Carol Leesley

Response to Regulation 28 Report to Prevent Future Deaths  

From: 

, Head of Adult Safeguarding, Sheffield City Council, 

Moorfoot, Sheffield, S1 4PL  

To:   Mr David Urpeth, Assistant Coroner for the Coroner area of South Yorkshire 

West  

1.  In the report of 12th December 2016, the Coroner stated that, during the 

course of the inquest into the death of Carol Leesley, evidence showed that 
the GP made a safeguarding report on 04/03/2016 but for reasons unknown,, 
despite there being an automated acknowledgement, the referral was not 
acted upon. The Coroner stated that it was unclear whether this was a case of 
unanimous error or IT error.  

2.  In the Coroner’s opinion, action should be taken to prevent future deaths and 
Sheffield City Council had  56 days to respond to the Coroner’s report with 
details of actions taken or proposed to be taken, setting out a timetable for 
action with regards to the issues which have arisen. 

3.  Summary of actions taken to date 

3.1 Immediate contingency measure put in place   

3.1.1   On 9th December 2016, the final day of the inquest, 

Advanced Practitioner in the Community Access Prevention Team, 
amended the wording of the automated response generated when a 
safeguarding report is received by the Adult Access Team.  

The amended text included a notification that, if the person making a 
safeguarding report was not contacted by the Adult Access team within 
2 working days, then they should contact the Adult Access team by 
telephoning 0114 273 4908 to check that the report had been received 
and that a referral was being progressed.  

3.1.2   It was recognised that in itself this action, whilst reducing the risk of a 

report being received and not actioned, was in itself not sufficient to 
address the underlying concern about system reliability.   

The Adult Access Team have had no further instances of referrals 
having been reported as sent not having been received by the Adult 
Access Team. Whilst the Local Authority recognises this, in itself, does 
not prove that all referrals are being received, it is a strong indication 
that the circumstances leading to the non-actioning of the safeguarding 
referral in the case of Carol Leesley occurred as an isolated incident  

 
 
 
 
 
 
 
 
 
 
 
 3.1.3   Since the wording on the automated response generated through Adult 

Access was changed on 9th December 2016 by 
, we 
have not been contacted as requested in the text of the automated 
response about a Safeguarding referral not having been followed up.  

The revised wording is as follows  

Please note that your email has not yet been seen by anyone in the 
Adult Access team.  

We aim to reply to your email with a written response within 1 working 
day. If you do not receive a written response to your email within 2 
working days of this acknowledgment then please call Adult Access as 
a matter of urgency on 0114 2734908, to confirm that we have 
received your email and are dealing with your request. 

3.1.4  The IT systems operating in the Adult Access Team are designed to 
prevent emails, including those that contain safeguarding referrals,  
from being accidentally deleted. To completely delete an email, it would 
have to be deleted from the inbox folder and then separately deleted 
from the deleted folder; two distinct actions. The Local Authority is  
putting in place a Journal function integrated into the IT system that will 
make it easier to retrieve and track deleted emails. Journal function  
enables the Local Authority to track every action in a specified  
mailbox, In this case the Mailbox for the Adult Access Team. 

3.2 Investigation into possibility of human error  

3.2.1   Having put an interim contingency measure in place by way of an  

amended automated response on the Adult Access Inbox, Sheffield 
City Council took steps to establish the reason why the safeguarding 
report in question was not acted upon and why the email sent into the 
SCC inbox for which acknowledgement was received cannot be traced.  

 In doing so, the Local Authority had to consider, as indicated by the 
Coroner, whether or not the possible cause was human error or an IT 
system error.  

, Advanced Practitioner in the Community Access  

 the Adult Access Team Leader 

 the Adult Access Team Manager conducted  

Prevention Team, with 
and 
an extensive search of the Adult Access email Inbox to establish  
whether or not the safeguarding referral email was in fact received but 
not acted upon on due to human error.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3.2.2   The in-depth search of deleted, archived, sent and inbox files took  
place on 8th December 2016 and looked at the relevant date of 4th  
March 2016.  

This produced no trace of the email. Emails were then searched  
by name of the subject of the safeguarding referral and by the name of 
the GP medical practice.  

The referral completed by the Phlebotomist Team, reported on at the 
Inquest, was evidenced as having been  received and been transferred 
to a Contact Assessment on 14th March and had been sent to the  
Community Access and Prevention Team for action as described in my 
statement to the Coroner.  

3.2.3   The Adult Access inbox is programmed to send an automatic response 

when an email is received into the inbox. 

3.2.4   Procedures for receipt of email in Adult Access mean that the system 
used by Adult Access prompts the Advice Worker to send a courtesy 
email to the safeguarding referrer explaining they have received the 
email and will give information on what team this has been sent to and 
also the allocated team’s telephone number.  

No courtesy email was found in sent items from 
adultaccess@sheffield,gcsx.gov.uk 

There is no available evidence to suggest that non-action was the 
result of human error either by action or omission on this occasion.  

3.2.5  However, to further reduce the risk of a report not being actioned, all 

staff working within Adult Access team have been reminded of the 
existing procedures and process for handling emails to further reduce 
the risk of emails being deleted or not actioned correctly.  

3.2.6  I am sufficiently assured that the risk of a report which has been  
received into the Adult Access Mailbox not being actioned due to  
human error has been adequately addressed and minimised.   

I and 
Re-ablement team who has overall responsibility for the Community 
Access Prevention Team, are keeping this under review. 

 the Head of Service for the Access Prevention and 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4. 

IT systems audit 

4.1  In parallel with the in depth search of the email boxes, 
  Authority Head of Information Management, commenced an IT systems audit. 

, the Local 

  The purpose of this audit was to establish if the email with the Safeguarding 
  Referral had been received but not acted upon either due to a fault or as the 
result of a failure in the IT systems supporting the work of the Adult Access 

  Team. 

  The Adult Access Team is the designated receiving point for  safeguarding 

referrals. A chronology of the actions taken to track the safeguarding 
report through an analysis of IT systems is set out below at 4.1.1 -4.1.10  

4.1.1   Following the court hearing, Sheffield City Council undertook an 

investigation into why this email from the GP medical practice had not 
been received by the secure email adultaccess@sheffield.gcsx.gov.uk 

4.1.2   This was also logged as a security incident, and a team was 

established to review and investigate what had happened and what 
actions needed to be undertaken.   

4.1.3   Unfortunately, it was confirmed by the Sheffield City Councils ICT 

provider Capita that as the email was sent by the GP medical practice 
in March 2016, no audit logs or emails would have been retained. The 
retention period was confirmed as 30 days.    

4.1.4  

It was also confirmed that a copy of the email from the GP medical 
practice could not be found within the mailbox 
adultaccess@sheffield.gcsx.gov.uk where the email should have been 
received. 

4.1.5   Nor did Customer Services who manage the mailbox have any record 

of the email been received from the GP medical practice. (Customer 
services record emails received to this mailbox onto an excel tracker).  

4.1.6   As such, the Head of Information Management, 

, 

contacted the GP medical practice to request a forensic report from 
their email provider Accenture. Accenture are the ICT provider for 
NHS mail. 

4.1.7  Following a number of conversations with Accenture, they confirmed 

that they would be able to provide a forensic report going back to 
March 2016.  

 
 
 
 
 
 
 
 4.1.8   This would detail if the email servers used by the GP Medical practice 

had successfully sent the email to adultaccess@sheffield.gcsx.gov.uk.  
We are awaiting this report. 

4.1.9  

In addition to this the Head of Information Management instructed 
capita that more auditing tools are deployed to ensure that going 
forward we have audit evidence for a longer period of time. 
Technically this is called journaling and should be in place by March 
2017.  

4.1.10   This journaling tool will provide much more detailed audit information 

which would provide evidence of emails sent and received from this 
and other appropriate mailboxes used by Sheffield City Council. 

5  Summary of Actions  

5.1 The current position is that 

, the Head of information Management 

for the Local Authority, is putting in place an email Journal facility which will 
provide an on-going audit log of all emails received and sent for the relevant 
mailbox used by Adult Access. This will enable the Local Authority us to track 
all actions taken with a specific emails  

5.2 

 has requested a forensic report and audit log via the Accentuate 
the agency responsible for the IT System at the GP surgery used to send the 
email.  

This should enable us to trace directly from the originating source of the 
Safeguarding referral, the GPs surgery, the email that included the 
safeguarding referral.  

The GPs surgery have to make this request themselves. The request was 
made by the GP surgery on 20th February 2017.   

5.3 In accordance with our Information Management procedures Sheffield City 
Council has logged this as a Serious Incident. Whilst there is no prescribed 
time limit for concluding a Serious Incident investigation I anticipate that this 
will be concluded in the next 6 weeks.  

This investigation cannot be completed until a response has been received 
from Accenture who are compiling the forensic report requested by 

 Once the investigation is completed a report will be produced which 

will then be considered initially by Care and Support Leadership Team to 
determine what, if any, further actions are required final incident security 
report will be completed once the actions above are completed.  

 
 
 
 
 
 
 6  Proposed actions  

6.1 Although the work is continuing to establish why the report was not acted    

upon and the email sent by the GP practice cannot be traced, on balance my 
assessment at this time is that it is an IT system issue. 

6.2 Given that  

 
 
 

the Journal facility is still to be activated  
the NHS forensic audit log request is in process  
the Sheffield City Council Serious Incident process is yet to conclude  

I propose to provide the Coroner with a further update by 20th April 2016 

: Head of Adult Safeguarding 

Sheffield City Council