Jeffrey Warren

Date of report	4 Aug 2015
Reference	2015-0307
Deceased	Jeffrey Warren
Coroner	Bridget Dolan
Coroner area	West Sussex
Category	Other related deaths
Source	judiciary.uk record · original PDF
Responses published	1

The report

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

THIS REPORT IS BEING SENT TO:

1. The Chief Executive, Crawley Borough Council
2. The Director of Social Services & Chief Executive, West Sussex County
CORONER

I am Bridget Dolan, assistant coroner, for the coroner area of West Sussex

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 3 February 2015 the Senior Coroner commenced an investigation into the death of
Mr Jeffrey Warren The investigation concluded at the end of the inquest on 21 July 2015.
The conclusion of the inquest was accident, the medical cause of death being (1a)
bronchopneumonia (1b) broken ribs (2) hypothermia.

CIRCUMSTANCES OF THE DEATH

1. Mr Warren, who was born on 13 December 1928, was a tenant of Crawley Borough
Council (CBC). He was vulnerable in that not only was he elderly he also suffered
deafness. He had no family and no known friends nor were any neighbours known
to take any active part in looking after his welfare.

2. The CBC housing department were aware that Mr Warren was someone who would
benefit from support. However Mr Warren was an independent character and
reluctant to accept help. With no known family or friends to assist him or encourage
him to take the facilities and support that was on offer to him it was left to those
employed by public bodies to do so. It was the view of the allocated Tenancy
Support Officer (TSO1) that Mr Warren’s vulnerabilities were such that he ought to
move to a sheltered housing scheme, however he declined this when offered. When
his gas heating and cooking equipment was condemned in March 2014 he declined an
offer of having central heating installed. He was therefore provided with two electric
heaters by CBC.

3. Mr Warren’s case was allocated to the CBC Tenancy Support Team. The tenancy
support officer (TSO1) described how one of the particular tasks of the tenancy
support team was “to engage people’. TSO1 managed to achieve some engagement
with Mr Warren, including taking him shopping to purchase a microwave. She stated
in evidence that she believed he should be seen for support monthly. However she
changed post in April 14 and her replacement recorded Mr Warren’s case as “case
semi closed” on 28 April 2014.

4. Mr Warren was however referred to the “Older Persons Support team”. TSO1
informed the court that the rationale for the referral was that this team could visit Mr
Warren more regularly and should try and engage him in accepting services. Mr
Warren was reluctant to accept help and so would need extra effort to try and engage
him. However the evidence was that after meeting him once in August 2014 Mr
Warren was also discharged from that team.

5. Mr Warten was seen briefly again by TSO1 in December 2014 when he agreed to be
referred to a service that supports those with sensory impairments and also agreed to
the placement of a fire alarm in his flat.

6. On 14 January 2015, after having visited his flat to fit the alarm, the fire officer
reported to CBC by email that the flat was unsafe in that the electric heater provided
by CBC now had a broken leg and was leaning against non-flame retardant furniture.
Replacement with an oil heater was suggested. This electric heater clearly created a
continuing fire risk at the property, but this was neither noted as an urgent risk by
CBC nor treated as such.

7. On 21 January TSO1 in discussion with her manager determined that a ‘vulnerable
adult referral’ known as a “safeguarding alert” should be made to West Sussex
County Council Social Services (WSCC) because CBC were “very concerned for Mr
Warren’s health particularly given the cold weather”.

8. That safeguarding alert was received on 21 January by WSCC, although it was not
allocated to a social worker (SW1) until 26 January.

9. On 27 January SW1 decided that she would contact the police to request a welfare
check. She informed the police that there was no immediate concern for Mr Warren
and so a check could be made “in the next couple of days”. The police call handler
pointed out to her that this type of welfare check was not normally a service provided
by police — nevertheless, the police agreed to conduct a non-urgent ‘neighbourhood
policing team’ visit.

10. A letter was sent to Mr Warren by SW1 on 28 January seeking his consent to refer
him to the ‘prevention assessment team’, SW1 then discharged him from her team’s
caseload.

. The evidence of SW1 was that she was relatively new in post at the time and was
unaware of the criteria applied by police for welfare checks or how the police graded
the urgency of checks. She informed the court that neither before or since these
events had she been given any training or provided with any information regarding
when it is appropriate to use the police to conduct welfare checks or the protocols
the police are then likely to use when categorising the urgency of calls made to them
by social services. SW/1 stated that although she could have requested a more urgent
check to be conducted by a Social Worker from a locality team she referred to police
because she thought it was unlikely that the WSCC locality team would have accepted
the referral of Mr Warren because he would have been perceived to have had mainly
housing needs.

1

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12.On 29th January members of the police ‘neighbourhood policing team’ conducted
the non-urgent welfare check as requested and found Mr Warren deceased at his |

home. His house keys were in the front door and hence anyone attending his flat
sooner could have gained access and found him sooner, although it is not possible to
establish when he died.

13. It appears, from the circumstantial evidence of the dates on his shopping, that Mr
Warren had fallen at his home on or around 24th January and was immobile on the
floor with a number of broken ribs. Whilst lying on the floor he contracted
bronchopneumonia and he also had physical signs associated with suffering
hypothermia. The medical evidence was that he would have suffered distress, pain
and stress.

14.No internal review of the events surrounding Mr Warren’s care and his death has
been conducted by either Crawley Borough Council or West Sussex County Council.
At the inquest hearing the Borough Council claimed to be in the process of
conducting such a review, but it appeared that the key staff involved in the events
were neither aware of that review nor had they, as yet, been interviewed or consulted
as part of the review.

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
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

(1) That neither CBC nor WSCC have a yet undertaken any formal review of this
case despite the death of someone known to both organisation and subject to a
safeguarding alert at the time of his death. An opportunity to learn lessons from
the above events has hence been delayed and potentially been lost.

(2) That Mr Warren had a potentially hazardous electric fire inside his home that had
been supplied by his landlords (CBC) and that was left in situ from 14" January

up until his death despite notification of this to the housing authorities;

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That WSCC Social Work staff sought to use police resources to conduct a non-
urgent social welfare check, rather than allocating that check to an appropriate
council employee;

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(4) That WSCC Social Work staff are not aware of, given any training regarding or
provided with any information about the criteria likely to be applied by police for
conducting welfare checks and/or the circumstances in which it is or is not
appropriate to ask the police to conduct a welfare check.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe your
organisations 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 29 September 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

I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons: The Chief Constable of Sussex, West Sussex Fire and Rescue Service

Tam 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.

4 August 2015 pp Bridget Dolan

Also filed under 2015-0307: 2015-0307-West-Sussex-County-Council.pdf

Care, Wellbeing and Education 0,5)
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; County Hall
033022 22653 (Direct) ;
(01243) 522825 (Fax) lac oponll sussex
avril.wilson@westsussex.gov.uk PO19 1RQ county
01243 777100 council

www.westsussex.gov.uk

Private and Confidential i) E ffs fa AN? 27 October 2015
Ms Bridget Dolan NN) ne gue cape Our Ref: AMM/pmc
Assistant Coroner for West Sussex il é 9 Ou! 2015

3 Orchard Street

Chichester PO19 1DD
PAIS SSA SA SS A sn

Dear Ms Dolan

Inquest into the death of Jeffrey Warren —Report to Prevent Future Deaths,
Regulation 28 of the Coroners (Investigations) Regulation 2013

Your letter of 15'” September refers.

You raised four matters of concern in your Regulation 28 Report, three of which related to
West Sussex County Council, and the fourth to Crawley Borough Council.

The specific concerns relating to the County Council were:

* The need for a formal review of the circumstances of Mr Warren as he was subject to a
safeguarding alert at the time of his death;

* The fact that Adults’ Services sought to use the resources of Sussex Police to undertake a
non-urgent welfare check rather than to allocate the case to a member of staff in Adults’
Services; and

* That staff in Adults’ Services did not appear to have had any training on the
circumstances in which a welfare check might be offered by Sussex Police.

I can confirm that we have now completed a detailed review (copy attached) of the
circumstances relating to our involvement with Mr Warren. We involved Crawley Borough
Council in the review process.

We have identified a number of issues that require further development for implementation.
These relate primarily to internal and inter-agency communications, understanding and
following the self-neglect procedures set out in the Sussex Safeguarding Adults at Risk Policy
and Procedures, and knowing about the role of the Coroner and how Inquests operate should
staff be summonsed to attend as witnesses.

An Action Plan has been prepared for these and other issues, and it identifies those
responsible for follow-up, as well as the timeframes for completion. The Action Plan,
embedded within the detailed review report, is already being implemented and the majority
of the issues are scheduled for completion by the end of 2015 or by the end of March 2016.
The second and third concerns raised in your Regulation 28 Report were picked up in the
review itself and are included in the subsequent Action Plan.

Page 1 of 2

The review report and the Action Plan have been discussed by senior managers through our
Quality Assurance Management Board. The Board, chaired by the Principal Social Worker
(Adults), will monitor progress over the lifetime of the Action Plan.

Yours sincerely

Avril Wilson
Executive Director of Care, Wellbeing and Education

Page 2 of 2

Responses

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.

Response from 1 (PDF)

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Contact: Karen Dodds n{ [s {3 fe aie
uy IS ro
Direct Line: 01293 438256 |
emai 28 Ser 95 Crawley
Borough Council
Date: 25 September 2015

Ms Bridget Dolan

Assistant Coroner for West Sussex
Coroner’s Office,

West Sussex Record Office,
Orchard Street

Chichester,

West Sussex,

PO19 1DD

Dear Ms Dolan

Inquest into the death of Mr Jeffrey Warren — 21% July 2015
Regulation 28 Report to Prevent Future Deaths

| am writing to you to respond to the matters of concern raised in your Regulation 28 Report to
Prevent Future Deaths report following the Inquest in to the death of Mr Jeffrey Warren. Your
report and the Council’s response have been carefully considered by the Council's Cabinet at
their meeting on 9 September 2015.

There are some matters of fact which | would like to correct in the Report

e CBC do not have a Tenancy Support Team, there is only one officer (TSO) within a
housing management team (Circumstances of Death ref para 3).

e The fire officer did not request an oil heater. The Council had already supplied two new
oil filled electric radiators to Mr Warren on 15 April 2014. These have castors on them to
aid moving around a room. It was one of the castors that had detached that was
observed on the fire officer's visit (Circumstances of Death ref para 6). There was some
confusion by Council staff following the visit of the fire officer regarding installing oil filled
radiators, however, when records were properly checked it was clear that oil filled
radiators had already been supplied. Enciosed with this letter are the Council’s record on
this matter.

e At the time of the Inquest the Council had carried out a Review, had spoken to the staff
involved and reviewed all of the case notes. The manager of the housing management
team initially carried out this review as part of the preparation of the report for the Inquest
and this was then reviewed by the Head of Service with the service recommendations
coming from further discussions. The recommendations were not contained in the report
for the Inquest. Recommendations 1 and 2 below had come out of this Review. We are
of the view that the line of questioning of the Council witness TSO1 meant that she
thought there was something other than the discussion she had had with her line
manager.

Switchboard; 01293 438000 Town Hall
Main fax: 01293 511803 The Boulevard
Minicom: 01293 405202 Crawley

DX: 57139 Crawley 1 West Sussex
www.crawley.gov.uk RH10 1UZ

nplates\Le\ lettter.dot

Borough Council

Following the Regulation 28 Report to Prevent Future Deaths and with respect to the matters of
concern the Council has reviewed the circumstances of its involvement and responds as follows:

1.

The Council's involvement with Mr Warren stemmed from the need to replace the heating
system to his flat. It is the Council's policy to install gas central heating in all of its
properties (where possible) as this provides the most cost effective and efficient form of
heating for well-being. Installing central heating was the focus of staff’ effort with Mr
Warren but where tenants remain adamant that they do not want such a system installed
then other options should be considered and in Mr Warren's case this may have been a
replacement gas fire to the wall or storage heaters, which would have provided a
permanent solution to the heating problem. While not ideal as a space heating solution it
was clear that he was not going to accept a central heating system. This has been
actioned, although such circumstances are rare.

The Council has reviewed the terms of its contract to provide housing support for older
people. One of the eligibility criteria is that “the customer must be willing to accept
support as a condition of the support agreement”. In this instance Mr Warren was very
clear that he did not want the service but we accept that there may need to be more
effort to engage people whose very independence can be a barrier to accepting the help
they may need. In this case the TSO had maintained a relationship and managed to
engage and therefore although difficult more could have been done to assist Mr Warren.
This has been actioned although again the circumstances are rare.

The fire officer contacted the Council on 14 January 2015 via a generic email address.
Although the email was passed to the heating team on the same day it took two days for
the repair to be issued to an engineer. We will review all of the generic emails to ensure
only those people who can action the requests are recipients and then ensure that all of
those staff can input the service request on all work streams. This will be completed by
30 September 2015.

The heating engineer visited 5 or 6 times between 16 January and 27 January when he
reported back to the TSO that he was unable to gain access. Unfortunately, the engineer
did not go beyond the entry phone door after 24 January 2015 so did not observe Mr
Warren's keys in the front door. Currently entry phone door keys are not available to our
contractors and we intend to change this to ensure that they can access the building and
the front door to the property. Initially we will carry out a review of all of the door entry
systems, which we intend to complete 30 September 2015, and then we will carry out an
upgrade programme so that we can have systems with either a master key or master
switch. This will overcome the problem of having to have a large set of door entry keys
for all of our properties. This is a longer term plan as there are numerous systems but
we will prioritise the older systems. Where there is a known access problem the
contractor will be provided with the specific door entry key (linking with 5 below).

We also accept that the difficulty in gaining access should have been referred back to the
TSO more promptly and where there are concerns this needs to be highlighted within the
repairs system. Action has been taken to flag cases where the TSO or floating support
team are involved on the repairs system.

Switchboard: 01293 438000

Town Hall

Main fax: 01293 511803 The Boulevard

Minicom: 01293 405202

Crawley

DX: 57139 Crawley 1 West Sussex
www.crawley.gov.uk RH10 1UZ

Crawley

Borough Council

6. Finally, the Council did not have a procedure for immediately reviewing a death where a
safeguarding alert had been made. The Council's review was prompted by being
contacted by the Coroner's office on 11 February 2015. Safeguarding alerts will be
followed and reported to senior managers and any future deaths where a safeguarding
alert has been made will immediately be subject to review. This has been actioned.

CBC has been working with West Sussex County Council in respect of its review, and we will
add any additional recommendations as part of that joint work.

Yours Sincerely

Karen Dodds
Head of Crawley Homes

Switchboard: 01293 438000 Town Hall
Main fax: 01293 511803 The Boulevard
Minicom: 01293 405202 Crawley

DX: 57139 Crawley 1 West Sussex

www.crawley.gov.uk RH10 1UZ

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