Tessa Summers

Enquiries to

Direct Line

Date

Q Hampshire

County Council

Mr David Horsley LLB Solicitor
Coroner for Portsmouth and South
East Hampshire

Coroner's Office

Adult Services Department
34 Floor, Elizabeth Il Court West
Sussex Street

The Guildhall Winchester

Guildhall Square Hampshire $023 8UQ

Portsmouth PO1 2AB Telephone 01962 847200
My reference

24" October 2014 — _

Dear Mr Horsley

| am writing in response to the Regulation 28 Report issued to our department under the
Coroners (Investigations) Regulations 2013 sent to Hampshire Adult Services following
the inquest into the death of Tessa Summers on 3 July 2014. | understand you have
issued this report because during the course of the inquest the evidence revealed
matters giving rise to concern. You have stated that it is your opinion there is a risk of
future deaths unless action is taken. Those concerns relate to the following:

1. You heard evidence that the social workers who decided on amendments to
Tessa’s risk assessment did not record in that document their rationale for
downgrading her from high to low risk of self harm and allowing her to have
access fo her medication which she could then take without supervision by her
Shared Lives Carer. You were told the social workers were not required to do so
as a matter of routine to record why details of risk assessments for any of the
clients were being changed.

2. You gained the impression from some of the inquest witnesses that Adult
Services could beneficially provide more training for Shared Lives Carers where
the carers would be called upon to work with clients with mental health and
emotional problems.

You are of the opinion that action should be taken to prevent future deaths to address
these concerns and that Hampshire County Council has the power to take such action.

Hampshire Adult Services were extremely saddened by Tessa’s death. We are sorry
that the evidence given at the inquest has given rise to concerns about practices within
our department.

Director of Adult Services
Gill Duncan

In terms of the skills and knowledge of our staff in respect of risk assessment and risk
management we have in place a Positive Risk Policy which underpins the practice of
social care staff. In addition, all of Hampshire's policies support positive risk taking in
working with service users to maximise control and independence in their lives. There is
a clear expectation set out in our polices and in our training that all staff document their
rationale for any decision making in relation to risk and that there is shared
understanding of risk between professionals.

All social workers employed with us have obtained a diploma or degree level
qualification and they will have studied risk as part of their qualification. All newly
qualified social workers also undergo an Assisted and Supported Year in Employment
(ASYE) in their first year post qualification where risk assessment is covered.

On an ongoing basis, the management of risk is incorporated as part of our core
assessment training provided to all social work staff. It is included in many of our
courses and training programmes including safeguarding, Mental Capacity Act and
Deprivation of Liberty Safeguards. Specialist risk assessment training is accessible for
mental health staff through Southern Health NHS Foundation Trust as we have a formal
partnership arrangement with the Trust to deliver integrated mental health services.

In reviewing the practice in the support offered to Tessa and her family, we have not
identified that any action is needed in respect of the system of assessing and managing
risk more generally.

Following Tessa’s death this department undertook a full critical incident review to
analyse the services offered to her and her family. The report made a number of
recommendations which have resulted in changes in practice in the following areas:

1. We have issued guidance for the purposes of recording case notes on the social
care electronic recording system for staff in mental health teams.

2. We are working to improve the interface between our mental health services and
adult social care teams including Shared Lives so that teams work more closely
and communicate effectively.

3. We have clarified the arrangements in relation to shared funding agreements for
people whose needs span across more than one service. It is now the case that
one team will always take the lead to avoid any confusion or delay in decision
making.

4. We have re-issued guidance to staff involved in delivering services to adults at
risk whose needs span across more than one service.

In Tessa’s case a risk assessment and risk management plan was developed on 29h
April 2013 at a meeting between Tessa, her Shared Lives Carer, the Shared Lives

2

Manager and Tessa’s Social Worker at the time. The risk of suicide at this time was felt
to be high as Tessa had made two recent attempts. The response to this risk was that
the Shared Lives Carer was to safely and securely store Tessa’s medication, ensuring
that Tessa only had access to the dose required at the time.

This risk assessment was updated following a visit to Tessa on 17" July 2013 when she
was visited by a social worker from the mental health team in order for him to assess
her mental health needs. The records made by the social worker show that a low risk of
completed suicide was indicated and he recorded his rationale as being that ‘Tessa had
sought appropriate help from previous overdose attempts and stated that she wants
help to improve the quality of her life.’ The assessor did recognise that a factor likely to
increase risk was Tessa's impulsive behaviour and the likelihood of her acting on this
impulsivity.

It was also noted that Tessa was working well within the current placement and was
accepting guidance and advice. During this assessment it was established that Tessa
would like to return to work at some point and that she would work towards independent
living with an extension to the placement of six months proposed to enable her to
prepare for more independence.

Following this risk assessment carried out by the social worker, care records
demonstrate that the Shared Lives Carer updated her copy of the previous risk
assessment as follows ‘following mental health assessment agreement was made that
Tessa will be responsible for her own medication with support by myself to prepare for
her move into independent living.’ This document is dated 17" July 2013.

The risk assessment was further updated on 14" August 2013 following a review visit
from a social worker from the physical disabilities team with the Shared Lives Carer in
attendance. The purpose of this visit was to discuss supporting Tessa with building
independent living skills. The Shared Lives Carer then updated her documentation on
the risk issues as follows ‘medication now to be kept in filing cabinet to maintain the
safety of others including the dog. Tessa has agreed not to take large quantities out of
the house in case of loss and theft.’

In response to point 2 in your Regulation 28 Report you have suggested that Shared
Lives Carers may benefit from more training and support when working with people with
mental health issues and emotional problems.

The Shared Lives Placement offers supported accommodation in a homely
environment where adults are supported to exercise their autonomy and
independent decision making in a non restrictive and enabling environment.
Suitable carers are recruited by the Shared Lives Scheme through a recruitment
and selection process.

Once selected, they are required to attend a full induction programme which
includes mandatory training on the safe use of medication. Other areas of

mandatory training include safeguarding and an induction course on service
standards.

Mental health training is available through our department training team and an
independent ‘service user led’ training provider.

All Shared Lives Carers also receive regular supervision and support from the
Shared Lives Manager whose role it is to support the carers in a particular
geographical area.

Tessa’s Shared Lives Carer was very experienced. She had a history of working
in care including working with people who are homeless and supporting women
who are transitioning from refuge support.

This case has highlighted for us the importance of Shared Lives Carers being
suitably equipped to support people with emotional difficulties. We will be
undertaking a review of the training and support needs of the Shared Lives Carers
when working alongside people with mental health and emotional problems. We
will have reached conclusions on this by end of November 2014. We will also be
undertaking a broader review of the Hampshire Shared Lives Scheme. We expect
the outcome of that review and recommendations for consideration to be available
by the end of March 2015. Hampshire County Council is committed to the
provision of the best possible services for the residents of Hampshire.

Yours sincerely

Director of Adult Services