Dr Giraldi Home Inquiry Day 10 - Gibraltar

Dr Giraldi Home Inquiry

Day 10

October 15, 2013

Opus 2 International - Official Court Reporters

Phone: +44 (0)20 3008 5900Email: [email protected]: http://www.opus2international.com

October 15, 2013 Dr Giraldi Home Inquiry Day 10

Official Court Reporters +44 (0)20 3008 5900Opus 2 International [email protected]

1

1 Tuesday,15October2013

2 (10.00am)

3 Housekeeping

4 THECHAIRMAN:Goodmorning,everyone,andwelcometoDay10

5 oftheDrGiraldiHomeInquiry.Wearerunningslightly

6 behindscheduleintermsofthewitnessestobecalled,

7 sothereisapossibilitythatwemayhavetositforat

8 leastpartofFriday.SoIhopethatpeoplewillbear

9 thatinmindincasetheirdiariesareotherwise

10 occupied.Wewillkeepyouinformedofthataswe

11 progress,butthereisapossibilityofthat.

12 Right,wecancontinue,then.Yes,MrEnright?

13 MRENRIGHT:Yes,sir.MrIsolaservedastatementlast

14 nightandheiscomingasawitnessonThursday.Hewas

15 thesolicitorfortheSocialServicesAgencyatthe

16 IndustrialTribunalcase.Itjustdidseemabitof

17 asurprisethatasolicitorwascomingtodiscusshis

18 privilegedinstructionswithhisclientregarding

19 anIndustrialTribunalcasethatwasoversomeyears

20 ago.

21 THECHAIRMAN:Youaretalkingaboutwho,MrEnright?

22 MRENRIGHT:MrMarkIsola.

23 THECHAIRMAN:Right.

24 MRENRIGHT:Itjustseemsveryoddthatthesolicitoris

25 beingcalledinthisway.

2

1 THECHAIRMAN:IthinkitaroseoutofMrBossano'sevidence

2 abouttheunfairdismissalproceedings,sofor

3 completeness,MrBossanoactuallymentionedMrIsolaand

4 hisparticipationintheproceedings,sowethoughtit

5 appropriatethatheshouldcomealongandclarifyhis

6 positioninthatrespect.Butifyouareembarrassedor

7 wanthimcalledlateroranythinglikethat,letme

8 know.

9 MRENRIGHT:Ijustwantedtoexpressmyclient'sconcern

10 thatshefeltbasicallytheIndustrialTribunalisbeing

11 runagain.

12 THECHAIRMAN:Right,theansweristhatitwasinresponse

13 toMrBossano'sevidenceabouttheunfairdismissal

14 claim.

15 MRENRIGHT:Thankyou,sir.

16 THECHAIRMAN:Okay.MrAzopardi?

17 MRAZOPARDI:Sir,wearegoingtocarryonwith

18 MrsAdamberry.

19 THECHAIRMAN:Yes,right.

20 MRSMANUELAADAMBERRY(continued)

21 (Evidenceviainterpreter)

22 THECHAIRMAN:Goodmorning,MrsAdamberry.Muchasgracias

23 paravolverestemanana.

24 Yes,MrAzopardi.

25 QuestionedbyMRAZOPARDI(continued)

3

1 MRAZOPARDI:MrsAdamberry,Ihadafewmorequestionsfor

2 you.CanIfirststartwithaquestioninrelationto

3 theroom,whatyoucalledyesterdaytherelaxationroom,

4 whichisalsoreferredtoasthe"time‐outroom".

5 Ithinkyousaidyesterdaythatyourecallthatroomnot

6 havingalock,butthatlater,whenSharoncame,alock

7 oraboltwasinstalled;isthatcorrect?

8 A.It'salongtimesincethisoccurred.Irememberthe

9 doornexttothepatio,therewasalargebolt,alock.

10 Ithinktherewasakeytoit,otherwisethechildcould

11 openitfromtheinside.BecauseIdon'tremembervery

12 well,whenIarrivedthatevening,it'snotthefirst

13 timeIhadseenthechildinthere,andIbelieveand

14 Ithinktherewasalock,Idon'trememberquite

15 exactly,butIknowthechildwasinthere,andthe

16 faeceswasthere,hadbeenthereforalongtimebecause

17 itwasdry.

18 Q.Thisistheincidentthatweweretalkingabout

19 yesterday?

20 A.Yes.

21 Q.Right.Okay.Canyourecallthelockornot,oryou

22 arenotsure?

23 A.Iamnotsure.

24 Q.Right.

25 A.Idon'tknowiftheyactuallychangedthedooritselfor

4

1 not.ButIthinkyes,therewasone,yes.

2 Q.Allright.Youcanonlytelluswhatyouremember.

3 A.(Answernottranslated)

4 Q.CanItakeyoutoadocumentwhichisat{M27/14/4}.

5 Canyouseethisisagainadiaryentry,andin

6 particular‐‐thetranslator,inparticularIam

7 interestedintheparagraphthatstarts"Manolita

8 arrived",andifyoucantranslatethattoher,and

9 thereisapartoverthepage.Unfortunatelyit'squite

10 long.

11 THEINTERPRETER:Okay,it'sthispageandoverthepage?

12 {M27/14/5}

13 MRAZOPARDI:Yes.

14 (Pause)

15 THEINTERPRETER:Canwepassthepage,please?

16 (Pause)

17 A.No.

18 MRAZOPARDI:Notowhat,sorry?Thereisalotthere.

19 A.Letmethink.Thisreportshouldbeintheincident

20 book.Ihaven'tseenthisreport.I'veseenthisnow.

21 Q.Okay.

22 A.ThisreferstowhatIspokeaboutyesterday.

23 Q.Ithoughtitmightbe,that'swhyIwantedtoshowitto

24 you.

25 A.I'veneverseenthis.Whenshewroteintheincident



5

1 book,shedidn'twriteitonthedayitoccurred.She2 diditnextday.WhenIwentinwiththenightcarer,3 Iaskedhertoreadittome.Whenshereadit,Isaid4 thathalfofitdowntherewasn'ttrue.Iwaitedfor5 Sharontoarrive,IthinkIcalledforhertocome,and6 Iwaitedforher,andIsaidtoherwhatshehadwritten7 therewasn'ttrue.SothenIstartedtotellherhow8 thingshadreallyhappened.Shewenttothebackofthe9 incidentbook,andstartedtowritewhatIwassayingto

10 her,anditwasn'tthis.11 Q.Right.12 A.Ifshewereagoodprofessional,andshewasdoingher13 jobwell,whydidshechangethethingswhichIknew14 weretherewhich‐‐intheincidentbook,whichhadn't15 occurred?16 Q.Okay.17 A.Whywasn'tIshownthisreportatthetime?18 Q.CanIjustaskyouafewquestionstoseewhatexactly19 youaresayingisnottrue?Firstofall,youseethe20 signatureonthatpage?Itappearstobethesignature21 ofSharonOpenshaw.22 A.AnditshouldalsoincludeFlor'sandmine.23 Q.Youcanseethatsignature?24 A.That'shers.Yes.WhereismysignatureandFlor's25 signature?

6

1 Q.Yes,Iunderstandthat,Ijustwanttoaskyouafew

2 questionsaboutthatpassage.Firstofall,did

3 SharonOpenshawspeakSpanish?

4 A.No,nothing.

5 Q.Sohowdidyoucommunicatetoeachother?

6 A.Withmycolleague.

7 Q.Whowas?

8 A.RoseSeruya,orifitwasn'tRoseSeruya,itwaswhoever

9 waswithme.

10 Q.Flor?

11 A.No.Withthenightcolleague,thenightstaff.Could

12 beNazareth,whoalsodidn'tspeakEnglish.Ithinkon

13 thisoccasionitwasAdelaideFortuna,Ithink,who

14 wouldhavebeenworkingwithmethatnight.

15 Q.ButSharonOpenshawthencouldn'tcommunicatedirectly

16 withyouorNazarethorFlor?

17 A.No,notdirectlywithme.FlorandCoreywentonduty

18 atmiddayandIleftat9.

19 Q.Allright.

20 A.SowehadtocallSharonBerkenshaw‐‐

21 Q.Openshaw?

22 A.Openshaw.Soshewasthere,sowecouldtellherwhat

23 wewantedtosay,whathadhappened.Ineverspoketo

24 herdirectly.

25 Q.Iunderstand.CanIjustaskaboutthisparticular

7

1 incident?IsittruethatLstruckyouwith‐‐

2 A.Yes,hehitthethreeofus.

3 Q.ThethreeofyoubeingFlor‐‐

4 A.Flor,SharonOpenshaw,andmyself.

5 Q.Sohehitallofyou?

6 A.Yes,yes.

7 Q.Sothatpartistrue?

8 A.Andhespatatus.

9 Q.Isee.

10 A.Yes,thatistrue.

11 Q.Isitalsotruethatyouhadgreatdifficulty,allof

12 you,inrestraininghim?

13 A.Isaidityesterday,yes.Si.

14 Q.Iamtryingtogettowhichpartyousayisnottrueand

15 whichpartistrue,that'sall.

16 THECHAIRMAN:MrAzopardiandMrInterpreter,Ithinkwe

17 needtogoalittlemoreslowlyhere,becauseit'svery

18 difficultforthetranscriberstogetitalldownas

19 it'sbeingspoken.Soifyoucantrytowaituntilthe

20 questionhasfinished,obviouslythewitnesswilltell

21 you,MrInterpreter,andthenifyoucangivethe

22 answer.

23 MRAZOPARDI:Iunderstandyouexplainedthisyesterday.

24 A.Yes.

25 Q.Iamjusttryingtoputquestionstoyoutounderstand

8

1 betterwhichpartsofthispassagearetrueandwhich2 partsarenottrue.Soifyoucanjustbearwithme,3 I'lljustaskafewquestions.4 IsthepartwhereitissaidthatyoutookL'shand5 andputitinhismouth,isthattrue?6 A.HowamIgoingtogethishandandputitintohis7 mouth?8 Q.Soareyousayingthat'snottrue?9 A.Ofcourse.Florwasholdinghimbytheshoulders,we

10 eachhadonearm.Wecouldn'trestrainhim,hewas11 seeingwhathecoulddotous.HowamIgoingtodo12 whatitsayshere?13 Q.Okay,soyourpositionisthatyounevertookhishand14 andforceditintohismouth,asitsaysinhere,this15 passage?16 A.No,never.17 Q.Okay.Isittruethatduringthestrugglehehitoutat18 thecurtainsandthecurtainsandpolefelldown?19 A.Yes,anditfellontopofthethreeofus.Itwasn't20 withthehand,withhisfeet,hegotcaughtwiththe21 curtainwithhisfeetanditpulleddown.22 Q.IsittruethatLgrabbedthecurtainpoleandswungit23 atMrsAdamberry?24 A.No,hecouldn'tgetit,becausethechildwassittingon25 thebedandthecurtainwasoverthere(indicated).No.



9

1 Q.Okay.Wereyouawarethatameetingwasheldas2 aresultofthatincidenttodiscusshowthebetter3 precautionscouldbeputinplacetotakecareofL4 duringtheseincidents?5 A.IwasnotinformedaboutanymeetingandIwasnot6 informedaboutthiseither.AllIsawwaswhatwasin7 theincidentbookthere,becauseshedidn'tevendo8 areport.AsfarasIremember,shedidn'twrite9 areport.

10 Q.Okay,itappearsthattherewasameeting,becausethere11 isadocumentwhichisinEnglish,albeit,at{M27/18/1}12 .Now,youseeatthetopofthepage,it'sclearyou13 arenotatthatmeeting,butitappearstherewas14 ameetingbetweenallthosepeople,including15 ChrisWilson,whoatthetimewaspartoftheSocial16 ServicesAgencymanagement.Youseethefirstsentence17 says:18 "Purpose‐‐wayforwardfor[L].Difficultiesof19 late.Agreewayforward."20 Sothemeetingappearstobetodiscusshowbestto21 dealwithLbecauseofhismorefrequentaggressive22 behaviour.Ifyougotothenextpage,{M27/18/2}this23 isadescriptionofvariousthings,butyouseeunder24 "Decisions"itsays:25 "Increasestaffing2:1."

10

1 Soitappearsanywaythat,asaresultofthatand2 otherincidents,thatwasthetimewhenL'scarerratio3 wasincreased.Woulditaccordwithyourrecollection4 thatitwasaroundthattimethatmanagementdecided5 thatLalwaysneededtohavetwocarers?6 A.Iknowthattheyincreasedtwotoone.Ididn'tknowit7 wasbecauseofthisornot,becauseIwasnotinformed8 ofthis.9 Q.Okay.Well,ifyouweren'tinformed,that'sokay.But

10 shewasawarethatitwasaroundthattimethatthey11 placedhimtwotoone?12 A.Maybeyes,maybeno.13 Q.Okay.Thingstendedtogetworseevenafterthatwith14 L;isthatright?15 A.Yes,itgot‐‐itwasgettingworsedaybyday.16 Q.Andindeeditledtoadecisionbeingtakeninprinciple17 ofthinkingthatLshouldperhapsgotoEngland?18 A.IrememberwehadtowaitoutsideforLatschool,we19 couldn'tevengoinsidetopickhimup,becausethings20 weregettingimpossible.Wecouldn'tgoandpickhim21 up,itwasdisastrous.Hisbehaviourwasworsening.As22 hedidn'tlikethenewstaff,theminutehesawthem,he23 startedtolashoutandtobreakthings.So24 AngelaLucas,whowastheheadthere,decidedthatwe25 shouldnotenterthepremisesoftheschool,thatwe

11

1 shouldwaitoutsidethegate.

2 Q.Okay.Now‐‐

3 A.Theteacherwouldbringhimoutandwewouldpickhimup

4 outside.

5 Q.Thesituationledtoanassessment,whichisat

6 {M27/36/25}.Thisisapre‐placementassessment.This

7 isareportthatwaspreparedbeforeLwassentto

8 England.Itdoesdescribeintheveryfirstpage‐‐

9 perhapsifyoutranslatetheparagraphthatstarts,it's

10 thefourthparagraph,"Staffarebeinghurtonaregular

11 basis..."

12 (Pause)

13 Thisassessmentappearstohavebeenaccompaniedby

14 acareplanwhichstartsat{M27/36/27},and

15 particularlyat{M27/36/30}.Doyouseetheparagraph

16 thatstarts,"Historically..."?Thesecondandthird

17 paragraph,ifyoucantranslatethatforher.

18 (Pause)

19 DothoseparagraphsaccordwithyourexperienceofL

20 towardstheend?

21 A.Yes.IalsostartedtoworkwithRose,whowasnew,and

22 itwas"Rosethis,andthat,ifyoudothingsthis

23 certainwaythechildwillnotstartgettingangrywith

24 you".Idon'trememberwhetheritwasayearortwo

25 years,andhe'shithertwoorthreetimes,butneverto

12

1 thepointwhereit'smentionedhere,totheextentit's

2 mentionedhere.

3 Q.Despitehisworseningbehaviour,youwerequitesadto

4 seehimgo;isthatnotright?

5 A.Yes.Itaffectedmequitebadly.

6 Q.That'sinyourstatement.

7 A.Yes.

8 Q.Whydiditaffectyousomuch?

9 A.ThewayIsawthings,andIwayIunderstoodthem,Isaw

10 thingsthatshouldn'tbehappening,forexample,ifhe

11 wasaffectedbythepresenceofhismother,whydidthe

12 seniortakehertothehouseeverynowandthen?This

13 wasaffectinghimdeepdown.Icouldseetheyweren't

14 doingthejobcorrectly.Ifhehadhadthesameteamas

15 hehadhadsometimeago,Ithinkthattodayhewouldbe

16 inGibraltar,inahomewhichwasbettersuitedtohis

17 needs,andIthinkhewouldbehere.Iknewthewayhe

18 wasgoing,ifhewasn'ttakenawayhewouldendupin

19 thementalinstitutionhere.

20 Q.Now,youareawarethatL,afterafewmonths,made

21 certainallegationsinEngland,generalallegationsbut

22 alsomentionedyourname.

23 A.Yes.

24 Q.Youareawareofthoseallegations?

25 A.Notalltheallegations,becauseI'velearntofsome



13

1 now.

2 Q.CanItakeyou,perhaps,ifit'sgoingtobehelpful,

3 {M27/23/4}.ThisisanemailfromWarwickshirePolice

4 toGibraltarPolice,wheretheysummarisesomeofthe

5 commentsthathadbeenmadebyLtotheminEngland.In

6 particular,Ithinkperhapsifyoutranslatejustthe

7 firsttenlinesorso.

8 THEINTERPRETER:Okay.

9 (Pause)

10 MRAZOPARDI:Okay.

11 THEINTERPRETER:Wherewouldyoulikemetofinish?

12 MRAZOPARDI:Maybefinishat"Itwouldappear...",which

13 isfourorfivelines.


15 (Pause)

16 Okay.

17 MRAZOPARDI:Soletmejustaskyou:youseethatspecific

18 mentionofyouandhisallegationthathewasgrabbed,

19 hisarmsweregrabbedandputbehindhisbackandhis

20 headwasputinthetoilet.Whatdoyousaytothat?

21 A.No,no,thisisimpossible.Firstbecausethetoilet

22 wasverysmall,andsecondlybecausethatwouldhave

23 neverbeendonetohim.No.

24 Q.Soyoudenythisallegation?

25 A.No,no,thisdidn'thappen.

14

1 Q.CanItakeyoualsoto{M27/37/3},whichisthenotes

2 ofaninterviewconductedwithLbyWarwickshirePolice,

3 andinparticularsortofalmosthalfwaythereis

4 aquestionthatstartsat00:14,doyouseethat,inthe

5 margin?

6 THEINTERPRETER:00:14,661,"Didyoutell..."?

7 MRAZOPARDI:That'sthetime."Didyoutell...",yes,if

8 youreadthatandtranslatethattoprobablytheend.


10 (Pause)

11 THEINTERPRETER:Sorry,inthelastline?

12 MRAZOPARDI:Yes,Ican'treadit.

13 THEINTERPRETER:"Thenheclarifiedhetold..."?

14 MRAZOPARDI:Idon'tknow,Ican'treadit.

15 (Pause)

16 THECHAIRMAN:Ithinkit's"Clarifiedhetold",andthenit

17 mustbeaname,"aboutthatincident,notCheryl".

18 THEINTERPRETER:That'sright.

19 A.Iftheyaskedhim"Didyoudrinkwater?",theyare

20 askinghimaquestion,thenhewillsay"Yes".

21 MRAZOPARDI:AndIthinkshesaid"Butno"?

22 A.Butno.

23 Q.Whatdoyoumeanbythat?

24 A.No,no.Nothinglikethishappened.Ithinkhe

25 mentionedthelastthreepeoplewhowerewithhim.Iam

15

1 notsureof,youknow,butIthinkthathejust

2 mentionedthelastthreepeoplewhowerewithhim.We

3 tookhimtotheairport,wetookhimtotheairport,we

4 tookhimontheplane,welefthimthere.Beforehe

5 saystheystuckaneedle‐‐

6 Q.Yes.

7 A.‐‐attheairportwehadtogivehimaninjection.In

8 hismind,allthatisworkinginhismind,workingaway.

9 Andhedoesn'tknow.Butnoneofthisistrue.

10 Q.Areyousayingthathe'smixingupeventsthathappened?

11 A.Yes.

12 Q.Soarewesayingthattheeventofhimbeingputinto

13 thetoiletalsohappened?

14 A.No,no.NotwhenIwasthereornotwhenIwasn't

15 there.He'squitebigandthereisnoway.

16 Q.Youalsosayinyourstatementatparagraph61,whichis

17 {E/1/8},thatyoudidn'tevenworktogetherwith

18 Sharon?

19 A.No.MaybeI'veseenheroneortwodayswhenIwas

20 workingthere,butIdidn'tworkwithher.

21 Q.IsLsomeonewhowouldregularlysaythingsinthissort

22 ofmixedfashionthatyoudescribe,ornot?

23 A.Likethisnow,yes.Sometimes,yes.Yes,sometimes.

24 Itwasquiterare,butyes,sometimes.

25 Q.IfIcanshowyouastatementthatwasmadeby

16

1 MaureenCaruana,{M27/29/1},whoseemstobeacarerat

2 theagency,astatementmadetothepolice.Atthenext

3 page,{M27/29/2}shesays,inthelasttwolines,ifyou

4 see:

5 "[L]usedtofantasisealotattimes..."

6 Isthataccurate,thatLusedtofantasisealot,

7 makingupstorieswhichhadneveroccurred,ornot?

8 A.Sometimes,yes.Yes,hewouldinventstories,butit

9 referredtothingswhichhehadseen.

10 Q.Isee.

11 A.Iwouldsitwithhim,toseeLionKing,towatch

12 LionKing,hewasthelion,Iwastheotherone,and

13 therethewholefamilywasthere.Andhewouldpoint

14 andsay,"That'syou,that'sSheila,that'sthebaby",

15 andIwouldsay"Oh,right"andhewouldwatchthe

16 LionKingforhoursandwewereallthefamily.Of

17 courseheusedtohavethesefantasiesinhishead,

18 Ithinktheywerefantasies.

19 Q.Okay.CanIshowyouawitnessstatementof

20 DeniseHassan,whichisat{F/23/1},andat

21 paragraph20‐‐

22 THECHAIRMAN:Sothat's{F/23/3}?

23 MRAZOPARDI:Yes,Ithinkso.

24 THECHAIRMAN:Itis.

25 MRAZOPARDI:Atparagraph20,canyoutranslatethatfor



17

1 her?

2 (Pause)

3 Now,whenwerefertothatresident,letmejust‐‐

4 Ithinkit'simportantifwerefertothatresidentthat

5 ismentionedthereasResidentN.Okay?Doyousee

6 whatMrsHassanissayingthereinthatparagraph?What

7 doyousaytothat?

8 A.(Pause).InN'sroom,wasthis?Whenitsayshelayon

9 top,wasitN'sroom?

10 Q.Yes,Ibelieveso.

11 A.Ican'trecallwhether2003IworkedorIdidn'twork.

12 WhatIdorecallvery,verywell,Ihavenevergrabbed

13 anybody'sbottom,andI'veneverdonethat.

14 THEINTERPRETER:Shemeanslyingontopof.

15 MRAZOPARDI:Okay.CanIshowyouaswell,Idon'tknow

16 howwedothis,butIwouldliketogotothetranscript

17 ofDay7,andpage75.{Day7:75/21}

18 Now,ifyoucantranslate,atline21,thereis

19 aquestionthatisputbyoneofmylearnedfriends,and

20 ifyoutranslatethat,andthenIamgoingtotakeyou

21 topartofthenextpage.


23 (Pause)

24 THECHAIRMAN:Whoseevidencewasthis,MrAzopardi?

25 MRAZOPARDI:ThisisMsHassan's.

18


2 MRAZOPARDI:Haveyoureachedtheend?

3 THEINTERPRETER:Yes.

4 MRAZOPARDI:Ifwegoover‐‐{Day7:76/1}

5 THEINTERPRETER:"Playingaroundwithhim",Icantranslate

6 itindifferentways.

7 MRAZOPARDI:Youwillseeitfromthecontextattheendof

8 thesentence.

9 THEINTERPRETER:Okay:

10 (Pause)

11 DoIcarryonthewholepage?

12 MRAZOPARDI:Maybejumptoline9.Thenifwegotothe

13 nextpage,{Day7:77/1}andyoutranslatefromline1to

14 line9.


16 MRAZOPARDI:Sorry,line10.

17 (Pause)

18 A.No.I'veneverdonethis,Ihaven'teventhoughtabout

19 that,itwouldn'tevencrossmymind,thisisalllies.

20 Hesometimesusedtotouchourbottoms,andweusedto

21 sayhadhim,youknow"Youdon'tdothat".ButI've

22 neverdonethis.Never.

23 Q.MrsAdamberry‐‐

24 THECHAIRMAN:Haveadrinkofwater,MrsAdamberry.

25 A.(Pause).Inflat1?

19

1 MRAZOPARDI:ItwasattheHomeitself,yes.

2 A.Ihaven'tworkedalotinthere,Yvettewasn'tworking

3 withmeinflat1,becauseifIwasthere,Iwas

4 coveringsomebody,andtheretherewereotherdifferent

5 people.I'veneverworkedinflat1.Yvettedidthe

6 nightshift,andsheneverdidanyovertime.Idid

7 overtime,yes.Butshedidn't.AndIdon'tthink,you

8 know,thatit'struethatYvettewasthere.Thisisnot

9 true.No.

10 MRAZOPARDI:Thankyou.Ihavenofurtherquestions,sir.

11 THECHAIRMAN:Right.MrVasquez?

12 MRVASQUEZ:Yes,Ihaveoneortwoquestions,ifthat'sall

13 right.

14 THECHAIRMAN:Yes,ofcourse.

15 QuestionssuggestedbyMRVASQUEZ

16 MRVASQUEZ:Ishouldjustwaitamoment.(Pause)

17 THECHAIRMAN:Don'tworrytoomuch,MrsAdamberry.Weare

18 nearlyfinished.

19 MRVASQUEZ:Ijusthaveoneortwoquestions,Iwon'tkeep

20 youverylong.Theyrelatetotrytoclarifyone

21 aspect,andthentheyrelatetoSharonBeriniand

22 SeanMatto.Beforewegotothat,inyourevidenceyou

23 havementioned"Sharon"frequently.Myunderstanding,

24 correctmeifIamwrong,isthateverytimeyoumention

25 "Sharon",youmeantSharonOpenshaw?

20

1 A.That'swhatIwantedtoclarify.That'swhyIhave

2 writtenout‐‐IamalwaysreferringtoSharon,Iamnot

3 referringtoSharonBerini.

4 Q.Thankyou.

5 A.That'swhatIwantedtoclarify.

6 Q.Thankyouverymuch.CanwegettoSharonBeriniand

7 SeanMatto?Haveyouworkedwiththem?

8 A.Yes.

9 Q.Haveyouworkedwiththemwhentheywerebothcarers?

10 A.Yes.

11 Q.Canyougiveusyouropinionofthem,oneatatime?

12 A.IworkedwithSeansincehewasachild.Heworkedas

13 asupply.Weworkedtogether.Weworkedverywell.He

14 wasagoodcolleague,healwayshelpedmeineverything,

15 ineverywaypossible.Thenhebecamesenior,oracting

16 senior,Idon'tknow.IfIneededhelp,hewouldhelp

17 me.Heisverygood.

18 Q.Thankyou.AndSharonBerini,youworkedwithheras

19 acarerandthenwhenshewasactingmanager;canyou

20 tellusaboutthat?

21 A.I'veworkedwithheralot.Inspiteofthefactthat

22 shewasEnglishanditwasdifficulttocommunicatewith

23 her,shealwaystriedtolistentomeandunderstand

24 whatIwanted,andI'vealwaysworkedvery,verywell

25 withher.I'veneverhadproblemswithher.



21

1 MRVASQUEZ:Iamverygrateful.Iwon'tkeepyouany

2 further.

3 QuestionssuggestedbyMSMORAN

4 MSMORAN:Sir,MsMoran,Iwouldliketoaskacoupleof

5 questions,ifImay,IrepresentMrsOpenshaw.


7 MSMORAN:Wehavecoveredcommunication.Isitrightthat

8 youdon'tread,write,speakorunderstandanyEnglish?

9 A.Yes,ifyouspeaktomevery,veryslowly,andwiththe

10 yearsIhavebeenworkingthere,Iknowafewthings.

11 AndifIhadtowriteareportbecauseIhavebeenonmy

12 own,yes,IhaveusedmymindinwhicheverwayIcould,

13 towritethingsdowninmyway.Butwhenitwas

14 somethingcomplicated,Ihadtofindsomebodytohelp

15 me.I'vedoneafewlittlethings,butnotcorrectly:

16 myway.IfyoupickupsomethingthatI'vedone,you

17 canseethattherearemistakes.

18 Q.Whatwasthechainofcommandintermsofwhoshewould

19 reportto?

20 A.Sharon,SharonOpenshaw.

21 Q.SharonOpenshaw.Canyougotoreference{E/1/6}inthe

22 witnessstatement.Therehasbeenalotmadethatin

23 MrsAdamberry'sopinion,ResidentLdidn'tlike

24 MrsOpenshaw,andinthisparticularparagraphregarding

25 thetriptotheUK‐‐Ithinkit'sparagraph40‐‐if

22

1 youjustreadthatparagraph.

2 (Pause)

3 A.Yes.

4 Q.CanIaskwhyyouwenttoseeMariaElenaMacias

5 directlyandnotraisedanyconcernswith

6 SharonOpenshaw?

7 A.IfIcan'tcommunicatewithher,andIthinkwehad

8 ameetingaboutthis,Ibelievetheyweresuggesting

9 people.Ithought,Iknowthatwhenheseesher,he's

10 goingtohaveareallytoughtime.Iamveryscaredof

11 theplane,butIthoughthe'smuchmoreimportantthan

12 myfear.SoIwenttoseeMariaElena,andIsaidif

13 shedidn'tmindthat,Icouldbe‐‐formpartofthat

14 grouptotryandavoidanupsettingsituationforthe

15 child.Icouldn'thave‐‐Iwassuccessful.Whenwe

16 wereabouttoleave,RoseandIsaidtohertodo

17 everythingpossiblesothathecouldn'tseeher.She

18 hadtogototheHome,andwesaidtoher,"Whenwe

19 leave,youcangoin",andthat'swhathappened.We

20 bothwentdownwiththeresident.

21 THECHAIRMAN:Yes,Ithinkwearegettingquitealongway

22 awayfromthequestionwhichMsMoranasked,whichwas

23 simplywhyyouwenttoseeMariaElenaandnot‐‐

24 A.BecauseIcouldn'tcommunicatewithSharonand

25 MariaElenawasthebossandshewastheonewhocould

23

1 sayyesorno.MariaElenacalledmeandsaid"Yes,no

2 problem".

3 MSMORAN:Intermsoftherecruitmentprocess,yousaid

4 yesterdaythatyouwereinitiallyavolunteer?

5 A.Yes.

6 Q.Andthenyoubecameasupplycareworkerandpermanent

7 whenMilburytookover.

8 A.Si.

9 Q.Isitnotarequirement,toworkinthecivilservice

10 hereinGibraltar,tospeakEnglishortoreadandwrite

11 English?

12 A.No.Notatthattime.BecausewhenMilburycame,Iwas

13 worried,soIaskedwhat'sgoingtohappentome,

14 Iwon'tbeabletocarryonworking.Theysaid"No,

15 theywouldalwaysbesomebodytherewithyoutohelp

16 you."IstartedworkingwhentherewasaGovernment,

17 Ididn'tknowhowtospeakEnglish,andwiththeother

18 oneandnothingwassaidtomeandnoone'severtoldme

19 off,andthereareSpaniardsworkingthere‐‐

20 THECHAIRMAN:Ithinkthewitnesshasansweredthat

21 question,MrInterpreter.

22 MSMORAN:Justacouplemorepoints,andIdon'twantto

23 holdanybodyup.

24 THECHAIRMAN:No,that'sfine.

25 MSMORAN:YousaidthatResidentLdidn'tlikethenew

24

1 team,especiallySharonOpenshaw?

2 A.Hedidn'tlikenewpeoplecomingin.ButIcould

3 notice,andIknewthatbecausehesaidthattome,

4 Icouldn'tbelieve100percentwhathesaidtome,but

5 Iknewhedidn'tlikeher.

6 Q.CanIreferto{M27/24/9}?It'sareportthat's

7 entitled"OnsetofIncident".Thisappearstohavebeen

8 dictatedbyMrsAdamberry,translatedbyaladycalled

9 AdelaideandwrittenupbyMrsOpenshaw.Ifyoucould

10 justreadthelastparagraphfrom"[L]thenattemptedto

11 kickManolita",justtotheend.

12 (Pause)

13 A.Thereissomethingherewhichdoesn'tquitefit.This

14 referstothepreviousreport.(Pause).

15 THEINTERPRETER:Shewantstoknowwhohaswrittenthis.

16 MSMORAN:ItwasdictatedbyManolita,translatedby

17 Adelaide‐‐

18 THEINTERPRETER:Whohaswrittenthisdocument?

19 MSMORAN:‐‐andsignedandwrittenbySharonOpenshaw,

20 thethreewerepresent.

21 A.Didshesignforme?

22 Q.Shejustsigned"SharonOpenshaw".

23 A.ThisiswhyIam‐‐Ithinkthereissomethingherethat

24 doesn'tquitesquarewithsomethingelse.

25 Q.AllIwanttoknowis:didhenotaskforSharontotake



25

1 himtotheroom?

2 A.Hewasoutofcontrol‐‐

3 THECHAIRMAN:LetmeseeifIcanshortenthisabit.If

4 thisiscorrect,itindicatesthatheaskedforSharon

5 totakehimtohistime‐outroom.Doyourememberthat

6 happening?

7 A.No.

8 MSMORAN:Justonelastpoint:youhavesaidthatyouwere

9 veryclosetoResidentL,andyouhadaverygood

10 relationship,youhadworkedwithhimalongtime.

11 A.Si.

12 Q.Inyourstatementon{E/1/5},yousaythatyoutriedto

13 tellthenewteamthebestwaytoworkwithResidentL.

14 THECHAIRMAN:Thisisparagraph36,thelastparagraphon

15 thepage?

16 MSMORAN:Bearwithme.

17 THECHAIRMAN:Imean,theanswertothatquestionis:yes,

18 itis.So,MrInterpreter,couldyoujustinterpret

19 thatbit?

20 THEINTERPRETER:Paragraph36?

21 THECHAIRMAN:Yes,ifyoucouldjustinterpretthat.

22 (Pause)

23 A.Whatusedtohappenisifwewentinonthenightshift,

24 andIsawcarerscrying,scared,Iusedtodaytothem,

25 "Youcan'tworkwithhimlikethis.Ifyoushowyouare

26

1 afraid,he'sgoingtodothisworse,he'sgoingtobe

2 worse.Youhavetobenormalwithhim".Itriedto

3 advisethemhowIthought,it'snotthatIknewhowto

4 doit,it'sjustthatItriedtohelpthem."Yeah,

5 don'tallthreeofyouhuddletogetherbecausethechild

6 canseeyouandheknowsyouareafraidofhim".Yes,

7 "Talktohim".

8 THECHAIRMAN:That'stheadvicethatyougave.What

9 reactionwastherefromthecarers?

10 A.Theyusedtolisten,theyusedtohearmeandsay

11 "Ican'tdoitlikeyou",andshesaid‐‐Isaid,"Well,

12 whydon'tyouasktochange"‐‐

13 THECHAIRMAN:Justamoment.Let'sgetitoneperson

14 speakingatatime.

15 THEINTERPRETER:Sorry.

16 THECHAIRMAN:Iappreciateit'sdifficult.Isthere

17 anythingmoreshesaidthatyouneedtointerpret?

18 THEINTERPRETER:Thatsheadvisedthemonhowtodothings

19 buttheyweresayingthattheycouldn'tworklikeshe

20 did,andsheissaying,"Whydon'tyouaskfor

21 atransfer?"

22 MSMORAN:Justonelastthing:doyouthinkit'spossible

23 thatyourpersonalclosenesswithResidentLperhaps

24 affectedyourprofessionalabilities?

25 A.No.Howisitgoingtoaffectme?

27

1 Q.Itdidn'taffectintermsofobtaininginstructionsfrom

2 theunitmanageror‐‐

3 THEINTERPRETER:Sorry,whatwasthat?

4 MSMORAN:Itdidn'taffectherintermsofobtaining

5 instructionsfromtheunitmanageronhowtodealwith

6 ResidentLandhiscondition?

7 A.Yes,Iusedtogotothemanager,andIexplainedwhat

8 Isaw.IamgoingtosaywhatIusedtosay,maybeit's

9 wrongbutIamgoingtosayit,thatthesepeople,you

10 know,weren'tuptoworkingwithhim,thattheywanted

11 tosortofbribehimbytakinghimaroll,takinghim

12 food.Yes,"Theboyisgoingtoeatthisandthenhe's

13 goingtohityou,andyoucannotbeofferinghimthings

14 alldaylong.Youhavetomaintaindisciplineasyou

15 havebeentold".

16 MSMORAN:Thankyouverymuch.

17 THECHAIRMAN:Yes,MsBalestrino.

18 QuestionssuggestedbyMSBALESTRINO

19 MSBALESTRINO:Sir,Ihavejustonequestioninrelationto

20 MrsAdamberry.

21 MynameisAnneBalestrino,Irepresentthe

22 DisabilitySociety.Ijusthaveonequestionin

23 relationtotheresidentthatyoulookedafter.Doyou

24 thinkhebenefittedfrombeingintheflatratherthan

25 DrGiraldiHome?

28

1 A.IknewthathehadtoleaveDrGiraldiHome,becauseit

2 wasn'ttherightplace,thereweremoreresidentsthere.

3 Buttheplacehewastakentowasnottherightplace,

4 itwasn'tadequate.Hewasinahouse,hewasin

5 ahome(?),therewasnoroomforhimtomovearound.He

6 wasokayinBishopHealy.Hecouldgooutonthepatio,

7 hewouldclearhismind,hewouldplay‐‐

8 Q.Soaflatwithperhapsapatiowouldhavebeenbest

9 suitedforhim?

10 A.Ofcourse.WeusedtosaythisFlatBastionRoadisnot

11 adequateforhim.

12 Q.ButatthesametimeDrGiraldiHomewasn'tadequate

13 either?

14 A.Itwasn'trightforhimbecausetherewereotherpeople

15 aroundhim.Ifhehadbeenthereonhisown,yes.

16 MSBALESTRINO:Iamgrateful,sir.

17 MRPITTO:Sir,IhaveafewquestionstoaskMrsAdamberry.

18 THECHAIRMAN:Yes,MrPitto,canyoufindamicrophone?

19 QuestionssuggestedbyMRPITTO

20 MRPITTO:Goodmorning,MrsAdamberry,Irepresent

21 MandySpencer,sheusedtobeMandySpencer‐Ball,you

22 workedunderhermanagementduringtheperiodthatshe

23 wasmanager.

24 A.Yes.

25 Q.Youdon'tmakeanyspecificmentioninyourwitness



29

1 statementaboutthatperiod,soIwanttoaskyoujust

2 afewquestionsaboutthat.

3 A.No‐‐ah,sorry.

4 Q.Wouldyouagreethatatthetimewhenmyclientwasthe

5 manageroftheHome,whichistheperiodof2001/2002,

6 thattherewasanimositybetweenstaffandmanagement?

7 A.Ican'tanswerthisbecauseshewasinrespite,Iwasin

8 flat2,Iwasinflat2orIwasupthere,Idon'tknow,

9 becauseIdon'trememberthedates.

10 Q.That'sfine.

11 A.IhadverylittlecontactwithMandy,becausewedidour

12 job‐‐

13 Q.That's‐‐

14 THECHAIRMAN:Ithinkshehasansweredthequestion.You

15 haveansweredthequestion,MrsAdamberry.

16 MRPITTO:That'sfine.

17 Youcouldn'tanswer‐‐ifyoucan‐‐doyouagree

18 thatitwasatoughperiodoftime,transitionalperiod,

19 2001/2002,betweenGovernmentandacontractingagent

20 company?

21 A.WhichGovernmentwasit?

22 Q.IbelieveitwastheGSD.

23 A.No.Never.

24 Q.Well,thelastpoint,then,Iamgoingtobringyou

25 to‐‐

30

1 A.(Answernottranslated).2 THECHAIRMAN:Ithinkshehasanswereditadmirably3 shortly.Let'shavethelastquestion.4 MRPITTO:Thelastquestioninrelationtomyclient's5 witnessstatement,ifIrefertoC2/2,paragraph3.6 It'sthewitnessstatementofMandySpencer‐Ballforthe7 IndustrialTribunal.{C1/2/2},sorry.Paragraph3,8 yes.Atthisparagraph,myclientmakesorstates9 thingsthatweretoldtoher.Inmanuscriptonthe

10 side,itsays"Thismemberofstaff",ifitcouldbe11 zoomedin,itreferstoanincidentatLourdes,ifthat12 couldbetranslatedtoher,thewholeparagraph3.13 (Pause)14 Canyouconfirm,inkeepingwiththatlittlecomment15 thatmyclienthasfilledinonherwitnessstatement,16 wasityouthattoldheraboutthisincident?17 A.No,becauseI'veneverseenitorlivedthroughthis.18 CanIexplainwhy?IwentwithFaithandLightto19 Lourdes.Atthattimemyfatherwasdying,Iremember20 wewereonthetrain,Emilia,myselfandthentwo21 residentsoppositeIdon'tknow,Emilia'sgrandson,and22 Idon'trememberwhowaswithme.23 Q.That'sfine.24 A.Icouldn't‐‐Iwasn'tabletoleavemyseat.Ididn't25 see‐‐IcanexplainwhatIsaw,aboutNigel.Hehelped

31

1 everyonealot‐‐

2 Q.AllIaskedwaswhether‐‐

3 A.AndIdidnotreportthisbecauseIneversawit‐‐

4 Q.Youdidn't‐‐

5 A.Icouldn'tcommunicate‐‐

6 THECHAIRMAN:Wehavethesenseofit,Ithink,MrPitto.

7 A.No.

8 MRPITTO:Thesimpleanswerisno.

9 THECHAIRMAN:Yes.

10 MRPITTO:Ithinkthat'stheanswerthatsuffices.Thank

11 youverymuch.

12 THECHAIRMAN:MrNavas,Ican'treallybelieveyouhaveany

13 questionsforthiswitness,butdoyou?

14 MRNAVAS:Sir,IthinkIhavebeenwhittleddowntotwo

15 questions,IthinkmostoftheissuesIwasgoingto

16 raisehavealready‐‐

17 THECHAIRMAN:Well,let'ssee.

18 MRNAVAS:Sorry,Iunderstandthattheyneedabreak.

19 THEINTERPRETER:It'suptoyou.

20 MRNAVAS:Idon'texpecttobemorethanacoupleof

21 minutes,butIaminyourhands.

22 THECHAIRMAN:Fireaway,MrNavas,iftherearetwo

23 questions,youprobablyhaveabouttwominutes.

24 MRNAVAS:Iwillgettothemveryquickly.

25 THEINTERPRETER:Okay,shewantstocarryon.

32

1 QuestionssuggestedbyMRNAVAS

2 MRNAVAS:MrsAdamberry,Iwilltakeyoutotheincident

3 regarding[nameredacted]‐‐sorry,ResidentN.So

4 sorry.

5 THECHAIRMAN:Thisistheallegationaboutthatresident?

6 MRNAVAS:Theallegation,that'sright.Forthatpurpose,

7 IwouldliketoshowMrsAdamberrytheplanat{A/22/1}

8 .Idon'tknowifitcanbereoriented.(Pause).

9 Thankyou.Now,MsAdamberry,whatyouareseeinghere

10 isthefirstflooroftheDrGiraldiHomeroughlyinthe

11 samelayoutthatitwasatthetimeoftheallegation

12 regardingyourselfandResidentN.

13 A.Yes.

14 Q.Now,generallyspeaking,abouthalfwayuponthe

15 left‐handside,thereisasquareboxwiththewords

16 "kitchen"writteninit.

17 THEINTERPRETER:Ontheright‐handside,no?

18 MRNAVAS:Yes,thanksforthat.Thatviewisperfect.

19 Adjacenttothenumber7,whichIcannowidentify.

20 A.Si,si.

21 Q.Right.Thatisthekitchenofwhatflat?

22 A.Theflat2.

23 Q.Okay,whichiswheretheincidentisallegedtohave

24 occurred.

25 A.Yes.



33

1 Q.That'sright.Youcanseewherethedoortothekitchen

2 issituated?

3 A.Yes,inthiscornerhere,yes.

4 Q.Inthetopleft‐handcorner.Now,ifwejustgo

5 slightlyacrossthecorridor,totheleft,thenyouhave

6 astore,thenyouhavethediningarea,andthen

7 alittlefurtheruptherearethreebedrooms.

8 A.Si.

9 Q.Now,onlytwoofthosebedroomsbelongedtoflatnumber

10 2;isthatcorrect?

11 THEINTERPRETER:Thefirsttwo.

12 Q.Right.

13 THEINTERPRETER:Thebottomoneandthemiddleone.

14 MRNAVAS:Now,DeniseHassanallegedthattheincident

15 occurredinthebedroomofResidentJ.

16 A.Okay.

17 Q.CanyoupointoutwhichbedroomwasResidentJ's?

18 A.Themiddleone.

19 Q.Inthesetofthree,theoneinthemiddle?

20 A.Yes,themiddleoneinthesetofthree.

21 Q.Okay.Canyouindicatewherethebedinthatbedroom

22 wouldhavebeenlocatedatthetime?

23 A.Itwasinthemiddleofthebedroom,slightlymore

24 towardsthewindow.

25 Q.Againstwhichwall,thetopwallorthebottomwall?

34

1 A.Thetopone.Thetopone.

2 Q.Now,MsHassansaysthatshewasinthekitchenwhenshe

3 sawthishappen.Right?Inyouropinion,couldsomeone

4 whowasinthekitchenhaveaviewofthebedfromthat

5 position?

6 A.Neitherinthekitchennoroutsidethekitchen.Because

7 youcan'tseethebedroom.Youseethedoor,butyou

8 can'tseetheinsideoftheroom.

9 THECHAIRMAN:That'sonequestion.What'stheotherone?

10 MRNAVAS:WhataboutifMsHassanhadbeenstandingatthe

11 doorofthekitchen?

12 A.No.

13 MRNAVAS:Okay.Ihaveathirdquestion,whichis

14 unrelated,anditwillbeveryshort,soifImay?


16 MRNAVAS:Thankyouverymuch,MsAdamberry,Ihaveone

17 morequestion.

18 MsAdamberry,whydoyouthinkthatMrsHassanmade

19 thisallegationagainstyou?

20 THECHAIRMAN:Isthataquestion,really?Imean,whatare

21 youasking,thewitness'sopinion,orwhat?

22 MRNAVAS:Shebelievesthattherewasamotivationfor

23 MsHassan,shehasanopiniononthat.

24 THECHAIRMAN:Allright,let'sseewhatshesays.

25 MRNAVAS:That'sthelastinformationIwanttoelicitfrom

35

1 her.2 A.I'vegotsomeveryclearideasinmyheadwhyIam3 sittingheretoday.Theycalledmetomakeareport4 againstSharonBeriniandNigelBassadone,andIrefused5 todothat,becauseIhadn'tseenanythingandIdidn't6 knowanything.Thefirsttime.Itwasthesecondtime,7 GabrielleLlambiasrangme,sortoflikebullyingme,8 intimidatingme,Ihadtodothisreportagainst9 NigelBassadone.IsaidtoherthatIalreadysaidit

10 oncebefore,thatIhadn'tseenanythingandIdidn't11 knowanything,andIcouldn'tdowhattheyaskedmeto.12 Andthethirdoccasion,MrsJoannaHernandezsentme13 aletteraskingmetosaysomethingagainstNigeland14 Sharon,andagainIsaid"No,anddon'tbothermeany15 more".AfterthatIreceivedaletter,Idon'tknowif16 itwasfromalawyerorwhoitwasfrom,thatIhadto17 dosomething.Idon'tknowwhoitwas.Irepliedthat18 Ihadalreadybeencontactedtwoorthreetimesbefore19 andIsaidIwasn'tgoing.Iwasn'theretocleanup20 anybody'simage.AndthenIgotthisletteraskingme21 tocometothis,andIthinkthatthisisthereasonwhy22 Ihavebeenaskedtocomehere,andthat'stheresult.23 THECHAIRMAN:Well,youhavebeenaskedtocomehere,24 MrsAdamberry,tohelpus,andyouhavehelpedus,and25 Iamverygratefulforyourattendance.

36

1 MRENRIGHT:Sir,canIaskjustonequestion?Iwasnot

2 goingtoaskanyquestions,butjustonequestion.

3 THECHAIRMAN:Allright.

4 QuestionssuggestedbyMRENRIGHT

5 MRENRIGHT:Howdoyoudo?MynameisDavidEnrightand

6 IrepresentJoannaHernandez.

7 YoujustsaidamomentagothatJoannaHernandez

8 wroteyoualetteraskingyoutocomeandseeherto

9 makeacomplaintaboutNigelBassadone?

10 A.Yes.

11 Q.Ihavetakeninstructionsfromher,andshesaidshe

12 neverdidanysuchthing.Areyousure?

13 A.Shesentmealetter,Iopenedtheletter,Isawwhoit

14 wasfrom,soItoreitupandthrewitaway.

15 Q.Soyoudon'thavethatletteranymore?No.Okay.

16 THEINTERPRETER:Ididn'tsayanything.

17 THECHAIRMAN:Ithinkthatanswersthat,MrEnright.

18 Well,MrsAdamberry,thankyouverymuchforcoming,

19 Iamverygratefulforthehelpthatyouhavegivenus,

20 thankyou.That'sslightlyoverdueforthebreak,but

21 Iwillcomebackatquarterto12.

22 THEWITNESS:Thankyou.

23 (Thewitnesswithdrew)

24 (11.30am)

25 (Ashortbreak)



37

1 (11.45am)

2 THECHAIRMAN:Yes,MrEnglehart.

3 MRENGLEHART:Sir,thenextwitnessisMrJonathanTeuma.

4 THECHAIRMAN:AmIrightinthinkingthathehasatime

5 limitonhisavailability,oramIwrong?

6 MRENGLEHART:Ibelieveheandthenextwitness,

7 MrsOpenshaw.

8 THECHAIRMAN:Howcanweaccommodatethat?

9 MRENGLEHART:Idon'tbelieveIshallbethatlongwith

10 eitherofthem.Famouslastwords,butIdon'tbelieve

11 so.

12 THECHAIRMAN:Okay.

13 MRENGLEHART:Idonotproposetogooveralotofground

14 thathasalreadybeencovered,becausethatwouldbeto

15 duplicatemattersunnecessarily.

16 THECHAIRMAN:Allright.

17 MRJONATHANTEUMA(called)

18 THECHAIRMAN:Goodmorning,MrTeuma,thankyouverymuch

19 forcoming.

20 A.Goodmorning.

21 THECHAIRMAN:Makeyourselfascomfortableasyoucan.

22 A.That'sokay,Iamgladtobehere,thankyou.

23 THECHAIRMAN:Weareverygratefulforthestatementsthat

24 youhavegivenus,andalsoforyourattendancehere

25 today.

38

1 A.Iamhappytobehere.

2 THECHAIRMAN:Sothankyouverymuchforcoming.Ifyou

3 needtorefertoaresidentbytheirname,usethe

4 initialsthatyouhaveonthebitofpaper.

5 A.Thelist.Theinitials.

6 THECHAIRMAN:Ithinkyouneedtobeawaybywhattime,if

7 possible?

8 A.Well,IamgrabbingatraininMalagaat6,soIneedto

9 beonmywayatleastagoodcoupleofhoursbefore

10 that.

11 THECHAIRMAN:Wewilldotheverybestwecan.

12 MrEnglehartwillaskyousomequestionsinamoment.

13 CouldIaskyou,firstofall,togiveyourfullname

14 andaddressfortherecord?

15 A.Yes.MynameisJonathanTeumaandIliveinCalle‐‐

16 Street‐‐deVicenteCameron,number50,3rdfloor,

17 Madrid.


19 QuestionedbyMRENGLEHART

20 MRENGLEHART:MrTeuma,youmadeawitnessstatementin

21 July,andcanweseeifyoucanidentifyit,that's

22 {E/64/2}.Canyouidentifythat?

23 A.Yes.

24 Q.Veryrecentlyyoumadeanotherwitnessstatement

25 respondingtocertainthingsthathavebeensaid.

39

1 A.Mm.2 Q.Thatisat{E/69/1}.Isthattheone?3 A.Yeah,thislooks...4 Q.Yourecognisethat?5 A.Yes.6 Q.Now,youhaveadegree;isthatright?7 A.Yes,Ihaveadegree.8 Q.AndyouworkedattheDrGiraldiHomefull‐timefor9 arelativelyshortperiodfrom2003until2005;isthat

10 right?11 A.Yes,onasupplybasisbutyeah,full‐timeintermsof12 thehoursthatIdid.13 Q.Oh,Isee,wereyouneverafull‐timeemployee?14 A.Iwasnever‐‐15 Q.Theoretically?16 A.No,Ineverhadacontract.Ididhave,youknow,17 normallyit'sa40‐hourworkingweek,youknow.18 Q.Soit'squiteasupply?19 A.Yeah,itwasquiteasupply.20 Q.Isee.Right.Youtellusthat,whenyoufirstbegan21 workingfull‐time,youworkedwiththeresidentwhowe22 knowasAE?23 A.Yeah,that'scorrect.24 Q.That'sright.Couldyoujusttellus,Idon'twantyou25 tobetoolongaboutit,butbroadlyspeakingwhatwas

40

1 yourimpressionofAEas‐‐Ihesitatetosayclient,

2 butyouknowwhatImean?

3 A.Yes,hewasoneofthemorechallengingserviceusersin

4 thecentre.Hehad‐‐IrememberwhenIcamein,hehad

5 areputationforhavingbeenviolent,although

6 IrememberthatIthinkatthistimehewasmoreheavily

7 medicated,andtheissuewasn'tsomuchviolent

8 outbursts,whichmightoccuronoccasion,butmore

9 averyrepetitivenature,veryobsessiveaboutcertain

10 things,andhewouldbevery,veryrepetitiveabout

11 them,andonoccasionwhenhedidn'tgetthemhemight

12 getviolent,althoughthiswasn'ttheprimaryissue,

13 Ithink,atthetime.

14 Q.Thenyoutellusthatyouworkedwiththeresidentwho

15 weknowasZ?

16 A.Z,indeed,yes.

17 Q.AndIthinkmostofthetimeyouwerewithhim?

18 A.Yes.Imightaddthat,youknow,Idid,becauseIwas

19 supply,Iwouldhavedoneoddshiftsinbetween‐‐

20 THECHAIRMAN:Forotherresidents?

21 A.Forotherresidents,yes,awholevariety.

22 MRENGLEHART:Youalsotellushow,duringthecourseof

23 thetimeyouwerelookingafterZ,youattendedvarious

24 courses,Ithink,bywayoftraining?

25 A.Yes,Ithink,Imean,I'vegotthedatessomewhere,



41

1 IthinkthatwasJanuary,butwedidvarious,wedid

2 reportwriting,medication,IrememberthisPROACT‐SCIP

3 courseaswellonintervention.

4 Q.Werethosecoursesyouhadtoattend?Wereyour

5 employerstellingyoutodosoorwereyoudoingit

6 voluntarily?

7 A.Ican'tquiteremember.WhatIdorememberisthatthey

8 wouldhavebeen‐‐attendancewouldhavebeensubjectto

9 shiftpatterns.Becauseobviouslywecouldn'tleave

10 carers‐‐

11 Q.No,Imean,theyweresandwichcourses?

12 A.Exactly.Theyweregenerallyonedayorhalfday

13 courses.Ihad,youknow,Ican'trememberclearly

14 becauseIhadapersonalinterestanyway,Ithoughtif

15 IamhereImayaswellgettraineduponit.Soeither

16 wayIdidn'treallypaymuchattentiontowhetherwehad

17 toorwhetherwewerejustinvitedtogo.Isawthe

18 opportunityandIwentforit.

19 Q.Didyougetanytrainingbeforeyoustartedwork?

20 A.No,not‐‐

21 Q.Didyoudoanyshadowingofanexistingcase?

22 A.Yes,Iwouldhavedoneshadowing.Youhaveseeninmy

23 statementthatevenpriortoworkingthroughpersonal

24 contacts,Ihadaccompaniedtheyoungerstudentswhodid

25 thestayandplayandIcanobservethemandhelpedout

42

1 whereIcould.2 OnceIwasworking,yeah,Iwouldhavehadatleast3 someshadowingsessionswithvarious...4 Q.Lookingbackonit,doyouthinkthatyoucouldhavehad5 moretraining,itwouldhavebeenpreferableifyouhad6 hadbettertraining?7 A.Definitely.Oh,definitely.Definitely.Alsoaswell,8 Ihavebeengivingitsomethought,it'snotonlythe9 questionoftrainingbutalsokindofthetiming,

10 becauseIthinkit'shardonce,andyouknow,ifitwas11 hard,youknow,itwasn'tsohardmaybeevenforme.12 Butyeah,evenformecertainthings,onceyoubeginto13 getworkincertainwaysandthenyougettrainingthat14 tellsyou:well,actuallythis;itbecomes,insteadof15 settingtherighthabitfromthebeginning,youhaveto16 changethehabitandthatsometimestakesalittlebit17 ofatransitionperiodwhileyougetusedtoit,and18 yourmodusoperandi...19 Q.WouldIberightinsayingthatthetwoserviceusers,20 orresidents,whicheveryouliketocallthem,thatyou21 wereinvolvedwithwereamongthemorechallengingof22 the‐‐23 A.Oh,definitely.24 Q.Definitely?25 A.Definitely.Thereweremanystaffthatwerereluctant

43

1 toworkwiththem.

2 Q.Manystaffwerereluctant?

3 A.Yes.

4 THECHAIRMAN:Canyoujustremindme,MrTeuma,whattheir

5 respectiveageswerein2003,roughly?

6 A.Yes.

7 THECHAIRMAN:StartwithAE.

8 A.AEis,Ithink,aboutmyage,sohewouldhavebeen

9 around‐‐Iwouldhavebeen23,24atthetime,sohe

10 wouldhavebeenaroundthere.Youknow.

11 THECHAIRMAN:Right.AndZ?

12 A.AndZwouldhavebeen,Ihadhimmoreorlessfromages

13 6to8,moreorless,Iwouldhavestartedattheageof

14 6.

15 MRENGLEHART:Andyouwereinaflat?

16 A.Wewereinaflat,yeah,whenIcameintheywereboth

17 actuallyinMerlotflat,tobespecific,theywerein

18 differentflats.

19 Q.Differentflats.

20 A.Theywereondifferentfloors,even.

21 Q.By"together"Imeanttheywerebothawayfrom

22 DrGiraldi?

23 A.Indeed.

24 THECHAIRMAN:InMerlotHouse,isthat?

25 A.InMerlotHouse,indeed.

44

1 MRENGLEHART:Oneofthethingsyoumentionisaboutusing

2 time‐outasamethodtocalmZdown?

3 A.Yes.

4 Q.Couldyoujustexplainabitmore?

5 A.Yeah,whenIcamein‐‐rememberalsothatIhadaspell

6 acoupleofsummersbefore,andrightnowIcan't

7 rememberifIwastoldtousethismethodinthefirst

8 summeroronceIcameintothetwo‐yearspell.Either

9 way,whatwassaidtouswaswhentheyareactingout,

10 whentheyareverystressed,iftheybecomeviolent,

11 invitethemorhelpthemtotheroomandgivethem

12 atime‐outtoallowthemtimetokindofcalmdownand

13 maybereflect.

14 Q.Yousay"theroom",wasthereaspecialroom,aseparate

15 room?

16 A.Well,Imean,in[nameredacted]'scaseitwouldhave

17 beenhisbedroom.Atthattime,whenI,youknow,given

18 thelackoftrainingthatIhad,Ibasicallyassociated

19 ittothewayIthinkmanyofusarebroughtup,you

20 know,whenyouarenaughtyyourmumsendsyoutoyour

21 room,youknow.Andthisisbasically,anditmade

22 perfectsensetome,youknow,Imean,thisisonething

23 thatmaybeIwouldliketopointout,thatveryoften

24 Imadeupforthelackoftrainingbykindofdrawingon

25 myownpersonalexperience.Attheendofthedayheis



45

1 disabledbutheisalsoachild,youknow,soIwould

2 drawonmyownpersonalexperience,andIdidn'tthink

3 anythingofit,youknow,sookay,sendhimtohisroom.

4 Q.SoZwouldbeaskedtoorsenttoorgotohisbedroom?

5 A.Indeed.

6 Q.Therewasnoseparateroom?

7 A.No,in[nameredacted]'sflat,no.

8 Q.No,Z.

9 A.Iamsorry.

10 Q.Iunderstand.

11 A.Iapologise.

12 Q.Weallmakemistakes.

13 A.Yes,itwouldhavebeenhisbedroom.

14 Q.Isee,andwastherealockonthat?

15 A.No.No,no,no,no.Iknowthatinoneofmyown,from

16 myownhand,Imentioned"Ilockedhiminhisroom",but

17 thisisjustanexpression,Ididn'tmean‐‐

18 Q.Iknowyoudosayyoulockedhim,whatyoumeanisyou

19 justshutthedoor?

20 A.Basically.

21 Q.Sototalkabout"locking"isnotliterallycorrect?

22 A.Itwouldhavebeenimpossible.

23 Q.What,becausetherewasnolock?

24 A.Exactly.

25 Q.Isee.Right.Ithinkthat'swhatMsHernandeztold

46

1 us.

2 A.Mm.

3 Q.Yourefertothefact,ofcourse,thatyouwerein

4 MerlotHousewithZ,andyourefertofairlyinfrequent

5 visitsfrommanagement.Isthatright?

6 A.Yes.

7 Q.Bymanagement,whoareyou...itwasthetimeof

8 MsHernandezandMsBeriniwasactingmanager,Ithink,

9 duringyourperiodbeforethat?

10 A.Duringmyfirst‐‐Ican'trememberexactlybutduring

11 thefirstfewmonthsitwas‐‐

12 Q.MoragJack?

13 A.MoragJack,Iamnotevensure,Idon'tremember,

14 Icouldn'tevenprofesstoMoragJack,Idon'tthinkshe

15 wastherewhenI‐‐IamprettysureitwasSharonand

16 thenJoanna,andyeah,theflatitself,youhavetobear

17 inmindthatIwasthereonspecificdays,itcouldbe

18 thattheywouldhavecomewhenIwasn'tthere,butat

19 theflatitself,wedidn'thaveparticularlymany

20 visits,youknow.

21 Q.Imean,canyougiveussomeideaofhowmany?How

22 oftendoyouseethemanager,forexample?

23 A.Themanager,well,itdepends.InthecaseofSharon,

24 itwas‐‐Iwouldsayitwasrelativelyoften.

25 DefinitelyalmosteverydayoreveryotherdayIwould

47

1 be‐‐IwouldcollectpettycashfromherandIwould

2 takethisopportunitytokindofcommentanythingIhad

3 inmindrelatingtothechildortheplansforthatday.

4 SonormallyIwouldgo,wewouldwalkup,eitherIwould

5 seeherpriortopicking[nameredacted]upfromschool

6 andthengoandpickhimupfromschoolandIwouldhave

7 achatwithherthere,orIwouldgowith[name

8 redacted]‐‐

9 Q.Z.

10 A.Sorry,sorry,Ireallydoapologise.IwouldgowithZ,

11 andpickthemoneyupwithhimandcommentupon

12 planningsorwhatever.

13 Q.HowoftenwouldSharonBerinicometovisittheflat?

14 A.Theflatitselfperhapsnotthatoften.Imight

15 remember,Idon'tknow,twoorthreetimes.

16 Q.Twoorthreetimes?

17 A.WhileshewasmanagerIthinkmaybeoveraperiodof

18 maybetwoorthreemonths,youknow.Maybeitwasmore,

19 maybe‐‐

20 Q.Soonceamonth?

21 A.Moreorless.

22 Q.Aboutonceamonth,Isee.WhataboutMsHernandez?

23 A.WithMsHernandezIhadfarlesscontact.Thepetty

24 cashwasn'thandledbyher,Ican'trememberexactlybut

25 Ithinkitwouldhavebeenoneoftheseniors,who

48

1 Itookthepettycashfrom.Idon'trememberhercoming

2 everormeetinghereverattheflat.Thisisnotto

3 saythatsheneverwent,but‐‐

4 Q.Youjustdon'tremember?

5 A.‐‐notonmywatch.

6 Q.YourefertoadocumentwhichIwouldliketotakeyou

7 tonow,it's{E/64/25}.

8 A.ShallIreadit?

9 Q.Toyourself.

10 THECHAIRMAN:Notthateasytodo,really.

11 A.Well,it'smywriting,I'llgetby.

12 THECHAIRMAN:Thewholething,MrEnglehart?

13 MRENGLEHART:Yes,Iwouldlikeyoutoreaddown.Iknow

14 it'snotthateasy.

15 A.That'sfine,Iamfamiliar.

16 MRENGLEHART:Abigpointismadeaboutthisbysome

17 people.

18 (Pause)

19 A.Okay.

20 Q.Gooverthepage.{E/64/26}Idon'tthinkweneedany

21 more.Right,sogoingback,then,tothepreviouspage,

22 {E/64/25}yourefertousingcoldwater?

23 A.Mm.

24 Q.Wasthatasapunishment?

25 A.No.



49

1 Q.Whywereyouusingcoldwater?

2 A.Iusedcoldwaterbecauseatthetime[nameredacted]

3 wasabitfranticandfrenetic.Ihadbeenkindof

4 overwhelmedandIwasmyselfabitoverwhelmedbythe

5 situation.[nameredacted]wasquitefrantic‐‐

6 Q.Z.

7 A.Sorry,Zwasquitefrantic,andwhenIputhiminthe

8 showerhewasabitresisting,soIcouldn'tspendthe

9 timetokindofplayaroundwiththeknobs.

10 Q.Thecontrols?

11 A.Andhecouldslip.Ihadtoholdhimwithonehandso

12 hewouldn'tslipandfall,andusemyotherhandtokind

13 ofputthe,toturntheshoweron,andIcouldn'tbe

14 testingthewater.Atthetime,asIsay,Imyselfwas

15 quitedistressed,andIjustwantedtogethimcleanand

16 resolvethesituationasquicklyaspossible.Sothis

17 wasmyonly‐‐theonlyreason,Ididnotwanttorisk

18 scaldinghimaswellwithhotwater,becauseagainit

19 wasn'tanormalsituationwhereIwouldnormally,you

20 know,hewouldwaitwhileI,whatever,sohewascovered

21 infaecesandsmearingallovertheplace,itwas

22 adistressingsituation,andIdidnothavethekindof

23 timethatnormallyIwouldhavetogivehimashower.

24 Q.Didyouusethethreatofgivingsomeoneacoldshower

25 asathreat?

50

1 A.Lookingback,it'saveryunfortunatechoiceofwords.

2 Imean,ifyoulookatthereport,Ithinkitshouldbe

3 takenintoaccountthatthisiswrittenafteraneight

4 hourshift,aparticularlydistressingoneinthiscase,

5 andthereisevenmistakeslike"Thereweren'tmuch

6 cereals"I'mobservingnow,it'snotwritteninmy‐‐

7 Q.Isthisyourwriting?

8 A.Yeah,thisismywriting,thisismine,Ihaveno

9 problemwithadmittingtoit.WhatImeantosayis

10 thatafteradistressingeightor12‐hourshift,Ican't

11 rememberwhatthisonewouldhavebeen,9,12‐hourshift

12 onedoesn'tperhapsusethebestchoiceofwords.It

13 wouldhavebeenwarnings,itwouldhavecomethroughin

14 amore,howcanIsay,maybeinaslightlyplayfulor

15 jokingmannerjusttogethimroundtodo.

16 Asyoucansee,well,lateron,throughouttheday,

17 heactuallystarted,hechangedhisbehaviour,ifyou

18 seeonthenextpage,andsothedaychanged.But

19 towardsthemorning,towardsthebeginningoftheday

20 andtowardsthemiddleoftheday,itwasquite‐‐and

21 Iwaspersonallygraspingatstraws.Ididn'tknow,

22 Ihadtriedtoperhapsredirecthimbyyou,know,

23 offeringgood,niceactivitiesthatwecoulddoifhe

24 behaved,thishadn'tworked,Ihadtriedthetime‐outon

25 variousoccasionsandthis,whichhadledmetoaneven

51

1 worsesituation,andIwasataloss,really.Theword

2 "threat"isreally,Idon'tthink,adequatelydescribes.

3 Iwouldnever,youknow,Icareddeeplyfor[name

4 redacted]andIwouldneverkindofbeaggressive

5 towardshim.Iwouldhavemaybemadeajokingcomment,

6 kindof,"Comeon,wedon'twantanothershower"or

7 somethinglikethis.

8 Q.Isee.Couldyoutellusabout‐‐youhavedealtwith

9 thatalreadyaboutyouruseoftheword"lock",Ithink

10 inthecommunicationsbookentrythatyouhaveseenyou

11 dousetheword"lock"butyouhaveexplainedthat,you

12 shutthedoor?

13 A.Exactly,yeah.Imean,therewasnolock.Youcould

14 verifythis,Isuppose,withotherwitnesses,andso

15 yeah,it'sanexpression,youknow.

16 Q.Now,didyouevertake‐‐youdid,Ithink‐‐Zoutto

17 yourhomeortoyourflat?

18 A.Yes.

19 Q.Youdid?

20 A.Yes.

21 Q.Howoftenwouldyoutakehimtoyourflat?

22 A.Idon'tknow,therewere‐‐therewasaperiod

23 perhaps...well,therewouldbeoddoccasions,likethe

24 onesthatIreported,forexample,forexamplethis

25 occasionwhenhehaddiarrhoea,anditwasbasically

52

1 easiertotakehimtherethantoapublictoilet‐‐

2 Q.Usethelavatory,yes.

3 A.‐‐becauseagainhewasmisbehavingandmyhouse

4 happenedtobeclosetothehealthcentre.

5 TherewasalsoaspellwhereIwasgettinghim

6 interestedtoplayguitar,andtherewewouldn't‐‐we

7 mightstop,grabaguitarthatIhad,andthenIwould

8 normallytakehimdownstairstothecourtyardatthe

9 Westsidearea,whereIwouldallowhimtoplayaround

10 withaguitar.Idon'tplaymyself,butIwouldfool

11 aroundwithitaswell.

12 Soontheseoccasionsandthismayhavegone‐‐we

13 wouldgo,pickitup,comedown,anddothat.

14 Q.MrBanderastoldusthatnowadaysitisforbiddento

15 takearesidenttoacarer'sownhome.

16 A.Yes.

17 Q.Butwereyouawareofanysuchrulewhenyouwerethere?

18 A.WhenIwasthere,no.Itwasinfactcommon,youknow,

19 itwasdone.Iwouldn'tsay‐‐Idon'twanttogoas

20 farastosaycommonpractice,Iamnot,Iwouldn't

21 know,butitwasdone,itwasdone.Youhavegotto

22 alsobearinmindthattherewasalotofemphasisin

23 generalintermsofbringingchildrenintothecommunity

24 andgettingthemtorelatewithpeopleoutsideofthe

25 Home,andallofthis.LikeIsaidbefore,withthe



53

1 lackoftrainingthatIhad,Iveryoftenkindoffell

2 backuponmyexperience,myupbringing,andsometimes

3 peoplearoundme.It's,peoplewhosuffer,youknow,

4 it'satoughjobtointegratepeoplewhosufferfrom

5 antisocialbehaviourintothecommunity.Sooften

6 Ithinkmyself,andIwouldventuretosayothercarers

7 whomighthavedoneit,wouldhavereliedonthis

8 resource,Iwouldsay,becauseitmakesthingseasierin

9 thesensethatyoucanpreparethepeoplewhoyouare

10 goingtointegratethemwithprior,youknow,youcan

11 talktothemaboutthechild,youcanexplain‐‐orthe

12 personinquestion.Youcanexplain:well,heisabit

13 likethat,heisabitlikethis,heisabitwaryof

14 this,heisabitwaryofthat.Andthatwouldease

15 theirtransition,youknow,intoamoreintegrated

16 setting.Thiswouldalsohelpthemlateronother

17 occasionswhentheywereoutonthestreet.

18 Q.Iunderstand.Now,therecameatime,andwehaveheard

19 somethingaboutthisalready,whenyoumadeaproposal

20 fortwoofthechildren‐‐

21 A.Mm.

22 Q.‐‐thetwoyounggentlemenwhoweknowasResidentL‐‐

23 A.AndZ.

24 Q.DoyouhaveL?AndZ,yes.

25 A.Mm.

54

1 Q.Thatproposalweseejustidentifiedat{E/64/40}.

2 A.Mm.

3 Q.Youhaveactuallyexhibitedittoyourwitness

4 statement.

5 A.Yes.

6 Q.Canwejustturnitup?

7 A.Ihaveitherewithme.

8 Q.It'squiteasmartdocument.

9 A.Thankyouverymuch.

10 Q.Turnovertothenextpage.{E/64/41}Youareproposing

11 aholiday,basically?

12 A.Mm.

13 THECHAIRMAN:Youwrotethisandpreparedthis,didyou,

14 MrTeuma?

15 A.Ipreparedthisinmyowntime,Ispentafairamountof

16 time,IconsultedwiththepeoplethatImentionhere

17 thatwouldbeattending,andtherestoftheteam.Yes.

18 Yeah,Itook‐‐Ididthisinmyowntime.

19 MRENGLEHART:Soitproposesathree‐daycountryholiday?

20 A.Exactly.

21 Q.Between28Marchand30March2005?

22 A.Indeed.

23 Q.Iamnotgoingtogothroughitall,butit'squite

24 acomprehensivedocument,butpage44,{E/64/44}Imight

25 justreferto.Doyouseeunder"Parents"?

55

1 A.Mm.2 Q.Oryouorsomeone,asfarasyouknew‐‐wasityouwho3 consultedtheparents?4 A.Ihadconsultedtheparents.5 Q.Youhadconsultedboth?6 A.Imadeit‐‐Imean,wehaddaily‐‐well,moreorless7 daily,everydayoreveryotherdayparentswouldcome8 in,[nameredacted]'sfather‐‐sorry,sorryagain.Z's9 father,Z'smotherwhenshecould,Z'sgrandmotheras

10 well.Sowehadto‐‐wespokeaboutthechildon11 adailybasis.12 Q.DoyouspeakSpanish?13 A.IspeakSpanish.14 Q.Iamsureyoudo.15 A.Yes.Youknow,anditmadesensetome,youknow.16 Imadeitextremelycleartothembecause,well,because17 Ididn'twanttocatchmyownfingers,youknow,with18 anything.ImadeitextremelyclearthatIdidnothave19 permissionfromtheHomeasyet,thatthetripwas20 pendingpermissionfromtheHome,butIthought21 because‐‐IshouldalsosaythatIwanted‐‐Iwasvery22 keen,because[nameredacted]wascomingalongvery23 well,hisbehaviourhadimprovedverymuch.The24 interactionwith[nameredacted]hadproventobevery25 positive.Itbenefittedbothatthetime,ingeneral,

56

1 because[nameredacted]tookon‐‐

2 Q.L?

3 A.Sorry.WithL,Ltookonakindofrolemodel,hewas

4 slightlyolderandbigger,andkindofbenefittedfrom

5 theresponsibilityofhavingaweakeryoungerpersonby

6 theside,and[nameredacted]kindoflookeduptohim,

7 hewasmaybeattimesabitfearfulofhim,youknow,

8 becausetheyweretworoughlittlekids,butthiskind

9 ofalso‐‐hehadsomebodytoplaywith,anditkept

10 him,youknow,wellbehaved.SoIthoughttheydeserved

11 it.Iwasawarehehadn'tbeenonholidayforages‐‐

12 Iamcomingtothepoint,sorry.

13 Q.Whatisthepoint?

14 A.Thepointisthatwhen,youknow,Ihaddailycontact

15 withthefamilywhoshowed,youknow,aninterest.When

16 weweresupposedtohaveameetingwithmanagement

17 regardingthisholiday,theydidnotturnup.Wewere

18 leftthere.Isentthereporttothemandtheydidnot

19 answer.

20 MRENGLEHART:Whoismanagement?

21 A.MsJoannaHernandez.Youknow,shedidnotturnup,she

22 didnotanswerwhenIsentherthereport,shedidnot

23 makeanycomment,andIwaspersonally‐‐and

24 professionallyIfeltontheonehandveryletdownand

25 ontheotherhandIwanted,Ireallywas,Iwaspushing



57

1 forit.SoI‐‐inordertomakethingsquickersothat2 onceifwegotpermissionwewouldn'thavetowaitnow3 fortheparents'permissionandthengoback,Ijust4 wantedtoskipabitofthebureaucracy,andgetthem5 in.6 Q.CanwelookatbundleE‐‐Iamsorry,IhopeIamnot7 cuttingyouoff.8 A.No,that'sfine.9 Q.Wemustgeton,youhavetogetbacktoMadrid‐‐

10 A.That'strue,yes,Iamsorry.11 Q.Canwelookat{E/64/31}?Wewillgothroughthe12 precedingpage,toseewhatthisis,justtoidentify13 it.Backone,sorry.{E/64/30}It'sameetingonZ.14 Doyouseethat?15 A.Yeah.16 Q.14April,sotwoweekslater.That'stwoweeksafter,17 Iamsorry,afteryouproposedtotakethem?18 A.Exactly.Yes.19 Q.Wereyouatthismeeting?20 A.No.21 Q.Thencanwegotoparagraph4onpage31?{E/64/31}22 Magnum31.Paragraph5,theonethatisringed.23 A.Yes.24 Q."Carerswantingtotake[nameredacted]totripsin25 Spain."

58

1 Readthattoyourself?

2 A.Ihaveseenthis,ifyoudon'tmindIwilljustread

3 overitagain.(Pause).Okay.

4 Q.Well,thetripdidnottakeplace,didit?

5 A.No,no.

6 Q.Imean,youputinthisproposal,andhowlongdidyou

7 nothearanything?

8 A.I‐‐

9 Q.Andifnot,forhowlong?

10 A.Iphoned,becauseIthinkperhapsImadeanadvance,

11 perhapsaweekorshorttimebefore,thiswasIthink

12 during‐‐itcoincidedwiththeEasterbreak,ashort

13 timebefore,roundaboutaweek,Iwouldsay.Iphoned

14 [nameredacted]'ssocialworkerdirectly.

15 Q.Z's?

16 A.Sorry.

17 THECHAIRMAN:Whowasthat?

18 A.Z's.Ibelieve,tobehonest,Ididn'trememberuntil

19 thisall,IthinkitwasoneJessicaPerez.Iphoned

20 herdirectly,andaskedherwhatherimpressionswereon

21 thematter,andifitwouldbepossible,andshe

22 commentedthatitwouldn'tbe.

23 MRENGLEHART:Shewhat?

24 A.Shesaidthat,no,itwouldn'tbepossible.

25 Q.Canwegoto{D9/142/26}?

59

1 A.Mm.

2 Q.HereisyouputtingcopiestoJessicaPerez,

3 SharonBeriniandKirushkaCompson,sentto

4 JoannaHernandez,butafterthedate,obviously.

5 A.Yeah,thisis‐‐

6 Q.Whenindeedyousay:

7 "Ithasnowbeenalmosttwomonths,Ihaveyetto

8 receiveanofficialnotice."

9 A.Exactly.Itwasveryfrustrating.

10 Q.Ifyoujustreadthatthroughtoyourself.

11 (Pause)

12 Didyoureceiveanycommunicationfrom‐‐

13 A.Just,sorry,justasecond.

14 Q.‐‐MsHernandezinresponse?

15 A.(Pause).Okay.Thefirst...thefirstIheardfrom

16 JoannaHernandezaboutthiswaswhenshecalledmeinto

17 givemeaverbalwarningabouthavingtold[name

18 redacted]'sfamilywithoutpermission,atwhichpoint

19 Itoldherthatshewasbeingveryunprofessionaland

20 Ididnotacceptthisverbalwarning.

21 Q.Isee.Sorelationswereabitstrainedbythistime?

22 A.Relationswerestrained.Itoldher,youcanseein

23 thisletter,thereasonswhy,becausetwomonthsafter

24 theeventIstillhadn'theardfromher,andIthought

25 itwasridiculoustwomonthsaftertheeventtobe

60

1 calledinandthefirstthingtohearisaverbal

2 warningaboutthis,whenitcouldhaveallbeensorted

3 outhadtheyattendedthemeetingwehad,orsetup

4 anotheroneiftheycouldn't,atthetime.

5 THECHAIRMAN:Whenwasthisverbalwarning?Theletteris

6 dated4May2005.

7 A.TheverbalIimaginewouldhavebeenafterthis.You

8 know,itdoesn'tmakesensetome,Imean,Ican'tgive

9 youanhonest,youknow,date,forit.

10 THECHAIRMAN:Shortlyafteryouwrotethisletter?

11 A.Butitwouldhavebeen,becausethisletterdoesnot

12 makesense,afteraverbalwarning.

13 MRENGLEHART:Sothewarningmusthavecomelater,mustn't

14 it?

15 A.Exactly,yes.

16 Q.Now,wouldyoulook,please,atadocumentat{D9/31/1}

17 .Doyouseeit's24November?

18 A.Mm.

19 Q.It'sateammeetingforZ,andIbelieveIamrightin

20 saying‐‐correctmeifIamwrong‐‐thatyouarethe

21 fourthinitialalong,aren'tyou?

22 A.Okay,thisis24December(sic).Yes.

23 Q.Thatisyou,isit?

24 A.Iimagineso,Imean,Ihaven'treadthis.

25 Q.Isthereanyoneelseitcouldreferto?



61

1 A.ButJT,Idon'tthinkso.2 Q.That'swhy‐‐3 A.Yeah.4 Q.Ithinkwecanidentifyeveryoneelsehere.Itsaysin5 thefirstparagraphthatZ'scurrentlivingarrangements6 shouldbeimprovedandrecommendationsshouldbeput7 throughtotheCEO.8 A.Yeah.9 Q.Doyourememberthat?

10 A.Yeah,Imean,Idon'trememberthisspecificdocument,11 Ican'tremember,butImean,Idorememberthatwefelt12 thatitwasn'tthebestofplacesforhim.Youknow,it13 was‐‐wedidn'thaveabudget,youknow,inwhichto14 buy,tokindofdecorativepurposes,thehousewasway15 toobigforhimanyway,Iremember,Ithinkithadat16 leastoneotherbedroomwhichwasjustanemptyroom17 therefornopurpose,wedidn't‐‐we‐‐itwasn't18 particular‐‐well,Iwouldn'tsay,itwasn't19 particularlychildfriendlyorserviceuserfriendly.20 Imean,Iwouldn'tsayitwasparticularlydangerous,21 butIsupposetherewerethingslikemaybe,youknow,22 softeningthecorners,youknow,giving‐‐whatisit?23 Z,no?Imean,giventhatZwaspronetofitsand24 falling,itwouldhavebeensaferwithit.Soyes,this25 wouldhavebeenaconcernofours.

62

1 Q.Well,Idon'tthinkweneedtogointotoomuchdetail

2 onthis.

3 CanInowjustaskyou,atthebottomofthepage,

4 doyouseethereisasentencethatbegins:

5 "Careplanswouldbeputinplacetoaddressmain

6 issuessurrounding[Z].Oncethisisdonewecancall

7 MrandMrs...tomeetusanddiscuss."

8 Doyouseethat?

9 A.Mm.

10 Q.Thenifwecangotopage145,whichistheendofthis

11 document‐‐

12 EPEOFFICER:Ionlyhavethreepagesinthisdocument,sir.

13 THECHAIRMAN:Thenextpage,isit?

14 MRENGLEHART:It'sthefourthpageofthisdocument.

15 Sorry.It'smyinternal...sorryaboutthat.{D9/31/4}

16 YouseeyouandJessicaPerezandSharonBerini

17 wouldgettogethertodiscussacareplanforZin

18 December?

19 A.Mm.

20 Q.Doesthatconclusionattheend,coupledwithwhatI've

21 shownyouonpage1promptyourmemory?Wasthere

22 acareplanforZinplace?

23 A.Aglobalcareplan?Ican'tremember,tobehonest.

24 Whatdoyoureferto,intermsof‐‐

25 Q.Thisdocument,doyouknow‐‐Ididn'twriteit,of

63

1 course‐‐careplansweregoingtobeputinplaceto

2 addressmanyissuesandyouweregoingtogettogether

3 todiscussthem?

4 A.Therewereparticularcare‐‐yeah,forcertainissues

5 therewereperhapssomeparticularcareplanintermsof

6 theideawewanted,youknow,theplantogethimout

7 moreintothecommunity,totryandgethimperhaps

8 into,whenthis,forexample,whenthisguitarinterest

9 turnedup,wewerelookingintoperhapsputtinghiminto

10 lessons.Therewere,forsomethings,yeah,thatmight

11 havebeen.

12 Q.Ifollowthat.Wasthereaformaldocumentwhichhad

13 alltheinformationaboutaresident?

14 A.Ican'trememberonenow,no.

15 Q.Youcan'tremember?

16 A.No.Ican'trememberonenow.

17 Q.Isee.Canwelookatthesecondpageofthisdocument,

18 please?Iwaswonderingwhetherthispromptedyour

19 memory.Thiswas24November.Doyousee"Carer's

20 taking[Z]home"?{D9/31/2}

21 "Ithasbeennotedthatcarersaretaking[Z]to

22 theirprivatehomesatvarioustimes.Thepositionof

23 theagencyregardingthisisthatitisnowapolicy

24 thatnochildincarecangotostaffmembers'houses,

25 asthestaffmemberandtheagencyareopentoallsorts

64

1 ofallegationsorcomplaintsbeingmade."2 Thatwouldsince,sinceyouwereatthismeeting,3 thatyouwereawareofapolicy?4 A.WhenIcamein,therewasnopolicyonthis,andIknow5 thatitwasdonegenerally.Ifthischanged,Iwould6 have,Ithink,Iprobablywouldhaveactedaccordingly.7 Q.DoyouremembertakingZhomeafterthismeeting?8 A.Whenwasthedateofthismeeting?9 Q.29November,Ithink.

10 A.Whatyear?11 Q.4.12 A.November2004?13 Q.Yes,Ithinkso.14 A.Idon'trememberrightnow.15 Q.24November2004.16 A.Idon'tremember.Honestly.IfIwouldhavedoneit,17 regardlessofthepolicy,Iwouldhavereportedit.So18 youcan‐‐Imean,itcouldbe‐‐it'saquestionof19 goingthroughthecommunicationbook.IfIwouldhave20 doneit,Iwouldhave,likeinallotherinstances,21 Iwouldhavereported,andtherewouldhavebeen22 areasonforthat.23 Q.CanInowreferyoutobundle{D9/140/2}?24 A.Sorry,justtoaddonthat.25 Q.Yes?



65

1 A.Thinkingaboutit,thisthingwiththeguitarthat2 Imentioned,probablywouldhavegoneonbeyondthat.3 LikeIsaid,Iwouldhavegonetomyhouse,pickedup4 theguitar,andimmediatelygonedownstairs,oryou5 know,ifitwasraining,wouldhavegonetohisflat.6 Justtoexplain,Iwouldhavekepttheguitaratmy7 housebecauseIcouldn'tbesurethatitwassafeinhis8 flat,becausehisoutbursts,itcouldhavebeen‐‐and9 itwassomethingthatwasusefultohim,therewasno

10 pointinriskingit.11 Q.Now,youwrotealettertoMsHernandez,afairly12 forcefulletter,on16February2005?13 A.Yeah.14 Q.Wouldyoujustcaretoreadittoyourself?It'sapage15 andahalf.16 (Pause)17 A.Iamjustgettingtotheend.18 Q.Yes,sure.{D9/31/3}19 (Pause)20 A.Yes.21 Q.Youcanquicklyreadit.22 A.Sorry,Iamaslowreader.23 Q.That'sallright,no,no.24 (Pause)25 A.Okay.

66

1 Q.Ionlywantedyoutoreaditsoyouhavethefull2 context,it'sonlyfairthatyoushouldseetheentirety3 oftheletter.4 A.Mm.5 Q.Justpickingupononeortwopointsonthis,itwould6 appear,doyourememberthis,therecameatimewhen7 MsHernandezwasproposingwholesalechanges?8 A.Yes.9 Q.Andyouwereobviouslynotatallhappywiththat?

10 A.No.Notsomuchthechanges,Imean,IthinkIamquite11 clearaboutthat,ItellherthatIamnotopposedto12 hermakingchanges,it'sjustthemannerinwhichshe13 wasgoingaboutit.Imean,priortothis,youhave14 alreadyseenwiththeholiday,therewasaseriouslack15 ofcommunicationandIthoughtinterestonherpart,you16 know,realinterestintermsofcomingdownandseeing17 whatwasgoingonandworkingwithus,youknow.So18 Iwasquitefrustrated.19 AsIsayinthisletter,"Iamnotopposedtoyou20 changing,that'sfine,Iwouldliketohelpyoudoitin21 anappropriatemanner".ThisiswhatIproposedtoher,22 inaperhapsstronglywordedmanner,butnevertheless23 IthinkonacoupleofoccasionsImakereferencethat24 "I'mhappytohelpyoumakethechangesbutlet'swork25 togetheronit".

67

1 Q.Ithinkyourproposalwaslaterthanthat,isn'tit?

2 A.Letme‐‐IthinkI'vejustreadsomething‐‐

3 Q.YourproposalwasfortheMarch2005,Easter.

4 A.Okay,youmeanthat‐‐okay,sorry.

5 THECHAIRMAN:Ithinkatthisstageyoumusthavebeen

6 waitingforaresponsetoyourproposal.

7 A.Itcouldhavebeen.Yeah.Eitherway,Imean,ithas

8 tobeunderstood,Idon't‐‐Imean,Ican'tanswerfor

9 herthinking,butwhenJoannacamein,Ididnotmeet

10 herpersonally,Idon'tthinkwehadameetingforher

11 tointroduceherselfeitheratallordefinitelynot

12 withinthefirsttwoorthreemonths.

13 Iwas‐‐shewasbasedinGiraldi,Iwasat

14 MerlotHouse.SoIdidn'thave‐‐evenifIhadbeenat

15 Giraldi,whenyouaretakingcareofavulnerable

16 serviceuser,disabled,youdon'thavetimetogoinfor

17 achatandgettoknowyourmanager.Youknow,sheis

18 theonewhohastotakethetime,Iwouldsay,it'smy

19 opinion,tocome,orsetupameeting,tokindof

20 presentitas"Thisneverhappened".

21 Myonlycontactatthispointwithherwerethrough

22 memos,someofwhichmayhavemademoresense,someof

23 whichmadeless.Andtobefair,eventheoneswhich

24 didn'tmakesensetome,itdoesn'tmeantosaytome

25 thattheywerewrongorthatshehadnoproperreason

68

1 fordoingthings,Ijustfelttheneedtobe,youknow,

2 moreinvolvedintheprocess.IfeltthatIcouldbe

3 usefultoherinherwork,andIfeltthatIwasbeing

4 ignoredinthatsense.Meandmanyotherworkers.

5 So‐‐

6 MRENGLEHART:Yousaythecompletereplacement.Whowas

7 theteam?Therewasyouandtherewasthesenior‐‐

8 A.Thesenioratthetime,Ican'tremember,Imean,Iam

9 rememberingmorefromwhatIseeherethandirectly.

10 IbelievethatmaybeKirushkaCompsonwouldhavebeen

11 aseniorforaperiod,DenielleGomezforanother

12 period.Thosearethenames,andItellyou,Igetthem

13 morefromthedocumentsIhavebeenseeingthesedays

14 thanfromdirectmemory.

15 Q.It'salongtimeago.

16 A.Thenthereweretwoworkersonnightduty,itwas

17 Immaculada,Ican'trememberhersurname,and

18 ChristianSantos,andtherewasalsoGayleEverest,and

19 ifImaysayso,Ithought,youknow,eventhoughwe

20 occasionallyhad,youknow,oddmaybeprofessional

21 discrepancies‐‐

22 Q.Disagreements?

23 A.‐‐ordisagreements,Ithoughtwegenerallyworkedvery

24 welltogetherandweprovidedtheconsistencythat[name

25 redacted]sodearlyneeded,youknow.



69

1 Q.WastheproposalyousaytoreplacethewholeofZ's

2 teaminonego?

3 A.Yes.Imean,Iknew,yeah,theproposalwas,andin

4 factitwaschangedalmostentirelyexceptformyself,

5 andIknewfromorworkerswhohadbeenaskedtotakeon

6 myshifts‐‐well,Icametotheconclusionthat

7 Ihadn'tbeenchangedbecausetheyjustcouldn'tfind

8 theworkerthatwaswillingtocomeintomyshift

9 pattern.Becausetherewereotherworkerswhotoldme,

10 "Yes,IhavebeenaskedtotakeoverbutIsaid,'Look,

11 IhavenightsandIamnotchangingtodays'",things

12 likethis.

13 Justtoputyouinthepicture,forgettingnoweven

14 aboutthedisabilities,whichareanotherattenuantthat

15 shouldbetakenintoaccount,butevenputtingthisto

16 oneside,an8‐yearoldchild,youknow,tochange,to

17 take,foran8‐yearoldchild,theprimarycaregivers,

18 thepeoplewhoaretherewithhimday‐to‐day,within

19 aperiodoftwoweeksandreplacethemwithpeoplewho

20 arestrangersorwithwhomhehashadverylittle

21 contact,Ithinkthisisprobablyoneofthemost

22 difficultthings[nameredacted]everhadtogothrough.

23 Wearetalkingaboutthepeoplewhofeedyou,thepeople

24 whotakeyoutobed,thepeoplewhotakeyoutoschool,

25 whogiveyouyourmeds,whowashyou,thiswouldhave

70

1 beenveryhardforhim.

2 Q.Iunderstand,wehaveheardalotofevidenceabout

3 continuitybeingimportant.CouldIjustaskyou,you

4 arenotpartytothisletterbutIwonderwhetherit

5 jogsyourmemoryandwhatit'sallabout.Ifyoulook

6 at,afterthat,yourletter,shortlyafterit,

7 MsHernandezwrotetoMsTosso,andthereferenceis

8 {D34/8/1}.It'squiteashortletter.

9 (Pause)

10 Wereyouawareofanygrossmisconductatthistime?

11 A.Atthistime,atthetimeofthisletter,Iwasnot

12 awareofthis.Well,Iamnotawareofthis,ofgross

13 misconductintheteamatanypoint.Idon'tthink

14 anybody‐‐Iamhappytospeakformycolleagueswho

15 Ithoughtwerealwaysveryprofessional.

16 ThefirstIheardoftheactualreasonsbehindthe

17 changeswasduringthemeetingfor‐‐theverbalwarning

18 meetingfortheholidayproposal,whichwaslateron.

19 Q.TelltheChairmanaboutthat.

20 A.We‐‐shecalledmein,asIsaidearlier,Iexpressed

21 toherthatIthoughtitwasquiteunprofessionalto

22 bringthisupsofarafterwhenshehadn'teven

23 commenteditatthetime,youknow,givenmeany

24 feedbackatthetime.Andthisledtoaquiteheated

25 exchangebetweenMsHernandezandmyself,andhereshe

71

1 saidtomethereasonsthatshesaidtometheteamhad2 beenchangedwasthatthetopsofthekitchencupboards3 were,youknow,ifyouunderstand,thetoppartofthe4 kitchencupboards,notinside,outside,weregreasy,5 werecoveredingreaseanddustanddirt,andthatshe6 hadfoundsomevegetablesthathadgoneoffinthe7 fridge.TowhichIsaid:well,Ithinkthisisreally8 notenoughofabasis,Imean,tellus,youknow.First9 ofallIquestionedher,"Isthishowyoudealwiththe

10 problem?Youtakeitfromoneplaceandyouputitin11 another,ifthisisyourproblem?"AndIquestioned,12 youknow,"Doyouthinkthisisreallyenoughreasonto13 createthiswholeupheavalin[nameredacted]'slife?"14 Q.Thankyou.Youareobviouslyawareofsomeofthe15 evidence,atleast,thathasbeenbeforethisInquiry,16 becauseyouhavedonethesecondwitnessstatement.17 A.Mm.18 Q.Idon'twanttotakeyouthroughit,it'sthere,and19 theChairmanhasit.20 A.It'sthere.21 Q.CanIjustsaythis:youcomment,Ithink,onthe22 evidencewehaveheardfromMrValarinoaboutthistrip23 toMorocco?24 A.Yes.25 Q.Idon'tthinkthereisanydisputeaboutit,youwere

72

1 apprehended,Ithink,withasmallamountofcannabison

2 youandyoureceivedapolicecaution?

3 A.IreceivedapolicecautionandIresignedfrom‐‐

4 Q.That'swhatIwanttoaskyouabout,becausewedon't

5 haveany‐‐atleastnodoubtsomeonewillshowmeifwe

6 do,butIcan'tseeanydocumentsaboutthis.You

7 resigned?

8 A.Well,yeah,IrememberatthetimeIwasinitially

9 suspendedforamonthpendingadisciplinaryhearing.

10 Q.Right.

11 A.But,well,Imean,Iwasgivenalloftheseissues,

12 IwaskindofabitfedupwiththeHomemyself,and

13 becauseofmystrainedrelationshipwithMsHernandez,

14 Iknewshewouldbeonthepanel,and‐‐

15 Q.Thepanelofthedisciplinary?

16 A.Ofthedisciplinary.EventhoughIknew,youknow,

17 Imean,IknewIhaddonewrong,Iapologisedtothe

18 father,IthinkIpaidthepriceformyactions,and‐‐

19 but,youknow,thisweighedheavily,myrelationship,

20 thestrainedrelationshipwithJoannaHernandezweighed

21 heavily,andIdidnotwanttoputmyselfinaposition

22 whereshewould‐‐andrightlyso,shewouldbetelling

23 meofforreprimandingme,inthiscasewithallthe

24 rightintheworld,butIjustdidn'twanttoputmyself

25 throughthat.



73

1 Q.Remindme,youwere23,wereyou,atthetime?2 A.Iwas23,24atthetime,yes.3 Q.Yousay,didyouwritealetterofresignation?4 A.Idid,yeah.5 Q.BecausethenIwouldliketoputtoyoutwopassages6 fromMsHernandez'sevidence,whicharerather7 contradictory,butstill,andseewhatyousayabout8 them.CanwelookatbundleE67,it'sMsHernandez's9 thirdstatement,atparagraphs247to254?{E/67/69}.

10 Couldyoureadtoyourself247to254?11 A.Mm.(Pause).Indeed,yes,youcangoover.{E/67/70}12 (Pause).Justalmostthere.(Pause).13 Q.Iamnotgoingtoaskyoutocommentonit,butasit's14 quiteavividpicturethat'spainted,andMsPerezhas15 alreadygivenevidencesayingshedisagreedwiththis,16 butthereweare.Whereisthereferencetoyouiswhat17 Iwanttoaskabout.18 A.Okay.19 Q.Youweren'tapparentlyatthisvisit,itwasMsPerez.20 Wereyoutheseniorattheflat?21 A.No.22 Q.No?23 A.It'simpossible,Iwasasupplyworker,Icould‐‐24 Q.Youwereasupplyworker.Youneverhadafull‐‐25 A.Icouldneverreachthatgrade,because‐‐

74

1 Q.Youneverhadapermanentcontract?

2 A.Exactly.Iwashiskeyworker.

3 Q.MsHernandezsaysthatsheremovedyouimmediately,as

4 shewasdeeplyunhappywiththecarethatwasbeing

5 providedforZ.Isthatright?

6 A.No,thisisnot‐‐no,notrightatall.Iamnotsure,

7 what'sthedateofthis?

8 Q.Canwegoforward?Iamnotsurewehavebeentold.If

9 wegotothepreviouspage,maybethathelps.

10 A.No,itdoesn'tsay.Eitherway‐‐

11 Q.Anyway,shesayssheremovedyouimmediately.Canwe

12 nowlookatparagraph365?{E/67/99}.Hereitis

13 somewhatdifferent,it's:

14 "MarieGomezdirectedmetodismiss[you].Ididso

15 onherdirection."

16 Iagreeit'snotwhollyconsistent,but‐‐

17 MRENRIGHT:Thisisatotallydifferentinstance.

18 MRENGLEHART:Youweredirectedandshedidso,doyou

19 rememberbeingdismissedonthedirectionofMsGomez?

20 A.No,notatall.Mymemoryoftheissue,whatIstated

21 earlier,whichiswhathappened,isthatIwassuspended

22 foraboutamonthpendingadisciplinaryhearing.

23 IwonderhowIcouldhavebeendismissedwithout

24 adisciplinaryhearingforstarters,butanyway,Iwas

25 suspendedforamonthpendingadisciplinaryhearing,

75

1 andasthedateapproachedIthoughtaboutit,andas

2 IsaidIdidnotwanttoputmyselfthroughit,so

3 Isentinaletterofresignation,andIjustbasically

4 didn'tturnupanymore.

5 THECHAIRMAN:Dowehavetheletter,MrEnglehart?

6 MRENGLEHART:Noletter.

7 THECHAIRMAN:Ofresignation.

8 MRENGLEHART:Eitherway,Ihaven'tbeenabletofindone.

9 Ishouldbeveryinterestedifsomeonehasmanagedto

10 findin61,000documentsthisletter.

11 A.Idon'tknowifthis‐‐Idon'tknowifyouwant,I'll

12 addsomething,whichIdon'tknowhowmuchweightit

13 has,butIwas,afterthiswholeincident,Idon'tknow,

14 IwasyoungerandIsupposecheekier,andIwrote,and

15 thislettermustbesomewhere,totheagencyactually

16 demanding,becausewhenyouareasupplyworkeratthe

17 timeyouhadtherighttoadayandahalfofleaveper

18 monthwhichInevertook,anddespite,youknow,the

19 unfortunatecircumstancesofthewayIleft,Ithought,

20 well,Inevertookthosedays,youknow,andIthought,

21 youknow,andIwrotekindofdemandingthatmoneyand

22 theysaidno.Idon'tthinkIwouldhavefeltwiththe

23 righttodothatifIhadbeendismissed,youknow.You

24 know,againIreiterate,Isentinaletterof

25 resignationandIneverheardfromJHagain.

76

1 Q.Ihaven'tbeenabletolocateeitheryourletterof

2 resignationorindeedanyletterfromMsHernandez,but

3 maybeonewillturnup.

4 Didyousendittoherpersonally?

5 A.Iwouldhavemadeit,Ithink‐‐Idoubtit.Idoubtit

6 giventhestrain.Ican'tremember.Ican'tremember.

7 Butitwouldhavehadcopiesperhapstootherpeople.

8 Ihonestlyreallycan't.IimagineIwouldhavesentit

9 toheadoffice,butgiven,youknow,particularlyagain

10 giventhestrainedrelationshipwithMsHernandezatthe

11 time,Iwantedtohaveaslittletodowithheras

12 possible.

13 Q.Wouldyoureadtoyourselfparagraph367?Leavingaside

14 thingswhichyouknownothingabout.

15 (Pause)

16 A.Mm.

17 Q.Imean,isitfactuallycorrect?

18 A.No.No.

19 Q.Areyouthenephew?

20 A.Ah,youmeanabout‐‐sorry.Sorry,yes,Iam

21 MrNetto'snephew,yes.

22 MRENGLEHART:Right.Ihavenomorequestions.Butsome

23 othercounselmay.

24 A.Thankyouverymuch.

25 THECHAIRMAN:Yes,MrVasquez.



77

1 QuestionssuggestedbyMRVASQUEZ

2 MRVASQUEZ:Verybriefly.

3 YouworkedwithSeanMattoandSharonBerini?

4 A.Yes,Iworkedwiththem,yes.

5 Q.SharonBeriniwastheactingmanagerforalittlewhile

6 whilstyouwereasupplyworkeratthebeginning?

7 A.Indeed,yeah.

8 Q.Canyougiveusyourviewsonher?Yousaidthatyou

9 sawhermorefrequentlythanyousawJoannaHernandez‐‐

10 A.Indeed,well,muchmorefrequently.Sharonwasvery

11 muchahands‐onmanager,Iunderstoodatthetimeand

12 Istilldothatshehadcomeupthroughtheranks,and

13 shewassomebodywhowould‐‐firstofall,shehad

14 averykeenawareness,sheknewtheserviceusersvery

15 well.She‐‐againunfortunatelyshewasverythinly

16 spreadbecausetherewasalotofstaff,therewere

17 alotofsupplystaffaswellwhocouldsaynoto

18 ashiftatthelast,soshealways‐‐butshewasthe

19 kindofpersonwhowouldrunaround,andifshehadto

20 stephimbecausesomebody,asupplystaffhadsaidnoto

21 ashift,shewouldhappilydothat.

22 Q.Shewouldworktheshiftasacarer?

23 A.Shewouldworktheshiftifshehadto.Obviouslyshe

24 wouldn'tleaveanybodyunattendedto.Youknow,she

25 wouldcomealongwhenheradministrativeduties

78

1 permittedher,shewouldcomealongondaytripsperhaps

2 thatweorganisedandshewouldkindofsuperviseand

3 help,andalsoforusnewcarerswhenwewerecomingin

4 shewashappyalwaystoofferadviceandstuff,

5 especiallyonthefirstdays,butalsothroughouther

6 timethere,whenshewasactingsenior,whenshewas‐‐

7 sorry,actingmanager,whenshewentbackdownto

8 assistantmanager.Ihave‐‐Ithinkprofessionally

9 Sharonwasaverygoodpersontoworkwith,youknow.

10 Q.Youtrustedandrespectedher?

11 A.Verymuchso.

12 Q.AndSeanMatto,doyouhaveanyexperienceofhim?

13 A.Yes,Ihave‐‐Iworkedaswellwithhimondifferent

14 occasions.Againveryoftenontripsthatwemade

15 togetherwiththewhole‐‐youknow,withvarious

16 residentstothebeach,torivers.Seanwas,like

17 Sharon,veryawareoftheneedsofserviceusers,he

18 was‐‐Seanwasaverygoodcommunicator,sohe

19 transmittedthatinformationverywell.Healsohad

20 aknack,Iremember,youknow,Irespectedhimalot

21 becausehe,youknowthateverybodyhasthingswhich

22 theyareverygoodatandstuff,andforexamplethere

23 wouldbecarerswhowouldmaybeverygoodwiththe

24 childrenbuthadtroubleintheinteractionwithparents

25 andintheserelations,andSeanwassomebodywhocould

79

1 speaktodifferentpeopleattheirownlevel,youknow,

2 andhewasequallyateasewithaserviceuser,aswith

3 aparent,aswithseniormanagement,andthisgaveas

4 aworkerthisgaveone‐‐

5 Q.Slowdownabit,yes.

6 A.Sorry.Thisgaveyoualotofconfidenceandease,you

7 know,inyourwork.UnfortunatelyIwouldsaytheywere

8 thinly‐‐perhapsthinlyspreadduetothestructure.

9 Q.Weheardevidenceaboutresources.

10 A.Butintermsofthat‐‐

11 Q.SeanMattowasasenioratthattime?

12 A.Hewasasenior,maybehemighthavebeenacting

13 assistantmanagerforawhileatthattime.

14 Q.Forawhile?

15 A.Forawhile,atthattime,Ifeltsupportedandwell

16 takeninbythem.

17 MRVASQUEZ:Thankyouverymuch.

18 THECHAIRMAN:MrEnright?


20 MRENRIGHT:Yes,sir.

21 MynameisDavidEnright,Irepresent

22 JoannaHernandez,Iwouldliketoaskyouafew

23 questions.

24 A.Goodmorningtoyou.

25 Q.Goodmorningtoyou.YoucaredforResidentZforquite

80

1 sometime,isn'tthatright?2 A.Thatistrue.3 Q.Hewasaveryyoungchild,anepilepticchild?4 A.Indeed.5 Q.Couldwehave{E/64/40}?Thisispartofthepackage6 youputtogetherforthetrip.Youwillseethepicture7 oftheboysthere.IamcorrectinsayingthatZison8 therightaswelookatit;yes?9 A.Indeed,yes.

10 Q.Verysmallchild?11 A.Mm.Well,yeah,takeintoaccountthat[nameredacted]12 wasaverylargechild,so‐‐buthewasayoungchild.13 Q.It'sworthlookingatthesepictures,becausethese14 childrenhavebeenpaintedtobesometimesogresin15 theseproceedings,theywereveryyoungchildren‐‐16 A.Yeah,yeah.17 Q.Ithinkweallneedtoremindourselvesofthat.Canwe18 have{E/64/3}?Thisisyourstatement.Lookat19 paragraph16whereyoudescribethetypesof‐‐thetwo20 typesofthingsyoucoulddotothechild:givehim21 atime‐outormakehimsitonamat?22 A.Sorry?23 Q.Furtherdownitsaystheothersanctionyouhadwasto24 gethimtositonamat.25 A.Letme‐‐canIhaveareadofthis,doyoumind?



81

1 Q.Absolutely,paragraph16ofyourstatement.2 (Pause)3 A.Idon'tknowwhatyoumeanbyamat.4 Q.Myapologies,Ihavereaditwrong.Anyway,youwere5 abletojustgivethematime‐out,thatwasallyou6 coulddo?7 A.Mm.8 Q.Yes?9 A.MaybeIcouldadd,thesewereperhapstheinitialthings

10 thatwouldmakethe‐‐withtimeand,forexample,with11 contactwithpeoplelikeSeanandSharon,whoperhaps12 didn'thavethetimetositdownandgiveyouacourse13 onit,butwhentheycamealongthroughexamplethey14 wouldleadandtheywouldshowusways,forexample,15 whenhesweared,justtogiveyouanexample,tokindof16 veerhimoffanduseasimilarwordtokindofgethim17 offonthattangentorredirecthim,butthesewere18 thingsthatcameonthroughtheprocess,throughthe19 timeweworkedthere.20 Q.Canwehave{E/64/36}?Thisisyourreportof21 10January2004.22 A.Mm.23 Q.Ifyoulookatthelastparagraph‐‐24 A.Thelastparagraph?25 Q."Wecamehome,Ilockedhiminhisroomforhalf

82

1 anhour."2 Wetalkedaboutthatearlier?3 A.Mm.4 Q.Itdoesquiteexplicitlysaythere"Ilockedhiminhis5 roomforhalfanhour".6 A.Well,therewasnolock,andthatcanbeverified,at7 theendoftheday‐‐8 Q.Surelyyouwouldhaveput"Iputtohim",youwere9 asked‐‐youdoquiteclearlysay"Ilockedhiminhis

10 room".11 A.No,it'sanexpression,thereisnothingmoretothat.12 Imean,ifyouwanttogoroundandlook,andifyou13 wanttoturnthewheelabitaround‐‐14 Q.Theyareyourwordsandyousaytheymeansomething15 else.16 A.‐‐that'sfine,butno,Isenthimtohisroom,Icould17 havesaidIsenthimtohisroom,Icouldhavesaid18 Iputhiminhisroom,IcouldhavesaidIlockedit‐‐19 Q.Yes,youcouldhave.20 A.Thepointishehadatime‐outforhalfanhour.It21 wouldhavebeenphysicallyimpossibletolockhiminhis22 room.23 Q.Thoseareyourwords.24 A.Yes,that'sfine.25 Q.Thisisyourreportof13December2003.Ifwelook

83

1 towardsthebottom:2 "Hedidnotlikethis,andthethreatofsticking3 himinthecoldshower"‐‐4 MRNAVAS:Excuseme,sir,IfeelIhavetointerjectonmy5 client'sbehalf.Idon'tknowwhatthepurposeofthis6 lineofquestioningis.Idon'tknowwhatMrEnright's7 clientorMrEnrightistryingtoachievewiththis.8 Idon'tknowwhetherMrEnrightorhisclientare9 entitledtomakethesequestions.Ithinkmyclienthas

10 dealtwiththisevidencecomprehensivelyintheevidence11 andboththewrittenandtheoralevidenceprovided12 today,andIreallydon'tknowwherethisisgoing.If13 wearehere‐‐ifMrEnrightwantstomakeanexampleof14 myclient,Idon'tthinkthisisthetimeortheplace15 forit.16 THECHAIRMAN:Well,MrNavas‐‐17 MRNAVAS:Really,Ifindthiscompletelyoutoforder.18 Iseewhereheisgoingwiththis,andthisis19 completelysensationalistcross‐examinationoftheworst20 kind.IfIremembercorrectly‐‐21 MRENRIGHT:Thosearehiswords.22 MRNAVAS:‐‐thiswasnottheaimortheobjectiveofthis23 InquiryorwhatthisInquirywaspreparedtoallowto24 do.25 THECHAIRMAN:Youarequiterightinsayingthiswas

84

1 13December2003,whichisbeforeyourclientactually2 arrived,MrEnright,andIthinkIdidmakeclearthe3 otherdaythatwhatIamlookingforisquestioningon4 behalfofthosewhoweredirectlyimplicatedinthe5 subjectmatterofwhateveritisthatyouwanttoask6 about.7 MRENRIGHT:Yes.8 THECHAIRMAN:SoIthinkMrNavasisrightatleastin9 sayingthatthisissomethingoutsidethescopeofwhat

10 Iindicatedwouldbetheappropriatescopeforthese11 questions.12 MRENRIGHT:IunderstandandIamconsciousofthat.13 MrTeumahaspresentedhimselftodayasbeingvery14 caringofthischildandcarefulofhiscare,andthere15 areissueshereintheevidencewhich,inhisownwords,16 don'tseemtosuggestthat'sthecase.17 MRNAVAS:Whichisfranklyirrelevanttohisclient's18 evidenceorpositionwithinthisInquiry.19 THECHAIRMAN:Please,MrNavas.WhatI'mgoingtodo,20 MrEnright,istoconfineyou,asIhavebeentryingto21 confineotherpeople,toquestionsaffectingtheir22 clientdirectlyinrelationtoincidentswhichare‐‐23 MRENRIGHT:Iamwithyou.24 THECHAIRMAN:‐‐directlyconcerningtheirclient,and25 Ithinkyouwouldagreethatthisdoesn'tfallwithin



85

1 thatcategory.Iamnotgoingtodescribeyour

2 questionsinanysortofpejorativeway,butitseemsto

3 methatthatiswhatwearelookingforhere,andthat's

4 certainlywhatwouldassistme.

5 MRENRIGHT:It'sonlytotheextentthatthegentlemanhas

6 beenquitecriticalofmyclient,andIthinkit'sonly

7 fairthatifthereareissuesaroundhiscredibility,

8 thattheybeputtohimandhecandenythem.

9 THECHAIRMAN:Well,hehas,andIthinkthatisprobably

10 wherewecanleaveit.Youhaveyourinstructionsand

11 Iappreciatethat.Youhavealsoheardwhatthewitness

12 hassaidaboutit,andIthinkwecanmoveon.

13 MRNAVAS:Sir,justonelastpoint.MrTeumahasnotbeen

14 criticalofhisclient.MrTeumahasrespondedto

15 allegationsmadeagainsthimbyhisclientandhasfelt

16 obligedtorespondinthatfashion.

17 THECHAIRMAN:Well,MrTeumahasrespondedandisperfectly

18 capableofrespondingtothesequestions.Frommypoint

19 ofviewIamnotassistedbyquestioningdealingwith

20 issueswhichareoutsidethescopeofaparticular

21 individualinthisroom.ButMrTeumahasbeen

22 extremelyhelpful,hehasbeenveryclearinhis

23 evidence,andthereweare,letthatstand.

24 MRENRIGHT:Iwillmoveon.

25 MSBALESTRINO:Sir,nowthattheinterruptionhasbeenmade

86

1 IwouldbegratefulifMrEnrightwouldtakebackthe

2 referenceto"ogres",Idon'tthinkanybodyhasreferred

3 tothemas"ogres"hereinthisInquiryandIthinkit

4 isquiteunreasonable.Challengingbehaviour,yes,but

5 togoasfaras‐‐

6 THECHAIRMAN:Ididn'thearthat,MsBalestrino.

7 MSBALESTRINO:Well,Ididanditwasmade.

8 MRENRIGHT:Well,IwouldliketoclarifybecauseIam

9 obsessive.Myclient'sconcernwasthatthechildren

10 werebeingdescribedasveryviolent,verydangerous,

11 andIwouldliketobringpeople'sattentionbacktothe

12 factthatthesewerechildren,verytinychildren,one

13 ofthem.

14 THECHAIRMAN:Ithinkifthatwordwasused,Ithinkyou

15 canwithdrawthat.

16 MRENRIGHT:Absolutely,butIwanttosaythattheywere

17 childrenandshouldbelookedafteraschildren.

18 THECHAIRMAN:Ithinkthat'saboutasfaraswecantake

19 that,MsBalestrino.

20 MSBALESTRINO:Yes.

21 THECHAIRMAN:Now,MrEnright,wehavegottooneo'clock.

22 Iwouldliketogoon,howmuchlongerdoyouthinkyou

23 willbe,confiningyourquestionsinthewayinwhich

24 Iindicated?

25 MRENRIGHT:SubjecttoMrTeuma'sanswers,aboutten

87

1 minutes.

2 THECHAIRMAN:Wewillcallittenminutesandthat'sall

3 youwillget,afterthatwewillhavetoadjournfor

4 anhourorso.

5 MRENRIGHT:Iwill,sir,thankyouverymuch.Couldwe

6 have{E/67/68}?ThisisMsHernandez'sthird

7 statement,andIamlookingatparagraph245tostart

8 offwith.

9 A.Whichparagraph,sorry?

10 Q.245.

11 A.Yes.

12 Q.MsGomezsayshisdietismadeupofmainlytakeaways?

13 A.Notonmywatch.

14 Q.Canwehavethenextpage?{E/67/69}

15 A.Whichone?

16 Q.Wewillgoparagraphbyparagraph.Readthefirstfew

17 linesof246.

18 (Pause)

19 Washecomingtoschooldirty,withoutunderpants?

20 A.NotthatI'mawareof,no.No.Imean,Iwouldhave

21 picked‐‐myrolewastopickhimupfromschool,and

22 Inormallyhadthekindof3to9shift,andInever,

23 never,everfoundhim,ifIhadIwouldhavereported

24 it,withoutappropriateclothingoranythingofthe

25 like.

88

1 Q.Movingontoparagraph247,thatwasthatwith

2 JessicaPerez.

3 (Pause)

4 Haveyouanythingtosayaboutthat?Youdidsayin

5 evidencethatthecabinetsweregreasy,vegetableshad

6 goneoffinthefridgeyouadmittedthatmuch?

7 A.Er‐‐

8 THECHAIRMAN:Ithinkwehavebeenoverthis,MrEnright,

9 hehasgivenhisevidenceaboutit,ifsomethingisnot

10 clear,thenbyallmeanslet'sclarifyit.

11 MRENRIGHT:Thishadnotbeenputdirectlytohimaboutthe

12 actualcare‐‐

13 A.Iwould,forthebenefitofmynightcolleagueswhowere

14 veryprofessionalandkepttheflatclean,contraryto

15 what'ssaidhere,Iwouldsayyouhavegottobearin

16 mindtheywouldstartat9whenthechildwaseither

17 asleeporsoontogotosleep,thenalltheirduties

18 entailedasfromthenonwouldhavebeentocleanthe

19 flat,cleanthekitchen,thefloors,thehall,the

20 bathroom,etcetera,etcetera.Thenat8o'clockor

21 whatever,moreorless,getthechild‐‐startgetting

22 thechildreadyforschool,youknow.Cleaningthe

23 flat,especiallywhenit'sbeendoneonadailybasis,

24 whichiswhyIamsosurprisedbyMsHernandez's

25 comment,doesn'ttakethatlong,youknow.Soyoucan



89

1 imaginethattheymaygettheircleaningdutiesdone2 between10and1‐‐3 THECHAIRMAN:IthinkMrEnrightisdirectingyoutothe4 lasttwolinesofparagraph247.5 A.Thisisabsolutely,youknow...(Pause)6 MRENRIGHT:Washesleepingonabaremattress?7 A.No,thisisabsolutelyfalse,thisisabsolutelyfalse,8 andalie.Idon'tknow,itcouldbe‐‐theonlykind9 of,let'ssay,healthyinterpretationthatIcouldtake

10 soasnottosecond‐guessyourclientwouldbethatshe11 cameonadaywhenthebedsheetswereinthewash.12 Thisistheonly‐‐andeventhentheywouldhavebeen13 replacedbyanothersetofbedsheets.But[name14 redacted]hadaquilt,[nameredacted]hadquiltcovers,15 someofwhich‐‐theyweremainlytherewhenIarrived,16 butIamawarethatthefamilycontributedtothisand17 theHome,thisisabsolutelyfalseandlies.18 Q.Hismedications,weretheyoutofdate?19 A.Hismedicationswererenewed,hehadamedsbox,like20 mostserviceusersthere,Iamnotsureifyouare21 familiarwiththem,theyaremedsbox,theygofrom22 MondaytoSunday,withlittlecompartmentsfor23 different‐‐forthedifferentdaysandtimeswhenhe24 had‐‐andwehadonemedsboxperweekorperhapsby25 twoweeks,andtheywouldhavebeenregularlychanged,

90

1 onceyoutaketheMondaymorningtabletout,it'sgone,

2 youknow,andthenextMondaymorningyouneedanother

3 one.Youknow,sotheywouldhavebeenrenewedon

4 aweeklybasis.

5 Q.Andfinallyparagraph252.{E/67/70}

6 (Pause)

7 A.Yeah,Iwouldliketoknowwhothesepeopleare,and

8 whattheyhavetosayaboutit.

9 Q.Theysayitwassodirtythatpeoplehadtoscrapethe

10 dirtoffthefridge.

11 A.Idon'tbelievethis.

12 THECHAIRMAN:Youtellmewhatyourememberaboutthe

13 conditionofthefridge.

14 A.Thefridgewas‐‐Iamnotgoingto‐‐shemighthave

15 found,likeshesaidtomeinthatmeeting,some

16 vegetableswhichwereoff,it'spossibleitcouldhave

17 beenoverlooked,Idon'tthinkit'saveryseriousissue

18 tohavetoanswerforittenyearslater,butanyway,it

19 wasnowherenearwhatshedescribes.Shewouldn'thave

20 needed‐‐likeIsayagain,thenightshiftworkerswho

21 wereresponsibleforthecleaningoftheflatwereboth

22 veryprofessionalinthatsenseandInever‐‐infact,

23 asadayworker,ifthishadbeen,ifstufflikethis

24 hadbeenthecase,Iwouldhavecomplainedbecauseit

25 wouldhaveinterferedwithmywork.Ifthedishesfrom

91

1 thepreviousdinner,forexample,weren'tdonethenext

2 day,itwouldmeanthatwhenIhavetocookforhim,

3 Iwouldhaveto,beforecookingforhim,cleanthemand

4 thiswouldnothavesatwellwithme,Icantellyouand

5 Iwouldhavereporteditmyself.Thisisridiculous.

6 Q.Canwehave{F/23/3}?Iamlookingatparagraph18.

7 ThisisawitnessstatementofDeniseHassan.She

8 describesthehygieneconditionsatMerlotHouseas

9 "disgusting".

10 A.It'snottrue.

11 Q.Okay.

12 A.Doyouwantmetoreadanythinginparticularorjust

13 respondtothat?

14 Q.Thatwasanotherperson'sview.Wehavebeentakento

15 thecorrespondence,therewasaletterof21February

16 whereMsHernandezwascomplainingtoMsTossoabout

17 you,sayinggrossmisconduct.Wouldyouacceptthat

18 conditionslikethisweregrossmisconduct?

19 A.Well,it'sreally‐‐no,Iwouldn'tacceptitatall,

20 andit'sreallybewildering,becauseifshefeltthat

21 therewasgrossmisconduct,whywouldshethenpropose

22 tosendtherestofustoworkwithothervulnerable

23 individuals?Itjustdoesn'tmakeanysense.Either

24 sheishighlyirresponsibleorjustdoesn'tknowwhat

25 sheisdoingorsheislying.I'llletyouchoose.

92

1 Q.Finally,aboutyourwishtotakethechildrenonatrip

2 abroad.Youwereconcernedthatshedidnotrespondto

3 youonthat?

4 A.Mm.

5 Q.Youhaveseenwhatshesays,shewasveryconcerned

6 aboutyourcareoftheresidents.Youdidtake

7 aresidentabroad,ResidentXIbelieve,andwhenyou

8 camebackyouwerearrestedforcarryingdrugs,soshe

9 wasrighttobeconcernedaboutyou?

10 THECHAIRMAN:Well,letmeintervenehere,MrEnright,

11 becausethereisnodisputeaboutthisandMrTeumahas

12 acceptedit,hedoesn't‐‐well,hefeelsbadaboutit,

13 asonewouldwellexpect.It'sallbeendealtwith,and

14 Ican'tseethepointofraisingthat,becausefurther

15 evidenceaboutthatisn'tgoingtohelpmeinanywayat

16 all.

17 MRENRIGHT:Iacceptthat,sir,Ihavenomorequestions.

18 THECHAIRMAN:MrNavas?

19 MRNAVAS:Noquestions,thankyou.

20 THECHAIRMAN:MrTeuma,yourevidenceisfinished,thank

21 youverymuchindeed.

22 THEWITNESS:Thankyouverymuch,goodluckwithyourwork.

23 THECHAIRMAN:Iamverygratefultoyouforyourhelpand

24 haveagoodtripbacktoMadrid.

25 THEWITNESS:Thankyouverymuch,goodluck.



93


2 THECHAIRMAN:Wewillresumeat25past2.

3 (1.10pm)

4 (Theshortadjournment)

5 (2.25pm)

6 THECHAIRMAN:Yes,MrEnright.

7 MRENRIGHT:It'sjustaboutwhatyousaidthismorning,

8 sir,inregardofsittingonFriday.ObviouslyIamnot

9 goingtoholduptheInquiry,andIwillbehereifit

10 needstobe,butyoucanimagineIhavecommitmentsin

11 London,Ihavebookedflights.Butifitgoeson,it

12 goeson.It'sjustifit'spossible‐‐

13 THECHAIRMAN:Iamsorrytohearthat,MrEnright.Iwas

14 abouttosaythatwewillactuallyneedtositon

15 Friday.

16 MRENRIGHT:Ifwemust,wemust.Thankyou.

17 THECHAIRMAN:Idon'tknowwhatIcandoaboutthat.

18 MRENRIGHT:Ijustwantedtoraiseit.

19 THECHAIRMAN:Anyway,thankyouformentioningit.

20 Yes,MrEnglehart?

21 MRENGLEHART:It'sMsOpenshaw.


23 MSSHARONOPENSHAW(called)

24 THECHAIRMAN:MsOpenshaw,thankyouverymuchforcoming,

25 andthankyouforprovidingyourstatement,andturning

94

1 upheretohelpus.Ifyouhavebeensittinginthe

2 roomabit,youwillknowhowthingsgo.Haveyoubeen

3 here?

4 A.Yes.

5 THECHAIRMAN:Don'tbenervous.MrEnglehartwillaskyou

6 somequestionsandtheremaybeotherquestionsfrom

7 othercounsel.Wewillnotkeepyouhereanylonger

8 thanweneedyou.Ifyouneedtogivethenameoryou

9 needtorefertoanyindividual,wehaveabitofpaper

10 therewhichyoucanseehowtodoit.It'snotvery

11 easytodo,andifanameslipsout,don'tworry,butwe

12 aretryingtopreserveanonymitywherewecan.

13 A.Yes.

14 THECHAIRMAN:CouldIstartbyaskingyoutogiveyourfull

15 nameandaddressfortherecord?

16 A.SharonOpenshaw,andmyaddressisAllSaintsVicarage,

17 Rochdale,UK.

18 THECHAIRMAN:Thankyou.MrEnglehart.


20 MRENGLEHART:Ithinkyouareparticularlyconcernedwith

21 theyoungmanwecallResidentL.IsitMsorMrs?

22 A.Ms.

23 Q.MsOpenshaw,canweturnup,firstofall,{E/61/1}.

24 Doyourememberrecentlymakingthiswitnessstatement?

25 A.Ido.

95

1 Q.Isthereanythingthatyouwanttoaddto,detractfrom,

2 sayanything‐‐

3 A.No.Imayhavegotsomedateswrong.

4 Q.Somedateswrong?

5 A.Mayhavegotdateswrong.

6 THECHAIRMAN:Itwasquitealongtimeagosoitwouldn't

7 besurprising.

8 MRENGLEHART:Apartfromthat,youarebroadlycorrectwith

9 whatyousay.

10 A.Yes.

11 Q.Verygood.Justforthetranscript,fortherecord,

12 it'sbundleE,tab61.

13 Right,youarenow,asIunderstandit,employedin

14 runningtwochildren'shomesinthenorthofEngland?

15 A.That'scorrect.

16 Q.InRochdale?

17 A.Yes.No,sorry,Wigan.

18 Q.Verywell.Yourunthewholeofthetwohomes,isit?

19 A.Yes.

20 Q.Whatdoesrunningtheminvolve?

21 A.Iamtheregisteredmanager,registeredbyOFSTED,and

22 theentireresponsibilityofthehomesisonmy

23 shoulders.

24 THECHAIRMAN:Sorrytointerrupt.MsOpenshaw,couldIask

25 youtofacethiswayabitmore,andkeepyourvoiceup,

96

1 ifyoucould.Idon'thavethebenefitofany

2 microphoneoranythingsoyouneedtospeaktomeso

3 Icanhear.

4 MRENGLEHART:Asamatterofinterest,aretheseNHShomes

5 oraretheyprivatehomes?

6 A.No,theyareprivaterun.

7 Q.YouworkedfortheSocialServicesAgencyherein

8 Gibraltar,youtellus,betweenAugust2007until

9 May2011?

10 A.That'sright.

11 Q.Soyoudon'toverlapwithMsHernandezatall?

12 A.No.

13 Q.Therecameatime,asweknowfromotherevidence,when

14 theyoungmanwhoIhavementionedseemstohavemade

15 somesortofallegationconcerningyouandtwoothers?

16 A.Yes.

17 Q.Firstofall,that'syou,RoseRobba,and

18 ManolitaAdamberry,whowasherethismorning.Ithink

19 youhavebeenheretoday?

20 A.Yes.

21 Q.Firstofall,canyouexplaintheset‐upasbetweenyou

22 three?

23 A.Iwastheunitmanagerandtheothertwostaffwerethe

24 nightshift.

25 Q.Sorry,youwerethe?



97

1 A.Iwastheunitmanager.

2 Q.AndsoRoseRobbaandManolitaAdamberrywerethecare

3 workers?

4 A.Yes.

5 Q.Whoreportedtoyou?

6 A.Yes.

7 THECHAIRMAN:Yousaythenightshift;weretheyallthe

8 timethenightshift?

9 A.Theywereregularnightstaff,yes.

10 MRENGLEHART:Andyouwerenightstafftoo,wereyou?

11 A.No,Iwasdays.

12 Q.Youwereday?

13 A.Yes.

14 Q.Whowasreportingtoyouthenfromthisteam,ifImay

15 callitthat,duringtheday?

16 A.Allthecareworkers,thedaystaff,thenight

17 staff‐‐asinnames?

18 Q.Wearetalkingaboutaflat,aren'twe?

19 A.Yes.

20 Q.Yes,sotherewereaprettyfinitenumberofcare

21 workersthere?

22 A.Yes.

23 Q.Whowouldithavebeenwhowouldbereportingtoyou

24 duringtheday?

25 A.DuringthedayitwasFlorGarcia,CoryAlman,

98

1 LucyMiddletonandMaryNoakes.

2 THECHAIRMAN:Wouldtherenormallybetwoofyouthere

3 duringtheday?

4 A.Therewastwoduringtheday,yes.

5 THECHAIRMAN:Youplusone?

6 A.No,twoplusme.

7 MRENGLEHART:Soitwasatwotooneortwoandahalfto

8 one,ifyoucountyourselfasahalf,care.

9 A.Yes.

10 Q.AtnighttherewouldbeRoseRobbaand

11 ManolitaAdamberry,asyoumentioned.Theywereon

12 theirown,werethey?

13 A.No,therewas,theothernightshifttendedtobe

14 supply,soitwasquiteirregularwhowasontheother

15 nightshift.

16 Q.Right,sowheredotheyfitin?

17 A.RoseandManolitaworkedsomanynightsaweekandthen

18 wehadsupplystaffworktheothernights.

19 Q.Isee,right,buttherewasnoseniorondutyatnight?

20 A.No.

21 Q.Right.Now,yourefertoadocumentwhichyouexhibit,

22 indeed,let'shaveitup,it'sbundle{E/61/15}.We

23 haveseenthisbefore.Youhavetooobviously,because

24 yourefertoit.DoyouseeResidentLismentioned,

25 andhisdateofbirth,on20October1993.He'sin

99

1 England,inUK,atthistime?

2 A.Yes.

3 Q.The"Reasonforandpurposeofstrategydiscussion".Do

4 youseethatsomenotveryexplicitallegationofabuse

5 was,physicalabuse,madeagainstyou,RoseRobbaand

6 ManolitaAdamberry.Doyouseethat?

7 A.Yes.

8 Q.That'sall,therewereobviouslynodetailsgiven,but

9 ifwemaynowlookattheconsequenceofthis

10 allegation,whichhadbeenmadeintheUnitedKingdom,

11 atbundle{E/61/19}.Youreceivedthisletter,you

12 wereinTorremolinos,actually.Isthatwhereyouwere

13 living?

14 A.No,IwaslivinginLaLinea.

15 Q.8October2009,youreceivedasuspension?

16 A.Yes.

17 Q.Pendinginvestigation.Asfarasyouwereaware,the

18 samehappenedtoRoseRobbaandManolitaAdamberry?

19 A.Tomyknowledge,yeah.

20 THECHAIRMAN:Wasthisthefirstthatyouhadheardofit,

21 MsOpenshaw,orhadyoubeenmadeawareofthese

22 allegationsbefore?

23 A.No,IactuallygotthisonthedayIreturnedto

24 Gibraltarfrommymother'sfuneralinUK.

25 MRENGLEHART:Thatpreviousdocumentwewerelookingat,

100

1 youhadn'tseenthat,hadyou?

2 A.Sorry,thisdocument?

3 Q.No,thepreviousone,sorry,thehandwrittenonewhich

4 talksabouttheunspecificallegation?

5 A.I'veonlyseenthatthisweekwithmysolicitor.

6 Q.Preparing,Iunderstandthat.

7 A.Yes.

8 Q.Thefirstyouknewaboutanyofthiswas,as

9 Iunderstandit,thisdocumentwearelookingatnow‐‐

10 A.WaswhenIwashandedit.

11 Q.E,tab61,page19,isthatcorrect?

12 A.IwashandedthisletterwhenIwentintotheoffice

13 uponmyreturnfromtheUK.

14 Q.WhattheChairmanisinterestedinknowingis:didyou

15 knowanythingabouttheallegationsbeforeyougotthis

16 letter?

17 A.No.

18 THECHAIRMAN:No,thiswasthefirstyouhadheardofit,

19 Ithinkyouweretellingme.

20 A.WhenIgotthatletter,yes.

21 MRENGLEHART:Soitwasasurprise?

22 A.Ashock.

23 Q.Abombshell,Icanimagine,yes.Anyway,thatwas2009.

24 Ithinkyouwereinfactinterviewedbythepolice?

25 A.Yes.



101

1 Q.Wehavetherecordofitsononeedtogointothat.2 Timemarcheson,andyoutellusinyourstatementyou3 actuallycontactedthepolicethefollowingMay,that's4 May2010,toaskwhatwashappening?5 A.ThatmaybewhereIgotthedateswrong,butIdid6 contactthemearlyinthenextyear.7 Q.Didyou?Becauseyouhadheardnothing?8 A.Ihadheardnothingfromsocialservices.9 Q.Didyouask,hadyouaskedsocialserviceswhat's

10 happening?11 A.Ihadnocontactwithsocialservicesatall,Ihadno12 pointofcontact,Iwaswaitingforthemtocontactme,13 soIcontactedthepolicetofindoutwhatwas14 happening.15 Q.DidyouknowMarieCarmenSantos?16 A.Byname.17 Q.Bynameonly?18 A.Yes.19 Q.Isee.HadyoudealtwithanyoneinTheCareAgency?20 A.Inwhatrespect?21 Q.Wasthereno‐oneinTheCareAgencyyoucouldringup22 andsay"What'shappeningtothiscase,mysuspension?"23 A.MylinemanagerwasMariaElena,andIcouldn'tcontact24 MarieElenabecauseshewascarryingouttheGibraltar25 investigationasfarasIwasaware.

102

1 Q.BythatyoumeanMacias?

2 A.Yes,sorry.

3 Q.No,justsoIknowwhoyoumeant.Wewillhearfromher

4 later.CanIask,youweresuspended,butbeingpaid?

5 A.Yes.

6 Q.Andthatwasjustcarryingon?

7 A.Andon,andon.

8 Q.Anyway,youcontactedthepolice,andwhenyoudidthat

9 whatdidtheytellyou?

10 A.Thatasfarastheywereconcernedeverythingwas

11 unfounded.

12 Q.Unfounded?

13 A.Unfounded,yes.

14 Q.Sowhatdidyoudothen?

15 A.Ithenwaitedforsocialservicestocontactmebecause

16 theyweredoingtheirowninvestigation.

17 Q.Youexhibit‐‐sorry,wereyouintouchwith

18 ManolitaAdamberryorRoseRobbaatthistime?

19 A.Notatall.

20 Q.Notatall?

21 A.Notatall.

22 Q.Sodidyouthinkyouweregoingtobe,yoursuspension

23 wouldbelifted?

24 A.Iwashopingso.

25 Q.ButyoumadenoenquiriesofTheCareAgencytofind

103

1 out?2 A.LikeIsaid,asfarasIwasaware,GibraltarPolice3 had‐‐theUKpolicehaddonetheirinvestigation,4 GibraltarPolicehaddonetheirs,Iwasawarenowthat5 GibraltarCareAgencywerecontinuingtheir6 investigation.7 Q.Isee.8 A.So‐‐9 Q.TheCareAgency,asfarasyouwereconcerned,were

10 stillinvestigating?11 A.Yes.12 Q.Isee.Butyoutellusinparagraph14,{E/61/2}13 Iappreciatethedetailsafterallthistimeare14 probablyabitvague,butthattherewasalso15 anallegationagainstyouofsomemismanagementof16 medication?17 A.Yeah,IfoundthatoutwhenIgotaphonecallaskingme18 toattendtheoffice,assumingIwasgoingbacktowork,19 tobetoldthatthereisadifferentallegationnowso20 suspensionwascontinuing.21 Q.Couldyoubeshown,please,adocument,Idon'twantto22 takeyouthroughitbecauseIdon'tthinkitreally23 impingesontheissuesthattheChairmanhastoenquire24 intointhisInquiry,butit'sbundle{E/61/23}.This25 isinyourhandwriting,isit?

104

1 A.Yes.

2 Q.Page21canwenowhave.{E/61/21}Youseeitsays

3 "Report"?

4 A.Yes.

5 Q.Itdealswiththemedicationmatter,ifImayputit

6 thatway.Whatwerethecircumstancesinwhichyoucame

7 towritethisreport?

8 A.ThatwasonceIhadbeenintotheofficeandtoldthat

9 theinvestigationhadchangedfromtheallegation

10 againsttheyoungpersontothemismanagementof

11 medication.Ithensentthatreportintotheoffice.

12 Q.Right.

13 THECHAIRMAN:Whatdatearewetalkingabout,MsOpenshaw,

14 roughly?

15 A.WhenwereIcalledinforthechangeofallegation.

16 THECHAIRMAN:Canyougivemeayear?Obviouslyit'ssome

17 timebetween‐‐

18 A.Itwouldbe2000and‐‐

19 THECHAIRMAN:HowlonghadyoubeenattheHomeatthat

20 time?

21 A.Ihadbeensuspendedforninemonthssoitwasjust

22 afterthat,whentheallegationchanged.

23 THECHAIRMAN:Soarewetalkingabout2008or2009?

24 MRENGLEHART:Ithinklater,aren'twe?

25 A.Suspendedin‐‐



105

1 Q.Paragraph19ofyourwitnessstatementIthinkhelps.

2 {E/61/3}

3 A.Suspendedin2008,sothiswouldhavebeen2009.

4 THECHAIRMAN:Sometimein2009.

5 MRENGLEHART:YouremainedsuspendedfromOctober2009

6 untilMay2011.

7 A.Yes.

8 THECHAIRMAN:Sorry,Iamabitconfusedthen.Sothis

9 incidentwiththemedicationwaspriortothe

10 suspension,before‐‐

11 A.Sorry?

12 THECHAIRMAN:Itwasbeforethesuspension?

13 A.Theincidentwas,yes.

14 MRENGLEHART:CanIaskyoutolook‐‐thismayclarify

15 matters‐‐atbundle{O16/13A/1}.Thisis

16 12October2009.It'saminuteofameeting.Canyou

17 justreadthroughthat?

18 (Pause)

19 Doyouseethepenultimateparagraph?

20 A.Pardon?

21 Q.Doyouseethepenultimateparagraphabouttherectal

22 diazepam?

23 A.Yes.

24 Q.Isthatwhattheinvestigationwasabout?

25 A.No.

106

1 Q.It'sanotherone,Isee.Sotheinvestigationwas,you

2 hadbettertellusverybriefly,becauseIdon'tthink

3 weneedbetroubledaboutitfortheInquiry?

4 A.Therectaldiazepamwassomemedicationthatwasfound

5 bymembersofstaffinthekitchenoftheflat,itwas

6 aprescribeddrugthatwashighlysedativeandshould

7 neverhavebeenthere,wedon'tknowwhereitcamefrom.

8 Theallegationagainstmyselfwasexcessmedicationthat

9 wasfoundontopofawardrobe.

10 Q.Isee.Anyway,tocutalongstoryshort,well,it's

11 notthatlong,it'slongintermsoftime,butifyou

12 lookat{E/61/25},wouldyouliketoreadthatto

13 yourself?

14 (Pause)

15 THECHAIRMAN:Isthattheendoftheletter,MrEnglehart?

16 MRENGLEHART:No,itgoesover,wecanturnover.{E/61/26}

17 A.Yes.

18 (Pause)

19 Q.Anyway,soyouhadhadenoughbynow,toputit

20 colloquially?

21 A.Yeah.

22 Q.Andyoudecidedthatafterallthistimeyouwouldgive

23 upinGibraltarandgobacktotheUK?

24 A.Yes.ImovedontoAustralia.

25 Q.Sorry?

107

1 A.ImovedontoAustraliafirst.

2 Q.YouwenttoAustraliafirst,didyou?

3 A.Yes.

4 MRENGLEHART:Verywell.Ipersonallyhavenomore

5 questions,sir.Maybesomeoneelsewill.

6 THECHAIRMAN:WouldanyonewishtoaskMsOpenshawany

7 questions?

8 QuestionssuggestedbyMSMORAN

9 MSMORAN:Sir,Iamjustlookingforthecorrectdocument.

10 Ididhaveit,butIcan'tseemtoputmyhandsonit.

11 Idobelievetherewasaninterviewwith

12 MariaElenaMacias,andMsOpenshaw,inJune2010,where

13 thatsecondallegationwas,andthensheremainedon

14 suspensionuntiltheMay2011.Itwassimplytoclear

15 thatupforyou.

16 THECHAIRMAN:Didyouhearthat,MsOpenshaw?It's

17 suggestedbyMsMoranthattherewasaninterviewwith

18 MariaElenaMaciasinJune2010,wherethesecond

19 allegationwasdiscussed,Ithink.

20 A.Yes.

21 THECHAIRMAN:Youdorememberthat?

22 A.Yes.That'swheretheytoldmethattheallegations

23 fromtheyoungmanhadbeenunfounded,howeveryouare

24 remainingsuspendedduetoanewone.


108

1 MSMORAN:IamafraidIcan'tfindthelettertoshowthe

2 court,ortherecordofthe‐‐

3 THECHAIRMAN:Sherememberstheoccasion.

4 MSMORAN:ItwassimplytoclarifyMrEnglehart's

5 questioningearlier.

6 MRENGLEHART:MrsMaciasisgivingevidencelateranditis

7 actuallyreferredtoinherwitnessstatement.

8 THECHAIRMAN:Doweneedtolookatit?

9 MRENGLEHART:Iwouldn'thavethoughttherewasanyneedat

10 all.

11 THECHAIRMAN:Right,Ithinkthatfinishesyourevidence,

12 MsOpenshaw,thankyouverymuchindeedforcomingand

13 thankyouforthehelpthatyouhavegivenus.Thanks

14 verymuch.


16 THECHAIRMAN:Yes,MrAzopardi?

17 MRAZOPARDI:WearegoingtocallRoseRobbanext.

18 MRSROSEROBBA(called)

19 THECHAIRMAN:Goodafternoon,MrsRobba.

20 A.Goodafternoon,sir.

21 THECHAIRMAN:Thankyouverymuchforcoming.Wouldyou

22 prefertogiveyourevidenceinSpanish?

23 A.No,inEnglishisallright.

24 THECHAIRMAN:Idon'tknowwhetheryouhavebeeninthe

25 roombefore‐‐



109

1 A.Si.

2 THECHAIRMAN:Youhave,soyouhaveseenroughlywhat

3 happens.Ifyouneedtorefertoaresident,

4 aparticularresidentattheHome,pleaseusethe

5 lettersthatwehavebeenusing.Youhaveabitof

6 paperthere,Ithink,whichtellsyouwhichtheletters

7 are.

8 Ifyoucouldjustbeginbygivingyourfullnameand

9 youraddress,please?

10 A.MynameisRoseRobba,Mrs,Ilivein19Medview

11 Terrace.

12 THECHAIRMAN:Youmighthavetokeepyourvoiceupalittle

13 bit,becauseIhavetobeabletohearwhatyousay.

14 MRNAVAS:Sir,ifImayjustassistinexplainingthe

15 reasonfortheinterpreter.MrsRobbarequestedthe

16 assistanceofaninterpreterincasethereisanything

17 thatshecannotexpressadequatelyinEnglishorany

18 documentthatshedoesn'tunderstand.Thankyou.

19 THECHAIRMAN:MrsRobba,ifyoufeelinanydifficultyin

20 speakinginEnglish‐‐

21 A.No,no,it'sallright,IspeakinEnglish.

22 THECHAIRMAN:‐‐youspeakinSpanishandthegentleman

23 nexttoyouwillsorteverythingout.

24 A.Okay.IspeakinEnglish.

25 QuestionedbyMRAZOPARDI

110

1 MRAZOPARDI:MrsRobba,Ijustwanttoaskyousome

2 questionsjusttobetterunderstandthisstatementthat

3 youmadetotheInquiry,whichisat{E/62/2}.Doyou

4 recognisethatstatement?

5 A.Yes.

6 Q.Yes?That'stheevidencethatyouaregivingthe

7 Inquiry;isthatcorrect?

8 A.Yes.

9 Q.YouworkedatTheCareAgency,intheDrGiraldiHome,

10 from2002?

11 A.No,I'veneverworkedinGiraldiHome.

12 Q.Sorry?

13 A.I'veneverworkedthere.

14 Q.Letmestartagain.Youworkedasacareworkersince

15 2002;correct?

16 A.Si.

17 Q.Yes.Duringyourtimeasacareworker,youworkedwith

18 ResidentL;isthatcorrect?

19 A.Yes.

20 Q.Ifyoulookatthelist?

21 A.Yes.

22 Q.Okay.Iunderstoodfromyourstatementthatyouhad

23 normallythenightshiftwithResidentL?

24 A.Yes.

25 Q.Andthatwouldbeanightshiftthatyousharedwith

111

1 MrsAdamberry?

2 A.Adamberry,yes.

3 Q.Isthatcorrect?

4 A.Yes.

5 Q.Wouldthatbewhatyouusuallydidafter2002?

6 A.Iwasonlywith[nameredacted]about‐‐sorry,L,for

7 aboutnearlytwoyears.

8 Q.Okay.Sofrom2002to2004;isthatcorrect?

9 A.No.

10 Q.No?

11 A.No.

12 Q.Tellus.

13 A.2008and2009.

14 Q.Okay,soyouwerewithResidentLtowardstheendofhis

15 stayinGibraltar?

16 A.EndofhisstayinGibraltar,si.

17 Q.BeforeyouwerewithResidentL,youworkedasacare

18 workerwithchildren?

19 A.Children,si,especiallychallengingbehaviour,usedto

20 work.

21 THECHAIRMAN:Sorrytobeanuisance,MrsRobba,couldyou

22 keepyourvoiceupabit?It'sabitdifficult.There

23 issomewaterthereifyouneedit.Itwillhelpifyou

24 lookthiswayalittlemore.

25 MRAZOPARDI:Thereasonyoustartedworkin2002withthe

112

1 children,andthereasonthatyouthenstartedworking

2 withL,wasbecauseLwas,wehaveheard,transferred

3 intothecareoftheChildren'sDepartment,ifIcanput

4 itthatway.

5 A.Yes,transferredtoFlatBastion.

6 THECHAIRMAN:FlatBastionRoad?

7 A.FlatBastionRoad.Therewasaflatthere.

8 MRAZOPARDI:ApartfromResidentL,didyouworkwithother

9 childrenofchallengingbehaviour?

10 A.Yes.

11 Q.Yes,okay.BeforeL?

12 A.BeforeL.

13 Q.Isee.ButLwasthefirstchildwithlearning

14 disabilitiesyouhaddealtwith;that'scorrect?

15 A.Yes.

16 Q.Sohehadthatcombinationthattheotherchildrenof

17 challengingbehaviourhadnothad.Didthatmakehim

18 moredifficulttodealwith?

19 A.Notreally,no.

20 Q.Okay.

21 A.IhadalotofhelpfromMrsAdamberry.

22 Q.Right.HowdidyoufindyourexperiencewithLduring

23 thosetwoyears?

24 A.Well,itwentverywellallthetime,Ithink,Irarely

25 hadanyproblemswithhim,becauseIkeptwithwhat



113

1 MrsAdamberrytoldmetodo,andIdidn'treallyhave

2 anyproblemswithit.

3 Q.Yousayinyourstatementatparagraph17,ifIcantake

4 youthere,{E/62/3},thatyoudescribehimas

5 agenerallywellbehavedandlovingboy?

6 A.Yes.

7 Q.Althoughhisillnessmadehimpronetoviolentoutbursts

8 bothphysicalandverbal?

9 A.Si,sometimes.

10 Q.Canyougiveusabitmoreinsightintothat?

11 A.Well,withme,IonlywhenIthinkabouttwice,twice

12 really‐‐hehitmetwiceonlyreally,oncewasn'tmeant

13 formeandtheotheronehediditfornoreasonatall.

14 Justasanimpulse,no?Thenheusedtocryandsay

15 "I'msorry,I'msorry"andheusedtokissme.Intwo

16 yearsthat'stheonlyproblemIhadwithhimreally.

17 Q.WehavealsoheardthatLknewwhenhewasbecoming

18 aggressive?

19 A.Yes.

20 Q.Andhewouldaskforsomeonetohold‐‐

21 A.Si.MrsAdamberryusedtotellme"Don'tgetnearhim",

22 bythetimeshetoldmeIhadalreadybackedoff,she

23 usedtosay"Don'tgethim,heisgoingtoget"‐‐

24 becausesheknewhimsinceheislittle,"Don'tget

25 him",soIusedtobackoff.Thenwhenhecalmeddown

114

1 weusedtotalktohim.Iusedtodancewithhim,with

2 me,fromthebeginninghehadaverygoodrelationships.

3 Ididn'thaveanyproblemwhatsoever.Weusedtotake

4 himto‐‐summernights,weusedtotakehimtotheMed,

5 youknow.

6 Q.Atparagraph19ofyourstatementyousay‐‐

7 A.Weusedtotakehimtothefair.

8 Q.Atparagraph19ofyourstatementyousayhewasalarge

9 boy?

10 A.Si.

11 Q.Isupposebythenhewasateenagerbythetimeyouknew

12 him?

13 A.Si.

14 Q.Andcapableofoverpoweringyouwithease?

15 A.Si,hewascapablebuthenever‐‐Imean,Ididn'teven

16 givehimachancebecauseIusedtobackoffwhenIsaw

17 himlikethat.

18 Q.Isee.

19 A.LikeIsaid,Ididn'thaveanyproblemswithhim.

20 THECHAIRMAN:Soreallyyoumeanthathecouldhave

21 overpoweredyouifyouhadn'tbackedoff?

22 A.Yes.Meandaboutthreeofus,si,becausehewas

23 reallylargeandhewasverystrongaswell.Hewas

24 averystrongboyforhisage.

25 MRAZOPARDI:Wasthepracticewhenyousawhimbeing

115

1 aggressivetojustbackoffandlethimcooldown?

2 A.Si,andthenheusedtocalmdown.Sonottolethim

3 escalate,youknow,becauseweusedtobackoffandthen

4 heusedtocalmdownorusedtotalktohim,and...

5 Q.Washesenttohisroomtocalmdown?

6 A.No,notreally.Iusedtostaywithhiminthesame

7 room.

8 Q.Youusedtostaywithhim?

9 A.Staywithhiminthesittingroomorwhatever.

10 Q.Isee.

11 A.Asweworkednightshifts,whenwewenthewasalready

12 inbedandinthemorninghedidn'thavetimebecausehe

13 usedtogetdressedandhadhisbreakfast.

14 Q.Sofairtosaythatreallyyourexperienceofhimwould

15 normallyhavebeenduringhourswhereIsupposehespent

16 mostofthetimesleeping?

17 A.Si.Mostofthetime,yes.

18 Q.Isee.

19 A.Well,exceptweekendssometimeslikeIsaidweusedto

20 takehimtothefairortosummernightsthatwehadto

21 bewithhim.

22 Q.CanIaskyouaboutparagraph23?{E/62/4}Yousee

23 paragraph23,yousaythat,indescribinghim,inthe

24 secondsentence,thathewouldoftengetconfused,

25 especiallywhenrecallinganearlierincident,speak

116

1 veryerratically,usingonlykeywordsandactions,and

2 hischronologywaswrong,oftenwrong,mixingupevents.

3 A.Si.

4 Q.Canyougiveusanexampleofwhatyoumeanbythat?

5 A.Si.Whenheusedtocomesometimesfromhismother's

6 house,[nameredacted]explainedtousthathehadhit

7 hissisterthere.Heusedtosaythathismother's

8 boyfriendwouldhithim,butitwasn'ttrue,his

9 mother'sboyfriendwastryingtogetholdofhimsohe

10 couldn't...that.Orwhen[nameredacted]hadafight,

11 heusedtomixeverythingup.Andweknewitwasn't

12 true.Weknowthatitwasn'ttrue.

13 Q.Didheusedtodothatalot?

14 A.Sometimesusedtodoit,si.Soheusedtodoit

15 sometimes.Butknowinghim,weknewthatitwasn't

16 true,knowinghismother,weknewitwasn'ttrue.

17 THECHAIRMAN:Didyouthinkthathewasgenuinelyconfused

18 ordidyouthinkthathewasbeingmischievous,orwhat

19 didyouthink?

20 A.No,Ithinkitwasconfused,heusedtogetalotof

21 thingsmixedup,withnamesandpeople,andincidents,

22 heusedtocombinetwoincidentstogetherandmakeit

23 one,youknow.Incidentsthathadhappened,perhaps,

24 whenthedaybeforethenandheusedtogetthetwo

25 incidentsandmixedituptogether.



117


2 A.Andweknewwhathadhappenedwas,weusedtoreadwhat

3 hadhappened.

4 MRAZOPARDI:Sohewouldmixeventsthathadhappened?

5 A.Si.

6 Q.Ithinkyousaidearlier,butIamjustcheckingwhat

7 yousaid,wouldhealsomakethingsup?

8 A.Aswell,yes.Sometimes,yes.

9 Q.Youtalkinyourstatementaboutachangeinhis

10 behaviourtowardstheend.Iamtalkingabout

11 specificallyparagraphs26and27.Yousayatthe

12 beginningof27thatwhentheychangedthemedication,

13 yousawachangeinhisbehaviour.Whatkindoftime

14 wouldthatbe?Wasthatverysoon,veryclosetothe

15 timethatheleftforEngland?

16 A.Si,itwasmoreorlessthetimeofthefair,because

17 whenwewenttomeetthedaystaff,andwewenttotake

18 himtothefair,wemethimoutsidethefair,andwesaw

19 [nameredacted]hadatic,doingallthetimelikethis

20 (indicated),whichweneversawwithhimbefore.Itwas

21 abitstrange.

22 THECHAIRMAN:WasthisaferiaorafairinGibraltar?

23 A.ThefairinGibraltar,roundaboutJune,July‐‐no,

24 September.

25 MRAZOPARDI:SothatwouldbeSeptemberbeforetheyear

118

1 thatheleft?

2 A.Theyearthatheleft,yes.

3 Q.SoitwouldbeSeptember2008?

4 A.Si,Irememberthatspecificallybecausewhenwesawhim

5 wesaw‐‐wedidn'tlikethewayhelookedthatday.

6 Q.HeleftforEnglandinaroundMay2009,Ithink?

7 A.Si,but‐‐

8 Q.Sowearetalkingaboutthelasteightorninemonths?

9 A.Yes,fromSeptember,that'sthefirstdayInoticedthat

10 somethingdifferent,Ithinkitwasperhapshis

11 medicationhadchanged,Idon'tknow,butwereported

12 it‐‐Imean,wewroteitdown,wedidn'tlikethetic

13 he...thewayhelooked.

14 Q.YouworkedwithLfortwoorthreeyears,Ithinkyou

15 said?

16 A.Nearlytwo,nearlytwo.

17 Q.Duringthattime,didyoueverseehimstrikeacarer?

18 A.Once,once.Once,aSpanishgirl.

19 Q.Okay.Thathestruckher?

20 A.Si.

21 Q.Isthatright?

22 A.IthinkManolitawasonleavethatday,andhedidn't

23 likesomebodynew.BecauseheknewIworkedwith

24 Manolita,andwhenIthinkshewasthesupply,and

25 she‐‐hedidn'taccepthertobewithme.

119

1 Q.Didyoueverseeacarerstrikehim?

2 A.No,no,never,never.Never.

3 Q.Orbeabusivetowards‐‐

4 A.No.

5 Q.‐‐himinanyparticularway?

6 A.No,never.

7 THECHAIRMAN:Washisbehaviourmorechallengingwhennew

8 carerscame,newfacesappeared?

9 A.Si.Si.

10 THECHAIRMAN:Howwouldhereacttonewpeoplecoming?

11 A.LikeIsaid,hewouldhit.Hewouldhit.Hedidn't

12 likenewfaces.

13 THECHAIRMAN:Hewouldtendtobecomemoreviolent?

14 A.Butthat'susuallywithautisticchildrenandthat,

15 becauseIworknowwithtwoautisticchildrenandthey

16 reactexactlythesameway.Theydon'thitbutyoucan

17 seethechanges.Theytakeofftheirshoes,youcan

18 see‐‐theycan'texpress,butI'vegotonewhodoesn't

19 talkatall,butyoucanseetheydon'tlike‐‐theway

20 thattheyareacting,theydon'tlike‐‐theydon't

21 acceptnewfaces.

22 MRAZOPARDI:Notsaiddirectly,butareyouputtingdown

23 thechangeinbehaviourtothechangeinmedicationthat

24 hehad?

25 A.Si,aswell,thatthing.Ithinkthatthemedicationas

120

1 wellhadalottodowithit.

2 Q.Plusalsothenewmembersoftheteamthat‐‐

3 A.Newmembersofteams.

4 Q.‐‐hewasreactingagainst?

5 A.Sometimessuppliesusedtocome,peoplefromADA,that's

6 acompanythatmaybeusedtocome.LikeIsaid,once

7 theyhavethingstheydon'taccept‐‐

8 Q.Sorry‐‐

9 A.Ithinkwearelikeafamilytothem,youknow.It's

10 normal,Ithinkit'snormalforthemtoreactthatway.

11 Q.Sorry,ADAareaprivateproviderofcarers,aren't

12 they?

13 A.Aprivateproviderofcarerswhentheydon'thaveenough

14 staff.

15 Q.Sowhatyouaresayingisthatfromtimetotime,dueto

16 lackofstaff,ADAwouldbeaskedtoprovidecarers?

17 A.Providecarersforus.

18 Q.Andthatwouldincreasethenumberofnewfacesthat‐‐

19 A.Ofcourse,ofcourse,ofcourse.

20 Q.‐‐woulddealwithL.Isee.

21 A.Evenforusit's,youdon'tfeelcomfortableorworking

22 withsomebodyyoudon'tknow,no?

23 Q.Yousayinyourparagraph29,Ithink,onthisissue

24 {E/62/5}thatwhilehewasreactingagainstthenew

25 membersoftheteam,equallytheywerequite



121

1 apprehensiveandscaredabouthim?2 A.Si.Si,theywerescared.Youcouldsee‐‐andhe3 couldseetheywerescared.4 Q.DidbeingscaredofLmakethesituationworse?5 A.Ofcourse.Ofcourse,because...6 THECHAIRMAN:By"thesituation",Ithinkmadehis7 behaviourmorechallenging.8 A.Evenworse,yes,ofcourse,becauseheknewtheywere9 scaredofhim.

10 MRAZOPARDI:Sohewouldgetworse?11 A.Worse,si.12 Q.Tellme,whenthedecisionwastakentogetyoutowork13 withLandLwasthefirstchildwithalearning14 disabilitythatyouhadworkedwith,didtheSocial15 ServicesAgencyarrangeanytraining,specialtraining?16 A.Yes.17 Q.Yes?18 A.Si,Ihavehadquiteafewcourses,Ihavehadbeforeas19 wellcoursesinhospitalaswell,andinBleakHouse20 before,becauseIusedtoworkwithchallenging21 behaviour,IhadaDTR,thecourse,andIhadbreakaway22 courseaswell,especiallywhentheybecamevery23 violent,theytoldustoabreakaway,andtheytoldus24 howtodoitproperly.25 Q.Forgivemeforasking,becauseIjustdon'tknowthe

122

1 answer,isthereaspecialtypeoftrainingforpeople2 withchallengingbehaviourwhohavealearning3 disability,orisitthesametraininggenerallyfor4 everyonewithchallengingbehaviour?5 A.No,Ithinkit'sthesameone.6 Q.Isee.7 A.Ithinkit'sthesameone.8 Q.YourecallthatLleftforEnglandinMay2009,andyou9 areawareofcoursethatLmadesomeallegationsabout

10 youandotherpersonsintheCareAgency.Youcomment11 onthoseallegationsinyourstatement,butperhapsif12 ithelpsyoujusttorespondtomyquestion,ifIcan13 pulluponscreen{M27/23/4},whichisanemailwhich14 containsasummaryoftheallegations.Soifyoujust15 readittoyourself,thisisanemailbetween16 WarwickshirePoliceandGibraltarPolice.17 (Pause)18 A.Si,I'vereaditinthehouseaswell.19 Q.Whatdoyousaytothatallegation?20 A.Well,whenCarmenMaskilltoldme,Iwasshockedand21 thenIlaughedbecauseIsaidnobodyhad‐‐likeIsay22 theword‐‐gutstogetoverhimandputhisheadonthe23 toilet.Anyway,thetoiletwasthatsmallthatwhenyou24 hadtogetinthetoiletyouhadtogoactuallyinand25 thenturnandthenclosethedoor,andanywayInever

123

1 workedSharonOpenshaw,shewas‐‐Iwasnightstaffand

2 shewasdaystaff,soI'veneverworkedwithher.

3 IthinklikeMrsAdamberrysaid,thatwewerethelast

4 threepersons,Itookhimtotheairport,Ididn't

5 actuallygototheUK,butItookhimtotheairport

6 withManolitaandwestayedwithhimandIwentinside

7 to...IthinklikeIsaid,it'sgotallconfused

8 becausetheinjectionhehaditactuallyinsidethe

9 waitingroom,andthenhegotconfusedwiththethreeof

10 ushadbeenthere.Ithinkinnowayfourpersonswould

11 havegotinsidethetoiletwithhim.Therewasonly

12 roomforone,letalonefour.Andanyway,likeIsaid,

13 I'veneverworkedwithSharon.Iusedto‐‐Sharonin

14 meetings.That'swhereIusedtoseeSharon.Inever

15 workedwithher.Ineverworkeddays.

16 Q.Yousay‐‐

17 A.JustononeexceptionIworkeddaysthat,butIhadto

18 meetsomebodyinthePiazza,thedaystaffinthe

19 Piazza,that'stheonlydayIworked.

20 THECHAIRMAN:That'stheonlytime?

21 A.Time.That'stheonlytimeIworkedintheday,withL.

22 ButIneversawSharonthereanyway.Itwasanother

23 careworker,SarahJones.

24 MRAZOPARDI:Yousay,MrsRobba,inparagraph56ofyour

25 statement,{E/62/7}andthisisthe‐‐youhadmade

124

1 apointearlieraboutLbeingconfused,andyoudo

2 mentiontherethattherewasachildincare‐‐

3 A.Yes.

4 Q.‐‐calledRobert;isthatcorrect?

5 A.Yes.

6 Q.Isthisachildthathadsufferedasexualabuse?

7 A.Idon'tknow.Idon'trecallthat,butIknowtherewas

8 achildincarenamedRobert.

9 Q.Butyousaythere:

10 "Isuspectthathehadoverheardconversations

11 regardingsexualabuseaboutachildincare..."

12 A.Yes,yes,nowIrememberbutthatwasanotherchildwith

13 thisRobert.

14 Q.So‐‐

15 A.Notacarer,itwasachildthat'sinUKnowatthe

16 moment,withRobert.

17 Q.Sorry,therewas‐‐

18 A.SomethingthathappenedwithRobertandanotherchild

19 whowasincareaswell.

20 Q.Allright.

21 A.Andperhapshemusthaveheardsomething,Idon'tknow,

22 carerscommentingaboutit,Idon'tknow.

23 THECHAIRMAN:Youthinkhemixeditup?

24 A.Hemixeditup.

25 THECHAIRMAN:Andgotconfused?



125

1 A.Hehasn'tgotanunclenamedRobert,andtherewasn't

2 anycarernamedRobert,onlythisRobert.Butanywayhe

3 never,heneverwaswithhim,becausehe‐‐sometimes,

4 si,insummernightstheyusedtobealltogether,but

5 likeIsaidheneverusedtobeinthehouseonany‐‐

6 butperhapshemusthaveheardsomethingabout‐‐

7 MRAZOPARDI:CanItakeitinstages,becauseIamgetting

8 confused?

9 A.Si.

10 Q.Areyousayingthattherewasachildincarenotcalled

11 Robertbutwho,toyourknowledge,thischildhad

12 sufferedsexualabuseand‐‐

13 A.Itwasamildone‐‐

14 Q.‐‐itwasinrelationtoapersoncalledRobert?

15 A.Si.

16 Q.Isthatcorrect?

17 A.Si.

18 Q.Isthatwhatyouaresaying?

19 A.No,no.

20 Q.That'swhyIwasconfused.Explainittome,then.

21 A.ThisRobert,theotherchildwhoisinUKnow‐‐

22 Q.IscalledRobert?

23 A.No.

24 Q.Allright.Let'shaveagoagain.

25 THECHAIRMAN:Don'tinterrupt,MrAzopardi,lether

126

1 describeit.

2 A.Heisnotincarenow.ThischildRobertisnotincare

3 now.Heusedtobeincare,andtherewasanotherchild

4 that'sincareinUK,hewassenttoUK,andtherewas

5 somethingtodowithsexualabuse,butverymild,

6 betweenthetwo.AsfarasIknow,but‐‐

7 MRAZOPARDI:Okay,sotherewasnoRobert?

8 A.TherewasaRobert,si,aboynamedRobert,si,incare.

9 AboynamedRobertandanotherboywhoapparentlydid

10 sexualabusetoRobert,whoisinUK.That'swhatIam

11 saying.

12 THECHAIRMAN:ThisInquiryisturninginto:whereis

13 Robert?

14 A.RobertisstillinGibraltarbutheisnotincarenow,

15 heusedtobeincare.

16 MRAZOPARDI:IthinkIhaveunderstooditnow.Iamnot

17 goingtotryagainbutIthinkIhaveunderstoodit.

18 Youweresuspendedfor‐‐

19 A.Ninemonths.

20 Q.‐‐pendinganinvestigationforninemonthsandthen

21 reinstated?

22 A.Reinstated,buttheagencyreally,CarmenMaskilltold

23 menottoworry,theyknewitwasunfounded,theyknew

24 itwasn'ttrue,andsi,theyreassuredmetheyknewbut

25 theyhadtosuspendedbecauseitcamefromUK,andthey

127

1 reallyhadtoinvestigatewhatissaid,it'snormal,no?

2 Itcouldbetrueanditnotbetrue,sotheysaid"Don't

3 worry,weknowit'snottrue",whenshecalledmetothe

4 officeto...

5 Q.Butyouwereanxiousandsurprised?

6 A.Anxious,surprised,anditcostmefourlittlestomach

7 ulcersandastomachhernia,fromtheworrying,you

8 worryanyway.Youknowitislittle,butyouworry.

9 Iworry,Iworryalot.

10 Q.Youarebackworkingwithchildreninthe‐‐

11 A.LikeIsaid,twoautisticchildren.

12 Q.Withchallengingbehaviour?

13 A.No.

14 Q.Justautisticchildren?

15 A.No,no,si,onedoesn'tspeakatall,theotherone,he

16 didn'tspeak,andsincehehasbeenwithushespeaks

17 SpanishandEnglishperfectly,heisveryintelligentas

18 well.

19 Q.Okay.

20 A.Theone,thetwoof...

21 MRAZOPARDI:Ihavenofurtherquestions,sir.

22 THECHAIRMAN:DoesanybodywishtoaskMrsRobbaany

23 questions?No.

24 MrsRobba,thankyouverymuchindeedforcoming.

25 Iappreciateit'sdifficulttodiscussthesemattersbut

128

1 youhavebeenagreathelp,thankyouverymuch.

2 THEWITNESS:Si,Iknow,it'sverydifficult.Thankyou

3 verymuch.



6 MRENGLEHART:Sir,thereisonemorewitnesstoday,

7 MsVallender.Wouldyouwishtogostraighton?

8 THECHAIRMAN:Straighton,yes.

9 MRENGLEHART:Idon'tbelievethiswitnesswillbevery

10 long.MsVallender,please.

11 MSMANDYVALLENDER(called)

12 THECHAIRMAN:Goodafternoon,MsVallender,thankyouvery

13 muchforcoming.Makeyourselfcomfortableifyoucan.

14 Youknowroughlyhowthingsgo.Youwillfindabitof

15 paperinfrontofyouwiththeinitialsthatweare

16 usingtoidentifyparticularresidentsifyouneedto

17 mentionthem.

18 A.Okay.

19 THECHAIRMAN:Sowewilltryanddothat.It'sveryeasy

20 foranametoslipoutsodon'tworry,butifyoucan

21 usetheletters,itwouldhelp.

22 MrEnglehartwillaskyousomequestionsin

23 amoment,theremaybesomeotherquestionsfromother

24 counsel.Wewon'tdetainyouanylongerthanweneed

25 to.Couldyoustartbygivingyourfullnameandyour



129

1 address,please?

2 A.MynameisMandyVallenderandIliveatVillaVerde1

3 inGuadacorte,Spain.

4 THECHAIRMAN:Right.Yes,MrEnglehart.


6 MRENGLEHART:Youhavemadeawitnessstatementquite

7 recently,canweputituponthescreen,itisbundle

8 {E/65/1}.Doyouremembermakingthatstatement?

9 A.Yes.

10 Q.Isitcorrect,oristhereanycorrectionyouwantto

11 make?

12 A.No.

13 Q.Addition,subtraction?

14 A.No.

15 Q.CanIaskyouafewquestionsaboutit,please?You

16 IthinkstartedworkingintheDrGiraldiHomeas

17 asupplyworker?

18 A.Yes.

19 Q.Isthatright?

20 A.That'sright,yes.

21 Q.Whenwouldthathavebeen?

22 A.Thatwasin2003,Ithinkthatwas.

23 Q.Thenyoubecameafull‐time‐‐

24 A.Afteraboutthreeorfourmonths,yeah.

25 Q.Areyoustillthere?

130

1 A.Yeah.

2 Q.Yes,Ithoughtyouwere,yes.Sowhenyouinitially

3 started,IbelieveIamrightinsayingyouwere

4 particularlyconcernedwiththeyounggentlemanwhowe

5 callResidentL;isthatright?Doyouhavealist

6 there?

7 A.Yeah.

8 Q.Isthatright?

9 A.Yes.

10 Q.Youmadeastatementlargelydealingwithmattersthat

11 hadbeenputtoyou,butIwouldjustliketogetupthe

12 documentsthatyoureferto.Wewillstartwith

13 adocumentyoureferto,whichistobefoundat

14 {D34/4/6}.ThisisthedocumentIthinkyouare

15 referringtoinparagraph3ofyourwitnessstatement.

16 Doyouseethat?

17 A.Yeah.

18 Q.Youmakethepointthatdoesn'tlooklike

19 KirushkaCompsonandifit'sanyconsolationtoyoushe

20 saysit'snothersignature?

21 A.Yes.

22 Q.Andshewasn'tasenior?

23 A.Iamnotsureifshewas.Ithinkshemighthavebeen

24 atthetime,yeah,Ithinkso,yeah.

25 Q.Right.Anyway,regardlessofwhetherit'smadebyher

131

1 orsignedbyher,isthereanythingthatyouwouldlike

2 tosayaboutthat?

3 A.That'sthefirstI'veheardofit,whenIpickedmy

4 papersupfortheInquiry,Ihadnotseennorheardof

5 itsincethen,Iwasn'tawarethatthatwasevenmade.

6 THECHAIRMAN:Youweren'tawareofitatthetime?

7 A.No.

8 MRENGLEHART:DidResidentL‐‐howdidyougetonwith

9 him?

10 A.Yeah,wehadquiteagoodrelationship,butobviously

11 he‐‐withhisproblemsandeverything,hewasvery

12 aggressiveattimes.

13 Q.Whatwouldmakehimaggressive,whatsortofthings?

14 A.Anychangeof‐‐evengoingtoschool,gettingonthe

15 businthemorning,hewouldlashoutsometimes,change

16 ofnewstaff,thingslikethat.

17 Q.Sowasthereanyparticularrhymeorreasonaboutit?

18 A.No,hejust‐‐that'showhewassometimes.

19 Q.Andquitesudden?

20 A.Yeah.Sometimesyoucouldpredictif,youknow,hewas

21 goingtobehavethatway,sometimesyoucouldn't.

22 Q.Didanyoneever‐‐Iknowwhatyouaregoingtosay,

23 Ithinktheanswerisno.No‐oneeverputthisincident

24 toyouuntiltheInquirytookplace;isthatright?

25 A.No,theincidentwasbroughttomyattentionbyJoanna,

132

1 IhadaninterviewwithJoanna‐‐

2 Q.Youdid?

3 A.Yes.

4 Q.Oh,right,Ididn'trealisethat.

5 A.ButforthisactualdocumentIdidn'tknowanything

6 aboutthis.

7 Q.Yes,that'stheone,youarequiteright.Soifwelook

8 at{P/24/14}.Well,let'slookat{P/24/7}to9.

9 A.Thisonethat'sonthescreenatthemomentalso

10 Ididn'tseeuntilIpickedupmypapers.

11 Q.Youdidn'tseeit?

12 A.No.

13 Q.Let'slookattheoneImention,P,tab24.

14 A.ThisalsoIdidn'tseeuntilIpickedupmypapers.

15 Q.Thisone?

16 A.Yeah.

17 THECHAIRMAN:Whatarewelookingat,P/24/7?

18 MRENGLEHART:Yes,Ithinkweare.Yes.P/24/7.Thisis

19 thenoteofameetinginwhichJoannaHernandezhadwith

20 ResidentL.Haveyoueverseenthis?

21 A.OnlywhenIpickedmypapersupfortheInquiry.

22 Q.Let'sidentifyit,whatseemstohavebeensaidto

23 JoannaHernandez.Doyouseeinthemiddleofthe

24 left‐handpage:

25 "JH:Didsheslapyou?



133

1 "L:Yes,onthatface."2 A.Yeah.3 Q.Hepointstohisrightcheek.4 "JH:That'snotnice,Idon'tlikethat.5 "L:Writeitdown?Tellhernottohitmeorhe6 willgetdie.GoawayMandy."7 WhichIassumeisyou?8 A.Yes.9 Q.Therewouldn'tbeanyotherMandy,wouldthere?

10 A.No,notthatIknowof.11 Q."JoannaHernandez:Didsomethingelsehappen,[L],do12 youwanttotellmesomethingelse?13 "L:Shethrewacupofwateratmyhead."14 Waseitherofthosesuggestionscorrect?15 A.No,notatall.16 Q.Thengoingoverthepage,{P/24/8}fourthlinedown:17 "Sean,Stefan,solo,SharoncallSharonnow."18 WhoIpresumewouldbeareferencetotheladywe19 havejustseen?20 A.No,no,nottheoneyouhavejustseen,SharonBerini.21 Q.Sosorry,youarequiteright.Ofcourse,thatwouldbe22 SharonBerini.Quiteright.23 A.Yeah.24 Q."JH:Wewilltrytogetsomeoneyoulike."25 Sharonwasaway.Thengoinghalfwaydownthepage,

134

1 doyousee?Itsays:

2 "L:Callthepolicenow."

3 A.No,I'velostit,sorry.

4 THECHAIRMAN:Abouthalfwaydown,wherethemarkis.

5 A.Yeah.

6 MRENGLEHART:"Glasson[nameredacted]'sheadclotheswet.

7 Puttingtheglasson[nameredacted]'shead.Sharon

8 cometosee[L]now.

9 "JH:Didyouchangeyourclothes?

10 "L:No.

11 "JH:Weren'tyoucold?Didyousleepwithwet

12 clothes?

13 "L:No,Mandydidit."

14 Iamnotquitesurewhatthatmeans,butIdon't

15 thinkyouareeither.

16 THECHAIRMAN:Canyouthrowanylightonthisatall?

17 A.Theonlythingwith[nameredacted]ismostmorningshe

18 wouldsoilhimselfbeforecomingoutofhisbed‐‐there

19 wouldbeaveryrareoccasionwherehedidn't.Hewould

20 cometohisdoorandhewouldopenthedooralittle

21 bit,andyouwouldseehim,andthenhewouldsay"Caca,

22 Mandy,caca",andhewouldbe‐‐youknow,hehas

23 alreadydoneit.

24 MRENGLEHART:Canwenowgo,then,that'stheinterview,

25 Ijustwanttoputthisincontext,becauseyousayyou

135

1 gotconfrontedbyJoannaHernandez,andthereis

2 aminutewehaveofthat,whichisatbundle{M1/4/1}.

3 It'sameetingwithyou.Doyourememberthismeeting?

4 A.Yes,butthisisn'ttheactualmeeting.

5 Q.Iamgoingtocometothat.

6 A.Okay.

7 Q.Thisiswhathasbeenretainedonthefiles,and

8 Iappreciatetoyourwitnessstatementyouhaveput

9 anamendedminute‐‐

10 A.Yeah.

11 Q.‐‐whichseemsnottohavebeenputonthefile,butwe

12 willcometothat.

13 A.Okay.

14 Q.Justlookingattheoriginaldocument,firstly.

15 A.Yeah.

16 Q.Thethirdparagraphdown,youweretoldthiswasnot

17 adisciplinary?

18 A.Mm.

19 Q.Doyouseethat?

20 A.Yeah.

21 Q.Wereboth‐‐itlooksasiftheywere‐‐SharonBerini

22 andJoannaHernandezatthismeetingwithyou?

23 A.Yes,theydid,yeah,Sharontooktheminutesand‐‐

24 Q.AndyoutoldJoannaHernandezthatyouhadnevereven

25 raisedyourvoicetohim,letalonehithim?

136

1 A.Yeah.

2 Q.Isthatright?

3 A.Yeah.

4 Q.Youneverhithim,didyou?

5 A.No.

6 Q.No.

7 A.Never.

8 Q.Thethrustofthisinterviewit'sonthenextpageover,

9 {M1/4/2}abouthalfwaydown.

10 "What[L]isexpressingisjustwithyou,notwith

11 NB~..."

12 That'spresumablyNigelBassadone?

13 A.Yeah.

14 Q."...thefocusisjustonyouandhehasconsistently

15 saidittodifferentpeople,hehasbeenveryclearin

16 relatingwhathashappened."

17 Yousay:

18 "Well,youdon'tknowmebutSharonknowsme."

19 A.BecauseI'venevermetJoannauntilthatinterview.

20 Thatwasmypointofsayingtoherwhenshewasspeaking

21 tomethewayshewas,becauseshewasveryintimidating

22 andjustnotparticularlyveryniceatall,soIwas

23 thengettingupsetbecauseshewassayingthistomeand

24 sothat'swhatIsaidwhatIsaidbecauseIhadknown

25 Sharon,sheknewme.SoIwassayingtoSharon,you



137

1 know,"Youknowme,shedoesn't".SoIwasvery‐‐you2 know,Iwasupset.3 Q.YouthoughtSharonwouldthinkitwasn'tthesortof4 thingyouwoulddo?5 A.(Witnessnods)6 Q.AndMsHernandezisrecordedassaying:7 "Don'tgetupset,thesethingshappen."8 Andyouarerecordedassaying:9 "Iknowbutit'snotbloodynicewhenit'snot

10 true."11 A.Yeah.12 Q.Wasthatprettymuchwhatyouwerethinking?13 A.Yeah,yeah.14 Q.ThenyouweretoldbyJoannaHernandez:15 "Well,Ihavetomoveyoufromtheteamforyourown16 benefitbecauseofthethingsthat[L]issayingheis17 goingtodotoyou.Iwillpassthisinformationonto18 MarieGomezandifthereisgoingtobeadisciplinary19 thenIwillletyouknowinwriting."20 A.Yeah,yeah.21 Q.Sowhatwasyourreactiontothat?22 A.Well,Ijustthoughtitwasabitodd,becauseIassumed23 thatIwouldbe‐‐obviouslynotthatIwantedtobe,24 butIassumedthatIwouldbesuspendedbecauseifyou25 are‐‐

138

1 Q.Wereyou?

2 A.No.Ifyouhavebeenaccusedofsomethinglikethat,

3 Ididn'tunderstandwhytheyweremovingmetoflat2,

4 wherethereisclientsthataremorevulnerablethan

5 [nameredacted]is,andtheycan'tspeak,andifI've

6 justbeenaccusedofthat,formethatjustdidn'tseem

7 tomakeanysenseatall.

8 Q.Youexhibittoyourwitnessstatementadocumentwhich

9 wefindat{E/65/12}to14,whichIbelieveis

10 anamendedminute‐‐

11 A.Yes.

12 Q.‐‐ofthatsamemeetingwehavebeenlookingat?

13 A.Ididthisthefollowingmorning.

14 Q.Youdidthisthefollowingmorning?

15 A.Yes.

16 THECHAIRMAN:Sothehandwritingisyours,isit,

17 MsVallender?

18 A.Yeah.

19 MRENGLEHART:Anditissoyoudidn'tthinkthatitwas

20 fullyaccurate,thepreviousminute.

21 A.No,because‐‐sorry,no,Ididn'tdoitthefollowing

22 morning,Iwentinthefollowingmorning,becauseSharon

23 saidtomeifyoucomeinthemorningyoucanpickup

24 theminute,sowhenIwentinthemorningshehandedme

25 theminutesandshesaid"Ifyoucansignthose",and

139

1 Isaid"I'mnotsigningthemuntilI'vereadthem".So2 Itookthemhome,thisiswhenIrealisedtherewere3 bitsmissing,someofitisn'tparticularlyrelevantbut4 itwasstillsaid,soIaddedit,Ithentookitback5 thefollowingday.6 Q.Whenyousaythefollowingday?7 A.Sorry,itwouldbetwodaysafterthat,itwouldhave8 been,becauseIwouldhavepickedtheminutesupthe9 followingmorningandthenItookminein,soitwould

10 betwodaysaftertheinterview.Sorry.11 Q.Iamgettingveryfiercelooksfromthetranscriber.12 A.SoIwouldhavetakenittwodayslater.13 THECHAIRMAN:Twodayslater?14 A.Yes.15 MRENGLEHART:AndhandedittoJoannaHernandez?16 A.Idon'tremember,Ithink‐‐Idon'tknowiftheywere17 bothintheoffice‐‐18 Q.Whodoyoumeanby"both"?19 A.Sorry,SharonBeriniandJoanna,Ican'treally20 remember,butIknowItookitinandsaid,"Look,there21 isbitsmissingoffofthis,Ihaveaddedit,soifyou22 wanttoreadthroughit,typeitup,thenifyou23 believe,youknow,that'sallcorrect,thenI'llquite24 happilycomebackandsignit".Nothingelsewasdone25 aboutit,Ineverheardanythingmoreaboutit.

140

1 Q.DidyouevergobackwithL?

2 A.No.

3 Q.No?

4 A.No.

5 Q.Youmovedontoadifferentteam?

6 A.Yeah,theymovedmeto,IthinkIdidanightwith‐‐

7 IthinkIdidonenightwithAE,andthenIthinkIwent

8 toflat2,andIdiddaysandnightsthereafterthat.

9 Q.Thatwaswithwhom,sorry?

10 A.ThenitwouldhavebeenResidentE.

11 Q.Right.

12 A.ResidentT,ResidentAA,ResidentABandResidentAI.

13 Q.Youaddressinyourwitnessstatementsomeoftheissues

14 thatarebeforetheChairman,thathehastoconsiderin

15 thisInquiry.Ingeneralterms,youarestillthere,

16 Imean,havethingschanged‐‐

17 A.Yeah.

18 Q.‐‐since2005?

19 A.Yeah,yeah,theyhave,yeah.

20 Q.Forthebetterortheworse?

21 A.Forthebetter.Thereisdefinitelymore,youknow,

22 moretraining.Wedefinitelydidnothavetheright

23 trainingatthattime,whenIwaswith[nameredacted].

24 IhaveonlyjustnowdonemyDCRT1,Icouldhavedone

25 withdoingthatthen‐‐



141

1 Q.Sorry,whatisDCRT?

2 A.Forrestraining,youknow,restrainingsomebodyinthe

3 properwayand‐‐

4 Q.Physically?Howtorestrainpeoplephysically?

5 A.Yeah.Yeah.

6 Q.Sodidyougetanytrainingbeforeyou‐‐

7 A.Yeah,wedidthebasictrainingonreportwriting,

8 confidentiality,thingslikethat,medication,and‐‐

9 Q.Butnot‐‐

10 A.Butnotanythinglikethat,thatIwouldhaveneeded

11 thatearlyon,becauseIhadonlybeenliterallythere

12 threeorfourmonthsbeforeIwasputwith[name

13 redacted]‐‐

14 Q.L?

15 A.Sorry.

16 Q.It'sveryeasilydone.Yes.Soyoureceivednospecial

17 trainingforthat?

18 A.No.

19 Q.Asfarasyouknow,didanyoneelse?

20 A.No,becauseitjustwasn't‐‐thereisnow,butthere

21 wasn'tatthetime.Itwasverysparse,therewasnot

22 verymuchatallreally.

23 THECHAIRMAN:Wehaveheardsomeevidencetotheeffect

24 thatthereweredifficultiesaboutattendingtraining

25 sessionsbecausethereweren'tenoughstafftogoaround

142

1 andthenifthetrainingsessionwasavailable,it

2 didn'tfollowthattherewasanybodythatcouldbe

3 pulledoffthejobtogoandattendit.Doesthat

4 accordwithyourmemory.

5 A.Yeah,yeah.

6 MRENGLEHART:Whilstweareonthattopic,whatabout

7 staff?Wehaveheardquitealotevidenceabouthow

8 thereweretremendousstaffshortages.Wasthatwhat

9 youwerethinking?

10 A.IonlyworkedmainlythenightshiftandIwastheonly

11 oneonthenightshift.Therewasnevertwopeopleon

12 anight.Duringtheday,hewouldhavetwocarers.

13 Q.Right.

14 A.Butonanighttherewasonlyone.

15 Q.Really?Didyoufindthatdifficultbeingtheonlyone?

16 A.Mostofthetimeitwasokay,becauseobviouslywhenyou

17 aregoinginat9o'clockhe'skindoflikegetting

18 readyforbedandthingslikethat.Hegenerallyslept

19 throughthenightreally.Hegotupquiteearlybuthe

20 didn'treally‐‐theonlymajorproblemIsupposewas

21 sortoftakinghimtoschoolbecauseyouhadtogoup

22 therampthereandsometimeshewouldsortofcreate

23 then,butsometimespeoplewouldbealreadyonshiftby

24 then,so‐‐becausehewasgoinguptothe‐‐uptothe

25 schoolbusat,like,quarterto9andsomepeoplethat

143

1 startedat9o'clockwouldgettherejustalittlebit

2 earlier.

3 Q.Whataboutsleepingonnightshift,wasthatsomething

4 thathappened?

5 A.No.

6 Q.Younevercameacrossit?

7 A.No.Ihavesince,butnotatthatparticulartime,no.

8 Q.Youhavesince?

9 A.Yes.

10 Q.Youneverheardofithappening?

11 A.No.

12 Q.Right.

13 THECHAIRMAN:Whenyousayyouhavesince,doyoumeanyou

14 haveheardofitsinceoryouhavewitnesseditsince?

15 A.No,I'vewitnesseditsince.


17 MRENGLEHART:Didyoueverfallasleeponnightshift?

18 A.No.

19 Q.Anyway,turningtoyourtreatmentoftheissues,you

20 keptasortofdiary,anincidentbook?

21 A.Yes.

22 Q.Yes?AreyouawareofanyincidentsofwhatIwould

23 callrealabuse?

24 A.No.

25 Q.Physicalabuse?

144

1 A.No.

2 Q.Doyourememberwhethertherewerecareplans?Yousay

3 therewere.Idon'tknowwhatyoumeanbycareplans

4 firstofall?

5 A.Theyarenothowtheyarenow,it'sdoneinadifferent

6 formatnow,butIknowwhenwestartedwith[name

7 redacted]hehadafile,butitwouldbekindoflike

8 whatyouhavethere,it'sjustpaperwork,it'slined

9 piecesofpaperwherepeoplehaveputin,Idon'tknow,

10 wayshowtohandlehim,ifitwasinthiskindof

11 situation,orsomethinglikethat.Butit'snothowit

12 isnow,asinit'sapropercareplanonaproper

13 form‐‐

14 Q.Astructureddocument?

15 A.Yeah.

16 Q.Butthatwasn'tthecase,therewererandombits‐‐

17 A.NotthatIremember,no.

18 Q.‐‐ofpaper?

19 A.Ijustreallyrememberkindofpiecesofpaperin

20 afile.

21 Q.Right.

22 THECHAIRMAN:Wealsoheardquiteabitofevidencethat,

23 onchangesofmanager,fileswentmissing,anditwas

24 difficultforthenewmanagerornewstaffcominginto

25 acquaintthemselveswithwhathadbeenhappeningbefore.



145

1 A.Yeah.

2 THECHAIRMAN:Doesthataccordwithyourrecollectionor

3 canyoucommentonitatall.

4 A.Notalot,really,butyeah,becausewehavehadlike,

5 Ithinkit'stennow,wehavehadabouttenmanagersin

6 thatperiodoftime.So...

7 MRENGLEHART:Hasthatcausedproblems?

8 A.Notwithme,no.

9 Q.Butjustgenerally,didyouhavetheimpressionthatit

10 createddifficulties?

11 A.Notreally,no.

12 Q.Yousay,askedaboutworkingrelationship,didthestaff

13 getonwell?

14 A.Yeah.

15 Q.Onthewhole?

16 A.Yes.

17 Q.Weretheretwocamps,asfarasyouareaware?Have

18 therebeen?

19 A.NotthatIwasawareof.

20 Q.Youtalkabout,youstartedatBishopHealyandthere

21 wereclearlyissues,yousay,inthatteenagerswould

22 mixwithyoungerchildrenatrecreationaltime.When

23 yousaytherewereclearlyissues,Iamnotquitesure

24 Ifollowwhatyourmeaningis?

25 A.Ifounditveryodd,becauseImean,Ihaven'tstudied

146

1 todothis,it'sdifferentnowbecauseIknowthejob

2 butatthetimeIdidn't,butIfoundthatveryodd,

3 thattherewerechildrenandadultsmixedtogether.

4 Q.Yes?

5 A.WithinBishopHealy,becauseyouhadpeoplelike...you

6 havelikeResidentAE.

7 Q.Yes?

8 A.MixingwithResidentR,whoisconsiderablyyounger,and

9 Ijustthoughtthatwasadanger.

10 Q.Diditinfactgiverisetoanyproblemsthatyoucan

11 remember?

12 A.Yeah,IrememberonedaythatIwasthere,Idon'tthink

13 Ihadbeenthereverylong,andResident‐‐justbear

14 withme.ResidentAE,Iwasactuallyinside

15 ResidentL'sloungewith...

16 Q.ResidentAE,yes?

17 A.(Pause).IwasinResidentL'sloungewithResidentC,

18 becausehehadhadaseizure,andthemajorityofthe

19 otherresidentswereoutsideonthepatio,andthen

20 Iwasawarethattherewasacommotionoutside,andwhen

21 wewenttolookoutside,ResidentAEhadpickedup

22 agreatbigconcreteflowerpotandproceededtochuck

23 itacrossthepatio,andsoeverybodywasaskedtocome

24 inside.So‐‐

25 Q.Butwasthereanyspecificproblemsspecificallyrelated

147

1 tomixingofagesasopposedtodifficultbehaviour?

2 A.Well,yeah,Idon'tpreviousthatthat's‐‐

3 Q.Ofcourse,Iquiteunderstandthatshouldn'thave

4 happened.Butwasthatattributabletotheage

5 difference?

6 A.Erm...

7 THECHAIRMAN:Itsoundsfromwhatyouweredescribingas

8 thosetheincidentwiththeflowerpotwasjust

9 dangerousforeverybody,whatevertheirageandwhether

10 theywerestafforresident?

11 A.Yeah,butIdothinkit'saproblemifyouhaveafour

12 yearoldwithsomebodythat'sofa‐‐

13 MRENGLEHART:Yes,right,it'smoredangerousforafour

14 year‐old.Anyway,it'sprettyundesirableactivity

15 anyway.

16 A.Mm.

17 Q.Howdoyougetonwithrelatives?

18 A.Ididn'treallyhavemuchcontactwithResidentL'smum,

19 really,becauseIwasthenightshift.Ihaddonedays

20 withhim,butthemajorityoftheyearandahalf,the

21 twoyears,thatIwaswithhim,itwasnightshift.So

22 Ididn'thavemuchcontact.

23 Q.Right.YourefertoBishopHealybeinganoldbuilding

24 withlimitedfacilities?

25 A.Mm.

148

1 Q.It'sclosed,isn'tit?2 A.Ibelievesonow,yes.3 Q.Youdon'tknow?4 A.(Shakeshead)5 Q.Wheredoyouactuallyworknow?6 A.IamworkingatDrGiraldi'sflat1now.7 Q.Atwhat,sorry?8 A.Flat1Iamworkingatnow.9 Q.Right.Whatdidyoudoaboutmedicine?Howdidthat

10 work?Youwereonnights.Didyouhavetoadminister11 medicineduringnights?12 A.Idon'tremember.Ithink‐‐IamnotsureifIdidin13 themorningornot.Idon'treallyremember,Ican't14 rememberhistimesofmedicationoranythinglikethat.15 Q.Werethereanydifficultiesyourememberwith16 medication?17 A.No.18 Q.Soyouknewalwayswhatpillstogive?19 A.Well,Idon'tknow,Idon'tactuallyrememberdoingit,20 Ican'treallyrememberbecauseonadaytime,whenIdid21 workontheday,likeIsay,Ididn'tdoverymany22 shiftsduringthedaybutifIdidtheothercarerused23 todoit.SoitwouldbeeitherNigelorJordanDavis,24 JennyGarrett,soitwouldbetheonesthatweremore25 experienced,becauseIhadonlybeenthereacoupleof



149

1 months.

2 Q.Youhavenevereverinyourtimeeverbeendistributing

3 medicines?

4 A.Sincethen?

5 Q.Yes,sincethen?

6 A.Yes,ofcourse.

7 Q.Youhavesincethen?

8 A.Yes.

9 Q.Whileyouhavebeendistributingmedicines,hasthe

10 systemgotbetter?

11 A.Yeah,itisnow,wehavenursesnowsotheydothat,but

12 atthemomentweareallintheprocessofdoingthe

13 medsassessments,soyouhavetopassobviouslythatto

14 beabletodothat,ifneedsbe.

15 Q.YousaythestandardofhygieneatBishopHealywasnot

16 good?

17 A.No,notreally,no.

18 Q.Whenyousaynotreally,wouldyouliketoexpandon

19 thatabit?

20 A.Well,therewasrats.

21 Q.Really?

22 A.Yeah.

23 Q.Howoftendidyouseethat?

24 A.Ipersonallysawitonemorning.

25 Q.Onemorning?

150

1 A.IwasreadingResidentL's‐‐astoryoutsideonthe2 patioanditwasjustinfrontofthekitchendoor,and3 heactuallysaidtome"Oh,rat,rat"andwhenIlooked4 therewasone,quiteabigone,runningacrossthe5 kitchenfloor.6 Q.Right,anyothertimes?7 A.No.Iknowtheydidcatchquiteafew.Butbathrooms8 were‐‐thethingisyouhavetodowhatyou‐‐youcan9 onlydowhatyouhavegot,youknow,andthebathrooms

10 towhattheyarenow,thenitwasjust‐‐nowwhenyou11 lookback,itwasterriblereally.12 Q.Bycomparisonwithwhatitistoday?13 A.Yeah.14 Q.Isee.Yousayyouhadneverseen,Ibelieve,acodeof15 conduct.Isthatright?16 A.Yeah.17 Q.Noteventoday?18 A.Sorry?19 Q.Noteventoday?20 A.Sorry,repeat?21 Q.Acodeofconduct?Youweresayingyouhadneverseen22 acodeofconduct?23 A.No,notthatIcan‐‐24 Q.Iwasjustsaying:haveyounotseenonetodayorthe25 lastyearorso?

151

1 A.No.No.

2 Q.Iwouldliketoaskyouaboutonedocumentwhichwefind

3 atbundle{M4/5/1}.Youarenamed,thisisthereason

4 Iamaskingyouaboutthis,onthetopright‐hand

5 corner.Doyouseethat?

6 A.Yes.

7 Q.It'sResidentT.Isthisyourhandwriting?

8 A.Yeah.

9 Q.Itis?

10 A.Mm.

11 Q.Right.Sothefirsttwoparagraphs,wouldyoujustread

12 themtoyourself,please?

13 (Pause)

14 A.Yeah.

15 Q.ThisIbelievearoseafterfollowingatripto

16 Barcelona,didn'tit?

17 A.Yeah,Ibelieveso.Thisreport,though,Idon'tknow

18 whythisisinhere,becauseasfarasIwasconcerned

19 nothingwasdoneaboutthis.

20 Q.No,no,Idon'twanttoaskyouthat.Doyouremember

21 theoccasion?

22 A.Yeah.

23 Q.Whataboutthebottomofthepage?"Theyaskthe

24 policeman",doyouseethat?

25 A.Yeah.

152

1 Q.Wouldyoureadthatandthenextfivelines?

2 (Pause)

3 A.Yeah.

4 Q.HereisResidentTobviouslycomplainingaboutthe

5 treatmentshewasgetting?

6 A.Yeah.

7 Q.Wasthatunusual?

8 A.FormethenbecauseIdidn'tknow,Ididn'tknowwhat

9 ResidentT‐‐wasitT?Yeah.Iwasn'tawareofher

10 behaviour,ofhowshecanbe,soI've‐‐Ididthisat

11 thattimebecauseshewasveryupset,shewasupsetmost

12 oftheday,mostofthatmorning,andthenIdidthis

13 report,andwhenIhandeditto,whoeveritwasnow,

14 LizGallagherIthink,shewasthesenioratthetime,

15 andshesaidtome"Iamnotgoingtodoanythingabout

16 that".Thiswasawhileago.Sheisveryrepetitive

17 andthisiswhatsheissayingallthetime,andIsaid

18 "Okay,Ididn'tknow,IwasdoingwhatIamsupposedto

19 do,soI'vedonethisreport".

20 Q.Yes,Iunderstandthat.Youstartedoffbysayingyou

21 didn'tknowwhatshewaslikeatthetime?

22 A.Mm.

23 Q.Wouldyouliketoexpandonthat,justtoexplainit?

24 A.Becausesheisveryrepetitiveandshestilltothisday

25 goesonaboutthis.



153

1 Q.Isshereliableinthethingsshesays?What'syour

2 appreciationofit?

3 A.Ithinknow,if‐‐toanswerhonestlynow,Idon'tthink

4 thatsheisreliable,no.

5 THECHAIRMAN:MrEnglehart,Idon'tknowifyouhaveany

6 morequestions?

7 MRENGLEHART:Iwasgoingtositdownatthatpoint.

8 THECHAIRMAN:It'squartertofour,sowewilltake

9 aquarterofanhourtobreaknowandperhapsIcould

10 ask:doesanybodyelsehaveanyquestionsofthis

11 witness,MsVallender?

12 MRENRIGHT:Ihadonequestion.

13 THECHAIRMAN:Canwewaitaquarterofanhour?Ithink

14 thetranscribersneedarestandthenIwillaskyou,

15 MrEnright.

16 Ifyouwouldn'tmindstaying,MsVallender,just

17 aquarterofanhour,andthenthereisanotherquestion

18 tocome.

19 A.Yeah.

20 THECHAIRMAN:So4o'clock.

21 (3.50pm)

22 (Ashortbreak)

23 (4.00pm)


25 MRENGLEHART:UnusuallyMrEnrightseemstobeabsent,and

154

1 MsVallendertoo.

2 MRNAVAS:Theyarecomingin.

3 THECHAIRMAN:MsVallender,wouldyoumindcomingbackjust

4 forashorttime?Thankyouverymuch.

5 A.Okay.

6 THECHAIRMAN:MrEnrighthasaquestiontoaskyou.


8 MRENRIGHT:Iamverysorryformakingyouwaitlikethat.

9 Itwillbeveryquickthough.

10 Understandablyyouwouldhavebeenupsetinregard

11 oftheallegationsthatthechildmade,Ifully

12 understandthat.Ihopeyouwillacceptitwascorrect

13 forthemanagertotakeitseriously,anallegationlike

14 that?

15 A.Yeah.

16 Q.Andtotakeacarefulnoteandtopassitupto

17 MarieGomeztomakeadecisionaboutwhattodoabout

18 it?

19 A.Yeah.

20 Q.Justfinally,youdidmentionBishopHealyHouseand

21 yourexperiencesofthat;couldyougiveusalittle

22 moreaboutBishopHealyHouse?Yousaidyouwerenot

23 happywiththebathrooms,etcetera,thatratswere

24 there?

25 A.Yeah,itwasjust,Imean,wemadeitascleanaswe

155

1 couldmakeit,butobviouslyitwasn'tagreatplaceto

2 be,itwasn'ttherightenvironmentIdidn'tthink.

3 Q.Atthattime,thereweretwochildresidentsthere;is

4 thatcorrect?

5 A.WhenIfirststartedthere,itwasall‐‐becausethere

6 hadbeenaflooding,sotherewas,Ithinktherewere

7 someresidentsliving‐‐thoughIcan'treallyremember,

8 butIknowitwasmainlyrespitethatwasupthere.

9 Yeah,itwasrespitelikeduringtheday,thenIgot

10 movedontothenightshift,sothentherewasonly

11 literallyacoupleofpeople,residentsonaweekendfor

12 respite.[Nameredacted]wasthereobviously

13 permanently.Theneverybodyelsegotmovedbackdownto

14 DrGiraldi'sandthenIthinkforthelastfourorfive

15 monthsthatIdidtherebeforeIwasmoved,Iwasonmy

16 job,therewasnobodyelsethere,itwasjustmeand

17 [nameredacted]onanight.

18 Q.Whatyearwasthat?

19 A.Thatwas,well,justpriortothatallegation,sothat

20 musthavebeen‐‐sothatwouldhavebeen‐‐Idon't

21 knowwhenthatwas.WasthatApril2005?Yeah.Soit

22 wouldhavebeenacoupleofmonthspriortothat,Iwas

23 onmyownupthere.

24 MRENRIGHT:Yes.Thankyouverymuch.

25 A.Thankyou.

156

1 THECHAIRMAN:Thankyouverymuch,MrEnright.Does

2 anybodyelsewanttoaskanyquestions?

3 Thankyouverymuch,MsVallender,thatistheend

4 ofyourevidence.YouhavebeenveryhelpfulandIam

5 verygrateful.Thankyouverymuch.

6 THEWITNESS:Thankyou.


8 MRENGLEHART:Sir,therearenomorewitnessestoday.


10 MRENGLEHART:Wehaveafairlyfullprogrammetomorrow.

11 THECHAIRMAN:Ithinkwehavesixwitnessesintheframe.

12 MRENGLEHART:Ithinkonlyfive,sir.Wehavethreemore,

13 Icallitforshorthand,section11andthenMrWilson,

14 andMrIsola,Queen'sCounsel.

15 THECHAIRMAN:Right.Wemustgetthroughthemasbestwe

16 can.That'sitfortoday,ladiesandgentlemen,wewill

17 meetagainat10o'clocktomorrow.

18 (4.05pm)

19 (Thehearingadjourneduntil10.00am

20 onWednesday,16October2013)

21

22

23

24

25



157

1 INDEX2 PAGE3 Housekeeping.........................................145 MRSMANUELAADAMBERRY(continued)....................267 QuestionedbyMRAZOPARDI(continued).........289 QuestionssuggestedbyMRVASQUEZ............19

1011 QuestionssuggestedbyMSMORAN..............211213 QuestionssuggestedbyMSBALESTRINO.........271415 QuestionssuggestedbyMRPITTO..............281617 QuestionssuggestedbyMRNAVAS..............321819 QuestionssuggestedbyMRENRIGHT............362021 MRJONATHANTEUMA(called)..........................372223 QuestionedbyMRENGLEHART...................382425 QuestionssuggestedbyMRVASQUEZ............77

158

12 QuestionssuggestedbyMRENRIGHT............7934 MSSHARONOPENSHAW(called).........................9356 QuestionedbyMRENGLEHART...................9478 QuestionssuggestedbyMSMORAN.............1079

10 MRSROSEROBBA(called)............................1081112 QuestionedbyMRAZOPARDI...................1091314 MSMANDYVALLENDER(called)........................1281516 QuestionedbyMRENGLEHART..................1291718 QuestionssuggestedbyMRENRIGHT...........15419202122232425



159October 15, 2013 Dr Giraldi Home Inquiry Day 10


A

AA (1) 140:12AB (1) 140:12abilities (1) 26:24able (7) 23:14 30:24

75:8 76:1 81:5109:13 149:14

abroad (2) 92:2,7absent (1) 153:25absolutely (6) 81:1

86:16 89:5,7,7,17abuse (9) 99:4,5 124:6

124:11 125:12126:5,10 143:23,25

abusive (1) 119:3accept (8) 59:20 91:17

91:19 92:17 118:25119:21 120:7154:12

accepted (1) 92:12accommodate (1)

37:8accompanied (2)

11:13 41:24accord (4) 10:3 11:19

142:4 145:2account (3) 50:3 69:15

80:11accurate (2) 16:6

138:20accused (2) 138:2,6achieve (1) 83:7acquaint (1) 144:25acted (1) 64:6acting (9) 20:15,19

44:9 46:8 77:5 78:678:7 79:12 119:20

actions (2) 72:18116:1

activities (1) 50:23activity (1) 147:14actual (4) 70:16 88:12

132:5 135:4ADA (3) 120:5,11,16Adamberry (33) 2:18

2:20,22 3:1 8:2318:23,24 19:1724:8 27:20 28:1728:20 29:15 32:2,732:9 34:16,1835:24 36:18 96:1897:2 98:11 99:6,18102:18 111:1,2112:21 113:1,21123:3 157:5

Adamberry's (1) 21:23add (5) 40:18 64:24

75:12 81:9 95:1added (2) 139:4,21Addition (1) 129:13address (8) 38:14 62:5

63:2 94:15,16109:9 129:1 140:13

Adelaide (3) 6:13 24:924:17

adequate (3) 28:4,1128:12

adequately (2) 51:2109:17

Adjacent (1) 32:19adjourn (1) 87:3adjourned (1) 156:19adjournment (1) 93:4administer (1) 148:10administrative (1)

77:25admirably (1) 30:2admitted (1) 88:6admitting (1) 50:9adults (1) 146:3

advance (1) 58:10advice (2) 26:8 78:4advise (1) 26:3advised (1) 26:18AE (9) 39:22 40:1 43:7

43:8 140:7 146:6146:14,16,21

affect (4) 12:8 26:2527:1,4

afraid (3) 26:1,6 108:1afternoon (3) 108:19

108:20 128:12age (5) 43:8,13 114:24

147:4,9agency (16) 1:15 9:16

16:2 63:23,2575:15 96:7 101:19101:21 102:25103:5,9 110:9121:15 122:10126:22

agent (1) 29:19ages (4) 43:5,12 56:11

147:1aggressive (6) 9:21

51:4 113:18 115:1131:12,13

ago (6) 1:20 12:1536:7 68:15 95:6152:16

agree (5) 9:19 29:4,1774:16 84:25

ah (2) 29:3 76:20AI (1) 140:12aim (1) 83:22airport (5) 15:3,3,7

123:4,5albeit (1) 9:11allegation (21) 13:18

13:24 32:5,6,1134:19 96:15 99:499:10 100:4 103:15103:19 104:9,15,22106:8 107:13,19122:19 154:13155:19

allegations (13) 12:2112:21,24,25 64:185:15 99:22 100:15107:22 122:9,11,14154:11

alleged (2) 32:2333:14

allow (3) 44:12 52:983:23

Alman (1) 97:25amended (2) 135:9

138:10amount (2) 54:15 72:1Angela (1) 10:24angry (1) 11:23animosity (1) 29:6Anne (1) 27:21anonymity (1) 94:12answer (16) 2:12 4:3

7:22 25:17 29:7,1730:1 31:8,10 56:1956:22 67:8 90:18122:1 131:23 153:3

answered (4) 23:2029:14,15 30:2

answers (2) 36:1786:25

antisocial (1) 53:5anxious (2) 127:5,6anybody (8) 23:23

70:14 77:24 86:2127:22 142:2153:10 156:2

anybody's (2) 17:13

35:20anyway (22) 10:1

41:14 61:15 74:1174:24 81:4 90:1893:19 100:23 102:8106:10,19 122:23122:25 123:12,22125:2 127:8 130:25143:19 147:14,15

Apart (2) 95:8 112:8apologies (1) 81:4apologise (2) 45:11

47:10apologised (1) 72:17apparently (2) 73:19

126:9appear (2) 13:12 66:6appeared (1) 119:8appears (7) 5:20 9:10

9:13,20 10:1 11:1324:7

appreciate (5) 26:1685:11 103:13127:25 135:8

appreciation (1) 153:2apprehended (1) 72:1apprehensive (1)

121:1approached (1) 75:1appropriate (4) 2:5

66:21 84:10 87:24April (2) 57:16 155:21area (2) 33:6 52:9arm (1) 8:10arms (1) 13:19arose (2) 2:1 151:15arrange (1) 121:15arrangements (1) 61:5arrested (1) 92:8arrive (1) 5:5arrived (4) 3:12 4:8

84:2 89:15aside (1) 76:13asked (18) 5:3 14:19

22:22 23:13 25:431:2 35:11,22,2345:4 58:20 69:5,1082:9 101:9 120:16145:12 146:23

asking (9) 14:20 34:2135:13,20 36:894:14 103:17121:25 151:4

asleep (2) 88:17143:17

aspect (1) 19:21assessment (3) 11:5,6

11:13assessments (1)

149:13assist (2) 85:4 109:14assistance (1) 109:16assistant (2) 78:8

79:13assisted (1) 85:19associated (1) 44:18assume (1) 133:7assumed (2) 137:22

137:24assuming (1) 103:18attempted (1) 24:10attend (3) 41:4 103:18

142:3attendance (3) 35:25

37:24 41:8attended (2) 40:23

60:3attending (2) 54:17

141:24attention (3) 41:16

86:11 131:25attenuant (1) 69:14attributable (1) 147:4August (1) 96:8Australia (3) 106:24

107:1,2autistic (4) 119:14,15

127:11,14availability (1) 37:5available (1) 142:1avoid (1) 22:14aware (27) 9:1 10:10

12:20,24 52:1756:11 64:3 70:1070:12,12 71:1478:17 87:20 89:1699:17,21 101:25103:2,4 122:9131:5,6 143:22145:17,19 146:20152:9

awareness (1) 77:14Azopardi (47) 2:16,17

2:24,25 3:1 4:13,187:16,23 13:10,1213:17 14:7,12,1414:21 16:23,2517:15,24,25 18:2,418:7,12,16 19:1,10108:16,17 109:25110:1 111:25 112:8114:25 117:4,25119:22 121:10123:24 125:7,25126:7,16 127:21157:7 158:12

A/22/1 (1) 32:7

B

baby (1) 16:14back (28) 5:8 13:19

36:21 42:4 48:2150:1 53:2 57:3,9,1378:7 86:1,11 92:892:24 103:18106:23 113:25114:16 115:1,3127:10 139:4,24140:1 150:11 154:3155:13

backed (2) 113:22114:21

bad (1) 92:12badly (1) 12:5Balestrino (11) 27:17

27:18,19,21 28:1685:25 86:6,7,19,20157:13

Banderas (1) 52:14Barcelona (1) 151:16bare (1) 89:6based (1) 67:13basic (1) 141:7basically (7) 2:10

44:18,21 45:2051:25 54:11 75:3

basis (6) 11:11 39:1155:11 71:8 88:2390:4

Bassadone (4) 35:4,936:9 136:12

Bastion (4) 28:10112:5,6,7

bathroom (1) 88:20bathrooms (3) 150:7,9

154:23beach (1) 78:16bear (7) 1:8 8:2 25:16

46:16 52:22 88:15146:13

becoming (1) 113:17bed (9) 8:25 33:21

34:4 69:24 89:1189:13 115:12134:18 142:18

bedroom (9) 33:15,1733:21,23 34:744:17 45:4,1361:16

bedrooms (2) 33:7,9began (1) 39:20beginning (5) 42:15

50:19 77:6 114:2117:12

begins (1) 62:4behalf (2) 83:5 84:4behave (1) 131:21behaved (3) 50:24

56:10 113:5behaviour (21) 9:22

10:21 12:3 50:1753:5 55:23 86:4111:19 112:9,17117:10,13 119:7,23121:7,21 122:2,4127:12 147:1152:10

believe (23) 3:1317:10 22:8 24:429:22 31:12 37:6,937:10 58:18 60:1968:10 90:11 92:7107:11 128:9 130:3138:9 139:23 148:2150:14 151:15,17

believes (1) 34:22belonged (1) 33:9benefit (3) 88:13 96:1

137:16benefitted (3) 27:24

55:25 56:4Berini (15) 19:21 20:3

20:6,18 35:4 46:847:13 59:3 62:1677:3,5 133:20,22135:21 139:19

Berkenshaw (1) 6:20best (7) 9:20 25:13

28:8 38:11 50:1261:12 156:15

better (9) 8:1 9:212:16 42:6 106:2110:2 140:20,21149:10

bewildering (1) 91:20beyond (1) 65:2big (5) 15:15 48:16

61:15 146:22 150:4bigger (1) 56:4birth (1) 98:25Bishop (7) 28:6 145:20

146:5 147:23149:15 154:20,22

bit (36) 1:16 25:3,1938:4 42:16 44:449:3,4,8 53:12,1353:13,14 56:7 57:459:21 72:12 79:582:13 94:2,9 95:25103:14 105:8 109:5109:13 111:22,22113:10 117:21128:14 134:21137:22 143:1144:22 149:19

bits (3) 139:3,21144:16

Bleak (1) 121:19bloody (1) 137:9bolt (2) 3:7,9

bombshell (1) 100:23book (8) 4:20 5:1,9,14

9:7 51:10 64:19143:20

booked (1) 93:11boss (1) 22:25Bossano (1) 2:3Bossano's (2) 2:1,13bother (1) 35:14bottom (6) 17:13

33:13,25 62:3 83:1151:23

bottoms (1) 18:20box (4) 32:15 89:19,21

89:24boy (7) 27:12 113:5

114:9,24 126:8,9,9boyfriend (2) 116:8,9boys (1) 80:7break (9) 10:23 31:18

36:20,25 58:12121:21,23 153:9,22

breakfast (1) 115:13bribe (1) 27:11briefly (2) 77:2 106:2bring (4) 11:3 29:24

70:22 86:11bringing (1) 52:23broadly (2) 39:25 95:8brought (2) 44:19

131:25budget (1) 61:13building (1) 147:23bullying (1) 35:7bundle (11) 57:6

64:23 73:8 95:1298:22 99:11 103:24105:15 129:7 135:2151:3

bureaucracy (1) 57:4bus (2) 131:15 142:25buy (1) 61:14

C

C (1) 146:17cabinets (1) 88:5caca (2) 134:21,22call (13) 6:20 42:20

62:6 87:2 94:2197:15 103:17108:17 130:5133:17 134:2143:23 156:13

Calle (1) 38:15called (25) 1:6,25 2:7

3:3 5:5 23:1 24:835:3 37:17 59:1660:1 70:20 93:23104:15 108:18124:4 125:10,14,22127:3 128:11157:21 158:4,10,14

calm (5) 44:2,12 115:2115:4,5

calmed (1) 113:25Cameron (1) 38:16camps (1) 145:17cannabis (1) 72:1capable (3) 85:18

114:14,15care (49) 9:3 11:14

23:6 62:5,17,22,2363:1,4,5,24 65:1467:15 69:17 74:484:14 88:12 92:697:2,16,20 98:8101:19,21 102:25103:5,9 110:9,14110:17 111:17112:3 122:10

123:23 124:2,8,11124:19 125:10126:2,2,3,4,8,14,15144:2,3,12

cared (2) 51:3 79:25careful (2) 84:14

154:16carer (10) 5:2 10:2

16:1 20:19 77:22118:17 119:1124:15 125:2148:22

carers (17) 10:5 20:925:24 26:9 41:1053:6 57:24 63:2178:3,23 119:8120:11,13,16,17124:22 142:12

carer's (2) 52:15 63:19caring (1) 84:14Carmen (3) 101:15

122:20 126:22carry (4) 2:17 18:11

23:14 31:25carrying (3) 92:8

101:24 102:6Caruana (1) 16:1case (13) 1:9,16,19

41:21 44:16 46:2350:4 72:23 84:1690:24 101:22109:16 144:16

cash (3) 47:1,24 48:1catch (2) 55:17 150:7category (1) 85:1caught (1) 8:20caused (1) 145:7caution (2) 72:2,3cent (1) 24:4centre (2) 40:4 52:4CEO (1) 61:7cereals (1) 50:6certain (7) 11:23

12:21 38:25 40:942:12,13 63:4

certainly (1) 85:4cetera (3) 88:20,20

154:23chain (1) 21:18Chairman (183) 1:4,21

1:23 2:1,12,16,192:22 7:16 14:1616:22,24 17:2418:1,24 19:11,1419:17 21:6 22:2123:20,24 25:3,1425:17,21 26:8,1326:16 27:17 28:1829:14 30:2 31:6,931:12,17,22 32:534:9,15,20,2435:23 36:3,17 37:237:4,8,12,16,18,2137:23 38:2,6,11,1840:20 43:4,7,11,2448:10,12 54:1358:17 60:5,1062:13 67:5 70:1971:19 75:5,7 76:2579:18 83:16,2584:8,19,24 85:9,1786:6,14,18,21 87:288:8 89:3 90:1292:10,18,20,2393:2,6,13,17,19,2293:24 94:5,14,1895:6,24 97:7 98:2,599:20 100:14,18103:23 104:13,16104:19,23 105:4,8



105:12 106:15107:6,16,21,25108:3,8,11,16,19108:21,24 109:2,12109:19,22 111:21112:6 114:20116:17 117:1,22119:7,10,13 121:6123:20 124:23,25125:25 126:12127:22 128:5,8,12128:19 129:4 131:6132:17 134:4,16138:16 139:13140:14 141:23143:13,16 144:22145:2 147:7 153:5153:8,13,20,24154:3,6 156:1,9,11156:15

challenging (12) 40:342:21 86:4 111:19112:9,17 119:7121:7,20 122:2,4127:12

chance (1) 114:16change (12) 5:13

26:12 42:16 69:16104:15 117:9,13119:23,23 131:14131:15 134:9

changed (13) 3:2550:17,18 64:5 69:469:7 71:2 89:25104:9,22 117:12118:11 140:16

changes (7) 66:7,1066:12,24 70:17119:17 144:23

changing (2) 66:2069:11

chat (2) 47:7 67:17checking (1) 117:6cheek (1) 133:3cheekier (1) 75:14Cheryl (1) 14:17child (42) 3:10,13,15

8:24 11:23 20:1222:15 26:5 45:147:3 53:11 55:1061:19 63:24 69:1669:17 80:3,3,10,1280:12,20 84:1488:16,21,22 112:13121:13 124:2,6,8124:11,12,15,18125:10,11,21 126:2126:3 154:11 155:3

children (23) 52:2353:20 78:24 80:1480:15 86:9,12,1286:17,17 92:1111:18,19 112:1,9112:16 119:14,15127:10,11,14145:22 146:3

children's (2) 95:14112:3

choice (2) 50:1,12choose (1) 91:25Chris (1) 9:15Christian (1) 68:18chronology (1) 116:2chuck (1) 146:22circumstances (2)

75:19 104:6civil (1) 23:9claim (1) 2:14clarified (2) 14:13,16clarify (8) 2:5 19:20

20:1,5 86:8 88:10105:14 108:4

clean (7) 35:19 49:1588:14,18,19 91:3154:25

cleaning (3) 88:2289:1 90:21

clear (11) 9:12 28:735:2 55:16,1866:11 84:2 85:2288:10 107:14136:15

clearly (4) 41:13 82:9145:21,23

client (16) 1:18 29:430:8,15 40:1 83:7,883:9,14 84:1,22,2485:6,14,15 89:10

clients (1) 138:4client's (5) 2:9 30:4

83:5 84:17 86:9close (4) 25:9 52:4

117:14 122:25closed (1) 148:1closeness (1) 26:23clothes (3) 134:6,9,12clothing (1) 87:24code (3) 150:14,21,22coincided (1) 58:12cold (6) 48:22 49:1,2

49:24 83:3 134:11colleague (3) 6:6,11

20:14colleagues (2) 70:14

88:13collect (1) 47:1colloquially (1) 106:20combination (1)

112:16combine (1) 116:22come (30) 2:5 5:5

35:21,22,23 36:836:21 46:18 47:1350:13 51:6 52:1355:7 60:13 67:1969:8 77:12,25 78:1116:5 120:5,6134:8,20 135:5,12138:23 139:24146:23 153:18

comfortable (3) 37:21120:21 128:13

coming (22) 1:14,1724:2 36:18 37:1938:2 48:1 55:2256:12 66:16 78:387:19 93:24 108:12108:21 119:10127:24 128:13134:18 144:24154:2,3

command (1) 21:18comment (10) 30:14

47:2,11 51:5 56:2371:21 73:13 88:25122:10 145:3

commented (2) 58:2270:23

commenting (1)124:22

comments (1) 13:5commitments (1)

93:10common (2) 52:18,20commotion (1) 146:20communicate (6) 6:5

6:15 20:22 22:7,2431:5

communication (4)21:7 59:12 64:19

66:15communications (1)

51:10communicator (1)

78:18community (3) 52:23

53:5 63:7company (2) 29:20

120:6comparison (1)

150:12compartments (1)

89:22complained (1) 90:24complaining (2) 91:16

152:4complaint (1) 36:9complaints (1) 64:1complete (1) 68:6completely (2) 83:17

83:19completeness (1) 2:3complicated (1) 21:14comprehensive (1)

54:24comprehensively (1)

83:10Compson (3) 59:3

68:10 130:19concern (3) 2:9 61:25

86:9concerned (8) 92:2,5,9

94:20 102:10 103:9130:4 151:18

concerning (2) 84:2496:15

concerns (1) 22:5conclusion (2) 62:20

69:6concrete (1) 146:22condition (2) 27:6

90:13conditions (2) 91:8,18conduct (3) 150:15,21

150:22conducted (1) 14:2confidence (1) 79:6confidentiality (1)

141:8confine (2) 84:20,21confining (1) 86:23confirm (1) 30:14confronted (1) 135:1confused (10) 105:8

115:24 116:17,20123:7,9 124:1,25125:8,20

conscious (1) 84:12consequence (1) 99:9consider (1) 140:14considerably (1) 146:8consistency (1) 68:24consistent (1) 74:16consistently (1)

136:14consolation (1) 130:19consulted (4) 54:16

55:3,4,5contact (14) 29:11

47:23 56:14 67:2169:21 81:11 101:6101:11,12,12,23102:15 147:18,22

contacted (4) 35:18101:3,13 102:8

contacts (1) 41:24contains (1) 122:14context (3) 18:7 66:2

134:25continue (1) 1:12

continued (4) 2:20,25157:5,7

continuing (2) 103:5103:20

continuity (1) 70:3contract (2) 39:16

74:1contracting (1) 29:19contradictory (1) 73:7contrary (1) 88:14contributed (1) 89:16control (1) 25:2controls (1) 49:10conversations (1)

124:10cook (1) 91:2cooking (1) 91:3cool (1) 115:1copies (2) 59:2 76:7Corey (1) 6:17corner (3) 33:3,4

151:5corners (1) 61:22correct (26) 3:7 19:24

25:4 33:10 39:2345:21 60:20 76:1780:7 95:8,15100:11 107:9 110:7110:15,18 111:3,8112:14 124:4125:16 129:10133:14 139:23154:12 155:4

correction (1) 129:10correctly (3) 12:14

21:15 83:20correspondence (1)

91:15corridor (1) 33:5Cory (1) 97:25cost (1) 127:6counsel (4) 76:23 94:7

128:24 156:14count (1) 98:8country (1) 54:19couple (9) 21:4 23:22

31:20 38:9 44:666:23 148:25155:11,22

coupled (1) 62:20course (21) 8:9 16:17

19:14 28:10 40:2241:3 46:3 63:181:12 120:19,19,19121:5,5,8,21,22122:9 133:21 147:3149:6

courses (6) 40:24 41:441:11,13 121:18,19

court (1) 108:2courtyard (1) 52:8covered (4) 21:7 37:14

49:20 71:5covering (1) 19:4covers (1) 89:14create (2) 71:13

142:22created (1) 145:10credibility (1) 85:7critical (2) 85:6,14cross (1) 18:19cross‐examination (1)

83:19cry (1) 113:14crying (1) 25:24cup (1) 133:13cupboards (2) 71:2,4current (1) 61:5curtain (3) 8:21,22,25curtains (2) 8:18,18

cut (1) 106:10cutting (1) 57:7C1/2/2 (1) 30:7C2/2 (1) 30:5

D

daily (5) 55:6,7,1156:14 88:23

dance (1) 114:1danger (1) 146:9dangerous (4) 61:20

86:10 147:9,13date (8) 59:4 60:9

64:8 74:7 75:189:18 98:25 104:13

dated (1) 60:6dates (6) 29:9 40:25

95:3,4,5 101:5David (2) 36:5 79:21Davis (1) 148:23day (53) 1:4 5:1,2

10:15,15 17:1725:24 27:14 41:1241:12 44:25 46:2546:25 47:3 50:1650:18,19,20 55:7,775:17 78:1 82:784:3 89:11 90:2391:2 97:12,15,1697:24,25 98:3,499:23 116:24117:17 118:5,9,22123:2,18,19,21139:5,6 142:12146:12 148:21,22152:12,24 155:9

days (16) 15:19 46:1768:13 69:11 75:2078:5 89:23 97:11123:15,17 139:7,10139:12,13 140:8147:19

daytime (1) 148:20day‐to‐day (1) 69:18Day7:75/21 (1) 17:17Day7:76/1 (1) 18:4Day7:77/1 (1) 18:13DCRT (2) 140:24 141:1de (1) 38:16deal (5) 9:21 27:5 71:9

112:18 120:20dealing (2) 85:19

130:10deals (1) 104:5dealt (5) 51:8 83:10

92:13 101:19112:14

dearly (1) 68:25December (3) 62:18

82:25 84:1December(sic) (1)

60:22decided (3) 10:4,24

106:22decision (3) 10:16

121:12 154:17Decisions (1) 9:24decorative (1) 61:14deep (1) 12:13deeply (2) 51:3 74:4definitely (10) 42:7,7

42:7,23,24,2546:25 67:11 140:21140:22

degree (2) 39:6,7demanding (2) 75:16

75:21Denielle (1) 68:11Denise (3) 16:20 33:14

91:7

deny (2) 13:24 85:8Department (1) 112:3depends (1) 46:23describe (6) 11:8

15:22 80:19 85:1113:4 126:1

described (1) 86:10describes (3) 51:2

90:19 91:8describing (2) 115:23

147:7description (1) 9:23deserved (1) 56:10despite (2) 12:3 75:18detail (1) 62:1details (2) 99:8 103:13detain (1) 128:24detract (1) 95:1diaries (1) 1:9diarrhoea (1) 51:25diary (2) 4:5 143:20diazepam (2) 105:22

106:4dictated (2) 24:8,16die (1) 133:6diet (1) 87:12difference (1) 147:5different (17) 18:6

19:4 43:18,19,2074:13,17 78:1379:1 89:23,23103:19 118:10136:15 140:5 144:5146:1

difficult (11) 7:1820:22 26:16 69:22111:22 112:18127:25 128:2142:15 144:24147:1

difficulties (4) 9:18141:24 145:10148:15

difficulty (2) 7:11109:19

dining (1) 33:6dinner (1) 91:1direct (1) 68:14directed (2) 74:14,18directing (1) 89:3direction (2) 74:15,19directly (12) 6:15,17

6:24 22:5 58:14,2068:9 84:4,22,2488:11 119:22

dirt (2) 71:5 90:10dirty (2) 87:19 90:9disabilities (2) 69:14

112:14disability (3) 27:22

121:14 122:3disabled (2) 45:1

67:16disagreed (1) 73:15disagreements (2)

68:22,23disastrous (1) 10:21disciplinary (8) 72:9

72:15,16 74:22,2474:25 135:17137:18

discipline (1) 27:14discrepancies (1)

68:21discuss (7) 1:17 9:2,20

62:7,17 63:3127:25

discussed (1) 107:19discussion (1) 99:3disgusting (1) 91:9

dishes (1) 90:25dismiss (1) 74:14dismissal (2) 2:2,13dismissed (3) 74:19,23

75:23dispute (2) 71:25

92:11distressed (1) 49:15distressing (3) 49:22

50:4,10distributing (2) 149:2

149:9document (28) 4:4

9:11 24:18 48:654:8,24 60:1661:10 62:11,12,1462:25 63:12,1798:21 99:25 100:2100:9 103:21 107:9109:18 130:13,14132:5 135:14 138:8144:14 151:2

documents (4) 68:1372:6 75:10 130:12

doing (11) 5:12 12:1441:5 68:1 91:25102:16 117:19140:25 148:19149:12 152:18

door (11) 3:9,25 33:134:7,11 45:1951:12 122:25134:20,20 150:2

doubt (3) 72:5 76:5,5downstairs (2) 52:8

65:4Dr (11) 1:5 27:25 28:1

28:12 32:10 39:843:22 110:9 129:16148:6 155:14

draw (1) 45:2drawing (1) 44:24dressed (1) 115:13drink (2) 14:19 18:24drug (1) 106:6drugs (1) 92:8dry (1) 3:17DTR (1) 121:21due (3) 79:8 107:24

120:15duplicate (1) 37:15dust (1) 71:5duties (3) 77:25 88:17

89:1duty (3) 6:17 68:16

98:19dying (1) 30:19D34/4/6 (1) 130:14D34/8/1 (1) 70:8D9/140/2 (1) 64:23D9/142/26 (1) 58:25D9/31/1 (1) 60:16D9/31/2 (1) 63:20D9/31/3 (1) 65:18D9/31/4 (1) 62:15

E

E (4) 57:6 95:12100:11 140:10

earlier (8) 70:20 74:2182:2 108:5 115:25117:6 124:1 143:2

early (3) 101:6 141:11142:19

ease (4) 53:14 79:2,6114:14

easier (2) 52:1 53:8easily (1) 141:16Easter (2) 58:12 67:3easy (4) 48:10,14



94:11 128:19eat (1) 27:12effect (1) 141:23eight (3) 50:3,10

118:8either (16) 9:6 28:13

37:10 41:15 44:847:4 67:7,11 74:1075:8 76:1 88:1691:23 133:14134:15 148:23

Elena (9) 22:4,12,2322:25 23:1 101:23101:24 107:12,18

elicit (1) 34:25email (3) 13:3 122:13

122:15embarrassed (1) 2:6Emilia (1) 30:20Emilia's (1) 30:21emphasis (1) 52:22employed (1) 95:13employee (1) 39:13employers (1) 41:5empty (1) 61:16England (9) 10:17 11:8

12:21 13:5 95:1499:1 117:15 118:6122:8

Englehart (72) 37:2,337:6,9,13 38:12,1938:20 40:22 43:1544:1 48:12,13,1654:19 56:20 58:2360:13 62:14 68:674:18 75:5,6,876:22 93:20,2194:5,18,19,20 95:896:4 97:10 98:799:25 100:21104:24 105:5,14106:15,16 107:4108:6,9 128:5,6,9128:22 129:4,5,6131:8 132:18 134:6134:24 138:19139:15 142:6143:17 145:7147:13 153:5,7,24153:25 156:8,10,12157:23 158:6,16

Englehart's (1) 108:4English (13) 6:12 9:11

20:22 21:8 23:1023:11,17 108:23109:17,20,21,24127:17

enquire (1) 103:23enquiries (1) 102:25Enright (56) 1:12,13

1:21,22,24 2:9,1536:1,4,5,5,17 74:1779:18,19,20,2183:7,8,13,21 84:2,784:12,20,23 85:585:24 86:1,8,16,2186:25 87:5 88:8,1189:3,6 92:10,1793:6,7,13,16,18153:12,15,25 154:6154:7,8 155:24156:1 157:19 158:2158:18

Enright's (1) 83:6entailed (1) 88:18enter (1) 10:25entire (1) 95:22entirely (1) 69:4entirety (1) 66:2entitled (2) 24:7 83:9

entry (2) 4:5 51:10environment (1)

155:2EPE (1) 62:12epileptic (1) 80:3equally (2) 79:2

120:25Er (1) 88:7Erm (1) 147:6erratically (1) 116:1escalate (1) 115:3especially (6) 24:1

78:5 88:23 111:19115:25 121:22

este (1) 2:23et (3) 88:20,20 154:23evening (1) 3:12event (3) 15:12 59:24

59:25events (3) 15:10 116:2

117:4Everest (1) 68:18everybody (4) 78:21

146:23 147:9155:13

evidence (30) 2:1,132:21 17:24 19:2270:2 71:15,22 73:673:15 79:9 83:1083:10,11 84:15,1885:23 88:5,9 92:1592:20 96:13 108:6108:11,22 110:6141:23 142:7144:22 156:4

exactly (13) 3:15 5:1841:12 45:24 46:1047:24 51:13 54:2057:18 59:9 60:1574:2 119:16

example (13) 12:1046:22 51:24,2463:8 78:22 81:1081:13,14,15 83:1391:1 116:4

exception (1) 123:17excess (1) 106:8exchange (1) 70:25Excuse (1) 83:4exhibit (3) 98:21

102:17 138:8exhibited (1) 54:3existing (1) 41:21expand (2) 149:18

152:23expect (2) 31:20 92:13experience (7) 11:19

44:25 45:2 53:278:12 112:22115:14

experienced (1)148:25

experiences (1)154:21

explain (9) 30:18,2544:4 53:11,12 65:696:21 125:20152:23

explained (4) 7:2327:7 51:11 116:6

explaining (1) 109:14explicit (1) 99:4explicitly (1) 82:4express (3) 2:9 109:17

119:18expressed (1) 70:20expressing (1) 136:10expression (3) 45:17

51:15 82:11extent (2) 12:1 85:5

extremely (3) 55:1655:18 85:22

E/1/5 (1) 25:12E/1/6 (1) 21:21E/1/8 (1) 15:17E/61/1 (1) 94:23E/61/15 (1) 98:22E/61/19 (1) 99:11E/61/2 (1) 103:12E/61/21 (1) 104:2E/61/23 (1) 103:24E/61/25 (1) 106:12E/61/26 (1) 106:16E/61/3 (1) 105:2E/62/2 (1) 110:3E/62/3 (1) 113:4E/62/4 (1) 115:22E/62/5 (1) 120:24E/62/7 (1) 123:25E/64/2 (1) 38:22E/64/25 (2) 48:7,22E/64/26 (1) 48:20E/64/3 (1) 80:18E/64/30 (1) 57:13E/64/31 (2) 57:11,21E/64/36 (1) 81:20E/64/40 (2) 54:1 80:5E/64/41 (1) 54:10E/64/44 (1) 54:24E/65/1 (1) 129:8E/65/12 (1) 138:9E/67/68 (1) 87:6E/67/69 (2) 73:9

87:14E/67/70 (2) 73:11

90:5E/67/99 (1) 74:12E/69/1 (1) 39:2E67 (1) 73:8

F

face (2) 95:25 133:1faces (4) 119:8,12,21

120:18facilities (1) 147:24fact (8) 20:21 46:3

52:18 69:4 86:1290:22 100:24146:10

factually (1) 76:17faeces (2) 3:16 49:21fair (12) 54:15 66:2

67:23 85:7 114:7115:14,20 117:16117:18,18,22,23

fairly (3) 46:4 65:11156:10

Faith (1) 30:18fall (3) 49:12 84:25

143:17falling (1) 61:24false (3) 89:7,7,17familiar (2) 48:15

89:21family (6) 16:13,16

56:15 59:18 89:16120:9

Famous (1) 37:10fantasies (2) 16:17,18fantasise (2) 16:5,6far (16) 9:8 47:23

52:20 55:2 70:2286:5,18 99:17101:25 102:10103:2,9 126:6141:19 145:17151:18

fashion (2) 15:2285:16

father (4) 30:19 55:8,9

72:18fear (1) 22:12fearful (1) 56:7February (2) 65:12

91:15fed (1) 72:12feed (1) 69:23feedback (1) 70:24feel (3) 83:4 109:19

120:21feels (1) 92:12feet (2) 8:20,21fell (3) 8:18,19 53:1felt (10) 2:10 56:24

61:11 68:1,2,375:22 79:15 85:1591:20

feria (1) 117:22fierce (1) 139:11fight (1) 116:10file (3) 135:11 144:7

144:20files (2) 135:7 144:23filled (1) 30:15finally (3) 90:5 92:1

154:20find (14) 21:14 28:18

69:7 75:8,10 83:17101:13 102:25108:1 112:22128:14 138:9142:15 151:2

fine (9) 23:24 29:1029:16 30:23 48:1557:8 66:20 82:1682:24

fingers (1) 55:17finish (2) 13:11,12finished (3) 7:20 19:18

92:20finishes (1) 108:11finite (1) 97:20Fire (1) 31:22first (41) 3:2,12 5:19

6:2 9:16 11:8 13:713:21 32:10 33:1135:6 38:13 39:2044:7 46:10,1159:15,15 60:1 61:567:12 70:16 71:877:13 78:5 87:1694:23 96:17,2199:20 100:8,18107:1,2 112:13118:9 121:13 131:3144:4 151:11 155:5

firstly (1) 135:14fit (2) 24:13 98:16fits (1) 61:23five (4) 13:13 152:1

155:14 156:12flat (39) 18:25 19:3,5

27:24 28:8,10 29:829:8 32:21,22 33:943:15,16,17 45:746:16,19 47:13,1448:2 51:17,21 65:565:8 73:20 88:1488:19,23 90:2197:18 106:5 112:5112:6,7,7 138:3140:8 148:6,8

flats (2) 43:18,19flights (1) 93:11flooding (1) 155:6floor (3) 32:10 38:16

150:5floors (2) 43:20 88:19Flor (7) 6:10,16,17 7:3

7:4 8:9 97:25

Flor's (2) 5:22,24flower (2) 146:22

147:8focus (1) 136:14follow (3) 63:12 142:2

145:24following (9) 101:3

138:13,14,21,22139:5,6,9 151:15

food (1) 27:12fool (1) 52:10forbidden (1) 52:14forced (1) 8:14forceful (1) 65:12forgetting (1) 69:13Forgive (1) 121:25form (2) 22:13 144:13formal (1) 63:12format (1) 144:6Fortuna (1) 6:13forward (3) 9:18,19

74:8found (9) 71:6 87:23

90:15 103:17 106:4106:9 130:13145:25 146:2

four (10) 13:13 123:10123:12 127:6129:24 141:12147:11,13 153:8155:14

fourth (4) 11:10 60:2162:14 133:16

frame (1) 156:11frankly (1) 84:17frantic (3) 49:3,5,7frenetic (1) 49:3frequent (1) 9:21frequently (3) 19:23

77:9,10Friday (3) 1:8 93:8,15fridge (5) 71:7 88:6

90:10,13,14friendly (2) 61:19,19friends (1) 17:19front (2) 128:15 150:2frustrated (1) 66:18frustrating (1) 59:9full (7) 38:13 66:1

73:24 94:14 109:8128:25 156:10

fully (2) 138:20154:11

full‐time (5) 39:8,1139:13,21 129:23

funeral (1) 99:24further (6) 19:10 21:2

33:7 80:23 92:14127:21

F/23/1 (1) 16:20F/23/3 (2) 16:22 91:6

G

Gabrielle (1) 35:7Gallagher (1) 152:14Garcia (1) 97:25Garrett (1) 148:24gate (1) 11:1Gayle (1) 68:18general (4) 12:21

52:23 55:25 140:15generally (8) 32:14

41:12 64:5 68:23113:5 122:3 142:18145:9

gentleman (3) 85:5109:22 130:4

gentlemen (2) 53:22156:16

genuinely (1) 116:17

getting (14) 10:15,2011:23 22:21 52:552:24 65:17 88:21125:7 131:14136:23 139:11142:17 152:5

Gibraltar (16) 12:1613:4 23:10 96:899:24 101:24 103:2103:4,5 106:23111:15,16 117:22117:23 122:16126:14

Giraldi (12) 1:5 27:2528:1,12 32:10 39:843:22 67:13,15110:9,11 129:16

Giraldi's (2) 148:6155:14

girl (1) 118:18give (26) 7:21 15:7

20:11 38:13 44:1146:21 49:23 59:1760:8 69:25 77:880:20 81:5,12,1594:8,14 104:16106:22 108:22113:10 114:16116:4 146:10148:18 154:21

given (13) 36:19 37:2444:17 61:23 70:2372:11 73:15 76:6,976:10 88:9 99:8108:13

givers (1) 69:17giving (7) 42:8 49:24

61:22 108:6 109:8110:6 128:25

glad (1) 37:22glass (2) 134:6,7global (1) 62:23go (60) 7:17 9:22

10:17,19,20 12:417:16 18:4,1219:22 21:21 22:1822:19 27:7 28:633:4 37:13 41:1745:4 47:4,6,7,1048:20 52:13,1954:23 57:3,11,2158:25 62:1,1063:24 67:16 69:269:22 73:11 74:8,982:12 86:5,2287:16 88:17 89:2194:2 101:1 106:23122:24 123:5125:24 128:7,14133:6 134:24 140:1141:25 142:3,21

goes (4) 93:11,12106:16 152:25

going (52) 2:17 8:6,1112:18 13:2 17:2022:10 23:13 26:1,126:25 27:8,9,12,1329:24 31:15 35:1936:2 48:21 53:1054:23 63:1,2 64:1966:13,17 73:1383:12,18 84:1985:1 90:14 92:1593:9 102:22 103:18108:17 113:23126:17 131:14,21131:22 133:16,25135:5 137:17,18142:17,24 152:15153:7

Gomez (6) 68:1174:14,19 87:12137:18 154:17

good (27) 1:4 2:225:12 20:14,17 25:928:20 37:18,2038:9 50:23 78:9,1878:22,23 79:24,2592:22,24,25 95:11108:19,20 114:2128:12 131:10149:16

Government (3) 23:1629:19,21

grab (1) 52:7grabbed (4) 8:22

13:18,19 17:12grabbing (1) 38:8gracias (1) 2:22grade (1) 73:25grandmother (1) 55:9grandson (1) 30:21grasping (1) 50:21grateful (8) 21:1 28:16

35:25 36:19 37:2386:1 92:23 156:5

grease (1) 71:5greasy (2) 71:4 88:5great (4) 7:11 128:1

146:22 155:1gross (5) 70:10,12

91:17,18,21ground (1) 37:13group (1) 22:14GSD (1) 29:22Guadacorte (1) 129:3guitar (7) 52:6,7,10

63:8 65:1,4,6guts (1) 122:22

H

habit (2) 42:15,16half (10) 5:4 41:12

65:15 75:17 81:2582:5,20 98:7,8147:20

halfway (5) 14:3 32:14133:25 134:4 136:9

hall (1) 88:19hand (9) 8:4,6,13,20

45:16 49:11,1256:24,25

handed (5) 100:10,12138:24 139:15152:13

handle (1) 144:10handled (1) 47:24hands (2) 31:21

107:10hands‐on (1) 77:11handwriting (3)

103:25 138:16151:7

handwritten (1) 100:3happen (6) 13:25

23:13 25:23 34:3133:11 137:7

happened (18) 5:86:23 14:24 15:1015:13 22:19 52:467:20 74:21 99:18116:23 117:2,3,4124:18 136:16143:4 147:4

happening (8) 12:1025:6 101:4,10,14101:22 143:10144:25

happens (1) 109:3happily (2) 77:21



139:24happy (6) 38:1 66:9,24

70:14 78:4 154:23hard (4) 42:10,11,11

70:1Hassan (8) 16:20 17:6

33:14 34:2,10,1834:23 91:7

Hassan's (1) 17:25head (10) 10:24 13:20

16:17 35:2 76:9122:22 133:13134:6,7 148:4

health (1) 52:4healthy (1) 89:9Healy (7) 28:6 145:20

146:5 147:23149:15 154:20,22

hear (9) 26:10 58:760:1 86:6 93:1396:3 102:3 107:16109:13

heard (25) 53:1859:15,24 70:2,1671:22 75:25 79:985:11 99:20 100:18101:7,8 112:2113:17 124:21125:6 131:3,4139:25 141:23142:7 143:10,14144:22

hearing (5) 72:9 74:2274:24,25 156:19

heated (1) 70:24heavily (3) 40:6 72:19

72:21held (1) 9:1help (20) 20:16,16

21:14 23:15 26:435:24 36:19 44:1153:16 66:20,2478:3 92:15,23 94:1108:13 111:23112:21 128:1,21

helped (4) 20:1430:25 35:24 41:25

helpful (3) 13:2 85:22156:4

helps (3) 74:9 105:1122:12

Hernandez (33) 35:1236:6,7 45:25 46:847:22,23 56:2159:4,14,16 65:1166:7 70:7,25 72:1372:20 74:3 76:2,1077:9 79:22 91:1696:11 132:19,23133:11 135:1,22,24137:6,14 139:15

Hernandez's (4) 73:673:8 87:6 88:24

hernia (1) 127:7hesitate (1) 40:1highly (2) 91:24 106:6Historically (1) 11:16hit (14) 7:2,5 8:17

11:25 27:13 113:12116:6,8 119:11,11119:16 133:5135:25 136:4

hold (5) 23:23 49:1193:9 113:20 116:9

holding (1) 8:9holiday (6) 54:11,19

56:11,17 66:1470:18

home (27) 1:5 12:1619:1 22:18 27:25

28:1,5,12 29:532:10 39:8 51:1752:15,25 55:19,2063:20 64:7 72:1281:25 89:17 104:19109:4 110:9,11129:16 139:2

homes (6) 63:22 95:1495:18,22 96:4,5

honest (3) 58:18 60:962:23

honestly (3) 64:1676:8 153:3

hope (3) 1:8 57:6154:12

hoping (1) 102:24hospital (1) 121:19hot (1) 49:18hour (8) 50:4 82:1,5

82:20 87:4 153:9153:13,17

hours (4) 16:16 38:939:12 115:15

house (17) 12:12 28:443:24,25 46:4 52:361:14 65:3,7 67:1491:8 116:6 121:19122:18 125:5154:20,22

Housekeeping (2) 1:3157:3

houses (1) 63:24huddle (1) 26:5hurt (1) 11:10hygiene (2) 91:8

149:15

I

idea (2) 46:21 63:6ideas (1) 35:2identified (1) 54:1identify (7) 32:19

38:21,22 57:1261:4 128:16 132:22

ignored (1) 68:4illness (1) 113:7image (1) 35:20imagine (6) 60:7,24

76:8 89:1 93:10100:23

Immaculada (1) 68:17immediately (3) 65:4

74:3,11impinges (1) 103:23implicated (1) 84:4important (3) 17:4

22:11 70:3impossible (5) 10:20

13:21 45:22 73:2382:21

impression (2) 40:1145:9

impressions (1) 58:20improved (2) 55:23

61:6impulse (1) 113:14incident (23) 3:18

4:19,25 5:9,14 7:19:2,7 14:17 24:730:11,16 32:2,2333:14 75:13 105:9105:13 115:25131:23,25 143:20147:8

incidents (8) 9:4 10:284:22 116:21,22,23116:25 143:22

include (1) 5:22including (1) 9:14increase (2) 9:25

120:18increased (2) 10:3,6INDEX (1) 157:1indicate (1) 33:21indicated (4) 8:25

84:10 86:24 117:20indicates (1) 25:4individual (2) 85:21

94:9individuals (1) 91:23Industrial (4) 1:16,19

2:10 30:7information (4) 34:25

63:13 78:19 137:17informed (5) 1:10 9:5

9:6 10:7,9infrequent (1) 46:4initial (2) 60:21 81:9initially (3) 23:4 72:8

130:2initials (3) 38:4,5

128:15injection (2) 15:7

123:8Inquiry (16) 1:5 71:15

83:23,23 84:1886:3 93:9 103:24106:3 110:3,7126:12 131:4,24132:21 140:15

inside (9) 3:11 10:1934:8 71:4 123:6,8123:11 146:14,24

insight (1) 113:10installed (1) 3:7instance (1) 74:17instances (1) 64:20institution (1) 12:19instructions (5) 1:18

27:1,5 36:11 85:10integrate (2) 53:4,10integrated (1) 53:15intelligent (1) 127:17interaction (2) 55:24

78:24interest (6) 41:14

56:15 63:8 66:1566:16 96:4

interested (4) 4:7 52:675:9 100:14

interfered (1) 90:25interject (1) 83:4internal (1) 62:15interpret (3) 25:18,21

26:17interpretation (1) 89:9interpreter (35) 2:21

4:11,15 7:16,2113:8,11,14 14:6,914:11,13,18 17:1417:22 18:3,5,9,1523:21 24:15,1825:18,20 26:15,1827:3 31:19,2532:17 33:11,1336:16 109:15,16

interrupt (2) 95:24125:25

interruption (1) 85:25intervene (1) 92:10intervention (1) 41:3interview (8) 14:2

107:11,17 132:1134:24 136:8,19139:10

interviewed (1)100:24

intimidating (2) 35:8136:21

introduce (1) 67:11

invent (1) 16:8investigate (1) 127:1investigating (1)

103:10investigation (9)

99:17 101:25102:16 103:3,6104:9 105:24 106:1126:20

invite (1) 44:11invited (1) 41:17involve (1) 95:20involved (2) 42:21

68:2irregular (1) 98:14irrelevant (1) 84:17irresponsible (1)

91:24Isola (4) 1:13,22 2:3

156:14issue (5) 40:7,12

74:20 90:17 120:23issues (13) 31:15 62:6

63:2,4 72:11 84:1585:7,20 103:23140:13 143:19145:21,23

J

J (1) 33:15Jack (3) 46:12,13,14January (2) 41:1 81:21Jenny (1) 148:24Jessica (4) 58:19 59:2

62:16 88:2JH (6) 75:25 132:25

133:4,24 134:9,11Joanna (23) 35:12

36:6,7 46:16 56:2159:4,16 67:9 72:2077:9 79:22 131:25132:1,19,23 133:11135:1,22,24 136:19137:14 139:15,19

job (7) 5:13 12:1429:12 53:4 142:3146:1 155:16

jogs (1) 70:5joking (2) 50:15 51:5Jonathan (4) 37:3,17

38:15 157:21Jones (1) 123:23Jordan (1) 148:23JT (1) 61:1July (2) 38:21 117:23jump (1) 18:12June (3) 107:12,18

117:23J's (1) 33:17

K

keen (2) 55:22 77:14keep (7) 1:10 19:19

21:1 94:7 95:25109:12 111:22

keeping (1) 30:14kept (5) 56:9 65:6

88:14 112:25143:20

key (3) 3:10 74:2116:1

kick (1) 24:11kids (1) 56:8kind (31) 42:9 44:12

44:24 47:2 49:3,949:12,22 51:4,653:1 56:3,4,6,861:14 67:19 72:1275:21 77:19 78:2

81:15,16 83:2087:22 89:8 117:13142:17 144:7,10,19

King (3) 16:11,12,16Kingdom (1) 99:10Kirushka (3) 59:3

68:10 130:19kiss (1) 113:15kitchen (14) 32:16,21

33:1 34:2,4,6,6,1171:2,4 88:19 106:5150:2,5

knack (1) 78:20knew (28) 5:13 12:17

24:3,5 26:3 28:155:2 69:3,5 72:1472:16,17 77:14100:8 113:17,24114:11 116:11,15116:16 117:2118:23 121:8126:23,23,24136:25 148:18

knobs (1) 49:9know (181) 2:8 3:15

3:25 10:6,6 14:1415:1,9 17:15 18:2119:8 20:16 21:1022:9 23:17 24:1524:25 27:10 29:830:21 32:8 35:6,1135:15,17 39:16,1739:22 40:2,15,1841:13 42:10,1143:10 44:17,20,2144:22 45:1,3,15,1846:20 47:15,1848:13 49:20 50:2150:22 51:3,15,2252:18,21 53:3,1053:15,22 55:15,1555:17 56:7,10,1456:15,21 60:8,961:12,13,21,2262:25 63:6 64:465:5 66:16,1767:17,17 68:1,1968:20,25 69:1670:23 71:3,8,1272:16,19 75:11,1175:12,13,18,20,2175:23,24 76:9,1477:24 78:9,15,2078:21 79:1,7 81:383:5,6,8,12 88:2288:25 89:5,8 90:2,390:7 91:24 93:1794:2 96:13 100:15101:15 102:3 106:7108:24 114:5 115:3116:12,23 118:11120:9,22 121:25124:7,7,21,22126:6 127:3,8128:2,14 131:20,22132:5 133:10134:22 136:18137:1,1,2,9,19139:16,20,23140:21 141:2,19144:3,6,9 146:1148:3,19 150:7,9151:17 152:8,8,18152:21 153:5 155:8155:21

knowing (3) 100:14116:15,16

knowledge (2) 99:19125:11

known (1) 136:24

knows (2) 26:6 136:18

L

L (68) 7:1 8:22 9:3,189:21 10:5,14,17,1811:7,19 12:20 13:514:2 15:21 16:5,621:23 23:25 24:1025:9,13 26:23 27:653:22,24 56:2,3,394:21 98:24 110:18110:23 111:6,14,17112:2,2,8,11,12,13112:22 113:17118:14 120:20121:4,13,13 122:8122:9 123:21 124:1130:5 131:8 132:20133:1,5,11,13134:2,8,10,13136:10 137:16140:1 141:14

La (1) 99:14lack (5) 44:18,24 53:1

66:14 120:16ladies (1) 156:16lady (2) 24:8 133:18large (4) 3:9 80:12

114:8,23largely (1) 130:10lash (2) 10:23 131:15late (1) 9:19laughed (1) 122:21lavatory (1) 52:2lawyer (1) 35:16lay (1) 17:8layout (1) 32:11lead (1) 81:14learned (1) 17:19learning (3) 112:13

121:13 122:2learnt (1) 12:25leave (9) 22:16,19

28:1 30:24 41:975:17 77:24 85:10118:22

Leaving (1) 76:13led (4) 10:16 11:5

50:25 70:24left (10) 6:18 15:4

33:5 56:18 75:19117:15 118:1,2,6122:8

left‐hand (3) 32:1533:4 132:24

lessons (1) 63:10letter (35) 35:13,15,20

36:8,13,13,1559:23 60:5,10,1165:11,12 66:3,1970:4,6,8,11 73:375:3,5,6,10,15,2476:1,2 91:15 99:11100:12,16,20106:15 108:1

letters (3) 109:5,6128:21

let's (12) 26:13 30:331:17 34:24 66:2488:10 89:9 98:22125:24 132:8,13,22

level (1) 79:1lie (1) 89:8lies (2) 18:19 89:17life (1) 71:13lifted (1) 102:23light (2) 30:18 134:16limit (1) 37:5limited (1) 147:24line (9) 14:11 17:18

18:12,13,14,1683:6 101:23 133:16

Linea (1) 99:14lined (1) 144:8lines (6) 13:7,13 16:3

87:17 89:4 152:1lion (4) 16:11,12,12

16:16list (3) 38:5 110:20

130:5listen (2) 20:23 26:10literally (3) 45:21

141:11 155:11little (19) 7:17 21:15

29:11 30:14 33:742:16 56:8 69:2076:11 77:5 89:22109:12 111:24113:24 127:6,8134:20 143:1154:21

live (3) 38:15 109:10129:2

lived (1) 30:17living (4) 61:5 99:13

99:14 155:7Liz (1) 152:14Llambias (1) 35:7locate (1) 76:1located (1) 33:22lock (12) 3:6,6,9,14,21

45:14,23 51:9,1151:13 82:6,21

locked (6) 45:16,1881:25 82:4,9,18

locking (1) 45:21London (1) 93:11long (20) 3:8,16 4:10

19:20 22:21 25:1027:14 37:9 39:2558:6,9 68:15 88:2595:6 104:19 106:10106:11,11 128:10146:13

longer (3) 86:22 94:7128:24

look (27) 50:2 57:6,1160:16 63:17 69:1070:5 73:8 74:1280:8,18 81:2382:12,25 99:9105:14 106:12108:8 110:20111:24 130:18132:7,8,13 139:20146:21 150:11

looked (6) 27:23 56:686:17 118:5,13150:3

looking (15) 40:2342:4 50:1 63:980:13 84:3 85:387:7 91:6 99:25100:9 107:9 132:17135:14 138:12

looks (3) 39:3 135:21139:11

loss (1) 51:1lost (1) 134:3lot (21) 4:18 16:5,6

19:2 20:21 21:2231:1 37:13 52:2270:2 77:16,1778:20 79:6 112:21116:13,20 120:1127:9 142:7 145:4

lounge (2) 146:15,17Lourdes (2) 30:11,19loving (1) 113:5Lucas (1) 10:24



luck (2) 92:22,25Lucy (1) 98:1lying (2) 17:14 91:25L's (6) 8:4 10:2 146:15

146:17 147:18150:1

M

Macias (5) 22:4 102:1107:12,18 108:6

Madrid (3) 38:17 57:992:24

Magnum (1) 57:22main (1) 62:5maintain (1) 27:14major (1) 142:20majority (2) 146:18

147:20making (5) 16:7 66:12

94:24 129:8 154:8Malaga (1) 38:8man (3) 94:21 96:14

107:23managed (1) 75:9management (9) 9:16

10:4 28:22 29:646:5,7 56:16,2079:3

manager (23) 20:1927:2,5,7 28:23 29:546:8,22,23 47:1767:17 77:5,11 78:778:8 79:13 95:2196:23 97:1 101:23144:23,24 154:13

managers (1) 145:5manana (1) 2:23Mandy (11) 28:21,21

29:11 30:6 128:11129:2 133:6,9134:13,22 158:14

manner (4) 50:1566:12,21,22

Manolita (13) 4:724:11,16 96:1897:2 98:11,17 99:699:18 102:18118:22,24 123:6

MANUELA (2) 2:20157:5

manuscript (1) 30:9March (3) 54:21,21

67:3marches (1) 101:2margin (1) 14:5Maria (8) 22:4,12,23

22:25 23:1 101:23107:12,18

Marie (5) 74:14101:15,24 137:18154:17

mark (2) 1:22 134:4Mary (1) 98:1Maskill (2) 122:20

126:22mat (3) 80:21,24 81:3matter (4) 58:21 84:5

96:4 104:5matters (4) 37:15

105:15 127:25130:10

Matto (5) 19:22 20:777:3 78:12 79:11

mattress (1) 89:6Maureen (1) 16:1mean (52) 14:23

25:17 34:20 40:240:25 41:11 44:1644:22 45:17,1846:21 50:2,9 51:13

55:6 58:6 60:8,2461:10,11,20,2364:18 66:10,1367:4,7,8,24 68:869:3 71:8 72:11,1776:17,20 81:382:12,14 87:2091:2 102:1 114:15114:20 116:4118:12 139:18140:16 143:13144:3 145:25154:25

meaning (1) 145:24means (3) 17:14 88:10

134:14meant (4) 19:25 43:21

102:3 113:12Med (1) 114:4medicated (1) 40:7medication (14) 41:2

103:16 104:5,11105:9 106:4,8117:12 118:11119:23,25 141:8148:14,16

medications (2) 89:1889:19

medicine (2) 148:9,11medicines (2) 149:3,9meds (5) 69:25 89:19

89:21,24 149:13Medview (1) 109:10meet (5) 62:7 67:9

117:17 123:18156:17

meeting (28) 9:1,5,109:13,14,20 22:848:2 56:16 57:1357:19 60:3,19 64:264:7,8 67:10,1970:17,18 90:15105:16 132:19135:3,3,4,22138:12

meetings (1) 123:14member (2) 30:10

63:25members (5) 63:24

106:5 120:2,3,25memory (6) 62:21

63:19 68:14 70:574:20 142:4

memos (1) 67:22mental (1) 12:19mention (9) 13:18

19:24 28:25 44:154:16 124:2 128:17132:13 154:20

mentioned (13) 2:312:1,2,22 14:2515:2 17:5 19:2345:16 65:2 96:1498:11,24

mentioning (1) 93:19Merlot (6) 43:17,24

43:25 46:4 67:1491:8

met (2) 117:18 136:19method (2) 44:2,7microphone (2) 28:18

96:2midday (1) 6:18middle (7) 33:13,18

33:19,20,23 50:20132:23

Middleton (1) 98:1Milbury (2) 23:7,12mild (2) 125:13 126:5mind (15) 1:9 15:8,8

18:19 21:12 22:1328:7 46:17 47:352:22 58:2 80:2588:16 153:16 154:3

mine (3) 5:22 50:8139:9

minute (7) 10:22105:16 135:2,9138:10,20,24

minutes (7) 31:21,2387:1,2 135:23138:25 139:8

misbehaving (1) 52:3mischievous (1)

116:18misconduct (5) 70:10

70:13 91:17,18,21mismanagement (2)

103:15 104:10missing (3) 139:3,21

144:23mistakes (3) 21:17

45:12 50:5mix (3) 116:11 117:4

145:22mixed (6) 15:22

116:21,25 124:23124:24 146:3

mixing (4) 15:10 116:2146:8 147:1

Mm (26) 39:1 46:248:23 53:21,2554:2,12 55:1 59:160:18 62:9,19 66:471:17 73:11 76:1680:11 81:7,22 82:392:4 135:18 147:16147:25 151:10152:22

model (1) 56:3modus (1) 42:18moment (8) 19:16

26:13 36:7 38:12124:16 128:23132:9 149:12

Monday (3) 89:2290:1,2

money (2) 47:1175:21

month (6) 47:20,2272:9 74:22,2575:18

months (16) 12:2046:11 47:18 59:759:23,25 67:12104:21 118:8126:19,20 129:24141:12 149:1155:15,22

Morag (3) 46:12,13,14Moran (22) 21:3,4,4,7

22:22 23:3,22,2524:16,19 25:8,1626:22 27:4,16107:8,9,17 108:1,4157:11 158:8

morning (25) 1:4 2:2228:20 37:18,2050:19 79:24,2590:1,2 93:7 96:18115:12 131:15138:13,14,22,22,23138:24 139:9148:13 149:24,25152:12

mornings (1) 134:17Morocco (1) 71:23mother (3) 12:11 55:9

116:16mother's (4) 99:24

116:5,7,9motivation (1) 34:22mouth (3) 8:5,7,14move (4) 28:5 85:12

85:24 137:15moved (7) 106:24

107:1 140:5,6155:10,13,15

moving (2) 88:1 138:3Muchas (1) 2:22mum (2) 44:20 147:18mustn't (1) 60:13M1/4/1 (1) 135:2M1/4/2 (1) 136:9M27/14/4 (1) 4:4M27/14/5 (1) 4:12M27/18/1 (1) 9:11M27/18/2 (1) 9:22M27/23/4 (2) 13:3

122:13M27/24/9 (1) 24:6M27/29/1 (1) 16:1M27/29/2 (1) 16:3M27/36/25 (1) 11:6M27/36/27 (1) 11:14M27/36/30 (1) 11:15M27/37/3 (1) 14:1M4/5/1 (1) 151:3

N

N (3) 17:5 32:3,12name (53) 12:22

14:17 27:21 32:336:5 38:3,13,1544:16 45:7 47:5,749:2,5 51:3 55:8,2255:24 56:1,6 57:2458:14 59:17 68:2469:22 71:13 79:2180:11 89:13,1494:8,11,15 101:16101:17 109:8,10111:6 116:6,10117:19 128:20,25129:2 134:6,7,17138:5 140:23141:12 144:6155:12,17

named (6) 124:8125:1,2 126:8,9151:3

names (3) 68:12 97:17116:21

nature (1) 40:9naughty (1) 44:20Navas (29) 31:12,14

31:18,20,22,2432:1,2,6,18 33:1434:10,13,16,22,2583:4,16,17,22 84:884:17,19 85:1392:18,19 109:14154:2 157:17

Nazareth (2) 6:12,16NB (1) 136:11near (2) 90:19 113:21nearly (4) 19:18 111:7

118:16,16need (25) 7:17 26:17

31:18 38:3,6,848:20 62:1 68:180:17 90:2 93:1494:8,8,9 96:2 101:1106:3 108:8,9109:3 111:23128:16,24 153:14

needed (5) 10:5 20:1668:25 90:20 141:10

needle (1) 15:5needs (4) 12:17 78:17

93:10 149:14Neither (1) 34:6nephew (2) 76:19,21nervous (1) 94:5Netto's (1) 76:21never (64) 4:25 6:23

8:13,16 11:2513:23 16:7 17:1217:13 18:18,22,2219:5,6 20:25 29:2330:17 31:3 36:1239:13,14,16 48:351:3,4 67:20 73:2473:25 74:1 75:1875:20,25 87:22,2390:22 106:7 110:11110:13 114:15117:20 119:2,2,2,6122:25 123:2,13,14123:15,22 125:3,3125:5 135:24 136:4136:7,19 139:25142:11 143:6,10149:2 150:14,21

nevertheless (1) 66:22new (20) 10:22 11:21

23:25 24:2 25:1378:3 107:24 118:23119:7,8,10,12,21120:2,3,18,24131:16 144:24,24

NHS (1) 96:4nice (4) 50:23 133:4

136:22 137:9Nigel (7) 30:25 35:4,9

35:13 36:9 136:12148:23

night (37) 1:14 5:26:11,11,14 19:625:23 68:16 88:1390:20 96:24 97:7,897:9,10,16 98:1098:13,15,19 110:23110:25 115:11123:1 140:6,7142:10,11,12,14,19143:3,17 147:19,21155:10,17

nights (9) 69:11 98:1798:18 114:4 115:20125:4 140:8 148:10148:11

nine (4) 104:21 118:8126:19,20

Noakes (1) 98:1nods (1) 137:5normal (5) 26:2 49:19

120:10,10 127:1normally (9) 39:17

47:4 49:19,23 52:887:22 98:2 110:23115:15

north (1) 95:14note (2) 132:19

154:16noted (1) 63:21notes (1) 14:1notice (2) 24:3 59:8noticed (1) 118:9November (5) 60:17

63:19 64:9,12,15nowadays (1) 52:14no‐one (2) 101:21

131:23nuisance (1) 111:21number (5) 32:19 33:9

38:16 97:20 120:18nurses (1) 149:11N's (2) 17:8,9

O

objective (1) 83:22obliged (1) 85:16observe (1) 41:25observing (1) 50:6obsessive (2) 40:9

86:9obtaining (2) 27:1,4obviously (17) 7:20

41:9 59:4 66:971:14 77:23 93:898:23 99:8 104:16131:10 137:23142:16 149:13152:4 155:1,12

occasion (8) 6:1335:12 40:8,1151:25 108:3 134:19151:21

occasionally (1) 68:20occasions (6) 50:25

51:23 52:12 53:1766:23 78:14

occupied (1) 1:10occur (1) 40:8occurred (6) 3:8 5:1

5:15 16:7 32:2433:15

October (6) 1:1 98:2599:15 105:5,16156:20

odd (7) 1:24 40:1951:23 68:20 137:22145:25 146:2

offer (1) 78:4offering (2) 27:13

50:23office (7) 76:9 100:12

103:18 104:8,11127:4 139:17

OFFICER (1) 62:12official (1) 59:8OFSTED (1) 95:21ogres (3) 80:14 86:2,3Oh (6) 16:15 39:13

42:7,23 132:4150:3

okay (58) 2:16 3:214:11,21 5:16 8:138:17 9:1,10 10:9,910:13 11:2 13:8,1013:14,16 14:916:19 17:5,15,2218:9,15 28:6 31:2532:23 33:16,2134:13 36:15 37:1237:22 45:3 48:1958:3 59:15 60:2265:25 67:4,4 73:1891:11 109:24110:22 111:8,14112:11,20 118:19126:7 127:19128:18 135:6,13142:16 152:18154:5

old (4) 69:16,17147:12,23

older (1) 56:4once (16) 35:10 42:2

42:10,12 44:847:20,22 57:2 62:690:1 104:8 113:12118:18,18,18 120:6

ones (3) 51:24 67:23148:24

one's (1) 23:18Onset (1) 24:7open (3) 3:11 63:25

134:20

opened (1) 36:13Openshaw (31) 5:21

6:3,15,21,22 7:419:25 21:5,20,2121:24 22:6 24:1,924:19,22 37:793:21,23,24 94:1694:23 95:24 99:21104:13 107:6,12,16108:12 123:1 158:4

operandi (1) 42:18opinion (6) 20:11

21:23 34:3,21,2367:19

opportunity (2) 41:1847:2

opposed (3) 66:11,19147:1

opposite (1) 30:21oral (1) 83:11order (2) 57:1 83:17organised (1) 78:2original (1) 135:14outbursts (3) 40:8

65:8 113:7outside (13) 10:18

11:1,4 34:6 52:2471:4 84:9 85:20117:18 146:19,20146:21 150:1

overdue (1) 36:20overheard (1) 124:10overlap (1) 96:11overlooked (1) 90:17overpowered (1)

114:21overpowering (1)

114:14overtime (2) 19:6,7overwhelmed (2) 49:4

49:4o'clock (6) 86:21

88:20 142:17 143:1153:20 156:17

O16/13A/1 (1) 105:15

P

P (1) 132:13package (1) 80:5page (38) 4:9,11,11,15

5:20 9:12,22 11:816:3 17:17,2118:11,13 25:1548:20,21 50:1854:10,24 57:12,2162:3,10,13,14,2163:17 65:14 74:987:14 100:11 104:2132:24 133:16,25136:8 151:23 157:2

pages (1) 62:12paid (2) 72:18 102:4painted (2) 73:14

80:14panel (2) 72:14,15paper (7) 38:4 94:9

109:6 128:15 144:9144:18,19

papers (4) 131:4132:10,14,21

paperwork (1) 144:8para (1) 2:23paragraph (50) 4:7

11:9,10,15,1715:16 16:21,2517:6 21:24,25 22:124:10 25:14,14,2030:5,7,8,12 57:2157:22 61:5 74:1276:13 80:19 81:1



81:23,24 87:7,9,1687:16 88:1 89:490:5 91:6 103:12105:1,19,21 113:3114:6,8 115:22,23120:23 123:24130:15 135:16

paragraphs (4) 11:1973:9 117:11 151:11

Pardon (1) 105:20parent (1) 79:3parents (6) 54:25 55:3

55:4,7 57:3 78:24part (12) 1:8 4:9 7:7

7:14,15 8:4 9:1517:21 22:13 66:1571:3 80:5

participation (1) 2:4particular (16) 4:6,6

6:25 13:6 14:321:24 61:18 63:4,585:20 91:12 109:4119:5 128:16131:17 143:7

particularly (10) 11:1546:19 50:4 61:1961:20 76:9 94:20130:4 136:22 139:3

parts (2) 8:1,2party (1) 70:4pass (4) 4:15 137:17

149:13 154:16passage (3) 6:2 8:1,15passages (1) 73:5patio (6) 3:9 28:6,8

146:19,23 150:2pattern (1) 69:9patterns (1) 41:9Pause (45) 4:14,16

11:12,18 13:9,1514:10,15 17:2,8,2318:10,17,25 19:1622:2 24:12,1425:22 30:13 32:848:18 58:3 59:1159:15 65:16,19,2470:9 73:11,12,1276:15 81:2 87:1888:3 89:5 90:6105:18 106:14,18122:17 146:17151:13 152:2

pay (1) 41:16pejorative (1) 85:2pending (6) 55:20

72:9 74:22,2599:17 126:20

penultimate (2)105:19,21

people (39) 1:8 9:1414:25 15:2 19:522:9 24:2 27:928:14 48:17 52:2453:3,3,4,9 54:1669:18,19,23,23,2476:7 79:1 81:1184:21 90:7,9116:21 119:10120:5 122:1 136:15141:4 142:11,23,25144:9 146:5 155:11

people's (1) 86:11Perez (6) 58:19 59:2

62:16 73:14,1988:2

perfect (2) 32:1844:22

perfectly (2) 85:17127:17

period (14) 28:22 29:1

29:5,18,18 39:942:17 46:9 47:1751:22 68:11,1269:19 145:6

permanent (2) 23:674:1

permanently (1)155:13

permission (5) 55:1955:20 57:2,3 59:18

permitted (1) 78:1person (7) 26:13

53:12 56:5 77:1978:9 104:10 125:14

personal (5) 26:2341:14,23 44:2545:2

personally (6) 50:2156:23 67:10 76:4107:4 149:24

persons (3) 122:10123:4,10

person's (1) 91:14petty (3) 47:1,23 48:1phone (1) 103:17phoned (3) 58:10,13

58:19physical (3) 99:5

113:8 143:25physically (3) 82:21

141:4,4Piazza (2) 123:18,19pick (9) 10:19,20 11:3

21:16 47:6,1152:13 87:21 138:23

picked (8) 65:3 87:21131:3 132:10,14,21139:8 146:21

picking (2) 47:5 66:5picture (3) 69:13

73:14 80:6pictures (1) 80:13pieces (2) 144:9,19pills (1) 148:18Pitto (10) 28:17,18,19

28:20 29:16 30:431:6,8,10 157:15

place (13) 9:3 28:2,3,349:21 58:4 62:5,2263:1 71:10 83:14131:24 155:1

placed (1) 10:11places (1) 61:12plan (8) 11:14 32:7

62:17,22,23 63:5,6144:12

plane (2) 15:4 22:11plannings (1) 47:12plans (5) 47:3 62:5

63:1 144:2,3play (7) 28:7 41:25

49:9 52:6,9,10 56:9playful (1) 50:14Playing (1) 18:5please (11) 4:15 60:16

63:18 84:19 103:21109:4,9 128:10129:1,15 151:12

plus (3) 98:5,6 120:2pm (5) 93:3,5 153:21

153:23 156:18point (23) 12:1 16:13

25:8 29:24 33:1744:23 48:16 56:1256:13,14 59:1865:10 67:21 70:1382:20 85:13,1892:14 101:12 124:1130:18 136:20153:7

points (3) 23:22 66:5133:3

pole (2) 8:18,22police (16) 13:3,4 14:2

16:2 72:2,3 100:24101:3,13 102:8103:2,3,4 122:16122:16 134:2

policeman (1) 151:24policy (4) 63:23 64:3,4

64:17position (6) 2:6 8:13

34:5 63:22 72:2184:18

positive (1) 55:25possibility (2) 1:7,11possible (10) 20:15

22:17 26:22 38:749:16 58:21,2476:12 90:16 93:12

pot (2) 146:22 147:8practice (2) 52:20

114:25precautions (1) 9:3preceding (1) 57:12predict (1) 131:20prefer (1) 108:22preferable (1) 42:5premises (1) 10:25prepare (1) 53:9prepared (4) 11:7

54:13,15 83:23Preparing (1) 100:6prescribed (1) 106:6presence (1) 12:11present (2) 24:20

67:20presented (1) 84:13preserve (1) 94:12presumably (1)

136:12presume (1) 133:18pretty (4) 46:15 97:20

137:12 147:14previous (8) 24:14

48:21 74:9 91:199:25 100:3 138:20147:2

pre‐placement (1)11:6

price (1) 72:18primary (2) 40:12

69:17principle (1) 10:16prior (7) 41:23 47:5

53:10 66:13 105:9155:19,22

private (5) 63:22 96:596:6 120:11,13

privileged (1) 1:18PROACT‐SCIP (1) 41:2probably (7) 14:8

31:23 64:6 65:269:21 85:9 103:14

problem (8) 23:2 50:971:10,11 113:16114:3 142:20147:11

problems (8) 20:25112:25 113:2114:19 131:11145:7 146:10,25

proceeded (1) 146:22proceedings (3) 2:2,4

80:15process (4) 23:3 68:2

81:18 149:12profess (1) 46:14professional (6) 5:12

26:24 68:20 70:15

88:14 90:22professionally (2)

56:24 78:8programme (1)

156:10progress (1) 1:11prompt (1) 62:21prompted (1) 63:18prone (2) 61:23 113:7proper (4) 67:25 141:3

144:12,12properly (1) 121:24proposal (9) 53:19

54:1 58:6 67:1,3,669:1,3 70:18

propose (2) 37:1391:21

proposed (2) 57:1766:21

proposes (1) 54:19proposing (2) 54:10

66:7proven (1) 55:24provide (2) 120:16,17provided (3) 68:24

74:5 83:11provider (2) 120:11,13providing (1) 93:25public (1) 52:1pull (1) 122:13pulled (2) 8:21 142:3punishment (1) 48:24purpose (5) 9:18 32:6

61:17 83:5 99:3purposes (1) 61:14pushing (1) 56:25put (39) 7:25 8:5,6 9:3

13:19,20 15:1217:19 49:7,13 58:661:6 62:5 63:169:13 71:10 72:2172:24 73:5 75:280:6 82:8,8,18 85:888:11 104:5 106:19107:10 112:3122:22 129:7130:11 131:23134:25 135:8,11141:12 144:9

putting (5) 59:2 63:969:15 119:22 134:7

P/24/14 (1) 132:8P/24/7 (3) 132:8,17

132:18P/24/8 (1) 133:16

Q

quarter (6) 36:21142:25 153:8,9,13153:17

Queen's (1) 156:14question (27) 3:2 7:20

14:4,20 17:1922:22 23:21 25:1727:19,22 29:14,1530:3,4 34:9,13,1734:20 36:1,2 42:953:12 64:18 122:12153:12,17 154:6

questioned (12) 2:2538:19 71:9,1194:19 109:25 129:5157:7,23 158:6,12158:16

questioning (4) 83:684:3 85:19 108:5

questions (59) 3:15:18 6:2 7:25 8:319:10,12,15,1921:3,5 27:18 28:17

28:19 29:2 31:1331:15,23 32:1 36:236:4 38:12 76:2277:1 79:19,23 83:984:11,21 85:2,1886:23 92:17,1994:6,6 107:5,7,8110:2 127:21,23128:22,23 129:15153:6,10 154:7156:2 157:9,11,13157:15,17,19,25158:2,8,18

quick (1) 154:9quicker (1) 57:1quickly (3) 31:24

49:16 65:21quilt (2) 89:14,14quite (49) 3:14 4:9

12:3,5 15:15,2422:21 24:13,2439:18,19 41:7 49:549:7,15 50:20 54:854:23 66:10,1870:8,21,24 73:1479:25 82:4,9 83:2585:6 86:4 95:698:14 120:25121:18 129:6131:10,19 132:7133:21,22 134:14139:23 142:7,19144:22 145:23147:3 150:4,7

R

R (1) 146:8raining (1) 65:5raise (2) 31:16 93:18raised (2) 22:5 135:25raising (1) 92:14ramp (1) 142:22random (1) 144:16rang (1) 35:7ranks (1) 77:12rare (2) 15:24 134:19rarely (1) 112:24rat (2) 150:3,3ratio (1) 10:2rats (2) 149:20 154:23reach (1) 73:25reached (1) 18:2react (3) 119:10,16

120:10reacting (2) 120:4,24reaction (2) 26:9

137:21read (34) 5:3,3 14:8

14:12,14 21:8 22:123:10 24:10 48:848:13 58:1,2 59:1060:24 65:14,2166:1 67:2 73:1076:13 80:25 81:487:16 91:12 105:17106:12 117:2122:15,18 139:1,22151:11 152:1

reader (1) 65:22reading (1) 150:1ready (2) 88:22

142:18real (2) 66:16 143:23realise (1) 132:4realised (1) 139:2really (46) 5:8 22:10

31:12 34:20 41:1647:10 48:10 51:1,256:25 71:7,12 76:883:12,17 91:19,20

103:22 112:19113:1,12,12,16114:20,23 115:6,14126:22 127:1139:19 141:22142:15,19,20144:19 145:4,11147:18,19 148:13148:20 149:17,18149:21 150:11155:7

reason (12) 35:2149:17 64:22 67:2571:12 99:3 109:15111:25 112:1113:13 131:17151:3

reasons (3) 59:2370:16 71:1

reassured (1) 126:24recall (6) 3:5,21 17:11

17:12 122:8 124:7recalling (1) 115:25receive (2) 59:8,12received (6) 35:15

72:2,3 99:11,15141:16

recognise (2) 39:4110:4

recollection (2) 10:3145:2

recommendations (1)61:6

record (5) 38:14 94:1595:11 101:1 108:2

recorded (2) 137:6,8recreational (1)

145:22recruitment (1) 23:3rectal (2) 105:21

106:4redacted (35) 32:3

44:16 45:7 47:5,849:2,5 51:4 55:8,2255:24 56:1,6 57:2458:14 59:18 68:2569:22 71:13 80:1189:14,14 111:6116:6,10 117:19134:6,7,17 138:5140:23 141:13144:7 155:12,17

redirect (2) 50:2281:17

refer (20) 17:3,4 24:630:5 38:3 46:3,448:6,22 54:2560:25 62:24 64:2394:9 98:21,24109:3 130:12,13147:23

reference (6) 21:2166:23 70:7 73:1686:2 133:18

referred (4) 3:4 16:986:2 108:7

referring (3) 20:2,3130:15

refers (3) 4:22 24:1430:11

reflect (1) 44:13refused (1) 35:4regard (2) 93:8 154:10regarding (7) 1:18

21:24 32:3,1256:17 63:23 124:11

regardless (2) 64:17130:25

registered (2) 95:2195:21

regular (2) 11:10 97:9regularly (2) 15:21

89:25reinstated (2) 126:21

126:22reiterate (1) 75:24relate (3) 19:20,21

52:24related (1) 146:25relating (2) 47:3

136:16relation (6) 3:2 27:19

27:23 30:4 84:22125:14

relations (3) 59:21,2278:25

relationship (7) 25:1072:13,19,20 76:10131:10 145:12

relationships (1) 114:2relatively (2) 39:9

46:24relatives (1) 147:17relaxation (1) 3:3relevant (1) 139:3reliable (2) 153:1,4relied (1) 53:7reluctant (2) 42:25

43:2remained (2) 105:5

107:13remaining (1) 107:24remember (70) 3:8,11

3:14 4:2 9:8 10:1811:24 25:5 29:930:19,22 40:4,641:2,7,7,13 44:5,746:10,13 47:15,2448:1,4 50:11 58:1861:9,10,11,11,1562:23 63:14,15,1664:7,14,16 66:668:8,17 72:8 74:1976:6,6 78:20 83:2090:12 94:24 107:21118:4 124:12 129:8135:3 139:16,20144:2,17,19 146:11146:12 148:12,13148:14,15,19,20151:20 155:7

remembering (1) 68:9remembers (1) 108:3remind (3) 43:4 73:1

80:17removed (2) 74:3,11renewed (2) 89:19

90:3reoriented (1) 32:8repeat (1) 150:20repetitive (4) 40:9,10

152:16,24replace (2) 69:1,19replaced (1) 89:13replacement (1) 68:6replied (1) 35:17report (26) 4:19,20

5:17 9:8,9 11:721:11,19 24:6,1431:3 35:3,8 41:250:2 56:18,2281:20 82:25 104:3104:7,11 141:7151:17 152:13,19

reported (7) 51:2464:17,21 87:2391:5 97:5 118:11

reporting (2) 97:14,23represent (5) 21:5

27:21 28:20 36:6



79:21reprimanding (1)

72:23reputation (1) 40:5requested (1) 109:15requirement (1) 23:9resident (57) 17:3,4,5

21:23 22:20 23:2525:9,13 26:23 27:627:23 32:3,5,1233:15,17 38:339:21 40:14 52:1553:22 63:13 79:2592:7,7 94:21 98:24109:3,4 110:18,23111:14,17 112:8130:5 131:8 132:20140:10,12,12,12,12146:6,8,13,14,15146:16,17,17,21147:10,18 150:1151:7 152:4,9

residents (12) 28:230:21 40:20,2142:20 78:16 92:6128:16 146:19155:3,7,11

resignation (5) 73:375:3,7,25 76:2

resigned (2) 72:3,7resisting (1) 49:8resolve (1) 49:16resource (1) 53:8resources (1) 79:9respect (2) 2:6 101:20respected (2) 78:10

78:20respective (1) 43:5respite (4) 29:7 155:8

155:9,12respond (4) 85:16

91:13 92:2 122:12responded (2) 85:14

85:17responding (2) 38:25

85:18response (3) 2:12

59:14 67:6responsibility (2) 56:5

95:22responsible (1) 90:21rest (3) 54:17 91:22

153:14restrain (2) 8:10 141:4restraining (3) 7:12

141:2,2result (3) 9:2 10:1

35:22resume (1) 93:2retained (1) 135:7return (1) 100:13returned (1) 99:23rhyme (1) 131:17ridiculous (2) 59:25

91:5right (103) 1:12,23

2:12,19 3:21,24 4:25:11 6:19 10:1412:4 14:18 16:1518:1 19:11,13 21:621:7 28:2,3,14 32:632:21 33:1,12 34:334:15,24 36:3 37:437:16 38:18 39:639:10,20,24 42:1542:19 43:11 44:645:25 46:5 48:2160:19 64:14 65:2372:10,24 74:5,675:17,23 76:22

80:1,8 83:25 84:892:9 93:22 95:1396:10 98:16,19,21104:12 107:25108:11,23 109:21112:22 117:1118:21 124:20125:24 129:4,19,20130:3,5,8,25131:24 132:4,7133:3,21,22 136:2140:11,22 142:13143:12,16 144:21147:13,23 148:9150:6,15 151:11155:2 156:9,15

rightly (1) 72:22right‐hand (2) 32:17

151:4ring (1) 101:21ringed (1) 57:22rise (1) 146:10risk (1) 49:17risking (1) 65:10rivers (1) 78:16Road (3) 28:10 112:6

112:7Robba (18) 96:17 97:2

98:10 99:5,18102:18 108:17,18108:19 109:10,15109:19 110:1111:21 123:24127:22,24 158:10

Robert (20) 124:4,8124:13,16,18 125:1125:2,2,11,14,21125:22 126:2,7,8,8126:9,10,13,14

Rochdale (2) 94:1795:16

role (2) 56:3 87:21roll (1) 27:11room (34) 3:3,3,4,5

17:8,9 25:1,5 28:534:8 44:11,14,1444:15,21 45:3,6,1661:16 81:25 82:582:10,16,17,18,2285:21 94:2 108:25115:5,7,9 123:9,12

Rose (16) 6:8,8 11:2111:22 22:16 96:1797:2 98:10,17 99:599:18 102:18108:17,18 109:10158:10

rough (1) 56:8roughly (5) 32:10 43:5

104:14 109:2128:14

round (4) 50:15 58:1382:12 117:23

rule (1) 52:17run (4) 2:11 77:19

95:18 96:6running (4) 1:5 95:14

95:20 150:4

S

s (8) 44:16 45:7 55:858:14 59:18 71:13134:6,7

sad (1) 12:3safe (1) 65:7safer (1) 61:24Saints (1) 94:16sanction (1) 80:23sandwich (1) 41:11Santos (2) 68:18

101:15Sarah (1) 123:23sat (1) 91:4saw (22) 9:6 10:22

12:9,9 25:24 27:830:25 31:3 34:336:13 41:17 77:9,9114:16,25 117:13117:18,20 118:4,5123:22 149:24

saying (30) 5:9,19 8:815:10,12 17:626:19,20 42:1960:20 73:15 80:783:25 84:9 91:17120:15 125:10,18126:11 130:3136:20,23,25 137:6137:8,16 150:21,24152:17,20

says (20) 8:12,14 9:179:24 15:5 16:3 17:830:10 34:2,24 61:474:3,11 80:2387:12 92:5 104:2130:20 134:1 153:1

scalding (1) 49:18scared (7) 22:10 25:24

121:1,2,3,4,9schedule (1) 1:6school (11) 10:18,25

47:5,6 69:24 87:1987:21 88:22 131:14142:21,25

scope (3) 84:9,1085:20

scrape (1) 90:9screen (3) 122:13

129:7 132:9Sean (11) 19:22 20:7

20:12 77:3 78:1278:16,18,25 79:1181:11 133:17

seat (1) 30:24second (8) 11:16 35:6

59:13 63:17 71:16107:13,18 115:24

secondly (1) 13:22second‐guess (1)

89:10section (1) 156:13sedative (1) 106:6see (104) 4:5 5:18,19

5:23 7:9 9:12,16,2311:15 12:4,1313:17 14:4 16:4,1016:11 17:5 18:721:17 22:4,12,1722:23 25:3 26:630:25 31:17 33:134:7,7,8,24 36:838:21 39:13,2045:14,25 46:2247:5,22 50:16,1851:8 54:1,25 57:1257:14 59:21,2260:17 62:4,8,1663:17,19 66:2 68:972:6 73:7 80:683:18 92:14 94:1098:19,24 99:4,6101:19 103:7,12104:2 105:19,21106:1,10 112:13114:18 115:10,18115:22 118:17119:1,17,18,19120:20 121:2,3122:6 123:14130:16 132:10,11

132:14,23 134:1,8134:21 135:19149:23 150:14151:5,24

seeing (4) 8:11 32:966:16 68:13

seen (25) 3:13 4:20,204:25 15:19 16:930:17 35:5,1041:22 51:10 58:266:14 92:5 98:23100:1,5 109:2131:4 132:20133:19,20 150:14150:21,24

sees (1) 22:9seizure (1) 146:18send (3) 45:3 76:4

91:22sends (1) 44:20senior (14) 12:12

20:15,16 68:7,8,1173:20 78:6 79:3,1179:12 98:19 130:22152:14

seniors (1) 47:25sensationalist (1)

83:19sense (12) 31:6 44:22

53:9 55:15 60:8,1267:22,24 68:490:22 91:23 138:7

sent (15) 11:7 35:1236:13 45:4 56:1856:22 59:3 75:3,2476:8 82:16,17104:11 115:5 126:4

sentence (4) 9:16 18:862:4 115:24

separate (2) 44:1445:6

September (4) 117:24117:25 118:3,9

serious (2) 66:1490:17

seriously (1) 154:13Seruya (2) 6:8,8served (1) 1:13service (9) 23:9 40:3

42:19 61:19 67:1677:14 78:17 79:289:20

services (8) 1:15 9:1696:7 101:8,9,11102:15 121:15

session (1) 142:1sessions (2) 42:3

141:25set (5) 33:19,20 60:3

67:19 89:13setting (2) 42:15

53:16set‐up (1) 96:21sexual (5) 124:6,11

125:12 126:5,10shadowing (3) 41:21

41:22 42:3Shakes (1) 148:4shared (1) 110:25Sharon (61) 3:6 5:5,21

6:3,15,20 7:4 15:1819:21,23,25,2520:2,3,6,18 21:2021:20,21 22:6,2424:1,19,22,25 25:435:4,14 46:15,2347:13 59:3 62:1677:3,5,10 78:9,1781:11 93:23 94:16123:1,13,13,14,22

133:17,17,20,22,25134:7 135:21,23136:18,25,25 137:3138:22 139:19158:4

sheets (2) 89:11,13Sheila (1) 16:14shift (28) 19:6 25:23

41:9 50:4,10,1169:8 77:18,21,2277:23 87:22 90:2096:24 97:7,8 98:1398:15 110:23,25142:10,11,23 143:3143:17 147:19,21155:10

shifts (4) 40:19 69:6115:11 148:22

shock (1) 100:22shocked (1) 122:20shoes (1) 119:17short (10) 34:14 36:25

39:9 58:11,12 70:893:4 106:10 153:22154:4

shortages (1) 142:8shorten (1) 25:3shorthand (1) 156:13shortly (3) 30:3 60:10

70:6shoulders (2) 8:9

95:23show (9) 4:23 15:25

16:19 17:15 25:2532:7 72:5 81:14108:1

showed (1) 56:15shower (6) 49:8,13,23

49:24 51:6 83:3shown (3) 5:17 62:21

103:21shut (2) 45:19 51:12si (43) 7:13 23:8 25:11

32:20,20 33:8109:1 110:16111:16,19 113:9,21114:10,13,15,22115:2,17 116:3,5116:14 117:5,16118:4,7,20 119:9,9119:25 121:2,2,11121:18 122:18125:4,9,15,17126:8,8,24 127:15128:2

side (5) 30:10 32:1532:17 56:6 69:16

sign (3) 24:21 138:25139:24

signature (6) 5:20,205:23,24,25 130:20

signed (3) 24:19,22131:1

signing (1) 139:1similar (1) 81:16simple (1) 31:8simply (3) 22:23

107:14 108:4sir (27) 1:13 2:15,17

19:10 21:4 27:1928:16,17 31:1436:1 37:3 62:1279:20 83:4 85:1385:25 87:5 92:1793:8 107:5,9108:20 109:14127:21 128:6 156:8156:12

sister (1) 116:7sit (7) 1:7 16:11 80:21

80:24 81:12 93:14153:7

sitting (5) 8:24 35:393:8 94:1 115:9

situated (1) 33:2situation (10) 11:5

22:14 49:5,16,1949:22 51:1 121:4,6144:11

six (1) 156:11skip (1) 57:4slap (1) 132:25sleep (2) 88:17 134:11sleeping (3) 89:6

115:16 143:3slept (1) 142:18slightly (6) 1:5 33:5,23

36:20 50:14 56:4slip (3) 49:11,12

128:20slips (1) 94:11slow (2) 65:22 79:5slowly (2) 7:17 21:9small (4) 13:22 72:1

80:10 122:23smart (1) 54:8smearing (1) 49:21social (9) 1:15 9:15

58:14 96:7 101:8,9101:11 102:15121:14

Society (1) 27:22softening (1) 61:22soil (1) 134:18solicitor (4) 1:15,17,24

100:5solo (1) 133:17somebody (12) 19:4

21:14 23:15 56:977:13,20 78:25118:23 120:22123:18 141:2147:12

somewhat (1) 74:13soon (2) 88:17 117:14sorry (67) 4:18 14:11

18:16 26:15 27:329:3 30:7 31:1832:3,4 45:9 47:1047:10 49:7 55:8,856:3,12 57:6,10,1357:17 58:16 59:1362:15,15 64:2465:22 67:4 76:2076:20 78:7 79:680:22 87:9 93:1395:17,24 96:25100:2,3 102:2,17105:8,11 106:25110:12 111:6,21113:15,15 120:8,11124:17 133:21134:3 138:21 139:7139:10,19 140:9141:1,15 148:7150:18,20 154:8

sort (12) 14:3 15:2127:11 35:7 85:296:15 109:23131:13 137:3142:21,22 143:20

sorted (1) 60:2sorts (1) 63:25sounds (1) 147:7Spain (2) 57:25 129:3Spaniards (1) 23:19Spanish (7) 6:3 55:12

55:13 108:22109:22 118:18127:17

sparse (1) 141:21spat (1) 7:8speak (18) 6:3,12 21:8

21:9 23:10,1755:12,13 70:1479:1 96:2 109:21109:22,24 115:25127:15,16 138:5

speaking (5) 26:1432:14 39:25 109:20136:20

speaks (1) 127:16special (4) 44:14

121:15 122:1141:16

specific (6) 13:1728:25 43:17 46:1761:10 146:25

specifically (3) 117:11118:4 146:25

spell (3) 44:5,8 52:5Spencer (1) 28:21Spencer‐Ball (2) 28:21

30:6spend (1) 49:8spent (2) 54:15 115:15spite (1) 20:21spoke (3) 4:22 6:23

55:10spoken (1) 7:19spread (2) 77:16 79:8square (2) 24:24 32:15staff (32) 6:11 10:22

11:10 29:6 30:1042:25 43:2 63:2463:25 77:16,17,2096:23 97:9,10,1697:17 98:18 106:5117:17 120:14,16123:1,2,18 131:16141:25 142:7,8144:24 145:12147:10

staffing (1) 9:25stage (1) 67:5stages (1) 125:7stand (1) 85:23standard (1) 149:15standing (1) 34:10start (10) 3:2 11:23

43:7 87:7 88:16,2194:14 110:14128:25 130:12

started (17) 5:7,910:23 11:21 23:1641:19 43:13 50:17111:25 112:1129:16 130:3 143:1144:6 145:20152:20 155:5

starters (1) 74:24starts (5) 4:7 11:9,14

11:16 14:4stated (1) 74:20statement (43) 1:13

12:6 15:16,25 16:216:19 21:22 25:1229:1 30:5,6,1538:20,24 41:2354:4 71:16 73:980:18 81:1 87:791:7 93:25 94:24101:2 105:1 108:7110:2,4,22 113:3114:6,8 117:9122:11 123:25129:6,8 130:10,15135:8 138:8 140:13

statements (1) 37:23states (1) 30:8



stay (6) 41:25 111:15111:16 115:6,8,9

stayed (1) 123:6staying (1) 153:16Stefan (1) 133:17step (1) 77:20sticking (1) 83:2stomach (2) 127:6,7stop (1) 52:7store (1) 33:6stories (2) 16:7,8story (2) 106:10 150:1straight (2) 128:7,8strain (1) 76:6strained (5) 59:21,22

72:13,20 76:10strange (1) 117:21strangers (1) 69:20strategy (1) 99:3straws (1) 50:21street (2) 38:16 53:17stressed (1) 44:10strike (2) 118:17

119:1strong (2) 114:23,24strongly (1) 66:22struck (2) 7:1 118:19structure (1) 79:8structured (1) 144:14struggle (1) 8:17stuck (1) 15:5students (1) 41:24studied (1) 145:25stuff (3) 78:4,22 90:23subject (3) 41:8 84:5

86:25subtraction (1) 129:13successful (1) 22:15sudden (1) 131:19suffer (2) 53:3,4suffered (2) 124:6

125:12suffices (1) 31:10suggest (1) 84:16suggested (21) 19:15

21:3 27:18 28:1932:1 36:4 77:179:19 107:8,17154:7 157:9,11,13157:15,17,19,25158:2,8,18

suggesting (1) 22:8suggestions (1) 133:14suited (2) 12:16 28:9summarise (1) 13:4summary (1) 122:14summer (4) 44:8

114:4 115:20 125:4summers (1) 44:6Sunday (1) 89:22supervise (1) 78:2supplies (1) 120:5supply (16) 20:13 23:6

39:11,18,19 40:1973:23,24 75:1677:6,17,20 98:1498:18 118:24129:17

supported (1) 79:15suppose (6) 51:14

61:21 75:14 114:11115:15 142:20

supposed (2) 56:16152:18

sure (16) 3:22,23 15:136:12 46:13,1555:14 65:7,18 74:674:8 89:20 130:23134:14 145:23148:12

Surely (1) 82:8surname (1) 68:17surprise (2) 1:17

100:21surprised (3) 88:24

127:5,6surprising (1) 95:7surrounding (1) 62:6suspect (1) 124:10suspended (12) 72:9

74:21,25 102:4104:21,25 105:3,5107:24 126:18,25137:24

suspension (7) 99:15101:22 102:22103:20 105:10,12107:14

sweared (1) 81:15swung (1) 8:22system (1) 149:10

T

T (5) 140:12 151:7152:4,9,9

tab (3) 95:12 100:11132:13

tablet (1) 90:1take (47) 4:4 9:3 12:12

13:2 14:1 17:2024:25 25:5 32:247:2 48:6 51:16,2152:1,8,15 57:17,2458:4 67:18 69:5,1069:17,24,24 71:1071:18 80:11 86:186:18 88:25 89:990:1 92:1,6 103:22113:3 114:3,4,7115:20 117:17119:17 125:7 153:8154:13,16

takeaways (1) 87:12taken (10) 10:16

12:18 28:3 36:1150:3 69:15 79:1691:14 121:12139:12

takes (1) 42:16talk (8) 26:7 45:21

53:11 114:1 115:4117:9 119:19145:20

talked (1) 82:2talking (8) 1:21 3:18

69:23 97:18 104:13104:23 117:10118:8

talks (1) 100:4tangent (1) 81:17teacher (1) 11:3team (14) 12:14 24:1

25:13 54:17 60:1968:7 69:2 70:1371:1 97:14 120:2120:25 137:15140:5

teams (1) 120:3teenager (1) 114:11teenagers (1) 145:21tell (29) 4:2 5:7 6:22

7:20 14:6,7 20:2025:13 39:20,2440:14,22 51:866:11 68:12 70:1971:8 90:12 91:496:8 101:2 102:9103:12 106:2111:12 113:21121:12 133:5,12

telling (3) 41:5 72:22100:19

tells (2) 42:14 109:6ten (6) 13:7 86:25

87:2 90:18 145:5,5tend (1) 119:13tended (2) 10:13

98:13terms (13) 1:6 21:18

23:3 27:1,4 39:1152:23 62:24 63:566:16 79:10 106:11140:15

Terrace (1) 109:11terrible (1) 150:11testing (1) 49:14Teuma (15) 37:3,17

37:18 38:15,2043:4 54:14 84:1385:13,14,17,2192:11,20 157:21

Teuma's (1) 86:25thank (44) 2:15 19:10

20:4,6,18 27:1631:10 32:9 34:1636:18,20,22 37:1837:22 38:2 54:971:14 76:24 79:1787:5 92:19,20,2292:25 93:16,19,2493:25 94:18 108:12108:13,21 109:18127:24 128:1,2,12154:4 155:24,25156:1,3,5,6

thanks (2) 32:18108:13

theirs (1) 103:4Theoretically (1)

39:15thing (10) 26:22 36:12

44:22 48:12 60:165:1 119:25 134:17137:4 150:8

things (46) 5:8,13 9:2310:13,19,23 11:2212:9,10 15:21 16:921:10,13,15 26:1827:13 30:9 38:2540:10 42:12 44:153:8 57:1 61:2163:10 68:1 69:1169:22 76:14 78:2180:20 81:9,18 94:2116:21 117:7 120:7128:14 131:13,16137:7,16 140:16141:8 142:18 153:1

think (169) 2:1 3:5,103:14 4:1,19 5:56:12,13 7:16 12:1512:17 13:6 14:1614:21,24 15:116:18,23 17:4 19:721:25 22:7,2123:20 24:23 26:2227:24 29:14 30:231:6,10,14,1534:18 35:21 36:1738:6 40:6,13,17,2440:25 41:1 42:4,1043:8 44:19 45:2,2546:8,14 47:17,2548:20 50:2 51:2,951:16 53:6 58:1058:11,19 61:1,4,1562:1 64:6,9,1366:10,23 67:1,2,567:10 69:21 70:1371:7,12,21,25 72:1

72:18 75:22 76:578:8 80:17 83:9,1484:2,8,25 85:6,9,1286:2,3,14,14,18,2288:8 89:3 90:1794:20 96:18 100:19100:24 102:22103:22 104:24105:1 106:2 107:19108:11 109:6112:24 113:11116:17,18,19,20117:6 118:6,10,14118:22,24 119:25120:9,10,23 121:6122:5,7 123:3,7,10124:23 126:16,17129:16,22 130:14130:23,24 131:23132:18 134:15137:3 138:19139:16 140:6,7,7145:5 146:12147:11 148:12152:14 153:3,3,13155:2,6,14 156:11156:12

thinking (6) 10:1737:4 65:1 67:9137:12 142:9

thinly (3) 77:15 79:8,8third (6) 11:16 34:13

35:12 73:9 87:6135:16

thought (24) 2:4 4:2318:18 22:9,11 26:341:14 42:8 55:2056:10 59:24 66:1568:19,23 70:15,2175:1,19,20 108:9130:2 137:3,22146:9

threat (4) 49:24,2551:2 83:2

three (25) 7:2,3 8:1911:25 14:25 15:224:20 26:5 33:7,1933:20 35:18 47:1547:16,18 62:1267:12 96:22 114:22118:14 123:4,9129:24 141:12156:12

three‐day (1) 54:19threw (2) 36:14

133:13throw (1) 134:16thrust (1) 136:8Thursday (1) 1:14tic (2) 117:19 118:12time (117) 3:8,13,16

5:17 9:15 10:2,4,1012:15 14:7 19:2420:11 22:10 23:1225:10 26:14 28:1229:4,18 30:1932:11 33:22 35:6,637:4 38:6 40:6,1340:17,23 43:944:12,17 46:7 49:249:9,14,23 53:1854:15,16,18 55:2558:11,13 59:2160:4 66:6 67:16,1868:8,15 70:10,1170:11,23,24 72:873:1,2 75:17 76:1177:11 78:6 79:1179:13,15 80:181:10,12,19 83:14

95:6 96:13 97:899:1 101:2 102:18103:13 104:17,20105:4 106:11,22110:17 112:24113:22 114:11115:12,16,17117:13,15,16,19118:17 120:15,15123:20,21,21130:24 131:6140:23 141:21142:16 143:7 145:6145:22 146:2 149:2152:11,14,17,21154:4 155:3

times (11) 11:25 16:535:18 47:15,1656:7 63:22 89:23131:12 148:14150:6

time‐out (8) 3:4 25:544:2,12 50:2480:21 81:5 82:20

timing (1) 42:9tiny (1) 86:12today (13) 12:15 35:3

37:25 83:12 84:1396:19 128:6 150:12150:17,19,24 156:8156:16

toilet (8) 13:20,2115:13 52:1 122:23122:23,24 123:11

told (26) 14:13,1623:18 27:15 30:930:16 44:7 45:2552:14 59:17,19,2269:9 74:8 103:19104:8 107:22 113:1113:22 121:23,23122:20 126:22135:16,24 137:14

tomorrow (2) 156:10156:17

top (11) 8:19 9:1217:9,14 33:4,2534:1,1 71:3 106:9151:4

topic (1) 142:6tops (1) 71:2tore (1) 36:14Torremolinos (1)

99:12Tosso (2) 70:7 91:16totally (1) 74:17touch (2) 18:20

102:17tough (3) 22:10 29:18

53:4train (2) 30:20 38:8trained (1) 41:15training (20) 40:24

41:19 42:5,6,9,1344:18,24 53:1121:15,15 122:1,3140:22,23 141:6,7141:17,24 142:1

transcriber (1) 139:11transcribers (2) 7:18

153:14transcript (2) 17:16

95:11transfer (1) 26:21transferred (2) 112:2

112:5transition (2) 42:17

53:15transitional (1) 29:18translate (10) 4:8 11:9

11:17 13:6 14:816:25 17:18,2018:5,13

translated (5) 4:3 24:824:16 30:1,12

translator (1) 4:6transmitted (1) 78:19treatment (2) 143:19

152:5tremendous (1) 142:8Tribunal (4) 1:16,19

2:10 30:7tried (6) 20:23 25:12

26:2,4 50:22,24trip (8) 21:25 55:19

58:4 71:22 80:692:1,24 151:15

trips (3) 57:24 78:1,14trouble (1) 78:24troubled (1) 106:3true (31) 5:4,7,19 7:1

7:7,10,11,14,15 8:18:2,5,8,17,22 15:919:8,9 57:10 80:291:10 116:8,12,12116:16,16 126:24127:2,2,3 137:10

trusted (1) 78:10try (7) 7:19 19:20

22:14 63:7 126:17128:19 133:24

trying (6) 7:14,25 83:784:20 94:12 116:9

Tuesday (1) 1:1turn (11) 49:13 54:6

54:10 56:17,2175:4 76:3 82:1394:23 106:16122:25

turned (1) 63:9turning (3) 93:25

126:12 143:19twice (3) 113:11,11,12two (67) 10:5,6,11

11:24,25 15:1916:3 19:12,1930:20 31:14,22,2333:9,11 35:1842:19 47:15,16,1853:20,22 56:857:16,16 59:7,2359:25 66:5 67:1268:16 69:19 73:580:19 89:4,2595:14,18 96:15,2398:2,4,6,7,7 111:7112:23 113:15116:22,24 118:14118:16,16 119:15126:6 127:11,20139:7,10,12,13142:11,12 145:17147:21 151:11155:3

two‐year (1) 44:8type (2) 122:1 139:22types (2) 80:19,20

U

UK (14) 21:25 94:1799:1,24 100:13103:3 106:23 123:5124:15 125:21126:4,4,10,25

ulcers (1) 127:7unattended (1) 77:24uncle (1) 125:1underpants (1) 87:19understand (21) 6:1

6:25 7:23,25 20:23

21:8 31:18 45:1053:18 70:2 71:384:12 95:13 100:6100:9 109:18 110:2138:3 147:3 152:20154:12

Understandably (1)154:10

understanding (1)19:23

understood (6) 12:967:8 77:11 110:22126:16,17

undesirable (1)147:14

unfair (2) 2:2,13unfortunate (2) 50:1

75:19unfortunately (3) 4:9

77:15 79:7unfounded (5) 102:11

102:12,13 107:23126:23

unhappy (1) 74:4unit (4) 27:2,5 96:23

97:1United (1) 99:10unnecessarily (1)

37:15unprofessional (2)

59:19 70:21unreasonable (1) 86:4unrelated (1) 34:14unspecific (1) 100:4unusual (1) 152:7Unusually (1) 153:25upbringing (1) 53:2upheaval (1) 71:13upset (6) 136:23 137:2

137:7 152:11,11154:10

upsetting (1) 22:14use (11) 38:3 44:7

49:12,24 50:1251:9,11 52:2 81:16109:4 128:21

useful (2) 65:9 68:3user (3) 61:19 67:16

79:2users (5) 40:3 42:19

77:14 78:17 89:20usually (2) 111:5

119:14

V

vague (1) 103:14Valarino (1) 71:22Vallender (12) 128:7

128:10,11,12 129:2138:17 153:11,16154:1,3 156:3158:14

variety (1) 40:21various (7) 9:23 40:23

41:1 42:3 50:2563:22 78:15

Vasquez (12) 19:11,1219:15,16,19 21:176:25 77:1,2 79:17157:9,25

veer (1) 81:16vegetables (3) 71:6

88:5 90:16venture (1) 53:6verbal (8) 59:17,20

60:1,5,7,12 70:17113:8

Verde (1) 129:2verified (1) 82:6verify (1) 51:14



Vicarage (1) 94:16Vicente (1) 38:16view (4) 32:18 34:4

85:19 91:14views (1) 77:8Villa (1) 129:2violent (8) 40:5,7,12

44:10 86:10 113:7119:13 121:23

visit (2) 47:13 73:19visits (2) 46:5,20vivid (1) 73:14voice (4) 95:25 109:12

111:22 135:25voluntarily (1) 41:6volunteer (1) 23:4volver (1) 2:23vulnerable (3) 67:15

91:22 138:4

W

wait (8) 7:19 10:1811:1 19:16 49:2057:2 153:13 154:8

waited (3) 5:4,6102:15

waiting (3) 67:6101:12 123:9

walk (1) 47:4wall (3) 33:25,25,25want (32) 2:7 6:1

23:22 24:25 29:134:25 39:24 49:1751:6 52:19 55:1771:18 72:4,21,2473:17 75:2,1182:12,13 84:586:16 91:12 95:1103:21 110:1129:10 133:12134:25 139:22151:20 156:2

wanted (16) 2:9 4:236:23 20:1,5,2427:10 49:15 55:2156:25 57:4 63:666:1 76:11 93:18137:23

wanting (1) 57:24wants (3) 24:15 31:25

83:13wardrobe (1) 106:9warning (7) 59:17,20

60:2,5,12,13 70:17warnings (1) 50:13Warwickshire (3) 13:3

14:2 122:16wary (2) 53:13,14wash (2) 69:25 89:11wasn't (42) 5:4,7,10

5:17 6:8 8:19 12:1815:14 19:2 28:2,428:12,14 30:2435:19,19 40:7,1242:11 46:18 47:2449:19 61:12,17,18113:12 116:8,11,12116:15,16 125:1126:24 130:22131:5 137:3 141:20141:21 144:16152:9 155:1,2

watch (4) 16:11,1548:5 87:13

water (9) 14:19 18:2448:22 49:1,2,14,18111:23 133:13

way (41) 1:25 9:18,1911:23 12:9,9,1715:15 20:15 21:12

21:13,16 22:2125:13 38:9 40:2441:16 44:9,1961:14 67:7 74:1075:8,19 85:2 86:2392:15 95:25 104:6111:24 112:4 118:5118:13 119:5,16,19120:10 123:10131:21 136:21141:3

ways (4) 18:6 42:1381:14 144:10

weaker (1) 56:5Wednesday (1)

156:20week (6) 39:17 58:11

58:13 89:24 98:17100:5

weekend (1) 155:11weekends (1) 115:19weekly (1) 90:4weeks (4) 57:16,16

69:19 89:25weighed (2) 72:19,20weight (1) 75:12welcome (1) 1:4went (24) 5:2,8 6:17

22:4,12,20,2325:23 30:18 41:1848:3 78:7 100:12107:2 112:24115:11 117:17,17123:6 138:22,24140:7 144:23146:21

weren't (9) 10:9 12:1327:10 50:5 73:1991:1 131:6 134:11141:25

Westside (1) 52:9wet (2) 134:6,11whatsoever (1) 114:3wheel (1) 82:13whichever (2) 21:12

42:20whilst (2) 77:6 142:6whittled (1) 31:14wholesale (1) 66:7wholly (1) 74:16Wigan (1) 95:17willing (1) 69:8Wilson (2) 9:15

156:13window (1) 33:24wish (4) 92:1 107:6

127:22 128:7withdraw (1) 86:15withdrew (5) 36:23

93:1 108:15 128:4156:7

witness (40) 1:14 7:2016:19 21:22 23:2028:25 30:5,6,1531:13 36:22,2337:3,6 38:20,2454:3 71:16 85:1191:7 92:22,25 93:194:24 105:1 108:7108:15 128:2,4,6,9129:6 130:15 135:8137:5 138:8 140:13153:11 156:6,7

witnessed (2) 143:14143:15

witnesses (4) 1:651:14 156:8,11

witness's (1) 34:21wonder (2) 70:4 74:23wondering (1) 63:18

word (6) 51:1,9,1181:16 86:14 122:22

worded (1) 66:22words (9) 32:15 37:10

50:1,12 82:14,2383:21 84:15 116:1

work (31) 11:21 15:1715:20 17:11 23:925:13,25 26:1941:19 42:13 43:166:24 68:3 77:2277:23 78:9 79:790:25 91:22 92:2298:18 103:18111:20,25 112:8119:15 121:12,20148:5,10,21

worked (44) 17:1119:2,5 20:7,9,12,1220:13,13,18,21,2425:10 28:22 39:839:21 40:14 50:2468:23 77:3,4 78:1381:19 96:7 98:17110:9,11,13,14,17111:17 115:11118:14,23 121:14123:1,2,13,15,15123:17,19,21142:10

worker (15) 23:658:14 69:8 73:2373:24 74:2 75:1677:6 79:4 90:23110:14,17 111:18123:23 129:17

workers (8) 68:4,1669:5,9 90:20 97:397:16,21

working (22) 6:1415:8,8,20 19:221:10 23:14,16,1927:10 39:17,2141:23 42:2 66:17112:1 120:21127:10 129:16145:12 148:6,8

world (1) 72:24worried (1) 23:13worry (9) 19:17 94:11

126:23 127:3,8,8,9127:9 128:20

worrying (1) 127:7worse (10) 10:13,15

26:1,2 51:1 121:4,8121:10,11 140:20

worsening (2) 10:2112:3

worst (1) 83:19worth (1) 80:13wouldn't (17) 18:19

49:12 52:6,19,2057:2 58:22,2461:18,20 77:2490:19 91:19 95:6108:9 133:9 153:16

write (11) 5:1,9 9:821:8,11,13 23:1062:25 73:3 104:7133:5

writing (6) 41:2 48:1150:7,8 137:19141:7

written (10) 5:6 20:224:9,15,18,1932:16 50:3,6 83:11

wrong (13) 19:24 27:937:5 60:20 67:2572:17 81:4 95:3,4,5101:5 116:2,2

wrote (9) 4:25 36:854:13 60:10 65:1170:7 75:14,21118:12

X

X (1) 92:7

Y

yeah (94) 26:4 39:3,1139:19,23 42:2,1243:16 44:5 46:1650:8 51:13,1554:18 57:15 59:561:3,8,10 63:4,1065:13 67:7 69:372:8 73:4 77:780:11,16,16 90:799:19 103:17106:21 129:24130:1,7,17,24,24131:10,20 132:16133:2,23 134:5135:10,15,20,23136:1,3,13 137:11137:13,13,20,20138:18 140:6,17,19140:19,19 141:5,5141:7 142:5,5144:15 145:1,4,14146:12 147:2,11149:11,22 150:13150:16 151:8,14,17151:22,25 152:3,6152:9 153:19154:15,19,25 155:9155:21

year (10) 11:24 64:10101:6 104:16117:25 118:2147:12,20 150:25155:18

years (9) 1:19 11:2521:10 90:18 111:7112:23 113:16118:14 147:21

year‐old (1) 147:14yesterday (7) 3:3,5,19

4:22 7:13,23 23:4young (9) 53:22 80:3

80:12,15 94:2196:14 104:10107:23 130:4

younger (5) 41:2456:5 75:14 145:22146:8

Yvette (3) 19:2,5,8

Z

Z (29) 40:15,16,2343:11,12 44:2 45:445:8 46:4 47:9,1049:6,7 51:16 53:2353:24 57:13 60:1961:23,23 62:6,1762:22 63:20,2164:7 74:5 79:2580:7

zoomed (1) 30:11Z's (7) 55:8,9,9 58:15

58:18 61:5 69:1

0

00:14 (2) 14:4,6

1

1 (11) 18:13,25 19:3,562:21 89:2 129:2

140:24 148:6,8157:3

1.10 (1) 93:310 (5) 1:4 18:16 81:21

89:2 156:1710.00 (2) 1:2 156:19100 (1) 24:4107 (1) 158:8108 (1) 158:10109 (1) 158:1211 (1) 156:1311.30 (1) 36:2411.45 (1) 37:112 (2) 36:21 105:1612‐hour (2) 50:10,11128 (1) 158:14129 (1) 158:1613 (2) 82:25 84:114 (3) 57:16 103:12

138:9145 (1) 62:1015 (1) 1:1154 (1) 158:1816 (4) 65:12 80:19

81:1 156:2017 (1) 113:318 (1) 91:619 (6) 100:11 105:1

109:10 114:6,8157:9

1993 (1) 98:25

2

2 (9) 29:8,8 32:2233:10 93:2 138:3140:8 157:5,7

2.25 (1) 93:52:1 (1) 9:2520 (3) 16:21,25 98:252000 (1) 104:182001/2002 (2) 29:5,192002 (5) 110:10,15

111:5,8,252003 (6) 17:11 39:9

43:5 82:25 84:1129:22

2004 (4) 64:12,1581:21 111:8

2005 (7) 39:9 54:2160:6 65:12 67:3140:18 155:21

2007 (1) 96:82008 (4) 104:23 105:3

111:13 118:32009 (10) 99:15

100:23 104:23105:3,4,5,16111:13 118:6 122:8

2010 (3) 101:4 107:12107:18

2011 (3) 96:9 105:6107:14

2013 (2) 1:1 156:2021 (4) 17:18 91:15

104:2 157:1123 (5) 43:9 73:1,2

115:22,2324 (7) 43:9 60:17,22

63:19 64:15 73:2132:13

245 (2) 87:7,10246 (1) 87:17247 (4) 73:9,10 88:1

89:425 (1) 93:2252 (1) 90:5254 (2) 73:9,1026 (1) 117:1127 (3) 117:11,12

157:13

28 (2) 54:21 157:1529 (2) 64:9 120:23

3

3 (5) 30:5,7,12 87:22130:15

3rd (1) 38:163.50 (1) 153:2130 (1) 54:2131 (2) 57:21,2232 (1) 157:1736 (3) 25:14,20 157:19365 (1) 74:12367 (1) 76:1337 (1) 157:2138 (1) 157:23

4

4 (4) 57:21 60:6 64:11153:20

4.00 (1) 153:234.05 (1) 156:1840 (1) 21:2540‐hour (1) 39:1744 (1) 54:24

5

5 (1) 57:2250 (1) 38:1656 (1) 123:24

6

6 (3) 38:8 43:13,1461 (3) 15:16 95:12

100:1161,000 (1) 75:10661 (1) 14:6

7

7 (2) 17:17 32:1975 (1) 17:1777 (1) 157:2579 (1) 158:2

8

8 (3) 43:13 88:2099:15

8‐year (2) 69:16,17

9

9 (10) 6:18 18:12,1450:11 87:22 88:16132:8 142:17,25143:1

93 (1) 158:494 (1) 158:6

Dr Giraldi Home Inquiry Day 10 - Gibraltar

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