity.

                        I was not aware at that time there was any, and in fact I don’t know the details now, but I gather there are issues as to whether some drugs that he had been given could conceivably be cardio-toxic.  I wouldn’t necessarily be able to tell that from the post-mortem, although I might have done histology or even electon microscopy, because some drugs can give changes that you can see at that level.  But often you don’t see anything at all other than the heart is usually sort of enlarged and flabby, which wasn’t the case here.  So I can’t really get into that, but because there are now issues in the background which I was not aware of at the time, I would probably prefer from a medical point of view to say that the cause of death is unascertained, and therefore would be a subject of the sort of inquiry that you are conducting today, Sir.

Q.        Well that’s very helpful.  Just for completeness though, the coronary arteries were patent.

A.        They were, yes.

Q.        So it’s not a question of ischemic coronary heart disease.

A.        No, no.

Q.        It appears to be, if anything, constrictive heart disease.

A.        Yes.

Q.        From the connection of adipose tissue around the heart.

A.        Yes.  That was my impression at the time.

Q.        I see.  Is that rare?

A.        It’s – well it’s like everything else that is related to obesity, it’s becoming more common.

Q.        And the picture that is presented of a person who developed heart failure as a consequence of – well it would constricted heart failure in effect, that would appear to be not an acute picture but rather a chronic picture.

A.        Well, of course the trouble with that is that the sort of symptoms like breathlessness and so on might be just related to somebody being overweight, or at least that might be how it would be construed.

Q.        Because you wouldn’t get the ischemic pain.

A.        No, no, no.  Oh, usually it’s a question of a gradual lack of mobility and breathlessness and so on, which could be due to the heart under strain, or it could be due to the obesity. I mean we are recognising, as the instance of obesity increases, that often people die suddenly without there being the sort of specific pathology that we’re used to seeing in other conditions.

Q.        So in effect what we’re edging towards is the position where people who carry too much weight are likely to die suddenly from a – there’s just a higher incidence of…

A.        That’s right.

Q.        …sudden unexpected death.

A.        That’s right.  I mean they may develop diabetes, they may have ischemic heart disease.  Quite often you just find that the heart is enlarged, which usually just implies that it’s been overworking.  But there may not be any specific pathology of the type that we would normally expect to find.

Q.        That’s the picture here, isn’t it?

A.        I think so, yes.

Q.        It’s an enlarged heart, but he was a large chap.

A.        Well it’s not – yes, but I – it is a bit large, but then he’s a large man.  I mean you have to relate it to the body size.  Anybody who is large, even if they are an athlete may well have a large heart.

Q.        So in effect the dilation of all four chambers may not be a significant finding.

A.        It may not – well, it’s part and parcel of…

Q.        Of a picture.

A.        Yes, that’s right, yes.  I mean clearly I think that he died of acute heart failure.  The question is have I identified in my report what that cause is or could there be another?

Q.        So you would be happier writing ‘unascertained’.

A.        Yes, probably with a note of what I did find, and that’s a possibility.  However, had I been told at the time that there was an issue over the treatment then the toxicology could have been focused that I probably would have taken histology and so on.

Q.        Yes, yes.  Well that’s very helpful.  Could it not better be recorded as sudden death in – sudden unexpected death?

A.        Sudden unexpected death in adulthood rather than in infancy, yes, that would be…

Q.        Well that’s very helpful, thank you very much indeed, I’m very grateful.  If you would just be kind enough to wait there for a moment.

A.        Yes, of course.

Q.        Dr Prasad, did you have any questions you wanted to ask this witness?

DR PRASAD:  No, Sir, nothing.

THE CORONER:  No, thank you very much.  Mr Docherty, was there anything you wanted to ask?

MR DOCHERTY:  Sir, could I just raise one matter for clarification and better wisdom?

 

Examined by MR DOCHERTY

 

Q.        Professor Risdon, good morning, I’m representing Hillgreen Care Home, where Mr Horne-Roberts was living before his death.  Have you got a copy of your report in front of you?

A.        I have, yes.

Q.        You’ve recorded under the heading ‘External Examination’, near the top of the page, the height as 183 centimetres, and the weight as 104 kilograms.  Now Harry Horne-Roberts was measured, was weighed a number of times in the months leading up to his death, and you probably didn’t know this, but he was weighed on 9 December 2009, and at that time his weight was found to be 144 kilograms.  I don’t know whether you have any written notes or anything which might suggest that might be a typographical error.

A.        Well I think – I mean when I came to look at this report again – remember, I did it two years ago.

Q.        Yes.

A.        I looked at that weight and I thought I’m sure it was more than that, so I think probably the other weight that you have recorded is the more accurate one, and it would in fact bring him into the category of morbidly obese.

Q.        Yes, so it may be that the zero is simply a typo, and it should have been 144.

A.        It might be.  Remember too that the scales we use in the mortuary or perhaps rather cruder than the ones that you’re talking about.  I would prefer to take the figure that you’ve just mentioned.

Q.        Thank you, Professor.

THE CORONER:  I mean with that figure now in my mind, does that again change your view?

A.        No, I don’t think so.  I mean it reinforces what I thought at the time without the knowledge that I have now, which I think I would have taken into consideration had I known it at the time.

Q.        So just to make it clear in my mind, and it’s entirely my fault not yours, your position today is that in the time that has elapsed between the post-mortem taking place and today, medical understanding of morbid obesity has changed?

A.        Well no, I think that what I said is correct.  He was morbidly obese.  I think that he was heavier than that weight in my report suggests, but the rest of it fits in very well, you know, that he has got fat round his heart and so on, which I think would be a reasonable explanation for his death.  But if there were other factors, I mean like everything, you don’t jump to the first conclusion that you come to.

Q.        No.

A.        And also, death is not necessarily due to one cause.  There may be a number of factors that bring about the death of an individual at a particular time.

Q.        So – I’m asking you the question in a clumsy fashion, why is it today then that you prefer the cause of death to be recorded as unascertained?

A.        Well because again, I’m sorry, I don’t know all the details that you’re now going to be given, but I’ve been told as I came in that there’s an issue about the medication that this subject had.  Now I know no more than that, but had I known that there was some issue over that, if that is so, then I would probably have made a comment to the toxicologist.  The fact that they found nothing at all I think would mean that it still wouldn’t have been helpful, and I would probably have done histology as well so that at least we would have the opportunity to look for drug related changes if that were the case.  But I don’t want to pre-empt your investigation, I’m just putting it in the context that I would probably have done things slightly differently had I known then what I appear to know now. 

                        I still think this is a perfectly reasonable natural cause of death.

Q.        Yes, but what I’m just suggesting is are we better not then leaving1(a) acute cardiac failure; 1(b) morbid obesity; and then waiting to see if the evidence changes it rather than for you to adopt a position which does not seem to fit with your examination?

A.        That would be entirely appropriate in my view, Sir.

Q.        All right.  So in fact the position we’re in is that you stand by the cause of death that you reached.

A.        Yes.

Q.        But you’re sensitive to the fact that there may be other issues that are raised that may affect or even change the cause of death.

A.        Yes.

Q.        These being matters you were unaware of, or are unaware of, would that a fairer way to put it?

A.        Yes, that is correct, Sir.

Q.        Mr Docherty?

MR DOCHERTY:  Thank you, Sir, I have no more questions of Professor Risdon.

THE CORONER:  Ms Pasaud?

MS PASAUD:  Thank you, Sir.

 

Examined by MS PASAUD

 

Q.        Professor Risdon, you’ve mentioned the toxicology that was undertaken, and that there was no evidence of drugs of abuse.  Just looking at the report from Dr Paterson, there was a test done for chlorpromazine.  Could you just confirm what the findings…

A.        Sorry, a test for…?

Q.        Chlorpromazine.

A.        I haven’t got that report.

Q.        You haven’t got the report from Dr…

A.        The report I read out is the only one that I have.

Q.        Right, but the toxicology report was something that would have been taken into account by you, isn’t it?

A.        I took account of this report that I have here.  I have no record…

THE CORONER:  Ms Pasaud, have you another document that shows the…

MS PASAUD:  Yes, I have the toxicology report.

THE CORONER:  I wonder if Professor Risdon might see that, that may be of assistance. 

A.        Well this is written on the report. Where did this come from?

MS PASAUD:  I’m not sure, that was provided to me in that format.

A.        Well as far as I’m concerned, what is printed here with his signature, this is added on afterwards, so I can’t really make any comment about where it came from. It is, I gather, in the therapeutic range anyway.  I mean this might be another drug that he was taking, but that should have been detected by the screen, and there should have been a comment in the printed part of the report.  I honestly don’t know where this has come from.

Q.        So are you able to say that chlorpromazine was a drug that was tested for that was below…

THE CORONER:  Well it would be on the rear of the form.

MS PASAUD:  That’s right.

THE CORONER:  Drugs detected in general screen of blood.

MS PASAUD:  The second page of the document.

THE CORONER:  Which is the reverse page. And in the first column of the basic screen.  And what we have here is the general screen.

A.        Yes, there is chlorpromazine, yes.

THE CORONER:  A general screen was undertaken, so one imagines that it would be one of the drugs detected.

A.        This screen indicates what drugs would be detected by the process.

MS PASAUD:  Yes.

A.        And the figure is LOD, that means the level of detection.  That’s the level which below that they wouldn’t be able to detect it, but that’s not relevant to this report, and I really don’t know where this has come from.

Q.        So you’re able to say that chlorpromazine was one of the drugs that was screened for.

A.        Well I’m not a toxicologist, I’m merely the pathologist, but I am…

THE CORONER:  It’s evident, Ms Pasaud, that from what is written on the back of the form, that that is one of the drugs that’s screened.  It appears that a level was established, and this has been written in afterwards, it being within the therapeutic range.

MS PASAUD:  Thank you, Sir.  Just in relation to the impact of the fat tissue around the heart, we have a weight chart which I can pass to you, from January 2008 to the date of Harry’s death.  I wonder whether you could just have a look at that.

A.        Yes.

Q.        It would appear from that chart that Harry’s weights have fluctuated over that period of January 2008 to December 2009.  It had been in the region of 140 – I think it got up to 145, came down to 125, and then up again to 145 before his death.  So that was over a sustained period.  Is it more likely that the pressure upon the heart over that longer period was likely to have caused significant and serious pressure on the heart than a raise in the weight in the nine months before Harry’s death of 4 kilograms?

A.        I think the – I don’t think the weights are terribly relevant to the question.  I think they merely point that he is in a weight range that would be regarded as morbidly obese.  Now in terms of whether or not there might be a sudden death, if the heart is under strain for whatever reason, it may suddenly give out, and you may not be aware from the clinical side that the heart is under strain until – I mean if you take coronary arteries, people seem perfectly well and then suddenly they drop dead.  It’s the same sort of thing.  If you have the background, as it were, the sub-strain in which sudden death might occur, it might do that.  Sometimes, with many diseases you have symptoms that can be referred to the disease, they gradually get worse and then the patient dies.  But many diseases, there is a sudden indication, and that’s the first thing that you know that somebody has an underlying condition.  And I suspect that that would be the case here.

Q.        Thank you very much.

THE CORONER:  Members of the family, did you have any questions?

MRS HORNE-ROBERTS:  Yes.

 

Examined by MRS HORNE-ROBERTS

 

Q.        Is there any evidence – is there any sign from your examination of our son that there was any problem with his heart muscle at all?

A.        No, not – I mean apart from the fact that it was dilated, but again, if there’d been an issue about the heart muscle then the thing to do would probably be to look at it under the microscope, which I didn’t do because in the circumstances I felt that I had explained the death adequately.  But I mean there are a lot of questions which one can’t answer, and one of the things is that of course the examination that is done with the Coroner as opposed to a full academic post-mortem or a full forensic post-mortem, which would be a much, much more extensive undertaking.  These sort of things might have been part of the investigation.  They weren’t in this case because I didn’t – it wasn’t felt that that was appropriate.

Q.        Well yes, we – is it possible that the drugs readings in the toxicology report, that the drugs could have been metabolised, to your knowledge?

A.        You can get toxic effects of drugs even if they – some time later when there may be no – none of that drug in the body at all.  It’s not necessarily that it has to be present at the time that a patient dies for their death to be the result of a drug reaction.

Q.        Thank you.  What about the weight change?  Because in October of 2008 Harry was put on citalopram, unbeknown to us, without us being informed or consulted as his parents, contrary to the Mental Capacity Act, which I’m sure you’re aware of, and from that time…

A.        I have two mentally ill children of my own, so I…

Q.        Pardon?

A.        I have two mentally ill children of my own so I’m well aware of that.

Q.        I’m sorry to hear that.  But from the time that he was put on citalopram, and then from February 2009 he was also put on chlorpromazine, CPZ, so he was on those two drugs until he died.  And during that time his weight rose approximately 20 kilos, so have you any comment to make on that?  Clearly those drugs…

MS PASAUD:  I’m sorry, Sir, but that’s…

MRS HORNE-ROBERTS:  According to Wikipedia and other – those drugs do cause massive weight gain.

THE CORONER:  Is it a matter you can comment on?

A.        I really – I mean I’m sympathetic to what you say because I’m aware of these complications, but not in an expert sense.  I mean my role is a pathologist, not as a clinician.  I’m sure there will be other people here to this inquest who will be able to answer that question more authoritatively than I can.

MRS HORNE-ROBERTS:  But you said three times that you considered Harry’s death was unascertained, that was your considered view – now, I mean.

A.        Well I think the point I’m making is that clearly his death wasn’t due to a straightforward cause.  I mean even my cause is based on an assessment of the, as it were, the clinical background as well as the actual mode of death, and that’s often the case with deaths.  I mean it’s fine if somebody has a ruptured aortic aneurysm, then there’s no question as to exactly what happened and whether there are any factors involved or not.  But in this sort of case, obviously I have to be open to the fact that although that may be the immediate or the most important aspect of the cause of death, there may be other factors involved.  That’s all I’m saying in terms of unascertained, because this case has come to inquest where all these issues can be aired and gone through, that’s the whole point of the inquiry.

Q.        Thank you very much.

 

Examined by MR ROBERTS

 

  Q.      With respect, can I ask just two things?  You say in your report that he had congestion in the lungs, which was something which we were unaware of.  I mean if he’d had a cold or something of the sort, I mean I’m not a doctor, obviously I don’t know how these things – but the congestion in the lungs, could that have caused him to choke?

A.        No, I think the point is when – the heart obviously pumps blood from the lungs and then round the body.  If for any reason the heart as a pump ceases to be effective, then the blood, as it were, dams back in the lungs, they become acutely congested with blood, and indeed they become what we call edematous, a pulmonary edema develops, and that is one of the signs of left ventricular failure, which is why – or acute cardiac failure, which is why I put that as the cause of death.  But it isn’t a separate entity, it’s part of the heart failure.

Q.        It’s a consequence.  Thank you.  The other question I was going to ask is not really quite for you, but in one of the reports it mentions his blood pressure was 170 over 80.  Now I know my blood pressure is about 130 over 80, and the doctor’s quite pleased with me, which is good news.  Is 170 over 80 some indicator – it was taken some time before he died obviously.  You can’t tell at the time of death what the blood pressure would be clearly, but is that – would that indicate that something was going wrong with his heart?

A.        I think it’s always very difficult to comment, particularly on one measure of blood pressure, because it can change very rapidly.  When I was a student it was the diastolic pressure that was regarded to be important, in other words if you had a diastolic pressure of 80 that was okay, whatever else.  We now regard systolic pressure, the higher level as being probably equally important.  And I think when you have quite a difference, you know, between the two it’s probably an indication that the heart is under strain, but it’s not – in other words his blood pressure was high in the sense that, you know, that might have been something that doctors would consider treating if it – I mean they wouldn’t do it on one reading.  But that would be one explanation of that, but I think it’s probably just another marker of a heart under strain.

Q.        Yes.  Thank you. 

THE CORONER:  Thank you very much, Professor, I’m very grateful to you.  You are released, you needn’t stay unless you wish to do so, but of course you leave here, as always, with my thanks.  Thank you very much.

A.        Thank you very much, Sir.

 

[The witness was released]

 

 

THE CORONER:  I am going to exhibit the toxicology report as C1.  The toxicology report that we have in front of us is signed by Dr Susan Paterson, Head of Toxicology Unit, and is dated 12 January 2010. 

                        It records: ‘Ethanol level at less than 10 milligrams per 100 millilitre in blood and also urine.’  She says, ‘No drugs detected in general screen and stomach contents or blood.  No drugs of abuse detected in urine.’  But what is written on the form in hand is, ‘Chlorpromazine, therapeutic levels range 0.05 to 0.13, which was under the level of detection, which is 0.1.’

                        Could I ask Dr Radley to step forward, please.  Dr Radley.

 

DR JANE RADLEY (affirmed)

Examined by THE CORONER

 

Q.        Thank you very much indeed.  Could you be kind enough to tell the court your full name?

A.        It’s Jane Radley.

Q.        Now you’re a consultant psychiatrist.

A.        That’s right.

Q.        And you were asked to look at the care provided to Mr Horne Roberts, is that right?

A.        That’s right.

Q.        And did you reach any conclusions about the care provided to Mr Horne-Roberts from your investigation?

A.        I felt the care provided to Mr Horne-Roberts was as I would expect from any qualified psychiatrist, and that it was appropriate.

Q.        Did you think…

MRS HORNE-ROBERTS:  I can’t hear.  Sorry, could you speak up a bit?

THE CORONER:  Sorry, could you just repeat that?

A.        Sorry, I thought the care provided was as I would expect from any qualified psychiatrist, and was appropriate and equivalent to the care that I would provide.

Q.        Is there any link between the medication that Mr Horne-Roberts was taking and weight gain?

A.        This type of medication can cause weight gain, yes.

Q.        Do you think it did, in your view, cause weight gain in Mr Horne-Roberts?

A.        It’s possible.  It’s hard to separate a number of factors.  He obviously had a long history of being overweight, but it does appear that he gained some weight while he was on it.  But he had been at that weight previously, so…

Q.        But do you think the gain in weight you speak of could be attributable to the medication he was taking?  Do you think it’s more likely than not the weight gain was medication, or can’t you say that?

A.        I can’t say.  It’s certainly possible.

Q.        Was there anything wrong in your view, or anything that would cause you concern about the prescription of that medication to Mr Horne-Roberts?

A.        The only issue, and this issue has been raised, is that there wasn’t a discussion with Mr Horne-Roberts’ parents before it was prescribed, and that would have been helpful.

Q.        I mean do you see that as a failure?  Should that have happened?

A.        It should have happened.  It might not have made a difference to the outcome, but it should have happened.

Q.        And why in this case should it have happened?  What was it about this case that meant that members of the family should have been consulted about medication?

A.        In any case where the patient doesn’t have the capacity to make the decision about medication then everybody who’s involved with the care of the person, so carers, relatives, medical staff should all have a discussion about whether that medication is of benefit.

Q.        What was the medication prescribed for in Mr Horne-Roberts’ case?

A.        He was prescribed citalopram, which is an antidepressant, and chlorpromazine, which is an anti-psychotic drug.

MRS HORNE-ROBERTS:  Sorry, I can’t hear again.

THE CORONER:  Could you try and keep your voice up.

A.        Sorry.  Citalopram, which is an antidepressant drug, and chlorpromazine, which is an anti-psychotic drug.

Q.        Why an anti-psychotic medication?

A.        Anti-psychotics are commonly used in small doses to treat anxiety and agitation both in the general population and more particularly in people with learning disabilities. 

Q.        And the dose that was given to Mr Horne-Roberts, was it a high dose?  A low dose?

A.        It was an average dose for treating anxiety.  It would be a low dose if it was used to treat schizophrenia. 

Q.        And in this case it was used to treat depression.

A.        It was used to treat anxiety and agitation, that’s my understanding.

Q.        Was there a diagnosis from Mr Horne-Roberts?

A.        The diagnosis was learning disability and autism.

Q.        And just help those in court who are unfamiliar with autism.  What is it?

A.        Autism is a developmental disorder present from birth, and causing difficulties in communication, social interaction and behaviour.

Q.        And is it treatable?

A.        It’s not in itself treatable, it’s a condition of the brain, but the symptoms can be helped both by environmental manipulation and by medication.

Q.        I see.  You also looked into the side effects of anti-psychotic medications, in particular the medications prescribed here.

A.        Yes.

Q.        And was there any evidence that Mr Horne-Roberts may have suffered from side effects of these medication?

A.        I couldn’t see any evidence that he’d suffered from side effects, apart from the possible weight gain.

Q.        But you can’t say that that’s more than a possibility, you can’t say it’s a probability, just a possibility.

A.        Yes.

Q.        Is that right?  Do you think on the review of the evidence that you were given that there was anything that should have been done differently in treating Mr Roberts?  I think we’ve touched on one element, and that’s the involvement of Mr Horne-Roberts’ family and other carers in the decision to prescribe chlorpromazine. 

A.        It may have been wise to have reviewed the medication in the light of the weight gain.

Q.        So would there be alternatives that might have been used?  You mentioned risperidone could have been used as an alternative to chlorpromazine because it was tolerated by Mr Horne-Roberts in the past.  But you go on to say, however, it’s not clear that this would have led to a different outcome.

A.        No.  All of the drugs of this type can cause weight gain.  So it could have done.  It may have been that a different drug would in his case have caused less weight gain.

Q.        You also go on to say an attempt could have been made to carry out an ECG recording prior to the administration of chlorpromazine.  Is that right?

A.        That’s correct, although it seems that it’s unlikely he would have cooperated with that, and it’s not usual to always carry out an ECG when these drugs are used.  And in any case it probably wouldn’t have shown an abnormality, given what I’ve heard from the pathologist.

Q.        Because what we now have a better understanding of is the fact that the space around the heart had become encased in fat, effectively.

A.        Yes.

Q.        So in fact what he would have suffered with is a constricted form of cardiac failure, the only symptom of which may be breathlessness.

A.        That’s right, yes.

Q.        And interestingly enough, in an ECG based on a patient in those circumstances, may show no changes.

A.        That’s correct.  What I had in mind was the rare incidence of irregularities of the heart, which can sometimes occur with – very rarely with this type of medication, which may or may not have shown up in an ECG, but it does seem in this case that actually that wouldn’t have been relevant.

Q.        So just to touch on that point, this medication is also associated, is it, with abnormalities or changes in heart rhythm?

A.        Very rarely, yes.

Q.        And are there any fatalities associated with changes in heart rhythm recorded for this medication?

A.        This group of medication, people taking it have a higher risk of death from heart irregularities than in the general population, but the extent of the change is not clear and is still being researched.

Q.        I mean the question is do you think that could have happened to Mr Horne-Roberts?

A.        Given what I’ve heard from the pathologist, no, I don’t.

Q.        So…

MRS HORNE-ROBERTS:  I can’t hear you again at all really.

THE CORONER:  Sorry, I wonder what we can do about this to make it a bit easier.

MR ROBERTS:  Speak closer to the microphone.

THE CORONER:  I’m just wondering if it would be easier to sit here.

MRS HORNE-ROBERTS:  Well I just think she ought to speak up.

MR ROBERTS:  Or speak closer to the microphone.

MRS HORNE-ROBERTS:  Speak closer to the microphone.

A.        Can you hear me better if I’m this close?

MR ROBERTS:  No.

A.        It’s not working, no, sorry.

THE CORONER:  No, I don’t think our microphone is working.

A.        I was expecting…

Q.        Well let’s just try – try to keep your voice up.

A.        I’ll try to speak more loudly.

Q.        The question I asked you was do you think that the rare complication of changes in heart rhythm could have been something that brought about Mr Horne-Roberts’ death.

A.        I don’t.  Now that I’ve heard from the pathologist that the lungs were congested, I think that heart failure is the direct cause of death.  I think the only question that could be related to the medication is whether it contributed to the weight gain which caused the excess of fat around his heart.

Q.        So do you think – let’s just put the question another way.  Do you think that the medication more than minimally or trivially contributed to Mr Horne-Roberts’ death on the balance of probability?

A.        On the balance of probability it may have minimally contributed.

Q.        But it has to be more than minimally or trivially contributed.

A.        Can you remind me how much weight gain could possibly be attributed?

MS PASAUD:  Sir, shall I pass over the weight charge?

THE CORONER:  Yes.  Here’s the weight chart, have a look at this.

A.        Thank you.

MR DOCHERTY:  Sir, sorry to interrupt, but having looked at that, I don’t think that identifies when the citalopram and the chlorpromazine prescription started.

MRS HORNE-ROBERTS:  It does in the bar chart.

A.        I do have that information.

THE CORONER:  Yes, I think it does.  It is helpful. 

A.        So when it was started he was 140 kilograms, and at the time of his death he was 144 kilograms, so no, I don’t think that was a significant contribution at all.

Q.        The question is not a significant – it’s language, lawyer’s language, it’s very precise, and forgive me if I just ask the question again just so that we have it clear.  The question is whether or not the weight gain experienced by Mr Horne-Roberts when he was prescribed these medications more than minimally or trivially contributed to his death on the balance of probability.

A.        No, I don’t think it did.

Q.        And you say that because the weight gain following the prescription of these medications was from 140 kilograms to 144.

MRS HORNE-ROBERTS:  No, 124 to 144. The chart shows 124 to 144.

THE CORONER:  Have a look.

A.        Sorry, on the chart…

MRS HORNE-ROBERTS:  That’s 20 kilos.

MR ROBERTS:  124 kilos.

MRS HORNE-ROBERTS:  It’s 20 kilos. 

MR ROBERTS:  So it’s a gain…

MS PASAUD:  Chlorpromazine was started on 3 February 2009.

THE CORONER:  Yes.

MS PASAUD:  So we’re looking at the weight gain from 3 February 2009 to December 2009.

MRS HORNE-ROBERTS:  Citalopram causes weight fluctuations.

A.        No, citalopram does not significantly cause weight gain.

MRS HORNE-ROBERTS:  It causes weight fluctuations.

A.        It’s more likely to cause weight loss than weight gain.

THE CORONER:  Shall we just focus on this point and see if we can get this clear?  The weight gain is from 120 kilos to 144.

A.        The lowest weight recorded on this chart is 125 kilograms in May 2008.

Q.        But the medication was started in 2009.

A.        The citalopram was first prescribed in October 2008, but the medication I focused on, the chlorpromazine was started in March 2009.

Q.        So from March 2009…

MRS HORNE-ROBERTS:  February.

A.        February 2009.

MR ROBERTS:  February.

MRS HORNE-ROBERTS:  13 February.  Jesus, you can’t read.  It’s 124 kilos, it says it quite clearly on the chart.  Just read it.

THE CORONER:  Let’s just – let the witness have a look at these figures.  Have a look at these figures.

A.        The figures say that on 4 May 2008 he weighed 125 kilograms on this chart.

Q.        Yes.

A.        It says that on 15 February 2009 he weighed 140 kilograms, and at the time of death, or shortly before his death he weighed 144 kilograms.

Q.        So that again shows the increase from 125 to 140 kilos.  That’s from May to when he was weighed in February.

A.        Yes.

Q.        Is that related to the prescription of medication?

A.        I would not have thought so.  For citalopram to cause weight gain would be unusual, and certainly would not be something I would expect or check for.

Q.        So just in conclusion then, for both these medications it’s your opinion that they didn’t contribute more than minimally or trivially to his gain in weight.

A.        That’s my opinion, yes.

Q.        So what was responsible, do you think, for the increase in weight from 125 kilos to 140 kilos?

A.        The most likely explanation would be changes in his diet and exercise levels.

Q.        Well that’s very helpful.  Just let me turn up your report again.  Finally you say this, ‘We were looking at was there anything that should have been done differently in treating Mr Horne-Roberts,’ and your final point was, ‘once Mr Horne-Roberts’ behaviour was settled it may have been possible to reduce or discontinue the chlorpromazine.  However, it would be usual to continue the medication for at least six months before attempting reduction,’ is that right?

A.        That’s correct, yes.

Q.        But if I understand what you’re saying, the medication that Mr Horne-Roberts took did not more than minimally or trivially contribute to his weight gain on the balance of probability, is that right?

A.        That’s right.

Q.        Is there any other way that these medications could have more than minimally or trivially contributed to Mr Horne-Roberts’ death?

A.        Not in my opinion.

Q.        Well that’s very helpful.  Dr Prasad, was there anything you wanted to ask?

DR PRASAD:  No questions. 

THE CORONER:  Doctor, you don’t need to stand up.  It’s only lawyers who need to stand up.

DR PRASAD:  All right, thank you.

THE CORONER:  Make yourself comfortable when you ask your questions.  Mr Docherty, was there anything you wanted to ask?

MR DOCHERTY:  I’m grateful, Sir.

 

Examined by MR DOCHERTY

 

Q.        If I could just clarify a couple of points, Dr Radley.  You were asked about risperidone.

A.        Yes.

Q.        Is it right that the research into heart disease and anti-psychotic drugs is generally related to anti-psychotic drugs as a whole?

A.        Yes.

Q.        And that risperidone as well as chlorpromazine is an anti-psychotic drug?

A.        That’s correct.

Q.        So in other words there would be no material – there would be no scientific material to suggest you’d be better off, from a cardiac point of view, with one prescription rather than the other.

A.        No.

Q.        Thank you.  Now Dr Radley, you’ve been asked about the weight charts.  Can I just ask you a little more?  The charts that I’m working from, so it may be useful to know, are the manuscript ones, which I think are the originals, but which, as I understand it, are the basis for this typed document.  These are weight monitoring charts.  Mr Horne-Roberts’ weight was taken quite regularly at Hillgreen, the home where he was.  Do yours start in 2008?

A.        Yes, 4 January 2008.

Q.        And the weight there is 145 kilograms, is that right?

A         That’s right, yes.

Q.        And I can tell you, just for information, that that’s about the weight at the time of admission in 2007, because these charts go a bit further back in time.

THE CORONER:  Yes.

MR DOCHERTY:  Now it’s right, isn’t it, Dr Radley, that what one sees during the first half of 2008 is weight reduction.

A.        That’s correct.

Q.        From 145 down to 125 in June.

A.        Yes.

Q.        But then in July the pattern changes and that is reversed, and there is a gradual weight increase…

A.        That’s right.

Q.        … through the second half of 2008.  Now we know that the citalopram prescription started in October 2008.  Just concentrating for a moment on 2008, you’ve been asked as to whether drugs influenced the weight fluctuations.  It’s right, isn’t it, that one sees a pattern of weight loss followed by weight gain going from the first half of 2008 and then weight gain through the second half.

A.        Yes.

Q.        And would it be fair to say that there’s no visible sign of that pattern changing when the prescription of citalopram starts?

A.        The weight gain that has started continues.

Q.        Yes, the weight gain’s already started, hasn’t it?

A.        Yes.

Q.        By the time of the prescription.  And it carries on.  But citalopram is not a drug associated with weight gain per se.

A.        No.

Q.        And then when one goes into 2009, the chlorpromazine prescription I think actually started in February, I believe you said March, but I think it started in February.

A.        Sorry, February.

Q.        But at 25 February we have 141 kilograms, and then it stays at or around – it stays in the lower half of the 140.  It rises to 145, and the last weight was 144.  So in the context of somebody who was that heavy, would you regard those variations as being significant?

A.        No.

Q.        Thank you, Dr Radley.

THE CORONER:  Ms Pasaud?

MS PASAUD:  No thank you, Sir.

THE CORONER:  Members of the family.

 

Examined by MRS HORNE-ROBERTS

 

Q.        Yes, thank you. Referring to your first report, Dr Radley, you say that Harry was a small baby.  He was in fact 6.75lb, which I think is average size, is it not?

A.        Yes, that’s right.

Q.        It’s not a small baby, he wasn’t a small baby.

A.        He was – I believe that average is 7lb, but yes, he was within an average range.

Q.        Well you seem to be trying to imply that there may have been something wrong with him at birth, which is definitely not the case.

A.        No, no, not at all.

Q.        Were you aware that he got 10 out of 10 on his Apgar scores?

A.        No, I hadn’t thought that there was any problem with him at birth.

Q.        He didn’t suffer from constipation, as you indicated in your report, and he was never on a milk and wheat free diet.  Do you accept that?

A.        I’m sure you know – this is simply the information I’ve taken from the records that were provided to me.

Q.        Keith had offered – my husband Keith, Harry’s father, had offered to help his GP, Dr Prasad, with testing Harry, and yet no monitoring of these drugs was undertaken either as a base line or during their use.  Is it not true that the – the Mental Health Trust has told us that they had guidelines on their intranet.  Have you any comment on that, on the failure to do any testing or monitoring while guidelines were in operation?

A.        If there were guidelines in operation, ideally they should be followed.  My impression was that it would have been difficult to carry out the testing on Harry, but I accept that with help it might have been possible.

Q.        And are you familiar with the Cambridgeshire and Peterborough guidelines for anti-psychotic drugs?

A.        I’m not familiar with the guidelines.

Q.        You’re not familiar with the guidelines?  You’re a psychiatrist.

A.        I’m not familiar with the Cambridgeshire and Peterborough guidelines.

Q.        Anyway, the Mental Health Trust was told, [Beryl Strowell?] of the Mental Health Trust told us that they had guidelines in operation on their intranet system similar to those of the Cambridge and Peterborough guidelines, and in fact internationally, standards were laid down in 2002 at the International Conference, guidelines for monitoring.  Were you aware of that?

A.        There has been a lot of discussion about the most appropriate monitoring of physical health in people taking psychotropic drugs, and there’s been a lot of debate about how much intervention is necessary.  It’s now generally accepted that there should be some sort of assessments, regular blood tests and possibly ECGs when people are taking these medications, but that’s relatively recent.

Q.        Well since 2002, 10 years ago.

A.        Things have changed even in the last three or four years in terms of the widespread use of these assessments.

Q.        The Royal Free Hospital and the Bridge School were both successful in testing Harry, one for an ECG a couple of years prior to his death, which was clear; and a blood test when he was 18, which was clear.  Have you any comment on that, to show that there were no problems with his heart?

A.        If he had no problems with his heart that would have been reassuring to me, had I been prescribing him psychotropic medication, that would suggest that the risk was not unusual in prescribing it.  So it’s good that he’d had a normal ECG.

Q.        What is your comment on the prescription of citalopram, which is now known to have dangerous side effects such as Torsade de Pointes?

A.        That is a very recent finding, and it was a surprise to discover that.  I think it’s a very rare side effect, but it’s something we’ve become aware of only in the last year. 

THE CORONER:  What is it?

A.        It’s an abnormality similar to the one I mentioned for chlorpromazine of irregularities of the heartbeat.

Q.        But how do we know that happened to Mr Horne-Roberts?

A.        Well because we know that he’s got – he had heart failure.  That suggests – that isn’t in keeping with Torsade de Pointes, which is simply a sudden irregularity of the heart rate causing a sudden collapse and death.

Q.        Could you not have both?

A.        You could have both, and we can’t be sure that he didn’t, but it is a rare side effect.

Q.        I see.  So the benefit of regular ECGs then would be to pick up any irregularities of heart rhythm.

A.        That’s right.

Q.        But you say in this case, in your understanding, it may have been difficult with Mr Horne-Roberts to persuade him to have such an ECG, is that right?

A.        Yes.

Q.        Thank you very much.  I’m sorry, I’m forever interrupting.

MRS HORNE-ROBERTS:  Thank you, Sir.  Could citalopram cause hypomania in Harry, do you accept that?

A.        It did appear that that’s what happened.

Q.        While he lived with us, until he was 18 years two months, Harry was on no drugs except for a two-week period of risperidone.  Why was – Harry wasn’t psychotic.  Why was it necessary to use drugs at all?  We suggest that Harry would have been healthier and probably wouldn’t have died if he hadn’t been put on these drugs, which have dangerous side effects, as you know.

A.        It’s always a difficult decision to balance the risks and benefits of these types of medication, but there did seem to be evidence that Harry was anxious and agitated, and that the medication might have helped, and that’s the reason why it was used.

Q.        But Dr Jaydeokar says in a letter of March 2009, 27 March 2009, that Harry’s problem was anxiety.  But these drugs weren’t appropriate for the anxiety which is a part of the autistic spectrum, is it?

A.        Actually citalopram, or drugs of that type are very commonly used to help autistic people who suffer from anxiety.  Chlorpromazine less commonly, but it’s also used.

Q.        Well I am suggesting they should not have been used on our son who had no capacity to consent, and certainly would not without consulting us, his parents, in accordance with the law.  The Mental Capacity Act required that.

A.        It would have been better to have discussed it with you, but what was done was in accordance with normal psychiatric practice.

Q.        And should anybody be given these drugs without any consent being given?  Harry didn’t have the capacity to consent, I think there’s no query about that.  So should these drugs ever be used where somebody doesn’t have the capacity to consent without consent being obtained from a relative?

A.        People with learning disabilities can’t be deprived of drugs that may be helpful to them because they can’t consent.  The Mental Capacity Act is there to ensure that best interests are taken – best interest decisions are taken by consulting everybody that is involved with the care of a person.

Q.        Maybe drugs may be helpful.  He didn’t need drugs while he was with us, and I suggest that these drugs may well have contributed to or caused or his death, either directly or indirectly by increasing weight, significantly increasing weight.  20 kilos from the time he was prescribed citalopram to the date of his death. 

A.        As I’ve said, what was done is in accordance with normal psychiatric practice.  The drugs may have contributed to his death, that is a rare side effect and a risk that has to be considered.

Q.        But weight gain is not a rare side effect, it’s an inevitable side effect with the use of anti-psychotic drugs.  It always occurs, doesn’t it, with the use of anti‑psychotic drugs?

A.        No, it doesn’t always occur, but it is quite common.

Q.        Did you hear the Dr Mitchell broadcast, the psycho-oncologist at Leicester University on 4 October last year, where a patient said that in the space of a couple of months on these drugs her weight rocketed by four stone, and that was quite a common occurrence.

A.        It’s a rare occurrence, but it can occur.

Q.        Well obviously it was happening to Harry, wasn’t it?  Because his weight was rocketing up, and why was nothing done about the fact that his weight was increasing?  It was a clearly a risk to his health, wasn’t it, if his weight increases by 20 kilos over the space of – from October 2008 until his death 15 months later.

A.        Certainly the weight gain presented a risk to his health.

Q.        Wouldn’t you expect a doctor to do something about it?

A.        It’s certainly something that the people involved in his care should have and perhaps did, I don’t know, look at and consider what might be done.

Q.        One of the things they could have done was take him off the drugs, wasn’t it? 

A.        That’s something that could be considered.  I think the first thing would be to look at his diet and exercise.

Q.        I’m just looking at my notes.  Just give me a moment, please, thank you.  Also, shouldn’t a mental capacity assessment have been done of Harry under the Mental Capacity Act before these drugs were considered?

A.        Yes, he should have had a mental capacity assessment, and best interest decisions should have been made and formally recorded, and that’s recognised in the root cause analysis report.

Q.        If CPZ, chlorpromazine is prescribed, is there not a maximum period advised of a few months?  Whereas Harry was on it for ten and a half months without any monitoring at all.

A.        No, it depends on the patient how long it’s prescribed for.  Some people remain on it for years if they need it.

Q.        It’s a question.  They may remain on it through malpractice, but should they remain on it?

A.        It depends on the patient and their needs.

THE CORONER:  Is it your opinion that Mr Horne-Roberts should not have been on this medication?

A.        No, that’s not my opinion.

Q.        Your opinion is he should have been on this medication.

A.        Yes, or he should have been on some medication, given the information that I have.

Q.        So just to put the question another way, do you think there was anything to criticise about the prescription of the medication to Mr Horne-Roberts?

A.        As I’ve said, the lack of a full consultation is something to criticise.

Q.        But that’s the only matter, is it?

A.        And the fact that it wasn’t reviewed between – I don’t think, between July and December, although patients may often go six months without a review.

Q.        Did you think any of these matters more than minimally or trivially contributed to Mr Horne-Roberts’ death?

A.        No, I don’t.

Q.        Right, thank you.

MRS HORNE-ROBERTS:  Why do you say that?

A.        Based on the evidence around…

THE CORONER:  Well let’s just take it in stages, because the first thing you said was the failure to – or rather the lack of communication with members of the family before the prescription of the medication pursuant to the requirements.  Now did that in itself more than minimally or trivially contribute to Mr Horne‑Roberts’ death on the balance of probabilities?

A.        In my opinion, on the balance of probabilities, it didn’t.

Q.        And the second matter that we discussed was the fact that Mr Horne-Roberts appeared not to have been reviewed since the prescription of this medication.

A.        Well not since the increase in July.

Q.        Not since July 2009.  Did that more than minimally or trivially contribute to Mr Horne-Roberts’ death on the balance of probabilities?

A.        On the balance of probabilities, in my opinion it didn’t.

Q.        No, all right.

MRS HORNE-ROBERTS:  You say in your opinion, but I mean an opinion surely has to be based on proper evidence.

A.        It’s based on my ex…

Q.        Not just a whitewash.

A.        … on my experience of using these drugs and my awareness of the evidence in relation to side effects and death resulting from the use of psychotropic drugs.

Q.        Isn’t it right that CPZ causes massive appetite increase?

A.        It can cause increase in appetite, yes.

Q.        Would you say that the GP was responsible for testing Harry before and while on these drugs, or was it the duty of the psychiatrist alone?

THE CORONER:  Surely it would be the person who wrote the prescription.

A.        Yes, yes.

Q.        To review, wouldn’t it?

A.        Yes, it would.

Q.        So it would be whoever wrote the prescription would then have the obligation to review.  There may be an initial prescription by the hospital or the psychiatric team, and they would then have to review in that period of time.

A.        Yes.

Q.        Then it would inevitably, it seems, be transferred back to general practice case in the community, and therefore the general practitioner would assume that responsibility.  Would that be right?

A.        In terms of the review – in terms of the investigations, it would have been something the psychiatrist could have done at the beginning of the prescription and recommended to the GP should be repeated, and then it would be the responsibility of the GP to do that.  But that recommendation wasn’t made.

Q.        No, you didn’t…

A.        But I don’t think it would have materially contributed to Mr Horne-Roberts’ death in any case.

MRS HORNE-ROBERTS:  Sorry, I didn’t hear that.

THE CORONER:  The fact that the review wasn’t taken, we’ve had an answer to this, wouldn’t more than minimally or trivially contribute to the death on the balance of probabilities, is that right?

A.        That’s right.

MRS HORNE-ROBERTS:  I don’t know whether you’ve seen my witness statements, but in the second witness statement I did, I did an analysis of the daily logs from Hillgreen Care, that showed that Harry’s behaviour did not improve while he was on the medication.  And he was on this medication, which had significant risks to say the least, and yet they didn’t manage to improve his behaviour.  So what’s the point of being on them?

A.        The impression I had from the records was that it did improve his behaviour.  But if it didn’t it should have been reviewed.

Q.        Thank you.

THE CORONER:  Yes.

 

Examined by MR ROBERTS

 

Q.        Sir, may I just very in short say thank you very much for all that, but the thing that comes over to me, and I do hope will be borne out in the Judgment, if that’s the correct expression, is that the best interests assessment is the sort of thing we might have been having as we have this morning.  The sort of questions we’ve been talking about this morning would have been better asked before Harry died, obviously. And in that case, although we’re not doctors, we could at least have been part of that assessment.  We should have been part of that assessment, and I think if we could get it over that in future it will be or must be part of the assessment of the ongoing treatment.

A.        Yes.

Q.        Parents or guardians are people who we cannot afford to leave out. 

A.        That is correct, I agree with that.

Q.        Thank you.

THE CORONER:  Well that’s actually the position now.

A.        Yes.

Q.        But what happened here was it did not happen.

A.        That’s right.

Q.        But it should have done.

A.        It should have happened, yes.

THE CORONER:  Was there anything else, members of the family?

MRS HORNE-ROBERTS:  I don’t think there is.

MR ROBERTS:  Thank you, Sir.

THE CORONER:  Thank you very much indeed.  I am very grateful to you.  I will release you.  You needn’t stay unless you wish to do so, but of course you leave here with our thanks.  Thank you very much indeed.

A.        Thank you.

 

[Witness was released]

 

DR SUJEET SUDAKA JAVDEOKAR (affirmed)

Examined by THE CORONER

 

Q.        Would you be so kind as to tell the court your full name, please?

A.        It’s Sujeet Sudaka[?] Jaydeokar.

Q.        You’re a consultant psychiatrist, is that right?

A.        That’s right.

Q.        And how is your service best described?

A.        It is a partnership service, so although I’m employed by the Mental Health Trust, the Learning Disability Services are run by the local authority, who is the lead agency, and it is a partnership between the local authority, which is Haringey Local Authority, Whittington Health, which used to be Primary Healthcare Trust, and Barnet and Haringey Mental Health Trust.

Q.        And is it to provide care in the community?  Is it to provide hospital care?

A.        It is care in the community.

Q.        And is it for a particular group of patients within the community?

A.        This service is for people with learning disabilities.

Q.        And Mr Horne-Roberts, was he a man who fell into this category?

A.        Yes.

Q.        And just help us with an overview.  What would be your role?  I mean when did you take over your role with Mr Horne-Roberts?

A.        He was referred to our service by Islington Health Authority when he moved to Middleton Road, and then a referral was made by his then social worker to our service, and that’s how I got involved.  I think – I believe the first appointment I saw Harry was in 2007.

Q.        Now just help us with this.  How often would you expect to see Mr Horne‑Roberts?

A.        It will vary depending on the circumstances.

Q.        But in his case.  Because clearly it would vary, you would have made an assessment and determined how often you would need to see him.

A.        In his case, after the initial assessment, I had not prescribed him any medication. At the time I felt that many of his difficulties could be helped with other interventions. With that in mind I had made a referral to speech and language therapies, and a psychologist, and during that period as well I had also returned to Islington Local Authority about having some sort of structured day activities for Harry, because I felt that that will help someone like him with his behaviours.  I again got involved in 2000 and…

Q.        Well let’s just look at that, that period.  So this is shortly after he was referred to your team. 

A.        Yes.

Q.        How was he?  Was his physical health good?

A.        I focused more on behaviour.  He was referred for having learning disabilities, autism, and then associated behaviours.  At the time they were not major concerns in the sense he was settling in, he was attending regular college, so he had quite a good structure.

Q.        And where was he living?

A.        He was living at Middleton Road.

Q.        I see.  Now did his condition change such that medication became necessary? And if so, when was that?

A.        In – I was contacted again by his social worker, [Sophie Toha?], with a concern about his deterioration in his behaviour, and concerns were that he was becoming more agitated, banging his head, he was also not sleeping so that was a concern.  I felt at the time that it was due to – it was sort – we have a manifestation of his autistic spectrum disorder, and I felt that people with autistic spectrum disorder experience a lot of anxiety, and that leads to agitation and that leads to sometimes self-harming behaviour and aggression.  Many a times this anxiety is due to lack of routine, structures, activities and not having predictability in the regime.

Q.        So when was it that it was necessary to – it became necessary to consider medication?

A.        So at that time I decided that he will benefit by medication.

Q.        So on 14 October 2008 you say you saw Mr Horne-Roberts at his home.

A.        That’s right.

Q.        And you on that occasion started him on citalopram, 10 milligrams, once a day.

A.        That’s right.

Q.        And did you start any other medication?

A.        Not at the time, no.

Q.        And you saw him again on 11 November at his home.

A.        Yes.

Q.        Had his behaviour improved?

A.        There was – the staff reported some improvement in his behaviour, at the time they felt there was some reduction in his self-harming behaviour and aggravation, although there was not complete improvement, and there was no improvement in his sleep pattern.

Q.        So you increased the citalopram to 20 milligrams.

A.        Yes, that’s right.  I felt that there was some response to 10 milligrams of citalopram, which is a low dose, and considering his weight it was certainly a low dose.  I felt a further increase was warranted. 

Q.        And you saw him again on 6 January 2009, is that right?

A.        Yes.

Q.        And had his condition changed, because you increased his citalopram again on that occasion?

A.        That’s right, because I think that increasing – initial increase in citalopram, there was no further improvement and I felt that considering his size maybe we are not achieving any therapeutic level, and perhaps I can increase his citalopram a little bit more and see if there was any benefit. At the same time there was a lot of concern about his sleep, and I kind of thought…

Q.        So you had a trial of zopiclone.

A.        Yes, I had a trial of zopiclone.

Q.        Now was Mr Horne-Roberts a person who had a lack of capacity to make decisions himself?

A.        Yes.

Q.        So were the decisions concerning the medication starting, and indeed its increase discussed with members of the family?

A.        I think there was like a communication on my part, and I acknowledged that.  I think at the time the discussion was with the care home staff.  Care home staff had a very good relationship and contact with the family members, and it was assumed on my behalf that there will be a communication.  I believe actually there was a communication around citalopram starting or citalopram with the family from members of the care staff.  A social worker who was care manager…

Q.        So just to make that clear, it wasn’t from you but from the care home staff.

A.        It wasn’t from me, and with hindsight I think it would have been much better if it was directly from me with the family.  I mean since then we – I do copy all my letters to the family members as well, so that they are aware.

Q.        Quite so.  Now the zopiclone didn’t lead to a better sleep pattern.

A.        No.

Q.        So on 3 February 2009 you wrote to Mr Horne-Roberts’ general practitioner to ask him to prescribe chlorpromazine.

A.        That’s right.

Q.        And did that have any success with it?

A.        Yes, I think the chlorpromazine, there was – there was improvement in his level of agitation and sleep. Chlorpromazine has a good sedative action, which is – I mean all the anti-psychotic medication do have a sedative action, but chlorpromazine also are slightly different from something like risperidone.  For example, it’s most like the same action as cough syrup, sedative cough syrup, the same receptor action.  So that’s why I felt chlorpromazine will be a better option for Harry considering his sleep difficulties. 

Q.        Now on 13 May you got a letter – in fact on 27 March you wrote to Mr Horne‑Roberts’ parents, and then on 13 May you received an encouraging letter from members of the family, is that right?

A.        That’s right.

Q.        And you saw him at his home on 23 June 2009.

A.        Yes.

Q.        And how was he then?

A.        I mean I think there were, I think, after the second period there were deterioration in his presentation, and there was a slightly different pattern this time to his presentation.  And he – I mean apart from aggression, I’m afraid that there were underlying mood symptoms at the time.  There was hypomania, and he was running around, he was overactive.  I remember the assistant manager telling me that he used to put a bed sheet over his head and run around saying that he is the ghost of Middleton Road.  So I felt that actually – and plus there was deterioration in the sleep pattern, so I felt that he was actually having a hypomanic episode.

Q.        And this a side effect of the medication?

A.        It is not a side effect.  If there is a predisposition for someone to have a mood disorder then a prescription of antidepressant can precipitate the underlying condition.

Q.        Well do you think that’s what was happening here?

A.        I think that was what was happening in his case.

Q.        And members of the family, that’s their view as well, that the hypomanic moods were as a consequence of the medication.

A.        Yes, it precipitates if there is an underlying predisposition.

Q.        If there’s a tendency.

A.        A tendency.

Q.        Now you reacted to the hypomanic behaviour by reducing citalopram again, is that right?

A.        Yes.

Q.        So clearly at that stage you recognised a connection between the two.

A.        Yes.

Q.        There was no improvement, and on 30 June you advised staff to reduce citalopram to 10 milligrams for one week, and then to stop it.

A.        That’s right.

Q.        And you recommended gradual reduction, stopping of citalopram as this group of medications sometimes cause withdrawal symptoms.

A.        That’s right. 

Q.        On 30 July 2009 staff reported some improvement in Mr Horne-Roberts’ behaviour since the discontinuance of citalopram, however he continued to exhibit some episodic behaviour difficulties in the form of throwing things, physically disruptive behaviour, agitation and physical aggression.  So you’d advised to stop citalopram completely and decided then to increase the chlorpromazine to 25 milligrams morning.

A.        Yes, Sir.

Q.        25 milligrams afternoon, 100 milligrams at night.  Is that right?

A.        Yes.  I mean I think that would have been the usual course for me to gradually reduce citalopram, stop it and consider increasing chlorpromazine.  I mean chlorpromazine helps with mania, hypomania, agitation, aggression, it’s much broader than something like risperidone and as for BNF indications.  So that was my choice.

MRS HORNE-ROBERTS:  Sorry, could that be repeated, Sir?

THE CORONER:  Could you just repeat that?

A.        Chlorpromazine has a much larger indication profile as per British National Formulary, so it is indicated in much wider conditions as to risperidone.

MRS HORNE-ROBERTS:  Okay, thank you.

A.        So risperidone is used with autistic spectrum disorder for behaviour and management, but the main indication is psychosis, while chlorpromazine has much a wider remit, partly because of the number of receptors it has impact on.

THE CORONER:  And staff reported to you on 20 August an improvement in Mr Horne-Roberts’ behaviour, is that right?

A.        Yes, that’s right.  And I think since then his behaviour had remained reasonably settled, so I would have reviewed him again in January.

Q.        Now what about his weight, because we’ve talked already about his weight.

A.        Yes.

Q.        Did you see any connection between his weight gain and the medication that he was being prescribed?

A.        I mean I think my clinical thinking was – I think weight was a longstanding issue for Harry, so it’s not…

Q.        So it’s not connected with the prescription of this medication.

A.        Well he had a longstanding issue with weight, so from a clinical point of view I have to be careful as to what I prescribe.  It’s not a contraindication to prescribe it, but one has to be careful about – especially around the choice.  My initial choice for SSRI, that is citalopram as to something like chlorpromazine was partly based on that, because citalopram is known to have a negative impact on appetite and weight, so most commonly – more commonly it actually reduces appetite and reduces weight, hence it is advised that it is being given in the morning after breakfast.  So that was my automatic thinking.  However, because of what happened I had no choice but to go away from SSRIs and then, you know, I mean I had anti-psychotic medication already.  One of the things which staff had mentioned, and I think I had a sort of good working relationship with Hillgreen Care Home because I have other patients at that home, so I work quite closely with them, and one of the things they had repeatedly talked about is difficulty to control his diet.  And I think they felt that they were not able to do as much because of the behaviour.  I think they had more success looking at the weight chart in the initial part when he was more settled, but since his behaviour deteriorated they were struggling to manage his diet.  And I felt if you are able to control his behaviour then there will be more opportunities for access to the community exercise, and staff will be able to manage the diet.  So it is actually looking at the balance of risk and benefit and exercise –

Q.        But from what the pathologist has told us, Mr Horne-Roberts died because he had put on too much weight over whatever period.  And this is significant, isn’t it, because a lot of patients tend to be too heavy.  And what this really suggests is that in patients who lack capacity there has to be much firmer control over diet and exercise however difficult it must be, because in effect what we learn from Professor Risdon is that Mr Horne Roberts died because the control of his exercise and nutrition, his diet and nutrition were not adequate.  He should not have been able to get to that weight.

A.        Yes, I think it…

Q.        Do you think that’s a fair point to make?

A.        I think it is a fair point to make.  I think nutrition, diet, exercise is very important.  People with learning disabilities are known to have a poor healthcare outcome, and there have been a lot of reports and there has been a lot of work that has been done to promote the health, so there is a high prevalence of morbidity due to weight and nutritional difficulties in people with learning disabilities.  And in Harry’s case unfortunately it was not just learning disability, but autistic spectrum disorder, which makes repetitive, obsessive behaviour, and that makes people more difficult to control, the healthcare and diet.

Q.        Yes, I accept that, but what this case shows is that it’s necessary to address that.

A.        Yes.

Q.        However difficult it is, a patient should not be in a position where their health is put at risk because their weight grows too heavy.  And in this case Mr Horne‑Roberts’ heart became encased in fatty tissue.  Had his diet and his exercise regime been such as to not allow him to put on that weight, he would not have died.

A.        Yes, I mean it is a clear link with the weight, so any intervention to reduce weight, healthy living, would have been helpful. 

Q.        So I mean that really – the issue for Mr Horne-Roberts is really the control of his weight and the management of his diet.

A.        I mean although I’m involved with the mental health side of it, as a partnership we have recognised it as a major issue, the nutrition and health of people with learning disabilities.  And what we are actually trying to do, I mean one of our physiotherapists has started a nutrition and exercise programme, delivering a programme for people with learning disabilities, just focusing on them, partly because they have difficulty accessing mainstream gyms and exercise unfortunately, and services as well.  Also, our service is working a lot more closely with various GP practices in terms of making healthcare more accessible for people with learning disabilities.  And one of the things which we learnt from this incident as well is that the difficulty in getting investigations, difficulty in getting monitoring done.  So we do now have a healthcare team, a nursing team, who are more trying to work more closely with GP practices so that people could be supported.

Q.        But if I put the question another way, how was it allowed for Mr Horne‑Roberts to become morbidly obese?  How was that possible when he was receiving such regular care?

A.        It’s very difficult to answer that question.  I mean it is a longstanding, I think before he moved to Middleton Road also there were longstanding issues.

Q.        Well that’s before – when your team take over in 2007 you are presented with a person who is morbidly obese.  And how can it be that in the period between then and 2009 his weight did not reduce significantly, and his obesity diminished?  You can see the difficulty.

A.        Yes, yes.

Q.        When we sit here it stands up very prominently.

A.        Yes.  I mean I do understand that, and I think – I mean, you know, I’m sure Hillgreen Care would be able to throw a bit more light on some of the nutritional and management difficulties that they might have faced around this issue.  And I’m sure Dr Prasad will have some opinion on that as well as he likely made concerns about.

Q.        You see, it might be argued that part of basic medical care is ensuring somebody has a healthy diet and regular exercise.

A.        Yes.

Q.        And that didn’t happen here.

A.        Erm…

Q.        It’s hard to argue that it did in a case where Mr Horne-Roberts…

A.        I mean we can give the charts as far as weight is concerned.  I suspect, and I hear – you know, I mean I cannot like actually say on behalf of everyone else, but what I know from the care staff and some of the service users as well, that a lot of importance is given to encouraging healthy eating or encouraging healthy options.

Q.        I don’t doubt it, but it didn’t work in this case.

A.        It didn’t work, yes.  And I feel that Mr Horne-Roberts, the other difficulties might have contributed to a difficulty in having that…

Q.        Well, I mean was Mr Horne-Roberts buying his own food and preparing his own food?

A.        No, I don’t…

MS PASAUD:  Sir, I wonder whether these are questions for the care.

THE CORONER:  They may be questions for other witnesses.  Well that’s very helpful, thank you very much indeed.  Now if there were to be a recommendation or a report that persons who are clinically overweight should be the subject of special care, would you support such a thing?

A.        Yes, I will support it actually, and I think – I know the [inaudible] the Trust has also the nutritional health now as the key area on RiO, the case records that are kept.  And although we don’t use RiO, we have recognised that as a factor.  In fact my consultant colleague is actively driving that area.

Q.        Because your patient should not be allowed to become so overweight that it risks their life, which is what happened to Mr Horne-Roberts.

A.        Absolutely, all efforts must be made or should be made.

Q.        Yes, well that’s very helpful, thank you very much indeed.  If you just stay there a moment.  Dr Prasad, did you have anything you wanted to ask?

DR PRASAD:  No, Sir.

THE CORONER:  Mr Docherty?

MR DOCHERTY:  Thank you.

 

Examined by MR DOCHERTY

 

Q.        Dr Jaydeokar, you talked about the weight problems that Mr Horne-Roberts had.  I think your witness statement shows the weight was 140 kilos back in July 2006, that’s just after his 17th birthday, isn’t it?

A.        Yes, yes.

Q.        And it was, I think, 145 kilos on admission in September 2007 or thereabouts.

A.        That’s – yes, as I understand, yes.

Q.        And about the same the last weighing before he died.

A.        Yes. 

Q.        You’ve indicated that in your statement and giving evidence today that agitated behaviour makes control of diet all the more difficult.

A.        I mean any agitated behaviour, it’s going to have difficulties in lots of areas.

Q.        Yes.

A.        I mean, you know, overall management, daily living, access to the community, all those areas would be difficult.  So I assume the diet will be a rather difficult part of it.

THE CORONER:  Well can we just be clear about this?  A healthy diet does not make a person overweight.

A.        No, no, no.

Q.        Right.  So whether a person is anxious or otherwise, a healthy diet doesn’t affect that.

A.        Yes, absolutely.  And I think the issue comes, is that for the staff it is about encouraging healthy diet rather than forcing a healthy diet.  That’s where the problem comes.

Q.        Well I think in a person who’s morbidly obese, who lacks capacity as in Mr Horne-Roberts’ case, there are some decisions that the medical team need to make before a patient simply dies from being overweight.  That is what, in effect, Professor Risdon has suggested is the cause of death in this case.

A.        That’s right, yes.

Q.        Mr Horne-Roberts died because he was too overweight.

A.        That’s right.

Q.        And I appreciate that anxiety may have difficulties in the management of eating and the management of an exercise regime, but a healthy diet doesn’t affect any of those things.  Am I right?

A.        Yes – yes, I mean that will be the first port of call, change the diet, reduce the amount of calories that are going in.

Q.        Yes.  Just so that I have this clear, forgive me Mr Docherty, just to have this clear, who was responsible for the diet?  Who would be responsible for ensuring that Mr Horne-Roberts had a health diet?

A.        I would have thought that would be care staff at Hillgreen Care.

Q.        But what about yourself?  You are the consultant in charge of Mr Horne‑Roberts.

A.        For his mental health.

Q.        Yes.

A.        The physical primary healthcare will be with his GP, general practitioner, and so all healthcare or primary healthcare related issues will be with…

Q.        I see.  Well that’s very helpful.  That’s very helpful, thank you.  Mr Docherty.

MR DOCHERTY:  So he’s living at Hillgreen, and obviously they have day-to-day responsibility for feeding him while he’s there.

A.        Yes.

Q.        Insofar as obesity is a medical issue, would it be for the general practitioner to be involved, or would it be for the psychiatric services?

A.        I would have thought general practitioner and community dietician.

Q.        Yes.  Now can I, Dr Jaydeokar, take you to a letter which actually touches on two issues that you’ve given evidence on?  A letter you received in March 2009 from Mr Horne-Roberts’ parents.  I don’t know you if have a copy of that letter.

A.        I don’t have it in front of me.

Q.        No.  I have it after Item 19 in the Coroner’s bundle, it’s 16 March 2009. 

[Document is passed to Dr Jaydeokar]

A.        Yes.

Q.        This is a, as it were, a cry for help from Harry Horne-Roberts’ parents.  They deal with the problems of controlling the eating of someone like Harry in the second paragraph saying, ‘He eats compulsively when we take him on trips every weekend, each Saturday and Sunday.’  Is that consistent with your experience of some people with autism and learning disabilities?

A.        Yes, it could be, yes.

THE CORONER:  Well you say it could be, because there’s another feature.  A person who is as heavy as Mr Horne-Roberts will be hungry a lot of the time.

A.        Yes, yes.  I think what happens many a times, that’s a reflection of underlying anxiety and it sometimes becomes comfort eating as well, so that might be something that could happen on a daily basis.

Q.        So it’s a complex picture that we have.

A.        It is complex, yes.

Q.        Because if somebody is as heavy as Mr Roberts, he is going to have to eat a significant amount to keep his weight.

A.        Yes, yes.  I mean I think, you know, the appetite goes up over a period.  For example, if you don’t eat for a while and diet, it becomes difficult for us to have a large meal after that.  And it’s the same the other way round as well, so the appetite overall goes up.  And in his case, I know he was partial to chocolates and other things, I can’t remember exactly, that might be linked with it.  Here we are looking at someone not just with learning disability and lack of capacity, but autistic spectrum disorder, so the eating becomes – could be part of managing his own anxiety and it becomes a repetitive act.  But the reason people with autism are repetitive is in repetitive same actions, they get comfort, and I think that eating could have become part of that as well.

Q.        But you see what is surprising is that – what attempts were made to address this?  I mean from your point of view as a psychiatrist in charge of his care, what attempts did you make to address this aspect of his behaviour?  Because you first train as a doctor?

A.        Yes.

Q.        And you are very familiar with the difficulties associated with a person being overweight.

A.        Yes.

Q.        So when you say that part of his autistic picture, if that’s the right way to describe it, may be causing him to eat too much, what steps did you take to try to stop that?

A.        I think from my training and the therapeutic approaches that are available to me, I would consider medication, and that’s what I considered to manage his anxiety.  So my logical thinking would be that if I am able to control his level of agitation and anxiety, the need for this always eating might reduce.  So that would be my thinking.  I had also done a referral to a psychologist earlier on…

Q.        But just on that point, therefore increase in weight shows a lack of success in the medication.

A.        Well lack of success with regards to appetite, part of it, but not lack of success about the rest of the behaviour, because that was not the only behaviour I was treating.  There was a lot of self-harming behaviour, there was aggression, lashing out and sleepless nights.

Q.        I appreciate that.  But if part of the picture is a form of compulsive comfort eating, then it is also a measure, if a patient is putting on weight, it’s a measure of another element in the spectrum of his disorder which is not responding to treatment.

A.        Yes, although that wasn’t my primary focus of treatment.  My primary focus of treatment was his mental health, and I was hoping that by treating the mental health it would have a beneficial effect on his overall health as well.

Q.        Would it be fair to say that when we sit here today it’s much clearer to see this picture?

A.        Yes, it is, and I think it is – I mean we have taken a lot of learning out of it, which is very important, and it’s unfortunately when, but it has led us to learn and improve some of our practices.

Q.        Well that’s very helpful, thank you.  Mr Docherty, forgive my further interruption.

MR DOCHERTY:  No, I’m grateful, Sir, thank you.  Dr Jaydeokar, can I then refer you to the next letter that you received from Harry Horne-Roberts’ parents? 

THE CORONER:  Is this 13th of…?

MR DOCHERTY:  It’s 13 May 2009, yes.  I’ve got my copy, which is slightly marked.  I’m happy to hand it up if it would be helpful.

THE CORONER:  Have you a copy of this?

A.        No, I have no copy of that.

[Document is handed to the witness]

MR DOCHERTY:  Mr Jaydeokar, that’s just to refresh your memory of that letter.  Now I think you’ve said, in a way critically of yourself, that you felt you didn’t keep the family informed of the medication, as you now would.  You would copy them in correspondence.  However, clearly as at May 2009 the family had been informed of the medication, at least to some extent, I don’t know the extent to which there’s an issue.  And their view was that he was making excellent progress on the medicines which you prescribed.

A.        That’s right.

Q.        So did that give you some comfort that the medication was having the desired effect?

A.        Yes, it did.  I mean I think it did two things, I think.  I mean, you know, it just confirmed – I mean, sort of in good faith I felt that they were aware of what was the treatment and what was going on, and they were in the picture, so from my point of view the staff from Hillgreen Care were communicating with the family. And yes, I think it gave me some idea of the progress Harry was making.

Q.        Yes.  And the second paragraph specifically referred to there being some reduction of anxiety, which was one of the main things that you were trying to address with your medication.

A.        That’s right.

Q.        And then in the final paragraph of the letter there was reference to whether you had a strategy for reducing weight, which must be a long-term goal.

A.        Yes.

Q.        So something that the family and everyone else was obviously aware of as a problem.

A.        Yes, as an ongoing issue.  I didn’t have any specific strategy with regards to weight reduction, I didn’t see that as my area of expertise.

Q.        Now I think you didn’t review Mr Horne-Roberts after July 2009.

A.        I spoke with the assistant manager in August to get a feel about how things were.

Q.        The assistant manager at Hillgreen, at Middleton Road.

A.        Yes.

Q.        Yes.  You were planning to review Mr Horne-Roberts in the new year of 2010, is that right?

A.        That is right.  If someone is settled then I tend to have an appointment anything between one to six months.  With regards to Hillgreen Care, I do have other service users there, so when I go there now I always ask about everyone anyway although there is no specific appointment.

Q.        Yes, I see, thank you.  Now you didn’t, again, have any particular contact with the family or seek their views on the medication in the last half of 2009, is that correct?

A.        That’s correct.

Q.        Can I just take you to one final document, which is, Sir, for your benefit, the document at 24.

THE CORONER:  Yes.

MR DOCHERTY:  It’s an email of 2 November 2009.  If I could ask for a copy up to Dr Jaydeokar.

[Document is handed to the witness]

Q.        Dr Jaydeokar, that is not an email to you, it’s from I think Mrs Horne-Roberts to a Mr Cheek[?], who I believe was a social worker with responsibility for Harry Horne-Roberts.  And really from your point of view, I just want you to look at the – towards the bottom of that email, and see if you can – do you see reference to the views that the family had at that stage of how the medication was working?

A.        Yes, that is right, yes.

Q.        Thank you.  Can you just read out what that says?

A.        Yes, the highlighted part says, ‘With his medication he has made great progress and is gradually continuing to improve.’

Q.        Now I don’t know, did that ever come to your notice, that email?

A.        No.

Q.        If it had would it have given you some comfort that…

A.        It would have given me a lot of comfort.  First thing, I mean it clearly indicates there was some improvement in his quality of life compared to the earlier part, and also yes, he had maintained his progress and continued to maintain his progress.

Q.        Thank you very much, Dr Jaydeokar.  I wonder if I could have my document back?

THE CORONER:  Ms Pasaud, shall I let members of the family ask questions before you?

MS PASAUD:  Yes, please, Sir.

Q.        Yes.  Members of the family, did you have any questions?

MRS HORNE-ROBERTS:  Yes, Sir.

THE CORONER:  Do ask.

MRS HORNE-ROBERTS:  Yes, thank you.

 

Examined by MRS HORNE-ROBERTS

 

Q.        Dr Jaydeokar, we wrote to you.  First of all you had a meeting with my husband in December of 2007 following a meeting.  I was distressed so I didn’t stay in the room, but he reached an agreement with you that there should be a residential care plan.  That wasn’t done, was it?

A.        Residential care plan…

Q.        There was no residential care plan that ever came to our notice.

A.        I think the residential home had a care plan for Harry’s case, and the care manager usually is responsible for making sure that there is a care plan.

Q.        But you agreed to this, and yet wasn’t it part of your responsibility to see that that happened?

A.        My impression was that he had a care plan.

Q.        I see.  And what about a personal healthcare plan?  It was agreed that that should be drawn up.  Why was that not done?

A.        I think, again, Hillgreen Care had a healthcare plan.

Q.        Well we certainly haven’t see it.

A.        Or a health action plan.

Q.        And you also say you made a referral of Harry to speech and language therapy.

A.        That is correct.

Q.        That never came to anything, did it?

A.        I won’t be answer to that.  I did make two referrals.  I made one to a speech and language therapist and one to a psychologist, but I know that there was some response from a psychologist, direct contact with Hillgreen Care about it, but I’m afraid I don’t know about the speech and language therapist’s involvement.

Q.        I see, no, that doesn’t seem to have been followed up.  As regards the letters that – my husband sent you a letter on 21 December 2007 saying what had been agreed at that meeting.  Do you accept – do you recall that meeting?  It’s in the – it’s with the evidence.  Do you want me to show it to you?

A.        I remember meeting Mr Horne-Roberts.

Q.        And he sent you a note of what had been agreed.  Have you seen that?  Did you see it, because that included a personal healthcare plan, which we never received, and also referrals?

A.        I don’t recall it receiving it.

Q.        It has been served on the other parties, I think.  Have you got that, Sir?

THE CORONER:  Yes, I have, yes.

MRS HORNE-ROBERTS:  Yes, thank you.  So there was an agreed strategy, which in fact didn’t take place, did it?  There was no healthcare plan, there was no referral to speech and language therapists, and similarly Dr Prasad made a referral to a dietician, none of these were followed up.  Is it your experience within Haringey that a lot of referrals came to nothing?

A.        I do know that there are waiting lists operating in the various services within Haringey.  I know speech and language therapists have their own waiting lists, and psychologists have their own waiting lists, which I didn’t have that involvement or control with.  But my understanding is that everyone does get seen if they are on the waiting list.

Q.        Well Harry wasn’t seen by any of these people.  Do you accept that?  Why d’you think that was?

A.        He wasn’t seen by a speech and language therapist, I am aware of that, or I became aware of that.  And with the psychologist I know they had contacted Hillgreen Care, but I don’t know what was the outcome or follow up of that.

Q.        Well we were never informed that that was the case.  And Dr Jaydeokar, I wrote to you first of all on 21 January.  I don’t know whether you – about Harry’s progress, and then again on 16 March, and in fact I’ve only been informed by Lola Odukomaiya at Harry’s review on 9 March, when she mentioned Harry’s medication.  I said, ‘What medication?’  I was unaware he was on medication, and she then said, ‘Citalopram,’ and indicated that it was a mild tranquilizer.  That was the only medication I ever knew or we – and my husband ever knew that Harry was on.  So when we wrote to you subsequently in May 2009 we thought he was on a mild tranquilizer, not CPZ.  We were never told he was on an anti-psychotic drug.  And when we say that he was making good progress, this is because whenever we took Harry on holiday, we took him on long weekends five times a year, he was very happy and behaved extremely well.  Do you accept that Harry was distressed at not being at his family home?

A.        I mean I think to think about like he being distressed for not being with the family – at family home, and I can completely understand that.  For someone with learning disabilities and autism, any transition is always difficult, so it’s transition from childhood to adulthood or adolescence, it’s difficult, any change is difficult.  Change in environment, change in staffing, that is going to cause and promote anxiety and distress.  So he being distressed not being in a family environment is understandable.  I mean I think my impression was that over the period he had settled at the Middleton Road quite well, so I mean I think the initial report when initially I got involved, the transition had been successful.  But it’s not just that transition.  There were other transitions taking place as well.  He was attending college regularly, five days a week if I’m…

Q.        Well he left school…

A.        He left school, that’s right.

Q.        … in the summer of 2008.

A.        That’s right.

Q.        Which is when the problems seem to have began.

A.        That’s right, that’s right

THE CORONER:  But do you think that he was additionally distressed because he wasn’t living at home?

A.        I don’t think that was the contributing factor at that time.  I think the college was a contributory factor in 2008, where he used to attend college.  So he had a daily routine, every morning he would go and then he would come back, so you know, after three or four o’clock.  Very, very structured, just like every one else, he had that sense of structure, predictability, what’s going to happen, what’s not going to happen.  Unfortunately that stopped with his age at the school place, when it came to an end.  I was genuinely concerned that there was at the time no planning from Islington Social Services with regards to what’s going to happen when he finishes his school placement.  Not having a structured activity does have a negative impact on people with autistic spectrum disorder, their behaviour.  So I had written at the time to the then social worker, the necessity to have funding in place to make sure that he has a structured day activity programme.  And as I understand, there was arrangement, funding was agreed for two days a week, which was not the same as five days a week, and that might have contributed to some of the behavioural difficulties. 

THE CORONER:  That’s very helpful. 

MRS HORNE-ROBERTS:  You replied to my letter of 16 March, when we said that Harry was making good progress, because whenever we saw him he was happy and he was on good form  And you replied on 27 March, that’s the one letter we had from you, saying Harry’s problem was anxiety.

A.        That’s right.

Q.        It was therefore with considerable – very great – very, very great concern and distress that we learnt Harry had been treated with anti-psychotic drugs by you.

A.        Yes.

Q.        Why – he was anxious, not psychotic, wasn’t he?

A.        Yes, and I mean – no psychosis was not part of the formulation, I agree with that, and it was anxiety that had led to agitation and some of the behavioural difficulties.  And like I said, I tried to treat at first with citalopram.  That wasn’t completely successful, so I tried chlorpromazine.  Chlorpromazine is used to treat anxiety and agitation and other general behaviours.  In fact chlorpromazine has a much wider indication profile than something like risperidone, hence my choice for chlorpromazine.

Q.        Lola told us that you treat every autistic spectrum person in the care of Hillgreen Care with CPZ, is that right?  So it’s not a person specific treatment, it’s a general cosh.

A.        It is not actually, and I do not treat everyone with chlorpromazine.  We do have someone else there in fact who went to school with Harry, he’s not on any medication at the moment, who has a diagnosis of autism. 

Q.        What about at the time before Harry died, was there anybody – other autistic person who was not on CPZ?

A.        Well at that home there were only two individuals with the diagnosis of autistic spectrum disorder.  One wasn’t on any medication.

Q.        There were – do you accept that there were communication difficulties with some staff at Hillgreen Care, their English was very poor in some cases, is that right?

A.        I mainly communicated with Lola, who acted as the sort of liaison, and we had quite a good sort of communication link.  Even if I didn’t have any appointments there, if there are any concerns she used to phone and ask for advice.  So I mainly communicated with Lola, and I didn’t have any concerns there.

THE CORONER:  But the question in that arises from the root cause analysis investigation, which says, ‘Where there were multiple agencies working with a service user there should be in place a clear understanding of the communication framework which should identify which agency, and/or which professional member of staff would take forward the outcomes, meetings and discussions with other agencies including the service users involved, carers and the family members.’  So there clearly were concerns about communication, and the family are saying [inaudible] were asking was an aspect of that difficulty in communication, the difficulty in making yourself understood to members of staff.

A.        I didn’t have that problem with staff at Middleton Road, those I have spoken with.  I am not familiar with all the staff at Middleton Road.

Q.        So it wasn’t a problem for the staff.

A.        I didn’t have any problem there.

MRS HORNE-ROBERTS:  All right, thank you.  As far as we were concerned, Harry’s problems were that about twice a week he would become anxious, and he would get into a state, and when he was living with us we would divert his attention, take him out, take him to another room, start our work or do a computer programme.  That was our experience, so we weren’t told at Hillgreen Care that anything was very different, so we were very surprised to have it presented to us after Harry’s death that there was a range of problems which seemed to fall outside anxiety other than the hypomania, which appears to be associated with the citalopram.  But as far as we were – twice a week or so he would become anxious and he would have to be dealt with kindly and his attention diverted.  But you’re talking about a different picture here.

A.        Yes, that is the picture that, you know, I had observed and that was what was communicated to me by care staff.  I think there was a breakdown of communication, and I think with hindsight it would have been much better if I would have actually copied all the letters to you so that you would have been involved at a much earlier stage and, you know, discussed things with me or would have been aware of it.  And I think that has been a big learning for us.  I used to copy all my letters to care staff, manager of the home, all the letters to GPs used to go to the staff.  I realised that they have a link usually with the family so they will actually inform the family.  But we have changed our practice.  I actually copy all my letters to family members where appropriate.

Q.        And Harry didn’t feed himself, he was fed his meals.  We sometimes took him shopping to buy one or two things, not chocolate or sweets, but it was the – do you accept that it was the responsibility of the home to ensure that he didn’t eat too much?

A.        The care staff are there to support, yes, all his daily living needs, including diet.

Q.        And is it right your Trust, your Haringey Mental Health Trust has told us that you had intranet guidelines before prescribing anti-psychotic drugs, and that they are similar to the Cambridgeshire and Peterborough guidelines.  You do have those guidelines, do you?

A.        Well I do have access to those guidelines now.

THE CORONER:  At the time that Mr Horne-Roberts was being treated were there guidelines that you should have followed?

A.        There were guidelines that were there.  Unfortunately I had not seen them, the guidelines.  It wouldn’t have changed my management.

THE CORONER:  But did the guidelines reflect reviewing a patient on medication?

A.        It does, so I mean I think the guidelines do talk about investigations at the beginning…

Q.        Heart investigations?

A.        ECG is – now we are saying yes.  Yes, ECG should have been done as well.

Q.        At the time though.  At the time that Mr Horne-Roberts was being treated, what did the guidelines suggest?

A.        I think there was mention of blood investigations, the baseline investigations, and I believe ECG where indicated, where there is an underlying cardiac condition.

Q.        But only where there’s an underlying cardiac condition.

A.        That’s what my recollection is at the time.

Q.        That’s very helpful, thank you.

 

Examined by MR ROBERTS

 

Q.        May I raise a point?  Thank you very much, Doctor, for that.  But it seems to me there are two points that require to be addressed and I’m not quite sure whether this is you or the GP. One is that the diet was – that Harry’s weight as a result of the diet and the drugs was not adequately monitored or regulated, I’m not quite sure who was responsible for it.  Obviously the home feed him, but they must take advice from you, or whoever is clinically responsible for him must indicate where we were going wrong because the outcome was catastrophic. 

                        The other thing was that the monitoring of the outcome of the drugs, the follow up, as it were, seems to have been sketchy at least, and I can imagine because I know, I have been through this with Harry any number of times, getting a blood test wasn’t at all easy but it could be done with subterfuge, and if I was there to, you know, guide him – be there with him it would have helped, and ECG you practically had to anaesthetise him to do that, so I can understood it was very challenging to do that.  But if had lived for another 10 years I can’t imagine that being done.  So we want to make sure that that is done in future, so there’s two points.  Who is responsible for both of the points really, the outcome of the drugs and the question of controlling his weight, that is the way in which the diet was done, because there was supposed to be dieticians and they never seemed to come up.  And the people involved must have known that that was not happening because they could see he was getting bigger all the time, and so we must make sure we get a grip on that.

THE CORONER:  Because it may actually fall between two stalls, it may fall – the general practitioner may say, ‘Well actually this is a manifestation of his illness in the sense that this is part of a process to address anxiety’, and it may well then end up not getting addressed at all.  So there has to be a clear – I think in a patient who is overweight there has to be a clear plan to manage that patient’s weight, and it must be set out and adhered to, and whoever drafts it is – would it be the psychiatric team or would it be the general practitioner’s team?

A.        It would be the psychiatry team, although if there are, you know, relevant issues then the GP consultant would be involved in the process.  But that won’t come automatically and it will be a primary care issue.

Q.        So what should happen really is that for the patients under your care, there should be a plan, a nutrition plan, organised as part of your care plan.

A.        It will be a care plan as part of overall care plan, not necessarily part of my care plan.

Q.        Someone has to do it, you see, because unless somebody takes responsibility and says, ‘I’m going to make sure that this patient adheres to a proper dietary system’, it won’t get done.  So someone has to take control of it.  Now it is better controlled by the persons who see the patient more frequently.  In some cases it would be a general practitioner, but looking at the number of occasions that your team visited Mr Horne-Roberts, it would seem more appropriate that the assessments and the plan should be yours.

A.        I mean I take your point.  My impression was that it was discussed in his review.  My impression was that actually it was part of his care plan, the dietary part, and my impression was that he was actually referred to a community dietician and was on the waiting list for it.

Q.        But he just grew in weight, it didn’t work.

A.        And the responsibility was agreed as part of the care plan to be with – in care and family with regards to managing his diet.

Q.        But it didn’t work, so a new system has to be thought up to make sure it does work.  You can’t have people being sent off.  Someone has to, at the meeting, have, ‘Right, this is point one, what has happened to his diet?  Did he follow his diet this week?  Did he take regular exercise this week?’  It has to be managed at that level.

A.        I mean I think – I would have thought the primary care/healthcare area will be more appropriate for monitoring diet and healthcare needs, although I take your point that there needs to be a more joint approach, someone taking responsibility, and I think as the mental health team we cannot shy away from it.

Q.        No, especially when…

A.        Absolutely.

Q.        … a component of the process is found within the condition the patient suffers from.

A.        Yes, I mean one of the important points you made is that this shouldn’t happen again.  And I think I can reassure on that front, that as a team this is outside the HMSG, it’s a partnership.  We had to take a lot of steps to actually address this issue for people with learning disability, on nutrition and dietary plans.

Q.        So is there in the place now a specific part of every meeting that you have, your multidisciplinary meeting, which deals with dietary requirements; are they met/have they been exceeded?  The exercise regime; is this patient losing weight or gaining weight?  And there has to be a specific discussion.  It is as important as any other aspect of this patient’s physical health.

A.        There are two consultant psychiatrists working with the service, and both of us now make sure that every individual we see is weighed and the height is measured, and BMI is calculated and is inserted in our letters to GPs as well.  So at every appointment we are monitoring…

Q.        That’s the monitoring, that was done here.

A.        Yes, and…

Q.        It’s the next step.

A.        Absolutely.  And the next step is because we are monitoring it, if there are issues, if there are concerns about BMI then we will make appropriate referrals, and again, because we are monitoring as an outpatient we will be aware of what’s been happening in that.

Q.        Yes.

A.        So although we think that it should be a primary care responsibility, considering people with learning disability and problems with excess, we have actually taken that measure and we are actually improving that with every correspondence.

Q.        But it is such an important element of a person’s physical wellbeing, their weight, that it should not be put off to the third or fourth or fifth issue on the agenda for a multidisciplinary meeting.  It is up there with the most serious health concerns.

A.        I mean it is recognised, and we are taking steps.

Q.        Well that’s very helpful.

 

Examined by MRS HORNE-ROBERTS

 

Q.        Could I ask another couple of questions?

THE CORONER:  Of course you can.

MRS HORNE-ROBERTS:  The Mental Capacity Act 2005 requires a best interest assessment.

A.        Mmm.

Q.        But that wasn’t done before you started treating Harry, was it?

A.        Yes, I mean I think sort of like, you know, I genuinely felt that people were consulted at the time.  The social worker was involved, the care staff was involved and my impression was that family was spoken with about starting him on medication.  Now I understand that that wasn’t done.  There was an informal best interest meeting done, but you know, our understanding at the time was with the Mental Capacity Act, if people are consulted or, you know, notes you have been consulted, that is enough.  Now we make sure that we do actually have a formal best interest meeting.  So although it’s not always a requirement, we try to formalise the whole process, again, to avoid breakdown of communication and miscommunication.

Q.        But in Harry’s case nobody consented to this heavy duty medication, did they?  There was no consent.  He was incapable of consenting, so who consented on his behalf?

A.        I think no one consents.  Actually the Mental Capacity Act is very clear on that, that no one can consent on behalf of someone who lacks capacity, so consent is not an issue.  We know Harry didn’t have capacity, so the idea is that then the decision is taken in the best interest, consulting the people involved.  And I take your point that we know now that you were not consulted, and I didn’t explicitly consult you myself, so I acknowledge that, and I think that’s the change in the practice that we have made.  I think with regards to the clinical judgment, my clinical judgment still would have been the same in his best interests.

Q.        Do you accept that these drugs – citalopram can cause weight variations, can’t it, fluctuations?

A.        The conventional knowledge with citalopram is that it reduces appetite and it causes loss of weight rather than…

Q.        Well it didn’t, did it?

A.        Weight gain is known, but it is extremely rare circumstances, and it’s considered as a paradoxical reaction to citalopram.

Q.        When it in fact causes weight increase, didn’t it?  While he was on citalopram…

A.        Common knowledge is weight loss.

Q.        … his weight increased. 

A.        It commonly causes weight loss, citalopram.

Q.        Yes, but in fact while he was on citalopram his weight increased, so – and when he was on CPZ his weight further increased.  Did you know that these – that CPZ can cause a substantial appetite increase?

A.        All anti-psychotic medication can lead to an increase in appetite and weight gain. 

Q.        I suggest that if CPZ is prescribed it’s commonly held that it shouldn’t be prescribed for more than a few months, and yet Harry was on it for ten and a half months.

A.        That is not the case, it depends on the clinical presentation and needs of an individual.  People can be chlorpromazine, like any other anti-psychotic medication, for a substantial period of time.

Q.        Even though he wasn’t psychotic?  Well we suggest that he would have been better off, as when he lived with us until he was 18 and a half, on no medication.  What would be wrong with that, and handling his anxiety in a kind way, which they were handsomely paid to do at the home.

A.        I think we have to take into account that probably the presentation while he was at home and while he was at Hillgreen Care was quite different. There were really a substantial deterioration in some aspects of his behaviour. There were some serious incidences, for example, on one occasion he climbed on the roof and had to be – emergency services had to be called, so there were – he was posing himself quite significant risk.  And then one has to think about, well, is this going to a lead to a placement breakdown, or is this going to cause risk to him in some other way?  This [inaudible] was identified even before he moved to – I mean at the time he moved to Middleton Road as well, that was one of the first things that was identified.  So considering all those factors, I think the clinical judgment was that, yes, it needed intervention, medical intervention.

Q.        As an exhibit to my second witness statement, I did an analysis of the daily logs, and his behaviour seemed to deteriorate while he was on medication.  Have you got any comment to make on that?

A.        It certainly did in the beginning. When he was started on citalopram we had a brief period of improvement, which wasn’t sustained, and his behaviour was deteriorating or continued to remain as it was.  At the time I increased his citalopram and we went up to 30 milligrams.  Some change, but not substantial improvement.  The response to zopiclone also was not there, there was no improvement in sleep with zopiclone.  So zopiclone was tried only for two weeks.  It’s only when we started on chlorpromazine, that’s when we started seeing some improvement in his behaviour and reduction in agitation.

THE CORONER:  So the family’s analysis of the daily record sheets you would agree with.

A.        Yes.

MRS HORNE-ROBERTS:  And Dr Prasad’s statement shows on 1 October 2007 Harry had hypotension, 170 over 80, high blood pressure.  So CPZ is particularly contraindicated for patients with hypotension, isn’t that right?

A.        I don’t think it is contraindicated, but I think if one is known to have a cardiac condition one has to be careful with prescriptions.  Also, diagnosis of hypotension cannot be done on the basis of one measure.

Q.        Is it right that there was no line management of your role?  Because the documents that we’ve seen and the reviews from the Mental Health Trust suggest that you had no line management, no supervisor.  So did you take decisions by yourself or did you consult other medics before you took decisions on such as this medication?

A.        As a consultant psychiatrist, with regards to clinical decisions, I make the decision myself.  If I have, and it does happen sometimes, I have – if I’m not sure of the approach or the type of treatment I do consult my other consultant colleague for a second opinion. That’s a common…

Q.        Did you do that this in this case?

A.        I didn’t, I didn’t feel it was necessary.

Q.        And do you accept that Harry’s weight gain while on these drugs was dangerous and is likely therefore to have caused or substantially contributed to his death?

THE CORONER:  Well let’s just be clear. 

MRS HORNE-ROBERTS:  Sorry.

THE CORONER:  He died because his weight caused complications around his heart.  That’s what Professor Risdon has said, nobody doubts that. 

MRS HORNE-ROBERTS:  Mmm, right, sorry, Sir.

THE CORONER:  No, no, that’s quite clear.  But the question is whether or not the weight gain is due to the medication, or whether there were other reasons for his weight gain.

MRS HORNE-ROBERTS:  Yes.

THE CORONER:  So I think that is the correct question.

MRS HORNE-ROBERTS:  Yes, thank you, Sir, if you put – yes.

THE CORONER:  Do you think that the weight gain was the result of medication or other factors?

A.        I think from the information I had and discussions, the nutrition and diet was a substantial part of the problem.  The weight gain was an ongoing problem for a very, very long time, and the weight gain had already started even before he was on medication.

Q.        So as far as the medication was concerned, do you think there’s any link between the medication and weight gain?

A.        I do not think so.  I actually will say that with the medication probably the – because of the medication the weight gain continued the way it had actually continued beforehand.  The staff might have been able to manage the diet a bit better.

MRS HORNE-ROBERTS:  But it increases appetite, doesn’t it, CPZ?

A.        It’s another thing we have to look at two ways essentially.  It’s like ability to control in a way what he’s eating and what he’s doing and, you know, and sort of like balance that with actually the impact of medication.  Now in his case, if you look at it, the chlorpromazine was a very, very small dose.  We are looking at 150 at first…

THE CORONER:  Sorry, forgive me for interrupting, but the question you were asked was whether or not you accept that this medication increases appetite.

A.        It will be difficult for me to say.  I think appetite was increased beforehand. 

Q.        No.  So there is your answer.

MRS HORNE-ROBERTS:  And just one last question, have you seen this chart that shows Harry’s weight from the time he went on to the citalopram until his death?  It increased by almost 20 kilos during that time.  Surely that must have caused – should have caused immense alarm both in his medical practitioner and his carers.

A.        As I understand, his weight had actually started going up, and like I had said earlier, I felt that from the information which care staff was giving, they were finding it very difficult to control what he eats and what he doesn’t eat.

Q.        Well why?  They served his food.

A.        So that’s why I decided…

Q.        They served his food.

THE CORONER:  That’s a question for the care home then, isn’t it?

MRS HORNE-ROBERTS:  Yes, sorry, Sir.

A.        And I think that’s why, you know, I felt that getting hold of his behaviour is – control of his behaviour was important.  I mean I think diet was not the only thing actually, there were lots of other things that were happening.  He was putting himself in quite risk situations.

Q.        Thank you, Sir.

THE CORONER:  Ms Pasaud, was there anything?

MS PASUAD:  Yes, thank you, Sir.

 

Examined by MS PASAUD

 

Q.        Dr Jaydeokar, you mentioned that there were action plans or care plans in place for Harry.  Sir, I wonder whether we could have a look at those.  You should have them in the disclosure bundle at tab 1. 

THE CORONER:  Yes, I have it, yes.  Thank you, yes.

MS PASAUD:  Can I pass a copy up to the witness?

[Document is handed to the witness]

THE CORONER:  What would be interesting if the care plans, Ms Pasaud, what would be interesting would be if the care plans so far as nutrition were concerned.

MS PASAUD:  Well these do include nutrition, Sir.

THE CORONER:  Yes.

MS PASAUD:  Which is why I’d like to take the witness to them.  These health action plans look at all aspects of Harry’s health, so starting with his mental health needs, look at behaviour, physical health, and you’ll see under physical health that includes that weight is a problem, so looking at strategies to support that and persons responsible.  And it goes through the whole sort of diet, smoking, blood pressure, blood tests, so these were prepared for Harry from his start at Hillgreen Care Home.  I think you have the 2007 document in front of you, or 2008.

A.        May 2008.

Q.        And they are reviewed periodically in May 2009 and November 2009.  Sir, I wonder whether it would be helpful for the family to see these.

THE CORONER:  Yes.  Would you like to cover some other areas while we are waiting?

[Document is copied and handed to family members and others]

MS PASAUD:  Thank you, Sir.  Dr Radley was asked about the recently disclosed complication in terms of citalopram, of Torsade de Pointes.

A.        That’s right.

Q.        And was asked whether there was a possibility that that would have affected Harry or contributed to Harry’s death.  The citalopram was stopped in June 2009.

A.        That’s right, yes.

Q.        Is there any possibility that there could be an ongoing effect from a drug that was stopped six months before?

A.        No, I mean this is a new development, I think it’s the last two months that we have become aware of it.  And it is linked with the dose, so there is a clear link with the dose of citalopram and impact on QT interval –

THE CORONER:  So is it of relevance to us then?

A.        It is not because he was not on citalopram at the time of his death.

MS PASAUD:  No, thank you.  And you’ve been asked about the guidelines for monitoring this medication, and I think it was your evidence that the guidelines do recommend ECG tests be carried out and blood tests be carried out.  It’s not a mandatory requirement, is it?

A.        No.

Q.        It’s a recommendation.

A.        Yes.

Q.        And what are the specific circumstances when an ECG, for example, is required?

A.        If someone is known to have, or if there is a known cardiac condition…

THE CORONER:  If they have an already existing condition.

A.        An existing heart condition.

Q.        That would be the trigger, and in Mr Horne-Roberts’ case there was no such pre-existing cardiac condition.

A.        No.

MS PASAUD: So the ECGs taken previously, as we understand – we haven’t seen them, but we understand they were normal.

A.        Yes.

Q.        If they had been normal and if an ECG had been done, that wouldn’t be a contraindication…

A.        That would be – no, no contraindication.

Q.        … to starting the chlorpromazine.  And in terms of reviews subsequently, if a patient doesn’t have a pre-existing cardiac disorder, when would the next review take place?  Would it be six monthly or would it be annual?

A.        I think the review – there are two aspects of the review as well.  So there is the ongoing monitoring of mental state, so as to titrate dosage, and see the side effects like extrapyramidal side effects or any other side effects.  And then there is the monitoring of blood investigations and…

THE CORONER:  So you would have blood tests and you would have ongoing mental state evaluation.

A.        So the ongoing review will be the mental state, and at the same time, you know, you do a brief physical examination.

Q.        So what are you looking for in the blood?  You’re looking for levels in the blood of citalopram?

A.        Not citalopram. With chlorpromazine, with anti-psychotic medication they can have an impact on the liver, so liver function test.

Q.        So liver function test, yes.

A.        Liver function test and other things.

MRS HORNE-ROBERTS:  Sorry, could he repeat that?  Sorry, I didn’t hear that.

THE CORONER:  Liver function tests.

MRS HORNE-ROBERTS:  Thank you. 

THE CORONER:  Is there an argument to say that if you – if your patient is 20 stone they should have cardiac investigations regularly anyway?

A.        They should have cardiac investigations or monitoring through the primary care.

Q.        Triggered by weight alone.

A.        Triggered by weight, I would have thought so.  I mean I think that…

Q.        I mean you’re dealing with a…

A.        … Dr Prasad will be able to answer that question.

Q.        … high risk group of patients by virtue of the mental conditions, the psychiatric conditions that these patients suffer with.  They are maybe overweight, so these are the very patients who are at risk from the consequences of heart disease.  Those patients, were they not under your care, would almost certainly be visiting their GP, be given very strict advice about diet and exercise and being, where applicable, monitored.

A.        Yes, I think Dr Prasad will be able to answer that question as to what happens.

Q.        Yes, all right.  So that’s really a matter, general health would be…

A.        So general health linked with the – yes.

Q.        So general monitoring for the damage caused by being overweight would be something for the general practitioner to manage.

A.        I would have thought so.

Q.        But your concern would be to ensure that a person wasn’t at risk because of the diet that they had been given and the lack of exercise.

A.        Yes.

MS PASAUD:  So in relation to your responsibilities as a consultant psychiatrist, you are required to recommend to the GP that when certain drugs are commenced there are certain tests that should be carried out.

A.        I myself don’t have any facility to carry out tests.

Q.        Right.

THE CORONER:  So just to cut through this, you prescribed a series of medications and then you write to the GP, the general practitioner, saying that you recommend six-monthly liver function tests, annual liver function tests, whatever, is that right?

A.        That will be appropriate practice.

Q.        Yes.

MS PASAUD:  You were asked about the weight increase from the prescribing the citalopram to the time of Harry’s death, and I think it was put to you that there was a 20 kilogram increase.  Can I just pass you the weight chart, which actually I think you may have up there, because I passed it up earlier to another witness and it wasn’t passed back to me.  Can you check, please, whether that was the correct position?

A.        It’s not here with me.

THE CORONER:  Oh, well let me help you.

MS PASAUD:  Well the citalopram was started in October.

THE CORONER:  We’ve been over this, haven’t we, today, with…

MS PASAUD:  It’s just the question was put to the witness, Sir…

THE CORONER:  Well Dr Radley set it out clearly.  Do you need to set it out again?

MS PASAUD:  She did, Sir.  It’s just making it clear with this witness that the factual basis of the question was incorrect, and there was in fact an increase of I think 10 kilograms and not 20.

THE CORONER:  Well, if you think it necessary.

MS PASAUD:  Sir, Dr Radley did deal with this, so that’s why…

THE CORONER:  Yes, I’m just anxious that it’s maybe unnecessary to deal with matters again that have already been dealt with.

MS PASAUD:  Thank you, Sir.  The only matter then I want to raise with this witness is in relation to the health action plan.

THE CORONER:  The health action plan, yes.

MS PASAUD:  Which has just been copied. 

THE CORONER:  Perhaps a better way to deal with it is to say this.  You listened to Dr Radley’s evidence.

A.        Yes.

Q.        Did Dr Radley make any mistake about the dates for starting medication and the weight gain?

A.        I think she did correct the – correctly read the dates that were there.

Q.        Yes.

A.        Yes.  She did correct it.

Q.        And there’s nothing that you need to add to that?

A.        No.

Q.        No, all right. [pause] Do you have any copy of this document, Ms Pasaud, that you can question on?

MS PASAUD:  No, I’ve given it to the officer.

THE CORONER:  I see.  Thank you very much, that’s very helpful.

MS PASAUD:  Thank you very much.  So Dr Jaydeokar, when you were providing care for Harry you were aware of these action plans?

A.        I’m generally aware of the action plans or care plan, the overall care plan.

THE CORONER:  So perhaps we just ought to start by saying what these are and who created them.

A.        These are health action plans that are created by the staff and key worker at Middleton Road.

Q.        So this is Hillgreen Care.

A.        Yes.

Q.        Write a healthcare plan.  And they do it with you, or do they do it on their own?

A.        No, I wasn’t involved in this health action plan.  Usually it’s the key worker who prepares the health action plan, it’s a common practice in learning disabilities.

Q.        So is this the same as a multidisciplinary care plan?

A.        It’s almost like care coordination.

Q.        No, but is it the same as a multidisciplinary care plan?

A.        It will help if you separate…

Q.        I think the answer’s no, isn’t it?

A.        I think – it’s difficult, because I think different care plans have different roles.  For example, a CPA care plan is very different.

Q.        Nowadays.  Now?

A.        Yes.

Q.        Would you rely on this or would have your own plan?

A.        I should be part of this one.  So you have one care plan…

Q.        Right, so what would happen is this – would it be called a health action plan?

A.        It will still be called a health action plan, but it should have input from me.

Q.        So you would then, at a multidisciplinary staff meeting, a team meeting, you would determine what should be on the health action plan together with others.

A.        Yes.

Q.        So this was something that was written without your contribution.

A.        Yes.

Q.        Yes.

MS PASAUD:  So it was written without your contribution, but it’s a document that you would have been aware of.

A.        Yes.

Q.        And obviously it includes highlighting your areas of responsibility.

A.        Yes.

Q.        If we look at the document, health facilitator, key worker, [Deo Michael?], would that from your understanding be the person who’s responsible for ensuring that these care plans are carried out and reviewed?

A.        Yes, that will be – is the responsibility, and monitoring will be through Islington Social Services, so the care manager would be responsible.

Q.        Right.

THE CORONER:  So the key worker is the day-to-day person who liaises with, in this case, Mr Horne-Roberts, but there will be a manager.

A.        Care manager, which is the Islington Health Local Authority.

Q.        Yes, so it’s not the key worker’s responsibility to make it happen, it is the management structure above the key worker who should make it happen.

A.        Yes, so there will be a Hillgreen Management structure with the manager at home, who will be overall responsible for the staff and key workers there, but that service is purchased by Islington Local Authority, so the care manager will have responsibility to ensure that Hillgreen Care is providing the care that was needed.

Q.        Yes, so the key worker writes this.

A.        Yes.

Q.        And other people make it happen.

A.        Yes.

MS PASAUD:  Who was responsible for making sure that everyone makes it happen?  Is there a social worker or a coordinator?

A.        I would have thought the care manager will be responsible in this case, unless someone is on a CPA.

Q.        Thank you.  In terms of your responsibilities under this plan, you come under the first heading, Mental Health Reviews.

A.        That’s right.

Q.        Mental health assessments, psychologist Dr Jaydeokar.  Ongoing monitoring home assessments to be done by the social worker, Ms Starr[?].

A.        Yes.

Q.        But they also include within these reviews to monitor Harry’s physical health, so under physical health, specifically weight is noted to be a problem, and for one-to-one support to be provided with activities, walks and encouraging healthy food.  And those responsible were the staff and key worker, is that right?

A.        Yes, that’s what I thought it was.

Q.        So you weren’t specifically assigned any interventions in terms of Harry’s diet and Harry’s weight.

A.        No.

THE CORONER:  So I think the modern approach to this, or nowadays you would have an input into this.

A.        I would like to have input into this.  It doesn’t always work, but we as a service are trying to ensure that we will have input.

Q.        Well this is the opportunity where we can write a report to create changes in the system.

A.        Yes.

Q.        And it seems to me that one of the matters that may be of concern here is that the weight control, and this is not a criticism, was well recognised, and the weight record sheets refer to weight again and again.  But what it needed was professional input and control.  So it needed to be monitored not by staff and key workers, it needed to be monitored by yourself and your team.

A.        I think the day-to-day monitoring will still be with the staff, but I think a professional input in how it should be managed would have been useful.  It need not be from me, it could be a community dietician might be…

Q.        Exactly.

A.        …appropriate, or a psychologist might be more appropriate.

Q.        Someone who is…

A.        But professional.

Q.        … trained…

A.        Trained to do it.

Q.        … to deal with matters of weight and diet, and also physiotherapists?

A.        Yes, yes.

Q.        I mean it’s…

A.        Because to exercise and advising how it’s…

Q.        Exactly.

A.        Yes. 

MS PASAUD:  If we turn over to the second page of the 2008 plans, it also goes on to look specifically at diet, and again that’s to be monitored by staff.  And then blood pressure, because of the weight issue, it recognised that Harry was at high risk of getting high blood pressure.

A.        Yes.

Q.        And that’s to be monitored by staff and a doctor.  Would that be yourself or would that be the GP?

A.        The blood pressure I’m not able to monitor, I don’t have access to the means to monitor, I would have thought it would be…

THE CORONER:  So GP?

A.        Yes.

MR PASAUD:  Right.  And again, blood tests are something – the sort of physical healthcare is in the remit of the GP, and that would include the monitoring of the adverse health effects as a result of the weight.  But your intervention would be in terms of the medication…

A.        Yes, that’s right.

Q.        … which you were trying to use to control the behaviour.

A.        Yes.

Q.        And through the referral to the psychologist, which you did, but unfortunately it’s not [inaudible].

A.        That’s right.

Q.        Thank you, Sir.

THE CORONER:  Thank you very much indeed, I’m very grateful to you.  I’ll release you.  You needn’t stay unless you wish to do so, but of course you leave here with my thanks.  Thank you very much indeed.

A.        Thank you very much.

 

[The witness was released]

 

THE CORONER:  I am minded to call Dr Clifford, Ms Pasaud and Mr Docherty.  Can you see any difficulty with that at this stage?

MS PASAUD:  No, Sir.

THE CORONER:  Members of the family, can you see any difficulty with that?

MRS HORNE-ROBERTS:  No, Sir.

THE CORONER:  Because I am rather hoping that we can then have a better idea about the questioning for the remaining witnesses.

MS PASAUD:  Yes, Sir.

THE CORONER:  Dr Clifford, would you be so kind?  Dr Prasad, are you content with that approach?

DR PRASAD:  Yes.

THE CORONER:  Yes, right, thank you.

 

 

DR CHRISTOPHER PIERS CLIFFORD (sworn)

Examined by THE CORONER

 

Q.        Would you be so kind as to tell the court your full name, please?

A.        I’m Dr Christopher Piers Clifford.

Q.        Now Dr Clifford, your field of medical expertise is cardiology.

A.        I’m a cardiologist.

Q.        Now you will have listened with interest at Professor Risdon’s concerns about his conclusions.

A.        Mmm-hmm.

Q.        If you had to write a medical certificate of cause of death for this man what would you have written?

A.        I think I would have come to a similar conclusion to his original report, that he had an obesity related cardiomyopathy which has led to acute heart failure.

Q.        Can you see anything in the reports that you have read that would indicate to you, or give you the opinion that the medication that Mr Horne-Roberts was on more than minimally or trivially contributed to his death on the balance of probability?

A.        No, on the balance of probability I would have thought it unlikely they contributed to his cause of death.

Q.        Just help me with this.  How important is it that a person finds themselves, or is as far as possible encouraged not to become morbidly obese?  I mean how dangerous is it when a person is this overweight?

A.        I think it’s very dangerous.  I mean even simple obesity contributes to the development of type II diabetes; it contributes to the development of hypotension.  It will contribute towards development of, at this level of cardiomyopathy, in its own right independent of those two factors.

Q.        So what we have here really is a person who has died because their weight has not been controlled.

A.        I would have thought the weight has made a significant contribution to his death.

Q.        What other contributions do you think there are then, other than weight?  If that was a significant contribution, what else could there be?

A.        Well then it would be about the confounding variables, whether he would have developed hypotension independently of high blood pressure, independently of his weight gain, whether he would have developed diabetes independently of weight gain and such like.

Q.        But there have been some questions raised about blood pressure.  Perhaps you can help us with this.  Is there now a systolic reading above which a person is considered to be suffering from high blood pressure?

A.        Well the normal recommendation is that you commence treatment for blood pressure once your blood pressure is above 160 over 95 on three separate readings.

Q.        I see.

A.        That’s how NICE have run it.  And once you start to treat the blood pressure you are aiming to get it to below 140 over 85.  So you could argue that 140 over 85 is the level at which your risk of developing subsequent cardiac disease becomes that of the general population.  But you don’t start treating it until you’re regularly above a level which is two standard deviations above the normal.

Q.        Do you think that a person who is ill in the way that Mr Horne-Roberts was, and who is overweight, should have some form of monitoring of their heart?

A.        It wouldn’t necessarily be standard practice to monitor the heart.  What you would monitor would be the risk factors for developing heart disease, so that would normally be blood pressure, diabetes and such like.  So anyone who is obese or morbidly obese, I would imagine it’s part of the general practitioner’s contract to make sure that they are monitored for those potential complications of obesity which then in themselves can lead to heart disease.

Q.        I see.  Now we’ve also heard mention of some complications of the medication prescribed. 

A.        Mmm-hmm.

Q.        Leading to cardiac arrhythmia and death.  Is it right that it can’t be excluded?

A.        I think the reason why in my report I wrote I thought it was unlikely that medications in this case had contributed towards the death was because it’s a dose dependent effect.  The citalopram had been stopped at the time of his death, and the chlorpromazine was undetectable in the blood on the toxicology report that I saw, so therefore as a dose dependent effect, it was very unlikely that the drug in this occasion contributed to him developing an arrhythmia which could have led to his death.  If he’d had chlorpromazine in the blood combined with the underlying cardiomyopathy, the chance that chlorpromazine could have contributed to the death would have been relatively high, as again in my report it’s well known that if you have known or unknown underlying cardiac disease and then are given these drugs, your risk of sudden cardiac death is increased about fivefold, and that data is available in published form.

Q.        You see, we have written here that chlorpromazine, the therapeutic range is between 0.05 and 0.3.  But this – it was in fact under the level of detection for this, so that’s why it wasn’t detected.

A.        Yes.

Q.        So he may have been taking the drug, but it may not have been detected in the general screen.

A.        That is true, but sub-therapeutic levels like, it’s unlikely that the drug would have contributed towards the death because it’s a dose dependent effect.  So if you were in the standard range, the range would be – has been developed to say this a dose which is unlikely to be toxic to the organs which it can affect.  Now obviously there are idiosyncratic responses to all drugs, but for these drugs, particularly with the development of arrhythmic disease, it’s very much a dose respondent effect.

Q.        The condition as described by Professor Risdon, would that have been detected using an ECG?

A.        The fat around the heart?

Q.        Mmm.

A.        No. 

Q.        So would it have been detected by an echocardiogram?

A.        It could possibly be detected by echocardiography.  In very obese individuals it’s not uncommon for you to see fat in and around the pericardium.  We only really detect within the pericardium, which is the sack that surrounds the heart, because if it’s between the chest wall and the heart, that just comes under the general obesity patterns.  And what I understood from the pathologist’s statements earlier this morning was that I suspect this was mediastinal fat rather than intrapericardial fat, from what he was describing.  And certainly his post-mortem report never mentioned intrapericardial fat.

Q.        No, no, and that’s not what he described.

A.        No.

Q.        How long does it take to develop this – how long to get fat in this area?

A.        Fat in the mediastinum would be the same as developing any central fat deposits.

Q.        And once it is there can it be reabsorbed?

A.        Yes, weight loss in the same way as you lose abdominal girth if you go on a strict diet.  This is really just an example of fat deposition within the thorax rather than within the abdomen, so both would regress with proper dietary manipulations and exercise.

Q.        So in terms of health, right up at the top is preventing morbid obesity developing.

A.        In this young gentleman I believe morbid obesity could have been prevented by whatever means, then his chance of dying would be very, very much reduced.

Q.        So are you able to say that he not become morbidly obese he would not have died when he did?

A.        I think that is highly likely.

Q.        That’s very helpful.  Thank you very much indeed.  Could I just trouble you to stay there one moment?  Dr Prasad, was there anything you wanted to ask?

 

Examined by DR PRASAD

 

Q.        I’m just interested, when I noticed the blood pressure was 170 over 80, but it was very difficult [inaudible], he was very agitated, so I treated him on that condition, 170 over 80, I just want to watch him?

A.        On a one-off measure I personally would not initiate anti high blood pressure medication.

Q.        Thank you, thank you.

THE CORONER:  Mr Docherty?

 

Examined by MR DOCHERTY

 

Q.        Yes, I just wondered, Dr Clifford, you’re talking about morbid obesity.  Do you have a definition in mind when you use that phrase, or are you using it more generally?

A.        No, the normal definition as a BMI, which is a measure of weight and height as being over 40.

Q.        Yes, thank you.  And if the patient is 5’11” or 6’ or so, they seem to be the estimates of Mr Horne-Roberts’ height, do you know what the weight is?

A.        Depending on weight we took, and I think I wrote it in my report, and the weight that was in the pathologist’s report, which I think we all agree was probably incorrect, 104.  We’re working on the 140 to 144, calculating it on a BMI indicator, either 5’11” or 6’ would still come to over 40. 

Q.        Sorry, which would?

A.        If you used either of those heights it was above 40 when I calculated it on my computer.

Q.        But sorry, using which weight?

A.        Using the 140 to 144.

Q.        140.  And do you know how low the weight would have to go before it would be not morbidly obese?

A.        Well it was on the cusp, as I remember.  It came out at 41 on the BMI, so if the weight had dropped by about 5 kilograms – but obviously this is a relatively, like blood pressure, it’s a relatively random definition of where you draw the cut off, it’s just on standard deviations essentially.  There’s no specific thing saying you’re suddenly much higher risk because your BMI’s 40 rather than your BMI’s 39.

A.        Yes.  So would weights over 100 kilograms, would that be obese for somebody of that height on your definitions?

Q.        No, I mean I would say that 100 kilograms would not, in my practice as a cardiologist, would not be unusual for people who are 6’/6’ plus, but it would still be overweight.

A.        Yes, so where does obese as oppose to morbidly obese start?

Q.        Obese starts at 30, a BMI of 30.  And I couldn’t tell you exactly offhand where that cut off line would come for a 6’ person, but it gives him a BMI count [inaudible].

A.        All right, thank you very much.

THE CORONER:  Ms Pasaud?

MS PASAUD:  No, thank you, Sir.

THE CORONER:  Members of the family, did you have anything you wanted to ask?

MRS HORNE-ROBERTS:  Yes, Sir, thank you.

 

Examined by MRS HORNE-ROBERTS

 

Q.        You say that if there’s a one-off reading of hypotension, which was in Harry’s case 1 October 2007, he was 170 over 80, wouldn’t you think it was necessary for the doctor concerned to do more tests over later periods to establish whether this was a one-off or whether it was a pattern that needed to be dealt with by medication perhaps?

A.        Yes, the normal recommendation would be if you have a one-off abnormal measure that you would repeat it at intervals.

Q.        You would repeat.

A.        You would repeat, yes.

Q.        Thank you very much.  Professor Risdon said there was no question of heart muscle defect in Harry’s heart, but I think in your second report you thought there was a weakness of the heart muscle.  So…

A.        Well it’s a question of definition.  I’m not, if I’m honest, I’m not quite sure he could state that, that clearly.  If you’ve got a dilated hypertrophied heart, as your son appeared to have, in that his heart was at least two standard deviations above the weight of a normal male heart, combined with the fact that all four chambers were dilated, that would imply that he has what we as cardiologists would call dilated cardiomyopathy, which is a fundamental abnormality of the heart muscle.  So for him to say definitely that there was nothing with the heart muscle he would have to do histology, which we’ve already heard stated did not occur.

Q.        But he seemed to think that the heart itself physically was in quite good shape.

A.        You couldn’t tell that from looking at a microscopic organ.

Q.        Okay, thank you.  You said, I think, that you think on the balance of probabilities Harry died of over – he wouldn’t have died if he hadn’t been so overweight.

A.        Mmm-hmm.

Q.        Thank you very much.  A couple of years before his death Harry had an ECG that was clear, and blood tests that were clear also within two years of his death.  Have you got any comment to make on that?  It didn’t indicate any heart problem.

A.        No, you can have – if we’re assuming that he had a dilated cardiomyopathy related to morbid obesity then it is possible even with having a dilated cardiomyopathy to have a normal ECG.  There are some ECG abnormalities which are associated with having a dilated heart, but you wouldn’t always protect an abnormality of heart function on an ECG.  The only way you can really get at that would be by doing a sound wave scan or an echocardiogram, which absolutely definitively tells you whether the muscle is working normally or not.

Q.        If you had a patient like this, you were a consultant treating a problem like Harry had with his morbid obesity, what treatment would you have given?  Would it have rested on diet and exercise?

A.        Well I think in general if anyone is obese, diet and exercise is the first step.

Q.        Would you have done anything else?  Put any other form of treatment if you had a 6’ 20-year-old man who was morbidly obese, would you recommend any medical intervention?

A.        Well I mean I’d have to first say this is not my area of expertise.

Q.        Okay, sorry.

A.        So I may not be able to help on that.

THE CORONER:  So there we are, yes.

MRS HORNE-ROBERTS:  Do you think that large weight loss followed by large weight gain, because he did lose weight when he first went to Middleton Road, he lost nearly 20 kilograms and then he put on 20 kilograms, approximately the time that he was on the medication that we’re so concerned about as members of his family. Do you think that in itself, the fluctuation, could have been dangerous?

A.        I couldn’t give you any data that demonstrates that fluctuation makes any difference.

Q.        Thank you.  Thank you, Sir.

THE CORONER:  Was there anything else?

MR ROBERTS:  May I just…

THE CORONER:  Yes, of course.

 

Examined by MR ROBERTS

 

Q.        Just on this last question we’ve got here, which says do you think that the weight gain, which we believe was caused by the drugs or at least the drugs had a big part in that, the weight gain was the cause of his heart condition and therefore his death?

A.        From the evidence I have had provided to me in the document, I believe that his morbid obesity was the cause of his cardiac condition, and his cardiac condition led to his death.

Q.        Right, thank you.

THE CORONER:  Dr Clifford, thank you very much indeed.  I am very grateful to you.  I release you.  You needn’t stay unless you wish to do, but of course you leave here with my thanks.

A.        Thank you.

Q.        Thank you very much indeed.  Members of the family, we are going to break there.  I am going to say if we could be ready to start, please, by quarter to two, if that would not cause any inconvenience.  No?  Well we shall resume then.  Thank you very much, I will rise.

CLERK OF THE COURT:  Court rise, please.

 

[Luncheon Adjournment]

 

THE CORONER:  Do sit down.  Dr Prasad, please.  Doctor, do step in the witness box.

 

DR DENISSO PRASAD (sworn)

Examined by THE CORONER

 

Q.        Could you tell the court your full name, please?

A.        Dr Denisso[?] Prasad.

Q.        Dr Prasad, just help me wit this.  You’re a registered medical practitioner.

A.        Yes.

Q.        And which surgery do you work from?

A.        52, Middleton Road Practice.

Q.        And when did you first meet Mr Horne-Roberts?

A.        I first met him on 1 October 2007.

Q.        And what was your role in his care?

A.        Our role, to look after his primary, provide all the primary care, which is abiding by the GMC to do the best, 100% with my ability.

Q.        That’s very helpful.  So just so that I have it in my mind, Dr Jaydeokar would suggest prescriptions.

A.        Yes, Sir.

Q.        And you would write those prescriptions.

A.        Yes, I would.  He make the plan for treatment.

Q.        Now who would – let’s just pause there a moment.  The Hillgreen Care, is that yourself?

A.        No.

Q.        No.  So what is your relationship with Hillgreen Care?

A.        Well Hillgreen Care is just across from my surgery at 52.  I am 52, they are 53, and I think we just look after the residents in there.

Q.        So part of your duties as a surgery is to look after the physical wellbeing of the patients in Hillgreen Care at 53…

A.        Who came to register with me.

Q.        Ah, so of the patients at 53 Middleton Road, who registered with your surgery, you would look after them.

A.        Yes, correct.

Q.        I see.  And Mr Horne-Roberts was one of those patients.

A.        Yes, one of them, yes.

Q.        Who was looking after his weight?  Who was monitoring and looking after his weight?

A.        The other nurse – practice nurse does, health assistant or myself if they are busy.  Mainly done by the practice nurse.

Q.        So was the practice nurse – how often would the practice nurse see Mr Horne‑Roberts?

A.        Not often, because he – first time he came, when we register a person we have to take his height, weight, blood pressure, urine test, which is the normal way.  You can see here we have tried to do it, but it was very difficult.

Q.        Now, you see we understand that Mr Horne-Roberts lacked the ability to make decisions for himself about his health. 

A.        No, he’s not agreed to this then himself.

Q.        Yes, that’s right.  So when it came to managing his weight, that would fall to the physicians looking after him. 

A.        Yes, yes. 

Q.        How is it that Mr Horne-Roberts – how is that his weight was not reduced and he came to die as a consequence of morbid obesity?  How did that come to pass?

A.        Yes, it is one of the factors.

Q.        Well how did – what was the role of your surgery in preventing his morbid obesity?

A.        Yes, to help him to lose the weight.

Q.        So how did you do that?

A.        I referred him to the dietician.

Q.        Yes.

A.        But he, unfortunately it happened he was not able to attend the dietician, and at the same time I discussed with a carer to control his – or to be reducing his calorie intake.

Q.        Yes.  But that wasn’t working.

A.        No, I don’t think so.

Q.        So what then happened?

A.        Well I don’t – that is very difficult for me.  I can’t [inaudible].

Q.        Well the difficulty is that you’re responsible for his physical care.

A.        Yes.

Q.        And his physical care is he is suffering because his weight is not coming down and he is at a risk of the complications of being the weight he was.  So as his general practitioner, what did you do?  You’ve told us that you referred him for a dietician and that he wasn’t able to attend.  And you’ve told us that you had discussions with Hill Green Care about his calorie intake.

A.        Yes. 

Q.        Was that it?

A.        No.  But I’ve been watching him.  Last, his weight was 150 when I first did the pressure, the weight was 150 kilos.

Q.        Yes.

A.        And later on the weight was coming down to – we weren’t able to take the weight any more.

Q.        Yes, so when – what was your plan for Mr Horne-Roberts’ weight?  What was your plan?  How did you envisage his weight loss programme?

A.        Well we don’t know this [inaudible], I don’t know, how you can do it?  It is not…

Q.        So did you have a programme other than the advice you gave?

A.        Yes, to send him to exercise, but I think he’s not really coping.

MRS HORNE-ROBERTS:  Sorry, I didn’t hear that, Sir.

THE CORONER:  The answer was he’s not really coping with exercise.  Is that right?

A.        Yes, that’s right, yes.

Q.        You see, it’s very different if your patient has capacity to make decisions for themself.

A.        Yes.

Q.        But Mr Horne-Roberts couldn’t.  So do you think that there was in this case a failure to properly manage his weight?

A.        No, Sir, we are just following guidelines from the consultant as well, because he was looked after with a consultant, hospital practitioner.

Q.        But you’ve told us in your initial evidence that you were responsible for his physical health, including his weight.

A.        Yes.  But we don’t…

Q.        And you told us that taking that responsibility you referred him to a dietician and you spoke to the Hillgreen Centre about his calorie intake.

A.        Mmm-hmm.

Q.        And you’ve mentioned that his weight had come down from 150 kilos.  But I’m just asking you why his weight didn’t continue to come down, and why was it that he ended up in a position where he died from the consequences of being overweight?

A.        I can’t answer this question.

Q.        What I’m suggesting to you is that there was a failure here to properly manage a weight loss programme for him.

A.        The contents of this are – I didn’t…

Q.        I mean do you…

A.        While he is following the shared[?] care from the hospital as well, I was – it belonged to shared care.

Q.        Yes.

A.        And…

Q.        But do you think then there was a failure to provide an adequate weight reduction plan for this patient?  Not your failure, but somebody’s failure.

A.        I can’t answer for another person, but I tried to refer him to a dietician to get some help.

Q.        But do you see my point?  It didn’t work.  So when we look at it, he died as a consequence of being overweight.  So that seems to suggest there was a failure to have a plan that worked.

A.        Yes, but…

Q.        Is that fair?

A.        Yes, it is fair, okay.

Q.        I didn’t catch that.  Is that a fair way to summarise it, the plan as such that there was, was not adequate?

A.        In my point of view, Sir, how – my job is to look after his primary care.

Q.        Yes.

A.        I mean beyond that – well, Sir, I did my best.

Q.        I’m not criticising that.  I’m just saying that in Mr Horne-Roberts’ case his weight was not adequately managed.

A.        Yes.

Q.        Is that right?

A.        Because at the same time I was trying to do some blood tests, but I’m not able to get it, to find out other metabolic syndrome, he’s having some problem, but I couldn’t get it.  I went through the blood tests.

Q.        Yes, again, there’s no criticism intended, but the plan for his weight loss wasn’t adequate, was it?

A.        Yes, but I did our best ability to help him.

Q.        Even if you did your best.

A.        Yes, I did.

Q.        The plan itself didn’t work.

A.        It didn’t work, yes.

Q.        It wasn’t adequate, was it?

A.        No, how this happen, I don’t know how it happens. 

Q.        You see it’s different with a person who comes to you and says, ‘Doctor, I want to lose weight.’  You say, ‘Well take exercise and eat healthily.’  Then that patient goes away and they do that or they don’t do that.  When they come back and their weight hasn’t changed, it’s nothing to do…

A.        I understand your point of reason.

Q.        But the problem here is that Mr Horne-Roberts couldn’t do that.

A.        But Mr Horne-Roberts, whenever he comes there he’s just come for a few minutes to me in the surgery.  He’s very difficult in the surgery to examine, advise, and you have to talk to the care.

Q.        So is it your view then that there should be a person responsible for his diet?

A.        Yes, should be a person.

Q.        And his weight loss programme.

A.        Yes, there should be somebody.

Q.        Who should that be?  Should it be the consultant or should it be you?

A.        The first thing for the carer, I can say, the carer’s really is doing that one.

Q.        Yes, but the carers may not…

A.        And consultant are taking the regular – reviewing his case.

Q.        So the management of the weight reduction programme, or weight loss programme, should be led by the consultant.

A.        Yes, because that’s – we are just following him up, yes, in this area.

Q.        Yes, so it should be led by the consultant with you taking advice where necessary.

A.        Yes, when I need it.  Because when I get the plan he’s putting this medication [inaudible] plan to do the blood test and do this, refer to the –

Q.        Because effectively you’re acting on the instructions from the consultant.

A.        Consultant, yes.

Q.        Concerning his medication.

A.        Yes.

Q.        But what it seems to me here is absent was any plan to reduce Mr Horne‑Roberts’ weight.

A.        Yes, there’s a plan, that’s the one we have got when first registered to refer to the dietician, these are the first things that we do.

Q.        If he was given a diet of 2,900 calories per day, and he was given regular exercise, do you think he would still have been at 141 kilos?

A.        I’m not – I can’t say this.

Q.        It would be highly unlikely that his weight would not have fallen off.

A.        Yes, because he’s on the medication.  His exercise, no general exercise [inaudible] so I can’t say that.

Q.        Yes, but the point I’m trying to make is that if there was somebody in charge of his weight loss programme who was setting the number of calories that he should be given per day, and monitoring his response. You don’t starve somebody, you give them a weight reduction programme.

A.        Yes, we don’t do that, we usually refer to the dietician, and they follow that and we take the instruction from them.

Q.        But the problem here is the dietician – it doesn’t appear the dietician ever saw him.

A.        Yes, this is the thing, the major problem, he hasn’t been to see the dietician.

Q.        Yes.  But you see, what did you do about that when you discovered that he hadn’t been to see the dietician?  Did you write to the dietician and say, ‘He’s not going to come to you, you’re going to have to go to him’?

A.        No, I didn’t do that, I just said refer to dietician [inaudible].  Sometimes they find difficult, they make arrangement to come and visit the patient at home.

Q.        So do you think the answer here is for a consultant led service, and for there to be a programme for people in Mr Horne-Roberts’ position, a weight loss programme that is professionally led by dieticians.

A.        Yes.

Q.        And physiotherapists.

A.        Yes.

Q.        Do you think that is what should have happened here?

A.        Physiotherapists, I cannot feel he would get good help there, so maybe for him the best thing was to exercise [inaudible].

Q.        But somebody will have to be with him to exercise.

A.        To help him with it, of course.

Q.        Somebody needs to take him there.

A.        Yes.

Q.        A moving walkway, anything, there has to be a programme and there has to be somebody saying, ‘This man, unless we do something, will die because he is overweight.’  It seems to me there was no plan directed at that end.

A.        No, that I’m not able to answer.

Q.        No, well that’s very helpful.  And when was the last time that you yourself saw Mr Horne-Roberts?

A.        Yes, on 26 November.

Q.        Right.  Now his last visit to the surgery, was that 21 September 2009, seeing your colleague, Dr Patel?

A.        26 November 2009 – yes, 21 September 2009, yes.

Q.        Now on 16 December 2009 you were at work at the surgery when approximately 9:30 hours you were contacted by the police.

A.        That’s right.

Q.        To inform you that Harry Horne-Roberts had died, and asked if you could attend the care home to certify his death.  Is that right?

A.        Yes.

Q.        You made your way over to the Hillgreen Care Home at 10:30, and again, what you say is, ‘I’m unable to say who I saw or spoke to when I arrived.  I was shown directly in to Harry’s room.  Harry was on the floor, laid on his back with no clothes on.  I was informed that he was given his medication at 8 p.m. the previous evening, and at 7 a.m. he was found by a member of the staff lying on his abdomen face down.’  And you then examined Mr Horne‑Roberts and determined that he had died, is that right?

A.        Yes, Sir.

Q.        And you pronounced life extinct at 10:30, is that correct?

A.        Yes, Sir. 

Q.        Thank you very much.  Do just wait there a moment.  Mr Docherty, was there anything you wanted to ask?

MR DOCHERTY:  No, thank you, Sir.

THE CORONER:  Ms Pasaud?

MS PASAUD:  Yes please, Sir.

 

Examined by MS PASAUD

 

Q.        Doctor, I think you said to the Coroner that the management of the weight loss programme should be led by a consultant.  Are you talking about a consultant psychiatrist or a physical health consultant?

THE CORONER:  I meant a consultant dietician.

MS PASAUD:  Or a consultant dietician would be ideal, I just want to be clear what consultant you’re referring to.

A.        Consultant dietician I referred to him.

Q.        Right, so it would be within the physical health, and that’s a dietician not the psychiatric responsibility.

Q.        Yes, because he’d seen the consultant quite frequently, so he’s got more record than me.

THE CORONER:  There may be a bit of confusion creeping in here. 

MS PASAUD:  I think so.

THE CORONER:  The consultant psychiatrist would be regularly seeing Mr Horne‑Roberts.

A.        Yes, so he’s…

Q.        Is he the person who should be in charge of the weight loss programme, or should it be another consultant, a consultant in nutrition?

A.        Yes, consultant, a psychiatrist to give an instruction, because he’s checking weight in the clinic in the normal way.  So he should have advised on the care plan, he could have referred to the dietician.

MS PASAUD:  Right, I just need to be clear about this, because consultant psychiatrists are responsible for the mental health of patients.  It wouldn’t be for a consultant psychiatrist to lead in relation to the physical healthcare side of a patient.

A.        Yes, because we get them here.

Q.        They wouldn’t lead on that.  They may have some role in arranging referrals, but it wouldn’t be for the consultant psychiatrist to lead.  I think we heard from the cardiologist, the consultant cardiologist today that under the GP contract, morbid obesity is something that should be led by the GP with appropriate referrals being made by the GP.

A.        It is not [inaudible] joint effort to do it, but because he’s seeing quite frequent, so that’s what I’m saying.  If he found that his weight is not coming down they should raise the alarm and put in place a referral to the dietician, so that would help us as well. 

Q.        Right.

A.        Because how many times I’ve seen him, because a few times I’ve only seen him.

Q.        Right, so the psychiatrist should make an appropriate referral to yourself.

A.        Yes, that would help the…

THE CORONER:  Forgive me for interrupting, but there are two issues here.  The first issue is that morbid obesity, I understood that Dr Clifford said that the measurement of blood pressure was something contracted to the treatment of hypotension…

MS PASAUD:  And monitoring the physical health.

THE CORONER:  …was something contracted.

MS PASAUD:  Yes.

THE CORONER:  Not necessarily obesity.  And I think the real difficulty with this case is that there is a difference between people who have a capacity to make decisions for themselves and people who do not.  And Mr Horne-Roberts did not.  And the difficulty here is that there has to be, and we already know from the report into the incident, the root cause analysis, that there were communication errors of communication difficulties in this case.  My understanding would be, the solution would be for the consultant psychiatrist, where a patient is eating as a consequence of part of their disorder, then the consultant psychiatrist should lead.  Where there is no connection with the psychiatric disorder, and it is purely a matter of physical health, then that is something that the general practitioner should lead on.  But we have a difficulty because the general practitioner may not see the patient as often as the psychiatrists. 

MS PASAUD:  Yes.

THE CORONER:  So it’s not an easy one to solve.

MS PASAUD:  No, it’s not.  And I wanted to be clear about the evidence that this doctor had given when he referred to the consultant as to which consultant he was referring to.

THE CORONER:  And I think it’s the consultant psychiatrist to make referrals and give advice to the general practitioner about what steps to take.  But I think in a case such as this it would actually merit a dietician, an experienced dietician managing this case.

MS PASAUD:  Well it would be the dietician who would have the appropriate expertise to be able to manage the weight other than through medication or psychological therapies.

A.        Yes, all [inaudible] seen a consultant and give the alarm, he’s needed some expert opinion, what his weight he’s putting on after the medication.

THE CORONER:  Well here, you see, this is a man who came to you morbidly obese.

A.        Yes, Sir.

Q.        And he died morbidly obese.  And the question is why it was not possible in the years between for him to have been on a programme to reduce his weight, reduce the risk of death from the consequences of obesity.  That’s the difficulty.  It’s not just months that passed, years passed.

A.        Yes, but you can see, Sir, when he came his weight was 150.

Q.        Yes.

A.        And I don’t know what – I know it is overweight, obesity, but after a few years I see his weight was reducing.

Q.        Yes, but that was luck.

A.        And how is it reducing, controlling his diet or…

Q.        And then it went back up again.

A.        Went back up again. 

Q.        So what’s absent here, and we’re coming around in a circle, is a comprehensive plan for this man with targets and an exercise plan put in place.  Whoever leads it, whether it’s the general practitioner who leads it, or the consultant who leads it, will depend on the input from the medical – from the mental disorder component.  That would seem to be common sense.  If a person has got no – if there’s no connection so the person is suffering from diabetes and it’s the diabetes that is making the person unwell, then you would not expect the diabetic control to be led by the consultant psychiatrist. But I think Mr Horne-Roberts’ case is particularly challenging because of the level of involvement of the condition he’s suffered under, and its effect on his eating habits.  And I think what stands out is there was, in effect, no plan.  There were many attempts to help him lose weight, but there was no plan and there was no overall approach to help him lose weight.

MS PASAUD:  Sir, there may have been a plan in terms of the health plan, it’s whether that was followed.

THE CORONER:  Well we see the extent of the plan.  It’s not – I’m not being critical of the plan.  All the way through the daily – the weight recordings, every time it is recorded that he needs to lose weight.  So it’s not that the question wasn’t addressed or recognised, it was people were recording things but nothing was happening with the recordings in such a way that caused him to lose weight.  And I think it needed to be led by a dietician, a consultant dietician, somebody who had considerable expertise in managing conditions such as this.  I mean the home themselves can’t be expected to perform that task.

MS PASAUD:  No.

THE CORONER:  The general practitioner, in circumstances such as this, can’t be expected to perform that task.  It has to be – it has to be a determined effort as part of his care plan.

MS PASAUD:  No further questions, thank you.

THE CORONER:  Members of the family?

MRS HORNE-ROBERTS:  Yes, Sir, thank you.

 

Examined by MRS HORNE-ROBERTS

 

Q.        Dr Prasad.

A.        Yes.

Q.        When you saw Harry on 1 October 2007…

A.        First, let me say I am very sorry about Roberts, we lost, he was very dear to me as well.

Q.        Sorry?

A.        I’m very sorry we lost him.  You have my sympathy, I miss him too.

Q.        Thank you very much. 

THE CORONER:  You said he was dear to you as well.

A.        Yes, of course.  I look after so many gentlemen like that.  I always like them, and they go very well with them.  I respect their feeling, but life is…

Q.        When you saw Harry on 1 October 2007 his blood pressure was 170 over 80.

A.        Yes.

Q.        Why didn’t you take it subsequently, because that was a high figure, wasn’t it?

A.        Yes, Madam, but in my experience, when you take blood pressure for the first time high, we don’t start his treatment, we have to repeat and take the blood pressure again because he was very agitated and very – struggling to take blood pressure.

Q.        No, but you should have taken it – as I say, a few months later, or a few weeks later.

A.        Yes, but he didn’t come, I couldn’t take the blood pressure, it was very difficult I’m telling you.

THE CORONER:  So you said it was very difficult for you to…

A.        To take the blood pressure.

Q.        … attach a cuff.

A.        Yes.  The last time – the second time we took his blood pressure, I am able to take it on 7 April, it was 131 over 90. 

Q.        Mmm, okay.

A.        And this was done…

Q.        But his school doctor wrote to you in June of 2008, just before he left school, and said that it was most important that his weight be brought down and that his blood pressure be continued to be monitored.  Is that right?  Do you remember receiving that letter?  It’s in the medical records.

A.        No, I haven’t seen that one.

Q.        Well, do I hand it up or…

MS PASAUD:  Yes.

MRS HORNE-ROBERTS:  Okay.

[Document is handed to witness]

Q.        There are two letters from the school of June 2008, that’s from the school doctor and I’ve underlined it, and it says that it was important to bring his weight down and to continue to monitor his blood pressure.  You see I’ve underlined it?

A.        Yes.

Q.        And on the following letter of the same date, also it mentions the need to monitor his blood pressure and bring his weight down.  Do you remember seeing that letter, reading that letter?

A.        Yes, but I didn’t see that letter in my knowledge.

Q.        Well it was in the medical records.  My husband, Keith Roberts, who is sitting here, did offer to help you with testing Harry because he had in fact had an ECG done at the hospital, and then had a blood test done at school before he left school, which were both clear.  And so it was possible to test him.  Well why didn’t you avail yourself of my husband’s offer to help you with the testing of Harry, because that had been very effective in the past?

A.        Yes, I tried to ECG him but it was difficult to get an ECG done.  But as you see, I have sent him to casualty for blood tests, but he just denied to take the blood sample.

THE CORONER:  Just to make it clear, do doctors take blood any more?

A.        No, Sir.

Q.        Why is that?  Is it something that’s no longer taught as part of medical training?

A.        No, no, we have done it.  I don’t know why, because they all go to the hospital now, they take a form.

Q.        But you see, once again…

A.        Because we have not got…

Q.        Once again you have got a situation where you’re going to have to send Mr Horne-Roberts, an unwell patient, into a hospital to have a blood test when you could do it yourself.

A.        No, but he went to the Accident & Emergency Service [inaudible] and they wanted to take a blood sample, but he just wouldn’t take it.  But blood taking the surgery – and we arrange the transport because now we are not getting the service any more, so they are saying it is better to send him to hospital.

Q.        Yes, but…

A.        I had to do before.

Q.        It’s fine…

A.        Four years back I was doing it myself in the surgery.

Q.        Exactly, well I would imagine that this was something you did very regularly in the past.  The difficulty is that in patients who are unwell and find hospital a challenging, difficult place to go, and it may precipitate difficult behavioural patterns, then there has to be an alternative otherwise no blood gets taken.

A.        No, we’ve got a community blood technician comes to the homes to take the blood.

Q.        Much better though a person that the patient knows.

A.        Yes.

Q.        Their own doctor.  Much less likely to make them anxious.

A.        I know, but now they’re advising to send [inaudible] to take a blood letter home.

Q.        Well there we are.

MRS HORNE-ROBERTS:  And when the dietician appointment that Harry didn’t come with his carer – or didn’t go with his carer, was there any follow up?  Did you follow it up?  Because there had been an aborted appointment, did you follow it up?  Did you do anything about it?

A.        No, I didn’t follow it up because I haven’t seen that for a long time, so…

Q.        When you heard that Harry had passed away on 16 December 2009, why did you not go immediately?

A.        Because I got the message about 9:30, I just, it took me time to come because I had some meetings, I had a meeting [inaudible] the appointments in that time.

Q.        I didn’t hear that actually.

A.        I had – in the morning I started clinic, my clinic’s at 10:30, so I was in some meeting, I had some meeting, so I left the meeting and rushed to there.

Q.        When Harry’s blood pressure was high and when you were perhaps failing to treat him or test him, why didn’t you think of consulting us, his parents?  Under the Mental Capacity Act we were supposed to be consulted.  Why did you not think to speak – were you aware there was a Mental Capacity Act?  He should have had a mental capacity assessment, were you aware of that?

A.        Well I haven’t got any instructions from the parents.  Some parents give their instruction all together, if any problem I contact you.  But I didn’t have any instruction like this.

Q.        Well my husband did say to you that he could help you do testing of Harry, any testing of Harry.

A.        [Inaudible]

Q.        Well he did.  And also Harry – Dr Jaydeokar was prescribing these drugs for Harry, and Harry was unable to consent, and therefore you should have consulted his next of kin, his relatives. 

A.        Yes, of course, but I was getting all prescribed medicine just from the meetings at hospital care plan, you know.

Q.        The care plan.

A.        And this I follow.  I never prescribed recklessly, I have given very…

Q.        Were you involved in the drawing up of his healthcare action plan?

A.        Yes, I’ve seen, but I haven’t…

Q.        Were you involved at a meeting at which it was drawn up?

A.        No, I’m not involved, no.

Q.        You weren’t involved.

A.        No.

Q.        Okay.  But Harry had – but nobody consented to Harry’s treatment, did they?  Harry couldn’t consent.

A.        Yes, I thought the treatment was – it started in the hospital, so I thought that…

Q.        But you were carrying through Dr Jaydeokar’s prescription…

A.        Yes, instruction, yes.

Q.        … for these drugs.  But you must have been aware that Harry wasn’t – you knew Harry wasn’t able to consent, and you must have been aware that it was your duty to consult members of Harry’s family, both the psychiatrists and your duty under the law.

A.        I didn’t know – I’m not aware of this.

Q.        Did you know that there were guidelines for testing and monitoring the administration of these drugs, a drug like CPZ, which can have dangerous side effects, chlorpromazine, did you know that there were guidelines in existence?

A.        Yes, there is guidance, yes.  But his treatment started in the hospital.  They should have consulted this guideline better than me.

Q.        The hospital should have?

A.        Yes.

Q.        Yes.

A.        They started the treatments.

Q.        Did you know that these drugs could have dangerous side effects?

A.        Yes, I know that.

Q.        Mmm. 

A.        But…

Q.        Did you know that CPZ can cause massive appetite increase?

A.        Yes, sometimes it does increase appetite, yes.  They put on weight, yes, this is one of the…

Q.        And do you think the CPZ should be – did you have any opinion as to whether it should be prescribed for as long a period as ten and a half months, which Harry was on CPZ.  Some people say it shouldn’t be prescribed for more than six months at a time.  What’s your view of that?

A.        In my experience I have sometimes taken a bit longer period.  With observation, you know.  If he’s…

Q.        Do you think the London Borough of Islington should have monitored Harry’s treatment by you and by the psychiatrist, Dr Jaydeokar?  Should London Borough of Islington have been more involved?

A.        I didn’t hear what…?

Q.        Should Islington social workers, should they have been more involved in Harry’s care?

A.        No, the [inaudible] visited Harry and make a meeting, a group meeting and discuss if you want proper care, we should have a meeting…

Q.        You did have group meetings, did you?

A.        No, I didn’t.

Q.        You didn’t have group meetings.  Thank you.

THE CORONER:  Yes.

 

Examined by MR ROBERTS

 

Q.        Doctor, thank you for all that.  I just – I have to sympathise with you to a degree because Harry was very challenging.

A.        Yes. 

Q.        As you know, when we came, when I first met you with Harry he was all over the place, wasn’t he?  It was difficult to keep him in the room.

A.        Yes.

Q.        In fact I think I had to stand at the door, between the door and Harry to talk to you about it.  It was quite tricky.  And I think another problem you had was that obviously the primary care people were the people who had taken over his care, that is these people, Hillgreen Care, they drew this thing up.

A.        Mmm-hmm.

Q.        And probably, you know, you said you haven’t seen this before or you knew little about it, so they’re clearly – where it says his physical health, the staff key worker – well the staff key worker was Deo, who is here, Deo hardly speaks any English at all.  He’s a very decent chap and did look after Harry as well as he could.  He tried, but they’re not medical people.  And also you’ve got Dr Jaydeokar playing a role in this, so we’re falling between two stools all the time, nobody knows who’s doing what.  Jaydeokar, as far as I know, asked for the dietician to be involved and got absolutely nowhere with it, so it’s very hard to see, I sympathise with your predicament.  But the outcome was catastrophic, and we must make sure this doesn’t happen again. 

A.        Yes.

Q.        So that’s what I have to say, thank you.

THE CORONER:  Thank you very much indeed, Doctor, I’m very grateful to you.  Do take a seat again.  Professor Singh, please.  Professor Singh?  Ah, I see.  Did we agree at the last pre-inquest meeting that we didn’t need to call him?

MRS HORNE-ROBERTS:  I don’t think we wanted to call him particularly, thank you.

THE CORONER:  No, all right.  Well it’s an error on my witness list then.  Could I ask Mr J Olotu to step forward, please.

MR DOCHERTY:  Sir, just before Mr Olotu does, can I just make an observation, that in fact Mr Olotu only joined the staff a couple of weeks before Mr Horne‑Roberts died, whereas the next witness, Lola Odukomaiya was closely involved.

THE CORONER:  Well let’s hear from that witness first then, shall we?

MR DOCHERTY:  Yes, that’s what I was going to suggest, Sir.

THE CORONER:  Ms Odukomaiya, please.  Do step forward.

 

MS LOLA ODUKOMAIYA (affirmed)

Examined by THE CORONER

 

Q.        Would you be so kind as to tell the court your full name, please?

A.        Lola Odukomaiya.

Q.        Now the Hillgreen Care, 53 Middleton Road, that’s where you were working when Mr Horne-Roberts was a resident there, is that right?

A.        Yes.

Q.        Is it called Hillgreen Care or…?

A.        It’s called Hillgreen Care.

Q.        It’s called Hillgreen Care.  Help me with this.  Are there any onsite medical staff?

A.        No.

Q.        So there were no nurses?

A.        No.

Q.        So all you have in effect are support staff.

A.        Support work, yes.

Q.        Now in this care plan that we’ve seen here, who drafts that?

A.        This was drafted by the company, and it’s a form that all the other residents have.

Q.        So it’s filled in, it’s produced, and any resident will have to fill it in, or it will be filled in for any resident.

A.        No, we fill it in with the residents.

Q.        Oh, I see.  So it’s done with the residents.  One of the concerns about Mr Horne-Roberts was the management of his weight.  And what help did you have with the management of his weight?

A.        We didn’t have much help.  The only help we did have was from Mr and Mrs Horne-Roberts in terms of we supported them to take Harry swimming and trampolining.  Within the home we would try to take Harry for walks, if they had a place they wanted to take Harry to and they felt that they needed the support of our staff to do so.  We had Harry’s key worker, who had a very good relationship with Mr and Mrs Horne-Roberts, who would follow them in aspects to that.

Q.        Did you have at that time any gymnasium facilities?

A.        No.

Q.        You know, a treadmill or something like that?

A.        No, we don’t.

Q.        But if any of your residents needed that would they be able to get access to it?

A.        Yes, yes.

Q.        So in effect the attempts to control Mr Horne-Roberts’ weight were really at your own – you did your best.

A.        Yes.

Q.        Is that right?

A.        Yes.

Q.        Would you have benefitted from professional assistance?

A.        We would very much have benefitted.

Q.        Did you ever ask for professional assistance?

A.        It came up in Harry’s review about referrals to dieticians being made because we feel that if this was in place it’s just a matter of staff following the regimes.  Within the home, as Mr and Mrs Horne-Roberts would know, we try to introduce new food to Harry, salads, fruit, but Harry came in with a restricted diet.  He didn’t eat a lot of the food that other residents did, which limited what we could do and how much we had control over what he could and couldn’t eat.

Q.        So really that was the missing – yes, you needed a dietician to concentrate on a diet for Mr Horne-Roberts that you could assist with.

A.        Yes.

Q.        And input as far as physiotherapists were concerned to assist with his exercise.

A.        Yes.

Q.        Because it’s not just a matter that needs guessing at, a person in Mr Horne‑Roberts’ condition needs assistance.

A.        Yes, he does.

Q.        And one would imagine that that’s not something that you would have expertise, or your team would have expertise in.  It must have been frustrating for your team.

A.        It was very difficult because everybody – it was all hands on deck with Harry, because Harry was lovely, and his parents made our jobs easier, and a lot of the times we did consult them.  Almost…  It might not have been – I’m not a specialist, so I can only say as far as I know, you know, ‘This has been done for Harry, this has been done for Harry,’ whereas if there was a specialist involved it might have gone more in depth, so they would be properly informed and aware of everything.  But as far as our care goes, we do try very much to keep them…

Q.        Well that’s evident.  And you were responsible for keeping – or your team were responsible for filling in the weight charts.

A.        Yes.

Q.        And every one of them that I’ve seen has some comment about ‘needs to lose weight’ or ‘losing weight’, so clearly your team understood the importance to Mr Horne-Roberts.

A.        Yes.

Q.        But as we can see, it was difficult to have any success, because you would gain and then you would lose ground.

A.        Yes.

Q.        Were you on duty when Mr Horne-Roberts was found having died?

A.        I wasn’t on duty.  I saw him the day before that, and I was called in the morning.

Q.        And how was he?

A.        He was – I was very surprised, because when I left Harry he was very, very fine.  And Harry is the sort of person that – he’s very active, always active, so if anything was to happen to Harry, or you didn’t hear Harry, the panic would have been maybe he’s absconded because he’s gone quiet, or there’s something wrong.  And that wasn’t the case, he didn’t present to me like that, he was his normal self, he was fine as far as the staff were aware, physically.  Clearly we couldn’t have had – there would be no way for us to know what was going on inside, but physically he was – he appeared to be fine.

Q.        Well that’s – thank you very much indeed.  Well I’m very grateful to you.  Just help me with this, how many people are residents in this home at any one time, or were at that time?

A.        We’ve got a capacity for five, and there were five at the time.

Q.        There was five at the time, so it’s quite an intimate group of people.

A.        Yes.

Q.        I expect you get very close…

A.        Yes.

Q.        … to the people that you work with.  And how many members of staff do you have?

A.        We have about eight.  Some do – like some are more permanent and some come in, in between.

Q.        Yes.  That’s very helpful, thank you very much.  If you just wait there a moment.  Dr Prasad, did you have any questions you wanted to ask?

DR PRASAD:  No.

THE CORONER:  Ms Pasaud, was there anything you wanted to ask?

MS PASAUD:  No thanks, Sir.

THE CORONER:  Members of the family, anything you wanted to ask?

MR ROBERTS:  Yes, thank you.

 

Examined by MR ROBERTS

 

Q.        As before, we know how challenging this was, and of course it’s a 24-hour job, isn’t it?

A.        Yes.

Q.        So when you say you had eight staff, it’s hardly enough.  But we all – we were all very grateful to you for the tremendous work you did with Harry, and it’s very sad that it’s come to this.  But this business about – you kept very good records, which is quite impressive. I am impressed anyway.  And I think this business – we all understood that his weight was very important, wasn’t going in the right direction, although you did get a handle on it to start with.

A.        Yes.

Q.        In your favour, but it was going in the long-term in the right direction.  Very hard to deal with it, but if we’d had a dietician on the job, and it had been asked for, so I think it’s really – they let you down, your people let you down.  That’s not your fault, but it just goes to show how important it was.

A.        Yes.

Q.        And maybe the drugs didn’t help, but in some respects they did.  I know we congratulated on one occasion, we came back from a weekend, which we’d have otherwise found almost impossible.  We were in two minds as to whether we could do that, but we knew how important it was for Harry.  So we thought this was – we were on the right lines.  However, maybe it was the drugs that didn’t help by winding up his appetite, which was pretty big anyway, wasn’t it?  But he was, I think, let down by not having – not having your dietician on hand, or some advice to help you, but you can’t be expected to know everything, can you?

A.        Yes.

Q.        So anyway, thank you.

THE CORONER:  Mr Docherty, was there anything you wanted to ask?

 

MS LOLA ODUKOMAIYA (affirmed)

Examined by MR DOCHERTY

 

Q.        Just this, that there is a community care plan review form of 9 March 2009, which I believe your office has had, so it’s not gone into the bundle.

THE CORONER:  No.

MR DOCHERTY:  Can I – I believe all the parties have had. 

THE CORONER:  Yes.

MR DOCHERTY:  If I could perhaps just read the paragraph, and I might ask the witness then to comment on it.  If you think it’s necessary/appropriate, we can arrange copies, I hope.  Did you have regular reviews of how the care of Harry Horne-Roberts was going while he was at your home?

A.        In house we did.  Harry’s care plan would have been reviewed every five months, but if there was an incident and we needed to look back at it and probably restructure it, we would do so as and when it needed to be done.

Q.        But you had also reviews with other agencies involved, didn’t you?  Social services and so on.

A.        Social services, yes.

Q.        And do you remember such a review on 9 March 2009?

A.        Yes.

Q.        You probably don’t remember the date specifically, but –

A.        Yes.

Q.        And health was one of the subjects that you would cover in such meetings, wasn’t it?

A.        Yes.

Q.        The note of this meeting says the following: ‘Harry is in generally good health.  There are concerns about him being overweight.  He eats a restricted diet, for example he mainly liked carbohydrates.  Staff are gradually trying to introduce fruit, etc.  However, it’s difficult to stop him when he goes into the shop and buys crisps. He’s on the waiting list for a dietician from Haringey.  He’s recently gained weight, however he was 150 kilograms when he first came into the home, and is now 141 kilograms.  Jennie (mum) said that her research had shown that overeating is characteristic of boys with aggressive autism and part of his syndrome.’

                        Now do you remember a meeting at which a discussion of that kind took place?

A.        Yes.

Q.        And do you remember that Harry was on the waiting list to see a dietician at that time?

A.        Yes, because we had spoken about it to the GP and we had spoken about it to Dr Jaydeokar, and I know there was a waiting list, so we – I know we were never contacted to my recollection by a dietician because if we had then Harry’s parents would have been informed and most likely we would have gone along to there.

Q.        Yes.  Thank you, Sir.  Sir, that’s the document, that’s the page of it, so I don’t know if you want any copies, but just – there is some evidence that apparently a dietician was still potentially to be involved even at this stage.

THE CORONER:  Yes.

MR DOCHERTY:  But there was no – you never were aware of an appointment actually happening with a dietician?

A.        No.

Q.        Right, thank you very much.

A.        Thank you.

THE CORONER:  Thank you very much indeed.  I’m very grateful to you.  I’ll release you.  You needn’t stay unless you wish to do so, but of course you leave here with my thanks.  Thank you very much indeed.

A.        Thank you.

THE CORONER:  Is it necessary to hear from Mr Olotu?

MR DOCHERTY:  Sir, to my knowledge he would have nothing to add, but he is here, of course.

THE CORONER:  Yes.  Members of the family, did you have anything you wanted to ask Mr Olotu?

MRS HORNE-ROBERTS:  No.

THE CORONER:  He is the recent care manager.

MRS HORNE-ROBERTS:  Well the trouble is that he was – I had questions in relation to the period – the earlier period and throughout 2009/2008, and he wasn’t there at that time.

THE CORONER:  No, that’s right.

MRS HORNE-ROBERTS:  So I don’t know what he can add. 

THE CORONER:  Was the deputy manager there at that period?

MRS HORNE-ROBERTS:  Well, I’ll – yes, I have one or two questions, please.  Thank you.

THE CORONER:  Yes, well shall we re-call the deputy manager?

MR DOCHERTY:  Yes, I think questions for that period would be better applied to this witness.

THE CORONER:  Yes.  Do step back in the witness box, you’re still under oath from when you gave evidence.  Would it be helpful to ask the questions of this witness?

MRS HORNE-ROBERTS:  No, no, thank you.

THE CORONER:  Well that would mean those questions that you…

MRS HORNE-ROBERTS:  I think its’ not appropriate to ask Ms Odukomaiya these questions.  It’s rather difficult for us actually.

THE CORONER:  Well would you like me to ask the questions?

MR ROBERTS:  Yes, yes.

THE CORONER:  Have you got a list of them, and I’ll certainly ask them.

MRS HORNE-ROBERTS:  Yes, thank you.  I did hand them to your assistant, Sir, but I’ve got another copy there.

THE CORONER:  That’s very kind. 

 

Examined by THE CORONER (On behalf of the family)

 

Q.        The first question, why were we, that’s members of the family, not informed that Harry was on first citalopram and then zopiclone then CPZ?

A.        To answer that, I believe that we discussed this with the social worker, and also with a psychiatrist, and during our discussions with the social worker we were under the impression that she was going to have separate meetings with Mr and Mrs Horne-Roberts.  And I know that at some point, whether – it might not have been written down formally, myself or Deo would have said that Harry was on medication now.  I do admit that we might not have been able to go into details specifically or categorically what it was, but we would have had to mention it because there have been instances where Harry would have been taken away, and if we hadn’t mentioned it it’s very difficult to handle the medication without letting you know that he is on medication.

Q.        So if I understand it right, your discussions were with the social worker and psychiatrists, and your understanding was that at some point members of the family would be spoken to by the social worker or by the psychiatrist, is that right?

A.        Yes, yes.

Q.        The Mental Capacity Act 2005 requires that we be consulted and kept informed, and Harry was unable to consent to medication. Well that’s part of the same question really.

A.        Yes.

Q.        And your understanding remains the same.  Whose responsibility was it at HCL to keep parents informed according to that Act?  Well again, I think you’ve said it’s the social worker or the consultant.

A.        Again, it would have been the social worker, yes.

Q.        Are you personally aware of the Mental Capacity Act 2005?

A.        Yes, I am.

Q.        The next question is did you check whether these drugs were appropriate for autism or for anxiety?  It wouldn’t be for this witness to make such a check, it’s a medical matter.

MRS HORNE-ROBERTS:  No, no.

THE CORONER:  Whose responsibility was it at HCL to supervise overall the medication of service users?  Were you responsible for delivering medication?

A.        No.

Q.        So the medication was given to the residents?

A.        The medication was prescribed by the GP, and the staff dispensed the medication to them.

Q.        Ah, it’s me putting it clumsily.  Your team gave the tablets…

A.        Yes.

Q.        …to the residents.

A.        Yes, we did.  Yes, we did.

Q.        So that’s the extent.  You basically were given instructions to give the medication.

A.        At the time, yes.

Q.        Yes.  And the question is whose responsibility was it at HCL to supervise overall the medication of service users?  Did you ever think to get a second opinion? 

A.        No, we didn’t. We didn’t think there was a need.

Q.        Was there ever any suggestion that a chemical cosh was being used to keep Harry quiet?

A.        No, never.

Q.        I imagine you’d have been the first to complain were that to be the case.

A.        I would.

Q.        Were all the ASD services users at HCL on CPZ?

A.        No.

Q.        And the next question, did you do any checks on testing and monitoring which should be carried out prior to and during medication?

A.        The only testing we do is when Dr Jaydeokar prescribes the medication we are on the lookout to see how it coincides with his behaviour or anxiety because that was our main concern.

Q.        And the next question I don’t think’s really appropriate for this witness.  And the last question, what was the line management to regulate the clinical care?  Again, clinical care you’ve dealt with, I think, with the other witnesses.

MRS HORNE-ROBERTS:  Yes, thank you, Sir.

THE CORONER:  Those are the questions, are they?

MRS HORNE-ROBERTS:  That’s right, Sir.

THE CORONER:  Well I’ll pass this immediately back to you.

MRS HORNE-ROBERTS:  Thank you.

THE CORONER:  Was there anything else that you wanted to ask in addition to that?

MR ROBERTS:  No thank you, no thanks.

THE CORONER:  No.  Thank you very much indeed, do take a seat.

A.        Thank you.

 

[The witness was released]

 

THE CORONER:  Dr Karvounis, please.

 

DR KARVOUNIS (sworn)

Examined by THE CORONER

 

Q.        Now just help us with this, did you know Mr Horne-Roberts yourself?

A.        No, no, I have never met him.

Q.        So what was your role?

A.        My role is the chair of the clinical governance of the Barnet and Haringey Mental Health Trust, that relates – it’s a bit long, that relates to the service line, which is the dementia and cognitive impairment service line, where the consultants and the psychologists work into.

Q.        Yes.

A.        Now the arrangements are that actually the care delivered was by a partnership team, but does not belong to the Barnet and Haringey Mental Health Trust.

Q.        Yes.

A.        But we second our staff, the ones I mentioned, to the partnership service.  And it is then that the partnership service is working with Hillgreen Home, residential home, which is another establishment altogether.

Q.        Yes.

A.        So that has been the arrangement.  What we did, it was because…

Q.        Well can I just ask you this?  What do you think about what has come out from this inquest is the fact that Mr Horne-Roberts died because the management of his weight wasn’t adequate?  That doesn’t appear in your document.

A.        Because at that time what we particularly looked is the whole inter-service arrangements that we have with the other service that does not belong to us, does not come under us to say how they can conduct.

Q.        So how do we fix this?  I mean how do we make sure this never happens again?

A.        Yes, and that’s what we have discussed, and our contribution to that, is it, and that’s part of it.  It was actually part of our own clinical governance arrangements, are also observed by the partnership service, which – part of it is – touches upon specific issues that we have been discussing here.  There is a specific issue that our user remit for us in the Mental Health Trust are under the CPA arrangements as a way of coordinating the care of patients.  Now with people with learning disabilities, it is only a very small proportion, and my understanding is not more than 20% of the people that have mental health problems.  So their partnership service is looking after a vast amount of people that a psychiatrist doesn’t get involved at all.  And sometimes when they get involved, some of these people, they’re not even under the CPA arrangements.  So the arrangements they have, I understand, it is what you have asked the action health plan.

Q.        Yes.

A.        And that is the response…

Q.        Is this an actual health plan?

A.        That’s the one, yes.

Q.        But how do we stop – how do we ensure that patients like Mr Horne-Roberts are not allowed to become so overweight that they die?  How do we stop that?

A.        And that is what we have looked, and that is a thing of making that plan working much more robustly and being able actually to lead that particular change.  The first one of all that you might see there, actually our consultant was not even asked to attend.

Q.        Yes.

A.        And that has changed.  And our personnel, both the consultant and the psychologist, if necessary will be part of that action plan.  That is now much more – by law and my understanding, that has to be initiated by the home and the care manager, and that is the other difficulty with learning disabilities.  The care manager could – it was that social worker that comes from Islington.

Q.        Yes, but what we have here, you see, we must not forget, is that Mr Horne‑Roberts lacked capacity.

A.        Yes.

Q.        And this is the heart of his difficulty, was that in order for him to lose weight and reduce his risk of sudden death, he needed the input of a professional consultant dietician or somebody.  It never happened.

A.        Exactly.

Q.        And the care home were left to do the best they could, and we can see their efforts recorded diligently in the weight records that they kept.

A.        And that is where the partnership, my understanding is that with the new arrangements we have put now in place, actually they will be much more involved in not only the drawing of the action plan with the home, but actually of making sure that these things do happen. 

Q.        But it needs to be a specific plan.

A.        Yes.

Q.        So a person identified as lacking capacity needs to have a plan to deliver a weight loss programme involving as many professionals as necessary.

A.        Exactly.

Q.        But it must be led by either the consultant in charge or a consultant dietician, it has to be somebody who…

A.        Yes, absolutely, who has expertise.

Q.        … has got sufficient expertise. 

A.        Yes.

Q.        And it can’t just be a referral.

A.        No.

Q.        In the circumstances that happened here.

A.        But you see, there are so many people involved and so many services, and that is why it becomes so complicated. What we have seen is that actually part of that coordinating action, it is now as part of what the partnership service group is working much closer with homes to oversee, and seeing that that these health action plans are being carried out.  In this instance, as you said, there was a referral to a dietician, and that is what was to be made sure that it does happen rather than being there written, but not specifically followed up. 

                        The other one that we have discussed and who has come here is about the mental capacity assessment, and the involvement of the family.  And since then we have actually gone to every eligible person that the consultants will be involved, especially around medication, to do these mental capacity assessments.  And we are happy that we have done it for the patients that we are prescribing the medication.

Q.        That’s very helpful.

A.        The next part is about the – we discussed here about the physical health policy, and part of that is – and what we have put as mandatory, it is that we do the physical health service ourselves for the patients we have admitted to our wards, you see.  The patients who are in the community, we cannot take that responsibility of doing it when actually also the primary care are involved.  What we have updated, a policy that actually we make sure that that is happening, so we make sure not only that we write to the GPs, but we have a mechanism in process of checking that these are being done.

Q.        Yes.

A.        We have conducted audits about our letters going out to the GPs, and now all our letters going out to the GPs about the physical investigations.  And there are of course a percentage that we do know that actually these investigations are not happening, and we – that would be a continuous process of us involving ourselves with the GPs to make sure that that is happening.  So it is – what we have made sure for ourselves is that actually we pursue, we continue to pursue that particular issue.

Q.        Yes, thank you very much.  That’s very helpful.  Just wait there a moment.

A.        Yes.

Q.        Forgive me, I have lost my list.  Dr Prasad, was there anything you wanted to ask?

DR PRASAD:  No, thank you.

THE CORONER:  Mr Docherty?

MR DOCHERTY:  Thank you, Sir, no.

THE CORONER:  Ms Pasaud?

MS PASAUD:  Can I go last, Sir?

THE CORONER:  Yes, of course you can.  Members of the family?

MRS HORNE-ROBERTS:  Yes, Sir.

 

Examined by MRS HORNE-ROBERTS

 

Q.        Is it right that at the time our son died there had been, and while Dr Jaydeokar was treating our son, there was no direct line management, no overall supervision of Dr Jaydeokar?

A.        No, no, that’s not the case.  There is – there was a clinical director that

            Dr Jaydeokar is reporting, as myself.  And I don’t know exactly if you referred to supervision.  The consultants are responsible for their actions, and they bring their cases to peer supervision, which is established, and Dr Jaydeokar mentioned the other consultant in the service, that when we feel that that is the case, that we bring our decisions to discussing with our colleagues.

Q.        But Dr Jaydeokar said that he didn’t in fact, in Harry’s case, he didn’t consult another doctor.

A.        Yes, because it is not in a mandatory that we do that as a matter of course, as a junior doctor would do with a consultant.  The consultant would consult another colleague if they feel that they need to do so.

Q.        We’ve had a bundle of documents from the Haringey Mental Health Trust, and it suggested that a lot of procedures have been tightened up as a result of this tragic case.

A.        Yes.

Q.        In terms of the administration and management.  That’s what you’re – part of what you’re saying, isn’t it?

A.        Yes, yes, if you can call it – yes.  The – I think the term would be about the kind of the governance arrangements, you know, how the – the process is about how we ensure the best practice, clinical practice.

Q.        Yes, thank you.  And Beryl Strowell, in answer to our query about guidelines, concerns the prescription of anti-psychotic drugs, said you do have an intranet of guidelines, and they’re similar to the guidelines, Cambridgeshire and Peterborough is one example, but there’s guidelines in Avon, I think, established in 2005 or something, and there are international standards set up in 2002.  So at the time did you have an intranet set of guidelines on the intranet for internal use by your doctors?

A.        Yes, yes, we did.  At that time what we – what we know and what we’ve changed since then, it was actually our doctors were not working, and because they were seconded to a different service they did not have access to the computers to access that particular intranet for this service, and that’s what we have changed even since we have made what we call now mobile computing, that we have provided them with. 

Q.        Thank you.  Have you got any questions, Keith.

 

Examined by MR ROBERTS

 

Q.        Yes, please.  Doctor, you refer on a number of occasions in your talk there to a partnership.  Is that – what is that partnership?

A.        The partnership is the learning disabilities part of the PCT as well as the learning disabilities of the local authority, and the people who are involved in that partnership from the Mental Health Trust, which is the doctors and the psychologists.

Q.        The Trust is still the Haringey Mental Health Trust, and they are members of a partnership with the other people you mentioned.

A.        With the other – yes, with the Haringey Local Authority and the Haringey PCT.

Q.        Thank you for that.  I can see that – it seems to me all through this that there are so many parties involved you, a) have to be careful that you’ve got people with the appropriate competence to deal with a situation like the one that we’re dealing with, and also that you don’t fall between two stools.  I mean this is not your – not something I’m – you know, I’m digressing here slightly, but I mean that seems to me where we’re at.  And if your responsibility is to investigate the partnership in activities like the one we’re discussing here today, then I do hope that we will draw something from – some conclusion from this discussion, which the Coroner will no doubt tell us all about, which addresses these two issues, competence and responsibility. 

A.        Yes.  May I kind of respond?  That, as you said, kind of we did the investigation because some of our staff were involved.  But actually we were also very much interested because when our staff has a different service we wanted to make sure that actually what the arrangements we have about the best practice in safety is also being observed by the other organisations, and they were very helpful that we worked together.  And actually they’re – what the different actions they undertook as a result of the lessons learnt, they came and presented it repeatedly over the last year in our own clinical governance arrangements.  So they came and told us all the things that they were meant to do.  They told us and gave us evidence that they did.  So I’m in a much better position now to say that actually these arrangements, the inter-arrangements we have between the two different services are working much more, and I’m sure actually that their own arrangements about how the processes are working are much more robust and there is much more learning that has been happening there.

Q.        Thank you.  Just finally, in short two things occurred to me, particularly with reference to Harry.  One of the problems with Harry was that, and with people of his age and condition, was that when they come to the end of their school there’s nothing, it’s just a fall off a cliff.  There’s nothing for them to do.  There’s no prospect of them getting a job. Even leaving the house is quite difficult. I used to fear for Harry because I thought if you could look at him as if he were a prisoner it wouldn’t be actually too far. You know, the differences would be marginal.  So when you’re running your partnership or thinking about it, please think about what can you do with these young people which will, you know, give them some hope. 

                        And the other thing, well just a small thing, about the exercise which the Coroner mentioned.  The physical wellbeing of people is, especially this Olympic year, you can say very closely associated with their physical health.  And if you could provide some rudimentary exercise machines, because clearly they can’t always be going off to gymnasiums and swimming pools and so forth, although they can still do that a bit.  But the gymnasium could be in the back garden, couldn’t it, with an exercise machine or something like that.  We did actually produce an exercise bike.  I don’t know whether it got used very much, but do think about that, just as an aside.

A.        Yes.

Q.        Thank you, Sir.  Thank you.

THE CORONER:  MS PASAUD.

 

Examined by MS PASAUD

 

Q.        Thank you, Sir.  Dr Karvounis, I think your evidence is that as a result of this case the Mental Health Trust did work with the PCT, Primary Care Trust, and also the local authority to review the partnership arrangements.  Is it right that a new operational protocol has been drafted?

A.        Exactly, yes, and I have been sent the final draft actually that they have been working over the last year.

Q.        And does that clarify the lines of responsibility for ensuring physical health tests and for ensuring that the health action plan that we’ve seen is actually carried out?

A.        Yes, thank you for asking.  And also the different roles and responsibilities have been clarified within that partnership arrangement, and how they will be relating to the different problems that they – where the residents are living.

Q.        Okay.  You said in your evidence the partnership will work much more closely with the individual homes to ensure that the action plans are working.  Is there going to be someone who is tasked with that responsibility, and is that going to be audited?

A.        I don’t know how they’re going to do.  I mean I think there are people actually within this court that they could answer much more effectively than me about that.  But I do know that actually they, within their operation policy, it’s been described the process of how that will be happening, yes.

Q.        So how referrals will be made and followed up.

A.        Yes, exactly.

Q.        Thank you very much.

THE CORONER:  Did you think in this case it’s the absence of a dietician led programme to reduce Mr Horne-Roberts’ weight that caused his death?

A.        What you said about – sorry, about the making sure that there was a plan.  If that plan – I mean to what extent a dietician would be the leading figure there, or could be someone else, but I think the dietician would be an important person to do that and lead, and direct actions, that sort of thing.

Q.        Yes, so I mean what I suggested to you was the absence of a dietician led programme to treat Mr Horne-Roberts’ morbid obesity caused his death.

A.        Yes, well then the dietician would be part of what you said of how many calories he should be allowed also during the day, and that is beyond a dietician, yes.

Q.        That’s right.  A programme to treat his morbid obesity.

A.        A programme, yes.

Q.        Led by a dietician. 

A.        A dietician, yes.

Q.        And the absence of that caused his death.  Would you agree with that?

A.        Yes, it seems that – I think – it seems to me that the…

Q.        Well that’s very helpful.  Thank you very much indeed.  I will release you.  You need not stay unless you wish to do so, but of course you leave here with my thanks.  And thank you very much for the work you’ve done to prevent this happening again. 

 

[The witness was released]

 

THE CORONER:  Well I think that is all the evidence that we are to call this afternoon.  Members of the family, I’m going to ask Counsel first to deal with verdicts, and then I’ll come back to you, all right?  Ms Pasaud, what do you say about verdicts in this case?

MS PASAUD:  Sir, my submission would be that on the basis of the evidence that we have heard from the experts, natural causes may be an appropriate verdict.  Alternatively a narrative verdict, but I would ask, Sir, that if there is going to be a narrative verdict that you would consider the case of Lewis, the Court of Appeal decision in Lewis.

THE CORONER:  More than minimally or trivially causative on the balance of probabilities.

MS PASAUD:  On the balance of probabilities, yes, Sir.  It’s on the basis of Dr Jaydeokar’s evidence.  We heard evidence from Dr Radley that the areas where his practice was considered – or not considered to be, on the balance of probabilities, contributing.

THE CORONER:  Well yes, I think Dr Radley’s evidence excluded any criticism of the consultant psychiatrist in the care provided, and also gave firm views about the lack of connection between weight gain and the medications that were provided.

MS PASAUD: Yes, Sir.

THE CORONER:  And also any concerns about the appropriateness of the medication that was prescribed.

MS PASAUD:  Absolutely, so on that basis you shouldn’t find yourself into a narrative verdict, it wouldn’t be appropriate to be included within a narrative verdict.

THE CORONER:  Mmm, yes.

MS PASAUD:  In relation to the possibility of neglect, of course the definition of neglect is the gross failure to provide basic medical attention to someone in a dependent position.  I don’t think we’ve heard evidence from any of the experts that there was a gross failure to provide basic medical attention to Harry.  And there would also need to be evidence that there was a clear causal connection between the gross failure identified and the death.  So Sir, whilst there may have been deficiencies in following up the health action plan, so the dietician didn’t see Harry, that may have contributed, in my submissions that wouldn’t amount to neglect.

THE CORONER:  Well a previous witness agreed to the suggestion that the absence of a dietician led programme to treat the morbid obesity caused his death.

MS PASAUD:  There’s evidence that there may be a connection between the failure…

THE CORONER:  Well that’s not the words used by the previous witness.

MS PASAUD:  There was a referral to a dietician.  We haven’t heard any evidence as to what happened to that referral, why the appointment didn’t take place.

THE CORONER:  Well what we do know is that there was no dietician led programme. 

MS PASAUD:  We do, but we don’t have any evidence, Sir, that there was a gross failure…

THE CORONER:  No, no, I agree.

MS PASAUD:  … for the dietician to see.

THE CORONER:  There’s no evidence to suggest that it amounted to a failure to provide basic medical care…

MS PASAUD:  Yes, precisely.

THE CORONER:  … or indeed there’s no evidence to suggest that it amounted to a really serious or gross failure.

MS PASAUD:  So on that basis neglect wouldn’t be appropriate.

THE CORONER:  No.

MS PASAUD:  But it may – the failure to have a dietician involved in Harry’s care may be something that can be included within a narrative.

THE CORONER:  I think that must be right on the last one because it’s evidence low.  Yes.  Mr Docherty, what do you say about verdicts?

MR DOCHERTY:  Thank you, Sir.  Sir, I think I follow those submissions.  My first submission would be natural causes; secondly a narrative verdict is clearly a possibility.  Thirdly, if it is, neglect would not be appropriate for the reasons given.  Sir, there’s only one other further submission which I would make on the law, and it’s this, that I would simply submit that a certain caution is needed when looking at capacity, mental capacity, because clearly one starts with the presumption of capacity, and clearly there wasn’t capacity to make decision about medical treatment in this case.  But capacity is always issue specific, and a lack of capacity, for example, to make choices about medical treatment won’t necessarily mean that there is a lack of capacity to make choices, for example, about the type of foods one wants to eat or doesn’t want to eat, and that it isn’t necessarily purely a medical question when if one has a patient who lacks capacity it’s not necessarily a straightforward step thereafter to imposing a rigid diet upon that person, or imposing a rigid exercise regime.  Issue by issue these things have to be considered by those who have care.  Now clearly chiefly that’s for clinicians rather than for my clients as a care rather than a nursing home, but I simply raise it, Sir, as what might practically and legally be a somewhat complicating feature.

THE CORONER:  Well we know from the evidence that Mr Horne-Roberts lacked capacity to make decisions about his medical treatment for himself.

MR DOCHERTY:  Absolutely, yes.

THE CORONER:  We know that.  And we also know that a dietician would have bee able to assist the medical treatment of his morbid obesity, because it is treatment for it.

MR DOCHERTY:  Yes.

THE CORONER:  And it may well be that that treatment would restrict the number of calories in the diet, and it may well be that it would generate an exercise programme.  But as you say, whether a person is willing to comply with that and does not is a difficult matter.

MR DOCHERTY:  Yes.

THE CORONER:  But we know from members of the family that he went swimming and trampolining.  This is not a person who was resistant to exercise, he was always busy, always doing something.  What happened here was that there was no programme put in place for him.  And I think the Hillgreen Care diligently tried to reduce his weight without the assistance of a dietician.  That has to be right.

MR DOCHERTY:  Sir, I simply make those observations, but I have no other submissions.

THE CORONER:  That’s very helpful.  Dr Prasad, did you have any observations you would like to make about verdicts?

DR PRASAD:  Yes, well just that I’m thinking what is a primary check up, you know, have a proper check of weight, height, blood test, ECG, which we already started to do that.

THE CORONER:  Right, that’s very helpful.  Members of the family, there are two types of verdict recorded in this court; a short form verdict, you have heard mention of natural causes being a short form verdict.  But it seems to me that a natural cause verdict has two components.  The first is that the person died from a disease process, but the second is there is nothing in the circumstances that might make that death unnatural.  It seems to me that that should be the definition we should apply of natural causes.  I am going to pause there because I am going to ask Ms Pasaud whether that is something that Ms Pasaud would agree with.

MS PASAUD:  Yes, Sir, I would.

THE CORONER:  It has to be right.

MS PASAUD:  Yes, the Touche test.

THE CORONER:  Yes.  Mr Docherty?

MR DOCHERTY:  Yes, Sir, that’s right.

THE CORONER:  That must be right.  It’s not the standard Bench Book test from the Coroner’s Bench Book, but I think that must be wrong in the light of Touche and other cases.

MR DOCHERTY:  Yes.

THE CORONER:  So that’s the test I propose to apply unless you tell me that I have it wrong.

MR DOCHERTY:  No, Sir, no.  I resist the temptation to make any factual submissions on what would or would not amount to an unnatural aspect, as it were.

THE CORONER:  No, quite right.  What I’m going to do in this case, members of the family, is ask you for your view.  First of all, I don’t think this can be recorded as a natural causes verdict because I think the circumstances surrounding it make it unnatural.  And I say that because Dr Clifford made it abundantly clear that had Mr Horne-Roberts’ morbid obesity been appropriately managed he would not have died when he did.  That must be an enormously hard thing, members of the family, for you to hear.  And it seems to me that the centre of this matter is the absence of a dietician led programme to treat this morbid obesity, and that it is that, that absence that caused his death.

MRS HORNE-ROBERTS:  So that’s neglect, Sir, is it?

THE CORONER:  Well we’ll come on to neglect in one moment.  Now, that in my view means that this can’t be recorded as natural causes because that is sufficient, in my judgment, to make the death unnatural.  So how do we record it?  I think in the circumstances it should be a narrative verdict.  A narrative verdict is often described as setting out the time, place and circumstance together with a conclusion.  Even that is not an accurate description because the time, place and circumstances may not necessarily – a narrative verdict may not necessarily reach a conclusion as to the death.  So I propose in this case to record a narrative verdict unless, members of the family, you seek to persuade me that a short form verdict would be better.

MRS HORNE-ROBERTS:  No, Sir.  We accept that, Sir.

THE CORONER:  I would also say this about neglect.  Neglect is a very specific rider that can be added as part of a verdict.  It arises where there has been, on the balance of probability, a really serious failure to provide basic medical care to a person who is dependent on that care, and in this case by reason of infirmity, and who cannot provide it for themselves.  Those providing the care should or ought to have known it was necessary to provide that basic medical care, and there must be a direct causal connection in the sense that there was an opportunity for rendering care, which if taken would have prevented the death. 

                        Now you will see straightway that what we are lacking here is the first element, a really serious failure to provide basic medical care.  There is no doubt that Mr Horne-Roberts received basic medical care. We have been discussing it for the majority of the day.  What he needed, in my view, was a programme to reduce his morbid obesity, to treat that.  Had he had that, he would have had a chance.  That is what I propose to set out in my narrative verdict.  Are you content with that, members of the family?

MR ROBERTS:  Absolutely.

THE CORONER:  My usual policy in these matters, members of the family, is to read out what I propose to set down as the narrative verdict, and ask the parties whether or not there are any matters in it which have fallen in error either factually or in law.  Before I do that, I gave a definition of neglect, and I need now to ask Counsel whether or not they have any observations as to whether I’ve got that wrong as well.  Ms Pasaud, the definition of neglect that I set out, is that correct?

MS PASAUD:  It is, Sir.

THE CORONER:  Mr Docherty?

MR DOCHERTY:  Sir, I have no objection to that definition at all.

THE CORONER:  Dr Prasad, as a properly interested party, do you have any difficulty with that definition of neglect?

DR PRASAD:  No, Sir.

THE CORONER:  No, all right, thank you very much.  Well I don’t have to decide every matter that has been raised, only such matters as enable me to complete the inquisition.  And I do that having regard to the whole of the evidence, and forming my own judgment about the witnesses and which evidence is reliable and which is not.  I’m entitled to draw inferences, that is come to common sense conclusions based on the evidence that I accept, but I am not allowed to speculate about what evidence there might have been, or allow myself to be drawn into speculation.  Now the proceedings of evidence at an inquest are to establish solely the answers to four limited factual questions.  Who was the person who has died?  How, when and where did that death come about?  Neither a Coroner or a Jury can comment on any other matter, and no Coroner’s verdict should be written in such a way as to appear to determine any question of criminal liability on the part of a named person, or civil liability.  I am just going to pause there.  Are there any other directions I should give myself?  I should give myself an expert direction, shouldn’t I?

MR DOCHERTY:  Yes, I suppose, yes.

THE CORONER:  Yes.  In this inquest we have heard evidence from two experts, and how does the court approach expert evidence?  Well firstly, expert evidence is to assist the court in areas where the court would not have its own understanding or expertise.  But it is for me to assess that evidence and to decide whether I accept it or reject it, and I consider it as part of the evidence.  But it may assist me answering one or more questions that have arisen during the course of the inquest.  Ms Pasaud, would that be sufficient?

MS PASAUD:  Yes, Sir.

THE CORONER:  Mr Docherty?

MR DOCHERTY:  Yes, Sir.

THE CORONER:  What I propose to record is that on 16 December 2009, Harry Alexander Horne-Roberts was found having died suddenly at his home, Hillgreen Care.  Hillgreen Care diligently tried to reduce Mr Horne-Roberts’ weight, but without the assistance of a dietician.  Mr Horne-Roberts lacked capacity to make decisions about medical treatment for himself, and the absence of a dietician led programme to treat his morbid obesity caused his death. 

                        Do you think I need to add anything to that, members of the family?

MRS HORNE-ROBERTS:  No.

MR ROBERTS:  Not really, no.

THE CORONER:  Ms Pasaud?

MS PASAUD:  No, Sir.

THE CORONER:  Mr Docherty?

MR DOCHERTY:  No, Sir.

THE CORONER:  Dr Prasad?

DR PRASAD:  No, Sir.

THE CORONER:  No.  Thank you very much indeed in this inquisition taken for our Sovereign Lady the Queen at the London North Coroner’s Court on the 14th day of January 2010, and by adjournment on the 14th day of January 2012 at the London North Coroner’s Court, performed by Her Majesty’s Coroner for the Greater London Northern District.

                        I record Harry Alexander Horne-Roberts died, and the injury or disease causing death I am going to record as acute cardiac failure under 1(a) and 1(b) morbid obesity.  I do that because it is a conclusion supported by Dr Clifford, despite Professor Risdon’s reticence about the cause of death he originally recorded, and I see no reason to replace that with an unascertained cause of death in this case.  Paragraphs 3 and 4 in the inquisition I include in the narrative record, which is that on 16 December 2009 Harry Alexander Horne‑Roberts was found having died suddenly at his home, Hillgreen Care.  Hillgreen Care diligently tried to reduce Mr Horne-Roberts’ weight, but without the assistance of a dietician.  Mr Horne-Roberts lacked capacity to make decisions about medical treatment for himself, and the absence of a dietician led programme to treat his morbid obesity caused his death. 

                        Born on 29 June 1989 in London, Harry Alexander Horne-Roberts died on 16 December 2009 at his home at 53 Middleton Road, Wood Green in London.

                        Members of the family, can I just offer you my deepest sympathies once again, and thank you for your assistance.

MR ROBERTS:  Thank you, Sir.

THE CORONER:  There is no doubt that without your care and your approach to discovering documents and matters, this inquest would not have been as it is today, and thank you very much for that.

MR ROBERTS:  Thank you, Sir.

MRS HORNE-ROBERTS:  Thank you very much, Sir.

THE CORONER:  I owe you an apology, because it has taken far too long for this inquest to be heard, and nothing I can say can make up for the distress that that delay will have caused you.

MRS HORNE-ROBERTS:  I think we couldn’t have coped with it before actually, Sir, to tell you the truth.

THE CORONER:  Well thank you very much.

MRS HORNE-ROBERTS:  Thank you.

THE CORONER:  You have my deepest sympathies at this time, and I am very grateful for your assistance.

                        The final matter we must discuss is whether it is necessary in the circumstances to write a report to consider action that should be taken to prevent future fatalities.  In my judgment action has already been taken to do just that.

MRS HORNE-ROBERTS:  So you don’t want a Rule 43 then, you don’t think that ‘s necessary?

THE CORONER:  I don’t think it’s necessary in this case.

MRS HORNE-ROBERTS:  Okay.

THE CORONER:  The changes that have been brought about by the Trust as set out by Dr Karvounis address the condition, the difficulties that were faced.

MRS HORNE-ROBERTS:  Wouldn’t it be appropriate to warn other authorities though that, through the Government, that it might be useful for them to consider making similar changes?

THE CORONER:  I shall give consideration to that.

MRS HORNE-ROBERTS:  Thank you, Sir.

THE CORONER:  Ms Pasaud, it doesn’t seem to me that there is immediately a need to write a Rule 43 Report to the agencies that appear before this court today.

MS PASAUD:  Sir, no.

THE CORONER:  But I’m asked to consider writing a Rule 43 Report to a broader audience.  Do you have a view about that?

MS PASAUD:  Sir, I mean it might be helpful for other agencies to learn the learning that the Trust has, taking onboard.

THE CORONER:  Is there a method by which the learning from this…

MS PASAUD:  I was just taking instructions on that.

THE CORONER:  … can be passed to other Trusts?

MS PASAUD:  Sir, through NHS London, if we share the action plan with them, and the new operational protocol, they would be able to disseminate the learning more widely.

THE CORONER:  Well that may be of great assistance.  Mr Docherty, Rule 43?

MR DOCHERTY:  Sir, we have no observations to make on that, it seems to be outside of sphere of interest.

MRS HORNE-ROBERTS:  I think it might be useful if the Department of Health made some statement about it.  We’re guided by you clearly, Sir, on that.

THE CORONER:  The difficulty here is it is so glaringly obvious that if a person is overweight to the extent that it is a danger to their health, something should be done about it.  It shouldn’t need reports written, and Mr Horne-Roberts would be with us today if someone had taken that approach.  I have to be careful because it is clear that the Hillgreen Centre tried everything they could, and you can see from the diligently recorded logs they had some success.  But without a properly led programme it would be hit and miss whether they had a chance of success or not.  I will consider the matter.

MRS HORNE-ROBERTS:  Thank you, Sir.

THE CORONER:  But I will need to consider it.  I don’t want to say something now and then end up saying I’ve changed my mind.

MRS HORNE-ROBERTS:  Thank you, Sir.

THE CORONER:  Are there any matters that I can assist you with, members of the family?

MRS HORNE-ROBERTS:  No, thank you very much…

MR ROBERTS:  No, Sir.

MRS HORNE-ROBERTS:  …for your conduct in this matter, Sir,  Thank you very much indeed.

THE CORONER:  Well, I’m grateful, thank you.  Ms Pasaud, anything else I need to deal with?

MS PASAUD:  No thank you, Sir.

THE CORONER:  Mr Docherty?

MR DOCHERTY:  No thank you, Sir.

THE CORONER:  Dr Prasad?

DR PRASAD:  No thank you, Sir.

THE CORONER:  Thank you very much.  I will rise.

CLERK OF THE COURT:  Oh, yea, oh yea, oh yea, all persons having any business before Her Majesty’s Coroner draw near and give your attendance tomorrow at 10 o’clock in the forenoon.  God save the Queen.

THE CORONER:  Thank you very much indeed.

-----------------------

IN an historic verdict, a coroner  recorded that lack of treatment for obesity was the likely cause of death for a talented young artist Harry Horne-Roberts who was autistic.

Coroner Andrew Walker said he would consider issuing a nationwide warning to health authorities following the tragic death of 20-year-old Harry Horne-Roberts in a care home.

Recording a narrative verdict at the resumed inquest into the death of Mr Horne-Roberts, from Cheverton Road, Mr Walker said it was his firm belief that the young man would have been alive today if the care home in Haringey had employed a professional dietician and provided a proper exercise regime.

The inquest highlighted the serious lack of capability among care workers in dealing with rising obesity and its effect on young people with learning difficulties, who are often compulsive and “comfort” eaters.

Harry, a popular and gregarious young man, died of heart failure in his sleep on December 16, 2009.

He was 5ft 11in and weighed 20 stone.

 

 

Conclusion-Care Competence and Accountability.

 

1

Patients’ involvement and protection of their rights

Some staff have been found lacking in their knowledge of independent mental health advocacy (IMHA) and have failed to explain to patients, their carers, and or their parents/guardians how to access these services.

We place great emphasis on ensuring that patients, their carers, and or their parents/guardians are involved in the development and reviewing of their  treatment and care.

Recommendation

Providers should make sure that the principle of patient, their carers, and or their parents/guardians,  participation in care planning is fully embedded in staff training programmes. Clinical leaders should be helped to create an environment in which patient participation is the norm.

Advocacy

Primary care trusts have a statutory duty to provide independent mental health act advocacy (IMHA) services, which help and support patients etc understand and exercise their legal rights.

 

2

Consent to treatment

We need to look at the way in which people who use services give their consent to the examination, care, treatment and support they receive, and know how to change these decisions; and that they are confident their human rights are respected.

Recommendation

Providers should make sure that their staff take refresher courses on consent to treatment. Training should be provided in a range of formats – for example, e-learning and simulation/role play.

Revalidation and appraisal programmes for health care professionals should include assessments of knowledge and skills about capacity and consent.

Assessing capacity and consent

Checking a patient’s consent to treatment is at the heart of commissioners’ visits. It is essential that mental health practitioners know the law about assessing the capacity of a patient to give consent. If they are not capable of giving consent then the practitioners are bound by law to inform and consult parents or relatives of the patient.

 

3

Patients’ experience of care and treatment

People who use services should experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

 

4

Diet, Exercise and Therapeutic activities:

 

In conclusion the Coroner in Harry's Inquest on 4th January 2012 stated that had Harry had the advice of a Dietician and the provision of an appropriate exercise regime the weight gain which is now identified as being fatal  could have been avoided Harry might be alive today he said. The Coroner said he firmly believed that in that case Harry would still be alive today.

 

A further consideration is that the anti-psychotic drugs themselves may have caused a metabolic increase in the rate of weight gain this is borne out in Dr. Mitchell’s papers submitted by the parents and as publicised in the BBC Radio 4 broadcast on 4th October 2011 – ‘All in the Mind’.

 

Finally it should be stated that young persons with Special Needs, leaving school with no possibility of further training or employment should be given some opportunities to develop their skills and given some hope of a quality of life- a light at the end of the tunnel as it were. Homes must be actively encouraged to provide an activity programme to promote well-being and positive recovery for patients.