Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0133, written 1 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Apr 2015 |
|---|---|
| Reference | 2015-0133 |
| Deceased | Christopher Watson |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Director of Community Services — Adult Social Care Norfolk County Council County Hall Martineau Lane Norwich NR1 2DH 1 | CORONER 1 am JACQUELINE LAKE, Senior Coroner, for. the Coroner area of NORFOLK 1 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 9 January 2015, | commenced an investigation into the death of CHRISTOPHER WATSON, AGED 53 YEARS. The investigation concluded at the end of the inquest on 31 MARCH 2015. The conclusion of the inquest was medical cause of death: 1a) Exsanguination b) Deep laceration to left forearm and short-form conclusion: Mr Watson cut his own arm and died as a result of his action. His intention at the time is not known. 4 | CIRCUMSTANCES OF THE DEATH - Mr Watson lost his job about 4 years prior to his death and since then his general well- being deteriorated. He became isolated. A neighbour contacted Norfolk County Council Adult Social Care Department (ASC) on 9 July 2014 raising. concern that Mr Watson had not been seen for some time. As telephone contact was unsuccessful ASC asked Police to carry out a welfare check and to report back to them. The Police forced entry and found Mr Watson "painfully thin, unwashed and dishevelled’. The Police reported this to ASC who telephoned Mr Watson but the telephone number was unrecognised. A letter was sent to offer support and advice and stating “/f you do not require any care or support please ignore this letter.” No response was received and Mr Watson's file was marked “No further action” on:22 July.2014. Another neighbour became concerned at not seeing Mr Watson over Christmas and ‘| New Year and.on 7 January 2015 entry was gained to Mr Watson's property. He was found dead in-his bedroom. He had been dead for some weeks. 5 | CORONER'S CONCERNS 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 2 | CORONER’S LEGAL POWERS , circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) There is no concern over the actions of ASC prior to the letter being sent to Mr Watson. The concern is over the contents of the letter to the effect that if the person does not require action then they are to ignore the letter and the file is then closed. No steps are taken to ensure that the person actually receives, opens and understands the letter or whether they can read for instance. ; .| (2) Mr Watson was clearly vulnerable from the description provided by the Police ie. “painfully thin, unwashed and dishevelled’. Direct contact was not made with Mr Watson to ensure he understood help is available should he wish to take advantage of it.. His capacity may have needed to have been assessed. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. YOUR RESPONSE You are under a duly to respond to this report within 56 days of the date of this report, namely by 27 May 2015, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested I have also sent it to Assistant Director for Integrated Care (South Norfolk) who may find it useful or of interest | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coronér 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: 1 APRIL 2015 : | loka Jacqueline Lake. Senior Coroner — Norfolk Area
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.
Norfolk County Council - Adult Social Services County Hall Martineau Lane NORWICH NR1 2SQ Ms Jacqueline Lake ; General Enquiries: 0344 800 8020 Senior Coroner — Norfolk Area : Textphone: 0344 800 8011 69-75 Thorpe Road : _ Fax: 01603 223086 Norwich oo te _NR17UA ; Your ref; ; My ref: HB/JB/C03-0415 Date: 26 May 2015 ; Tel: Dear Ms Lake Response on behalf of Norfolk County Council to Regulation 28 Report to Prevent Future Deaths dated 1st April 2015 regarding Christopher Watson 4) There is no concern over the actions of ASC prior to the letter being sent to Mr Watson. ‘The concern is over the contents of the lefter to the effect that if | the person does not require action then they are to ignore the letter and the. file is then closed. No steps are taken to ensure that the person actually receives, opens and understands the letter or whatever they can read for instance. | can confirm that action has been taken to ensure o that practice across all Adult Social Services teams has been changed. An instruction has been issued to staff to ensure that the practice of sending a letter to individuals about whom concerns have been raised is ceased with immediate effect. In cases where the Department is unable to contact an individual by telephone, staff have been instructed to ensure that face-to- face contact is made with the person. (2) Mr Watson was clearly vulnerable from the description provided by the Police i.e. ‘paintully thin, unwashed and dishevelled’. Direct contact was not made with Mr Watson to ensure he understood help is available should he wish to take advantage of it. His capacity may have needed to have been assessed. | can 1 confi irm that staff have been reminded to record all the steps they have taken to make contact with the person about whom concerns have been raised. At each attempt, the level of risk must be assessed and recorded. If the risk to the person is thought to be significant, staff have been instructed that an immediate home visit will be arranged. Even where the risk to the person is thought to be low, if the time. taken to make contact extends to two.days, the case must be escalated to a.senior member of staff, either a Practice Consultant or- Team Manager. The manager will 1@. «INVESTOR AN PEOFLE www.norfolk.gov.uk be required to make a timely and appropriate decision regarding the next course of action. For example, this may mean a welfare check or emergency visit. This — ‘advice has been re-issued to staff in the.form of a best practice factsheet. It is also being formalised as a new Operational Instruction which will be completed shortly. | trust this addresses your concerns. Yours sincerely irector of Adult Social Services le) www.norfolk.gov.uk PIVESTOR IN PEOILE
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