Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0449, written 7 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jul 2014 |
|---|---|
| Reference | 2014-0449 |
| Deceased | Harold de Mello |
| Coroner | Gail Elliman |
| Coroner area | Inner North London |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. London Borough of Tower Hamlets – Social Services 2. (Family – Interested person) 1 CORONER I am Gail Elliman, Assistant coroner, for the coroner area of Inner North London 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 16 April 2014 I commenced an investigation into the death of Harold George de Mello, born on 13 April 1926. The investigation concluded at the end of the inquest on 7 July 2014 The conclusion of the inquest was that Harold de Mello died of bronchopneumonia and that this was a natural cause but was contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death were that Harold de Mello suffered from a number of co- morbidities – diabetes, hypertension, osteoarthritis and spinal stenosis, he was not mobile (using a wheelchair or mobility scooter outdoors and a wheeled zimmer frame in the home). He suffered from incontinence and there were related problems of personal hygiene and lack of care noted by his doctor. His incontinence was assessed in November 2013 and he was referred to a District Nurse for an incontinence assessment and given the details of Age UK and his case closed. A call from a concerned neighbour (on behalf of a voluntary organisation in the community called ‘Friends and Neighbours’) was made in February 2014 and this prompted a further visit and a further assessment on 27 February 2014. This assessment concluded that Mr de Mello did not require care in his home and his case was again closed. The next day he presented to his GP and was noted to be unkempt with urine and faeces on his clothes (his underwear). He appeared to believe that he was still under assessment by Social Services and possibly still under investigation for the incontinence. On 1 April 2014 he collapsed in his home and an ambulance was called when neighbours heard him calling for help about four hours after his reported collapse. The ambulance service noted that he was covered in urine and faeces and had rotting food in his home. A safeguarding alert was made and he was taken to the Royal London Hospital where he was treated for the bronchopneumonia but died at the hospital on 13 April 2014 which was considered to have been caused by the lack of hygiene and, therefore, the neglect and conditions in which he had been living. 5 CORONER’S CONCERNS 1 During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) that there are no good practice guidelines for assessments that are being carried out leading to the fact that: (2) a First Response Officer could go to a person’s home, could be told that it was OK to look in the occupant’s bedroom but feels it is ‘inappropriate’ to do so despite the fact that there have been concerns about the service user’s incontinence and personal hygiene from the referrer including a report as to the bedding being soiled with urine and faeces. Assessments should be made bearing in mind the referral and the actual concerns made and should be comprehensive, particularly when a service user has agreed to the assessment and examination proposed (3) that, given that a conclusion was made that there would be no social care provided, the assessment was made (and signed off by a senior colleague) without any reference to the rather different reports from the referrer and in the deceased’s historical record. There is an incongruence between the claimed observations of the First Response Officer and the information that led to the assessment that was not explored (4) that no reference was made to any of the people to whom the service user referred as being carers, that information was wrongly recorded (a person wrongly described as a niece who was not a relative) and that there is a significant difference in the fact that the visit assessment suggests that the deceased had adequate social care whilst also noting that a ‘carer’ was not fit and able to undertake domestic tasks. That no investigation was properly made into the actual care available to Mr de Mello and no contact made with either the claimed carer or the relative with power of attorney to confirm the reality of his situation and the extent of his dependence or needs (5) that there was a difference in the actions recorded in the assessment (apparently the ordering of urine bottles) and the letter written to Mr de Mello stating that a commode had been ordered and no consideration of whether he could use a commode (6) guidelines should, therefore, refer to both the manner and the recording of the assessments and senior colleagues should thoroughly check assessments against the referrals or reports made 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe London Borough of Tower Hamlets Social Services have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by . I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons – I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner [DATE] [SIGNED BY CORONER] 9 2 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
ay TOWER HAMLETS Directorate of Law, Probity and Governance Legal Services Poplar Coroner’s Office Mulberry Place 127 Poplar High Street 5 Clove Crescent London London E14 0AE E14 2BG 08 October 2014 Tel Fax Email = DX Tower Hamlets Legal Department DX 42656 Isle of Dogs www.towerhamlets.gov.uk Our Ref: SSADCM.143/JM Your Ref: 719/14/DB Dear Sir/Madam Re: HAROLD DE MELLO The Coroner's Report into Mr De Mello’s death was received on 17 July 2014. This report raised serious concerns in what the Coroner considered to be failings on the part of London Borough of Tower Hamlets Social Services. The Coroner concluded that Mr De Mello had a number of health and mobility issues, and that an assessment by Tower Hamlets Social Care failed to identify that he was living in unhygienic and unsafe conditions and action should have been taken. Although the cause of his death was bronchopneumonia, the Coroner ruled that it was caused by a lack of hygiene and therefore neglect was deemed a contributing factor. In accordance with Regulation 29 of the Coroners (Investigations) Regulations 2013, the London Borough of Tower Hamlets was required to respond to the Coroner's concerns detailing a timetable for action to be taken in respect of preventing future deaths. A Case Review meeting was convened to analyse the Council's actions on Mr De Mello’s case and consider what immediate practice issues should be addressed. This was followed by a meeting with the Independent Chair of Tower Hamlets’ Local Safeguarding Adults Board to review the case and consider the need for a serious case review or internal management review. The Chair took the view that an internal management review would be most appropriate, and this was urgently commissioned. ml internal management review of Mr De Mello’s case sought to; EQUALITY at Boy, ec = @ fs > FOR LOCAL 3 S v N, covernment =WYSF yy INVESTORS Lexc Cel EXCELLENT sage Sy ch IN PEOPLE ime: LH Hex a) Undertake a review and analysis of social work practice and management decisions taken in context of concerns raised by the Coroner and compliance with best practice. b) Submit recommendations arising from the internal management review. The comprehensive internal review was completed on 3 October 2014 and this has identified a number of areas where changes to practice or procedure have been implemented since Mr De Mello’s death or are currently being progressed, and where further improvements can be made to service provision to enhance the protection and wellbeing of vulnerable adults. The action plan arising from the review is enclosed in compliance with the requirements of Regulation 29. Compliance with the deadlines set in the action plan will be formally monitored through the Council's RAG monitoring system. If the Coroner has any further queries or concerns, please do not hesitate to contact me. a ——____ Principal Lawyer, Social Care Team For Service Head Legal Services Immediate Practice Improvements Action Plan arising from Internal Management Review (HD) team: Disseminate internal management review and action plan to management Phase 1: share with Service Managers Phase 2: share with the respective team managers from both frontline teams together, taking a whole system approach Phase 3: the respective team managers present the action plan to their teams for implementation Lessons learned from this case to be shared with the staff in the First Response Team and across the Department for discussion, reflection and reinforcement of national best practice guidance: Long Term Team Service Manager Service Users are given opportunity to invite other people to their assessment. Evidenced cross checking of the role and needs of informal carers within the service users support/wellbeing plan (formal or informal). Standard procedure to supply, with service user consent, feedback to referrers on outcome of social care interventions. Robust management scrutiny of assessment/interventions undertaken, checking for discrepancies between reports. Management instruction and decision making process/justification clearly evidenced in all decisions and case closures. Clear recording of decision making rational on the assessment of Team Manager, First Response Team, Long Term Team Service Manager Action Plan arising from Internal Management Review (HD) risk and application of FACS eligibility criteria evidenced in all assessments by all levels of staff. e Quality and proportionate signposting and wellbeing planning for Service users who do not meet eligibility thresholds. Implementation of a new practice protocol within the First Response Team | Adult Social Care and across the Department of ensuring copies of case closure letters are Dept. sent to the referrer with the service user's permission, thereby providing opportunity for the referrer to raise any concerns with the outcome. Introduction of a new mandatory Carers’ Views section in the electronic Adult Social Care record (Framework!) which records informal carer involvement thereby Dept. ensuring all supportive networks are considered as part of the assessment process. This will reduce risk of carers not being involved in the assessment process in the future. Appointment of a Principal Social Worker within the Adult Social Care Princip j department to embed research and evidenced practice within Adult Social | Worker, Care teams which supports an organisational culture of reflection, learning and skills development. Strengthen/Modify the existing quality assurance framework within the Princip i Department to ensure learnings identified from this case review are Worker, embedded into general practice. Quality Assurance Programme Learning and Development Lead Strategy & Performance Team Development of a Risk | Development of a risk analysis tool designed to enable positive risk taking _| Principal Social Analysis Framework Action Plan arising from Internal Management Review (HD) and planning derived from the Signs of Wellbeing and Safety framework. Such a framework would recognise likely areas of disagreement between people, their family, carers and practitioners and guidance on how to negotiate the service user's desired outcomes. Worker, Introduction of an eco—mapping tool which facilitates identification of a person's support network thereby ensuring quality, informed decision making and risks are appropriately identified and managed. The tool will support practitioners to consider: Who and what agencies are involved? | What is helping? What is hindering? Where are the gaps in support? Long Term Team Service Manager A programme of targeted Critical/Cumulative Analysis training with staff members has been scheduled for December 2014. Learning and Development Lead Care Act Implementation April 2015 - Development of new practice framework. With the implementation of the Care Act in April 2015 the London Borough of Tower Hamlets are in the formal process of developing: 1) Anew assessment and eligibility framework informed by best practice guidance. 2) Clarity of roles and responsibilities for various levels of practitioners across the Adult Social Care department. 3) A comprehensive training programme for staff resulting in a highly skilled and confident workforce. 4) Multi Agency practice guidance on the intervention and support to people who may be at risk of self-neglecting and poor environmental hygiene. anager, Head of Service, Principal Social Worker and Service & Learning and Development Leads Care Act Workstream 2.1: Assessment, Eligibility & Support | Planning
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