Back at Sheffield Coroner's Court for conclusion of the inquest into death of Laura Booth.

Asst Coroner Abigail Combes sits in Sheffield Town Hall and others join remotely.

Mark Lomas @3PBChambers instructed by David Evison @ACSLLP represent Laura's family @LauraBo87351752

Paul Spencer @serjeantsinn instructed by Diane Hallatt @DACBeachcroft represent @SheffieldHosp.

Laura died at the Royal Hallamshire Hospital in October 2016 #NHS

Coroner gives required warnings for using video and audio links, varies the contempt of court act.

Coroner: I'm grateful for receipt of submissions from Mr Lomas and Mr Evison on behalf of family on friday and from Ms Hallatt and Mr Spencer on behalf of Trust.

Reviewed submissions. Checks whether oral submissions to make above those in writing.

MrL: Three points in respect to submissions from Trust. Firstly in relation to those submissions, the latter part from para 23 onwards did, in my submission, descend to submissions about facts of case rather than law which family sought to avoid, matter for you...

MrL: In relation to submissions on neglect, the submission is made by Trust that there is no evidence that could cause you of making finding of gross failure to provide nutrition on basis no expert witness described as gross, in my submission its a matter for you...

MrL: thirdly in relation to cause of death submissions describe as sepsis, word used loosely throughout proceedings for infection, as a secondary point you're entitled to consider causes of death that are material, not simply identify single or primary cause of death

MrS: In support of submission lodged with you, you made clear we could make submissions in support of conclusion, from para 23 that's what we sought to do, if you feel we fell foul of Rule 27 you'll decide what to accept or not

MrS: Dr Patel was asked if he considered failure to be gross and he said no. That is a matter you can, and should we submit, take into account in considering whether gross failure in respect of Laura's death. We accept that's a matter for you.

MrS: Nothing to add in respect of Mr Lomas's third point

[sound dipping in and out]

C: Anything you wish to highlight in addition to your written submissions

Mr S content they stand as are

Coroner: Grateful for that, could I ask while I go through the findings and conclusions if I ask everyone put their microphones on mute. Grateful for no interruptions save for Mr and Mrs Booth if they can't hear me at any point.

C: this will take some time to read out, prepared document findings and conclusion, happy to share with parties

C: I am in receipt of written submissions and I'm grateful for these... oral submissions have been given consideration on basis of conclusion I'll deliver.

C: I've reviewed significant amount of evidence... been invited to take view of expert evidence from Dr Patel that he deviated from his statement and independent review and seemed unprepared [I think she said]...

C: it is clear nutrition one of most difficult for independent review to deal with... often clear disagreement.. I'm aware Trust consider Dr Patel deviated from what they consider his views in independent review...

C: Dr Patel was not author of independent review, can find no reason why he'd be mistaken he made view clear... can find no evidence he's being untruthful... can only conclude he gave his views and report author concluded

C: In his oral evidence he went further and said contributed more than trivially, minimally and negligibly... not unusual for witnesses to give more detail when called to give evidence..

Coroner points out Dr Wong and Dr Tattersall also changed their evidence from written when giving oral evidence - pointing out that is ok

C: I'm entirely comfortable with witnesses giving evidence in proceedings that do not accord with what previously given [paraphrase]

C: I dont want to lose sight of who these proceedings were about. Laura described as bubbly and bright girl... a prankster hiding jigsaw pieces... handbags... final say on where to go on holiday

Coroner outlines Laura's needs, none of which change her need for basic needs to be met including nutrition, shelter etc [cant keep up, sorry]

Coroner describes how Laura's parents Ken and Patricia cared for her

C: I can not put into words the admiration I have for Mr and Mrs Booth and Laura and how they dedicated themselves to each other living a full and happy family life

Coroner outlines reasonable concerns that the Booths had about transition and outlines the arrangements put in place by the Trust

C: In Sept 2016 Laura was due to have surgery for a corneal ulcer... low potassium not noted promptly and acted upon, not until admission decided she couldn't have surgery....

C outlines some of Laura's physical illnesses

C: On evidence Prof Lobo her Chrons disease was not active... on evidence of Dr Egner Laura was not more at risk of infection than other members of population....

C: on evidence of Dr Tattersall Laura's arthritis was not active, this too was well managed ...

Coroner outlines some of treatments Laura was receiving to manage her health conditions

C: On clinical records Laura is recorded as low risk for malnutrition on admission to hospital, if its case Laura had poor nutrition on admission there should have been monitoring from her admission

Coroner outlines 29 Sept, 3 Oct, 6 Oct 13 Oct (altho recorded as 13 Dec on chart) fluid charts [+ others]... one feeding chart recorded for 29 Sept 2016

C: Repeated entries from those on ophthalmology ward that others take over Laura's care... was entirely reasonable to try identify a medical ward better placed to support Laura from 26 Sept

C outlines referral request to nutrition team on 29 Sept [i think] does not appear t be made until 3 Oct... Laura put on supplement not appropriate to be put on due to lactose intolerance

C: Transferred to ICU by which stage not been eating for 8 days; dietician on ward reviewed Laura without talking to her or her parents... evidence from 29 Sept was clear contemplation additional steps needed to be taken to provide Laura with nutrition

C: No evidence of a best interests meeting being convened to discuss this and satisfied on the evidence I've heard that Mr Booth did not decline an NG tube on his daughter's behalf, I found it compelling they would not decline any intervention required, there's a long history

C outlines why any conversation that took place was not sufficient

C: Clear evidence was view forming Laura was not getting adequate nutrition...

C: Satisfied appropriate and correct to exhaust enteral feeding before moving to parenteral feeding... on 3 Oct dietician Alice Pugliese consulted with Laura, recorded she was well nourished and no risk of re-feeding...

C: requested feeding charts be held but no evidence this took place... invited to consider they were started but lost... Dr Wong said were not relevant.... Mr and Mrs Booth were not asked to complete any feeding charts.

C: I am satisfied on the basis of probabilities that feeding charts were not commenced for Laura

C discusses Dr Tattersall's entries that nutrition main concern

She gave oral evidence was her parent's concerns

C: Whether was or not, a senior clinician recorded in notes that was her main concern about Laura. Referral to TPN team on 6 Oct clearly states enteral feeding inadequate... results in involvement of Dr Wong, a consultant pharmacist...

C: Dr Wong confirmed she'd declined to allocate Laura to any of her team to the Friday round... view of Alice Pugliese on 6 Oct was Laura was not tolerating fortijuice and she calculates requirements for TPN, records suspected risk of malnutrition

C: This is marked increase from entry made on 3 October... she records ward sister stated NG feeding inappropriate, would need GA for placement and she was likely to pull it out at first opportunity

C: No involvement of Laura or her parents in discussion, no best interests meeting. If they had been involved her parents could have confirmed PICC line came out but Laura did not pull it out.

C: Dr Wong involved again on morning 7 Oct indicated unclear how PN would be weaned off so on hold until discussed, reviewed and agreed feeding plan...

C: further Dr Wong writes Laura's parents record she's had mash and peas, only entry so far in records that mentions Laura has food, Laura's parents dispute this is correct, difficult to see how Dr Wong arrived at this conclusion...

C: Prof Lobo reviews and indicates further nutritional input would be helpful but appeared not possible as Dr Wong has already instructed her team not to provide input

C: Prof Lobos' team request further referral, again indicates enteral feeding was inadequate. It appears as of 7 Oct 2016 Laura had not received regular nutrition for at least 12 days

C: On 7 Oct it is unclear who'd lead clinical decision making around nutrition or what plan was in place to provide nutrition. On 8 Oct entry in notes indicates feeding charts had commenced but no evidence of them

C recounts what was recorded including notes of Laura vomiting; not tolerating fortijuice

C: Plan is made to commence Elemental 028 commenced on 11 Oct 2016, on 10 Oct 2016 Laura had not had adequate nutrition for 14 days at this point

C: On 14 Oct 2016 there is a further TPN referral, dietician saw Laura confirmed nutritional status is not improving... again handed to TPN pharmacist and again decision made to remain on E028 and review after weekend

C: First reference to NICE Guidance after wknd, appears first time team consider balance required, first mention in entries

C: Decision was if Laura not for TPN consider more concentrated feed; Dr Wong's evidence was although they could advise on chemical make up for TPN it would be for Dr Lobo to make decision of when she get it.

Prof Lobo confirmed he'd never in 27 years made a decision about TPN....

Coroner outlines staff members who had all indicated it was not their role to decide on commencement of TPN

Coroner: that is relevant, it would appear no-one felt able to make decision to provide Laura with TPN... at no point in any of the reviews have I seen a full balance of pros and cons of TPN, weight only seems to have been applied to the risks of providing TPN

C: On a common sense approach if Laura was getting nutrition then risks of re-feeding must reduce...

Coroner quotes Prof Egner's evidence that it's common sense you need nutrition to fight infection

C: On 19 Oct TPN team review again and say can not start due to risk of re-feeding, appear to suggest is decision for Prof Lobo

Infectious Diseases MDT say TPN should be started as Prof Lobo given go ahead

Dr Tattersall received text from Mrs Booth too

Coroner: Dr Tattersall's entry on 19 Oct is compelling and I found it difficult to read... she says Laura will die eventually from malnutrition... its clear Dr T as senior clinician has felt it necessary to take control at this point and is gravely concerned for Laura....

Coroner sets out law

Article 2... how question includes in what circumstances... gathering evidence two stage process, funnelling process and I must direct myself as to which of those are relevant sufficiently I could consider them

C: Neglect is a finding, not a conclusion in its own right... in medical context neglect limited to cases where gross failure to provide adequate attention [includes nutrition]

C: failure to provide medical attention may amount to neglect... sufficient level of fault to find finding of neglect, does not mean no action at all but must be gross failure

[only catching half of this]

C: Neglect is not concerned with complex medical care and procedures but consequences of failing to make basic checks... conduct must have caused death in sense more than minimally, negligibly or trivially contributed to death

C: Must be shown care should have been provided and would have on balance of probabilities altered the outcome.

I have also set out various provisions of Mental Capacity Act [she outlines component parts]

C: S4 of MCA sets out way in which Best Interests Decisions should be made... must not make it merely on basis of age, appearance, condition of his, or aspect of behaviour.... person making determination must consider all relevant circumstances and take steps...

C: whether likely have capacity take decision.... must permit and encourage person to participate as fully as possible....

C: where determination relates to life sustaining treatment, must not be motivated by desire to bring about his or her death... must ascertain past and present wishes and feelings... beliefs and values...

C: must take account anyone named by person... anyone involved in caring for person...

Duties imposed by subsections 1-7 also apply to exercise of any power...

C: in case of act or decision made by person other than court, there's sufficient compliance with section if reasonably believes what does is in best interests of person concerned....

C: Having reviewed evidence I'll make following findings:

1) Laura's nutritional intake concern from admission despite this feeding charts were not commenced

2) Laura's nutritional intake was not given sufficient consideration from 29 Sept to 19 Oct [fuller answer] no discussion of benefits of TPN, instead heavy and in my view inappropriate focus on risks and need for plan to wean Laura off something she'd not been started on

C: Further inappropriate focus on need for unequivocal evidence Laura's gut was not working

3) Decisions were not made lawfully... Best Interests practices are not a matter of good practice, they are a legal requirement....

C: Alternatives to NG feeding not appropriately discussed and Laura and her parents were simply asked to try harder with enteral feeding

4) inappropriate weight placed on Laura's medical background... main immune conditions were under control, other than minor skin conditions she was mainly well... it appears to have masked an understanding that malnutrition was contributory factor to her demise

5) Laura should have been discussed in MDT and plan for Laura's nutrition no later than 7 October

6) other feeding should have been tried between X and Y

7) satisfied was gross failure of Laura's care ... continual failure from 29 Sept up until her death on 19 Oct

C: I am satisfied staff were considering her nutritional position, but it is clear no process by which clear decisions about Laura's nutrition could be made

8) Laura's malnutrition contributed to her death in way more than minimally, negligibly or trivially... reached this conclusion on the basis of the evidence of Dr Patel, Prof Egner and Dr Tattersall

C: I want to be clear I can not say Laura would have lasted much longer than 19 Oct or that she'd become well and be discharged, however I am satisfied if she'd received adequate nutrition the outcome for her on 19 Oct would have been different

C: I will amend medical cause of death to include malnutrition in part 2; considered whether natural causes is appropriate conclusion and don't think it adequately describes circumstances, therefore conclusion will return is narrative conclusion

C: Laura Booth went into the Royal Hallamshire Hospital on 25 Sept 2016 for routine procedure, became unwell whilst patient, amongst other illnesses also developed malnutrition... her death was contributed to by neglect

Coroner suggested we take short break so Mr and Mrs Booth can process what she's said, we'll be back in 10 mins (more like 5 now) for other matters

We're back in court

C: It's just after 12:30 before I move on to any issues in relation to preventing future deaths I think its important as coroner's we reflect on our work as well and our role in these cases

C: I want to offer a sincere apology to Laura's parents that it took a substantial effort on your behalf for it to reach inquest... I'm sorry it fell to you as parents that it took a considered effort...

C: Have also reflected on coronial practice and those with complex medical needs and learning disabilities....

C: I do intend to write to Chief Coroner with some suggestions Coroner's are routinely trained on MCA and changes coming up to DOL and register of whether specific expertise available to colleagues

C: I'm going to be bold and say I'll be incredibly grateful to Mr and Mrs Booth if they'd extend their support to me in writing to the Chief Coroner in this regard

[Assume they indicate they will because she thanks them - have no video here]

C says she'll allow Mr Spencer to address on PFDs but ask in first instance Trust approach Dr Ben Stone authorised verification of death form, colleague completed.

C: I'd be grateful if the Trust obtain an account of what the thinking was that Laura's death was an expected death on the circling of that form.

C: I am satisfied that the nutritional pathways in the teaching hospital have been significantly overhauled... and concerns I have about decisions in relation to Laura's nutrition have been resolved

Coroner: I remain gravely concerned in the hospital's approach to the Mental Capacity Act.

Concern of the over burden and under value placed on Mr and Mrs Booth and Laura throughout the duration of Laura's admission....

C: there were at least two occasions where Laura's parents required to intervene in clinical care... at same time they were completely excluded from decisions, if indeed their were decisions made, about Laura's nutritional status

C: I'm satisfied Dr Tattersall understand's principles of MCA and applied them... more concerned the evidence Prof Green... still appears to have a complete misunderstanding of the MCA ...

C: The Trust needs to find alternative means to get to senior clinicians in Trust to embed understanding of MCA and DOL Safeguard changes are good opportunity to do that over next 12mths.

C: I'm prepared to give up my time to come and support the hospital in doing that... if not offer want to take I'll take no bad feeling from that... know sometimes resources tight... prepared to make offer to the trust

C: That remains my one area of outstanding concern and it is a significant concern I still have.

Mr Spencer I'm happy for you to address me on that now or it go into report and address me on that in response?

MrS: Madam I'm sure the Trust would like to avail of the offer you've made... I'd like to reflect on that for short period of time if I may. May I invite you to rise for 10mins so I can take instructions [fuller answer, wants speak to solicitor and Trust Deputy Medical Director]

Coroner apologises to Mr and Mrs Booth that rising again but agrees sensible.

Court is adjourned for 10mins.

Back at 12:50

C: It's 12:54 I'll hand straight over to you

MrS: Taken instructions from Mr Galimberti, the Trust would welcome your invitation to deliver some training on MCA, potentially using this case as opportunity to explain court's concerns

MrS: Clinical directors forum might be an appropriate forum, Prof Green is a member and sits on that forum, I'll leave it to your officer and Ms Hallatt and the Trust to work out logistics of

MrS: Mr Galimberti accepts your concerns, he believes junior clinicians are well trained... its the older clinicians who may not have fully sight of it... can I invite you to consider in writing your report whether it ought to be focused towards older clinicians than younger ones

MrS: Trust will reflect quickly on concerns you've raised and take action. Thank you madam for opportunity to make submissions.

No matters from Mr Lomas

C: probably the hardest bit Mr and Mrs booth is to try and put into words the admiration I've got for you, not only the way you cared for Laura but the approach you've taken to these proceedings

Coroner: I hope you'll feel listened to if not I'd like you to feed back to me when we write to coroner. I'll ask my officer to set up virtual meeting in next 2wks to set up meeting to discuss writing to Chief Coroner.

Coroner: I'm really sorry you've had to go through what must feel like losing Laura again through last two weeks... thank you, I can see you were a very strong family unit of three, and now you're a strong unit but only of two and I want to offer my sincere condolences...

Coroner: on losing Laura and also offer my sincere apology that you didn't get what you should have from the coronial service when this first came to our attention.

My sincere condolences.

We're adjourned. Thank you.

That's it, @InquestLaura is complete.

I'll share a statement from Laura's parents @LauraBo87351752 shortly.

Thanks as always to those following, and my crowdfunders who support my coverage.