Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0165, written 22 May 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 May 2017 |
|---|---|
| Reference | 2017-0165 |
| Deceased | Kevin Morgan |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| Category | Community health care and emergency services 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.
Carl Thomas Ralph Osborne Senior Coroner for Milton Keynes REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Carole Mills, Chief Executive Milton Keynes Council CORONER | am Thomas Ralph Osborne, Senior Coroner for Milton Keynes CORONER’S LEGAL POWERS | 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 29" July 2016 | commenced an investigation into the death of Kevin George Morgan, aged 53. The investigation concluded at the end of the inquest on 19" May 2017. The conclusion of the inquest was “Open”. CIRCUMSTANCES OF THE DEATH Mr Morgan suffered from insulin controlled type 1 diabetes that was poorly controlled. He was not registered with a GP and had not been in contact with family for several weeks. Family called Police who attended the flat. On looking through the letterbox Mr Morgan could be seen deceased lying on the floor in the hallway. Entry was forced, ambulance attended and death confirmed, there were no suspicious circumstances. His body was heavily decomposed. At the time of his death it was known that he suffered from diabetes, that he had accumulated rent arrears, that his telephone had been disconnected, that he was without gas and electricity, that he was not claiming benefits and he suffered from mental health problems. 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 social services and the housing team were aware of the problems experienced by Kevin Morgan and yet there was no effective follow up. (2) That a safeguarding alert was completed by Kevin Morgan's Mother and, despite her serious concerns, the response was to arrange a visit where Kevin Morgan refused to engage. (3) That the case was reviewed by senior managers on at least two occasions and no further action was taken. (4) The police were never requested to conduct a concern for safety visit despite such a visit being recognised as appropriate. (5) It was accepted by the Adult Social Care Access Team that a meeting of senior professionals should have been called to consider the case and prepare a plan. (6) Following the death of Kevin Morgan there was no Serious Incident Review conducted by social services and it was not referred for a safeguarding review so that lessons have not been learned from this incident. Without such a review a similar incident could occur in the future. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you as the Chief Executive of Milton Keynes Council have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16" July 2017. |, 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 Persons Ill (Kevin’s mother) and to the CQC. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish eith¢rfr_both in a complete or redacted or summary form. He may send a copy of this report to a You may make representations to release or the pubsCation of your y. Dated 22° M Signature. Senior Coroner for Milton Keynes
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.
4 April 2018 Mr T Osborne Her Majesty’s Senior Coroner for Milton Keynes Civic Offices 1 Saxon Gate East Milton Keynes MK9 3EJ Dear Mr Osborne Re: Regulation 28 report to prevent further deaths I am the Independent Chair of Milton Keynes Safeguarding Board and am writing following your correspondence of 22nd May 2017 with Executive in relation to Kevin George Morgan. Thank you for returning my call as I always (as a totally independent chair) prefer (wherever possible) to deal directly with senior public sector leaders across the Milton Keynes system, whatever their role. , Milton Keynes Council Chief It is nearly 12 months since you wrote to sooner. I will be considering why it took so long as part of the actions I have decided to take, but believe it to be a consequence of a major restructure, major staff shortages and a lack of rigour in the tracking systems that were in place until relatively recently. Whatever the cause it should not have taken so long however and I apologise for the delay. , and the response should have come much wrote back to you on 12th July 2017 indicating that in response to the Regulation 28 report a referral was made to the Milton Keynes Safeguarding Board for a Safeguarding Adults Review (SAR) to be conducted under Section 44 of the Care Act 2014. That referral was made and the process of considering the case began. I received a recommendation from the Adults Case Review Panel recently but delayed making a decision until I had thoroughly examined all of the facts, taken advice and weighed it up carefully. My decision is that the case does not meet the criteria for a Safeguarding Adult Review, but as I share many of the concerns you expressed in your Regulation 28 report, I have commissioned another more flexible but no less rigorous form of review called a learning review in order to establish what can be learnt from the case to improve practice and reduce the likelihood of similar cases occurring. I am happy to send you my full decision should you wish to see it, but have set out below the decision and the commission for a learning review for your information. My decision is as follows: The case does not meet the criteria for conducting a Safeguarding Adult Review as set out in the Care Act 2014 S44 (1) and S44 (2). The rationale for this conclusion is set out in the section below. I have decided however that a multi-agency learning review, chaired by a relevant professional from one of the agencies who has no links to the case, should be undertaken, and that the review should involve: MKSB, Saxon Court, 502 Avebury Boulevard, Milton Keynes MK9 3HS Email: mkscb@milton-keynes.gov.uk/ tel: 01908 254373 Mr M’s mother and other family members of her choice (through the opportunity to meet and speak to the review chair and a review group member) A practitioner event involving all relevant practitioners in the NHS, the Council, the Police and the Voluntary sector An analysis of agency case reports In depth consideration of the areas for concern 1-6 in the Regulation 28 report and any other areas identified by Mr M’s family, identified in agency reports or identified at the learning event, A Signs of Safety approach to the learning process (what went well, what did not go so well, what does that tell us, what will we do as a result) A short report making recommendations for practice improvements to the MKSB Board (copied to the MKC Chief Executive) and suggesting effective ways to disseminate the learning to the multi-agency workforce A meeting with Mr M’s mother should she wish, to hear what has been learnt and what will change as a result of the review. The terms of reference for the learning review should be drafted by the panel and signed off by me. The review should be undertaken as swiftly as possible given that information about the case has already been collated. I anticipate receiving the report at the September 2018 Board meeting. I will be reporting to the Chief Executive and to Mr M’s mother on the conclusion of the review process. I am of course very happy to discuss further my decision should you feel the need to do so. I understand that there are a number of other cases that you have expressed concerns about. I discussed this with the MK Safeguarding Board Members and we are delighted you are happy to accept our invitation for you to meet with the Board to discuss areas of common concern, and how we could more effectively address those concerns in the future. We will, I am sure, find it extremely constructive to meet with you. Yours sincerely MKSB Independent Chair (jane@janeheld.co.uk ) cc Carole Mills – Chief Executive, Milton Keynes Council Michael Bracey – Corporate Director People, Milton Keynes Council Michael Kelleher – Service Director Housing & Regeneration, Milton Keynes Council MKSB, Saxon Court, 502 Avebury Boulevard, Milton Keynes MK9 3HS Email: mkscb@milton-keynes.gov.uk/ tel: 01908 254373
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