Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0223, written 11 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Sep 2017 |
|---|---|
| Reference | 2017-0223 |
| Deceased | Brian MaClean |
| Coroner | Nigel Meadows |
| Coroner area | Manchester City |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Other 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Matt Harrison, Chief Executive, Great Places Housing Association , Director of Housing - MCC Executive Director Strategic Commissioning & Department for Adult Social Services – MCC NHS Manchester Clinical Commissioning Group Copied for interest to: Chief Coroner Family of Deceased Manchester Local Medial Committee The Mayor of Greater Manchester, Mr Andy Burnham GM Fire and Rescue Service 1 CORONER I am Nigel Meadows, H.M. Senior Coroner for the area of Manchester City. 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 INQUEST I resumed and concluded the inquest into the death of Mr Brian MaClean on 6 September 2017 and recorded that he died from: 1a Smoke inhalation II Alcohol toxicity Somewhat unusually I recorded a conclusion of – Alcohol related 4 CIRCUMSTANCES OF THE DEATH The deceased was born on 20 December 1957 and had developed over a number of years a significant alcohol consumption problem. He was also a regular smoker of cigarettes. He had lost touch largely with his family and had spent periods of time in private rented accommodation and more recently at a Salvation Army Hostel. 1 He took up occupation of Flat 35 George Thomas Court, Harpurhey, Manchester, on 26 November 2012 and lived on his own. This accommodation is owned by Great Places Housing Association (GPHA). He was allocated a support worker who discovered that he had no telephone or access to email and was only ever intermittently available to see his support worker. The deceased was not in employment and was in receipt of state benefits. It seems that a referral was made to the Manchester City Council Adult Social Services Department on 26 January 2016. His support worker had discovered that he had no household appliances other than a microwave in which he cooked all of his meals and had little in the way of possessions. He claimed to have a nursing background and a long term chronic bowel condition. This apparently resulted in the local authority writing a letter to the deceased asking if he required any help or support and when they received no reply the case was closed. Greater Manchester Fire and Rescue Service (GMFRS) regularly work with housing providers to facilitate the referral of persons at increased risk of suffering a fire. No such referral was made in respect of the deceased. The deceased was registered with a GP at the Singh Medical Practice but was an infrequent attender, but with a diagnosis of Chrohn’s Disease and a long term alcohol problem. The fire had self-extinguished. On 19 March 2016 the deceased had consumed a very excessive amount of alcohol and had been smoking whilst sitting in his sofa. A fire started on the sofa which created a great deal of noxious smoke. It also caused him to suffer a burnt leg. When the alarm was raised and GMRFS attended he was found in the hall way having apparently made attempts to remove his trousers. He died as a result of smoke inhalation contributed to by alcohol toxicity. All other sources of ignition for the fire apart from a discarded cigarette were ruled out. The premises did not have an automatic water sprinkler system. Statistically a significant proportion of fatal fires involve single males living on their own having drink, drugs or mental health problems. Since the incident GMFRS have worked with GPHA to deliver fire prevention staff awareness training and to introduce them to the new ‘Safe and Well Visits’ that GMFRS are now offering. A copy of the record of inquest and the evidence accompanies this report. This report is being distributed to MCC Housing Department with a request that they consider it internally but also that they distribute it to all other Housing Associations within Greater Manchester. In addition to the NHS and the GP MPC. 2 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 Social Services did not take a more proactive role in pursuing any referral and understanding the risks presented by the deceased. This requires joined up thinking and working with GPs, the NHS locally, the housing provider and finally GMFRS. 2. There was no identification of the deceased as being potentially at risk of a fire in his premises and no referral to GMFRS. 3. There was no process for GPHA to automatically consider fire risks and prevention and make referrals to GMFRS for safe and well visits. 4. It is clear that GPHA did not have an automatic water suppression system (sprinklers) that could be fitted to properties which comprise blocks of flats and or for individuals at high risk. In addition appropriate smoke alarms and other assistive technology could have been installed. 5. The recipients of this report would be well advised to read and digest the detailed GMFRS Fire Investigation Report and its recommendations which are wholly endorsed by the court. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation 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 Wednesday 8th October 2017. 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 Interested Persons. I have also sent it to organisations who may find it useful or of interest. 3 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. 9 Signed: Nigel Meadows HM Senior Coroner Monday 11th September 2017 4
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.
Senior Coroner Adult’s Social Services Manchester City P.O Council 532 Box Hall Town Manchester 2LA M60 Meadows H.M. - Office Town Hall S. Nigel Coroner’s H.M PO 532 Box Manchester Albert M60 Square 2LA Date: 6th November 2017 Dear Mr Meadows, Report to HM Coroner Mr Nigel Meadows in response to the Regulation 28 Report Dated September 2017 11 Subject: Brian Maclean (d.o.b 20/12/1957), , Background Mr Maclean died in a fire at his home on 19 March 2016. He lived alone and was known to have a long standing alcohol abuse and health problems. On the day of his death, it is understood Mr Maclean had consumed a significant amount of alcohol and had caused a fire. A Fire and Rescue Report by Greater Manchester Fire and Rescue Service's (GMFRS) been identified ”. materials carelessly “ discarded smoking cause likely have the the fire to of The Coroner concluded the inquest into the death of Mr Maclean on 6 September 2017 and recorded that he died from smoke inhalation contributed to by alcohol toxicity. A conclusion of recorded. was “ alcohol ” related The Coroner identified a number of areas of concern in a Regulation 28 Report to Prevent Future Deaths including: “ That Social Services did not take a more proactive role in pursuing any referral and understanding the risks presented by the deceased. This requires joined up thinking .” GMFRS provider housing working locally, finally GPs, NHS with and and the the The Coroner directed that action be taken to prevent future deaths, such response to contain details of action taken or proposed to be taken and to set out the timetable for action or, proposed. alternatively, explain action why no to is Response on behalf of Manchester City Council A referral was made via an online form to Manchester City Council’s (MCC) Contact Centre for Children, Families and Adult Social Care on 26 January 2016 by Mr Macleans support worker provider. housing Places, Great from a The Contact Centre acts as the initial point of contact for all queries, concerns and referrals risk. raised connection adult child with or at in a The referral expressed concerns about Mr Maclean’s living conditions, personal hygiene, arrears. levels nutrition, capacity mental rent and of The referral was read and prioritised as 'not urgent' by a Customer Service Officer (Officer A) on the 26 January 2016. This referral was subsequently placed into a non-urgent folder to be processed. On 12 February 2016 another Customer Service Officer (Officer B) was allocated the referral and began processing it that day. Officer B contacted the referrer (Great Places) to request the GP details of Mr Maclean and to request the referrer contact him back when Mr Maclean was present to enable him to speak to the gentleman as there was no telephone number for Mr Maclean on the referral. This was to enable Customer Services to establish further information Maclean. consent from gain and Mr to An email was subsequently received from the support worker from Great Places on the 17 February 2016 with the GP details for Mr Maclean. Officer B then contacted Mr Maclean's GP on the 19 February 2016 to establish Mr Maclean's health condition and his capacity to consent to the referral. Following the discussion with Mr Maclean's GP Officer B took the decision to take no further action in respect of the referral. Officer B subsequently recorded no consent/concerns not substantiated by GP/NFA. onto the electronic recording system: “ Letter .” sent The letter to Mr Maclean stated that contact has been received from Great Places to advise that he may need support, that an officer had attempted to contact Mr Maclean to gather further information without success and Mr Maclean should contact the service again should he services access future. wish the to in Findings of the management investigation Following the concerns raised by the Coroner a management investigation has taken place. It is evident from the investigations of the actions taken by Officers A and B that internal procedures followed. were not Based on the information provided by the referrer the original officer, Officer A, who classified the referral should have identified that an urgent response was required and it should have been placed into the urgent folder to be processed immediately. The concerns expressed in the referral meet the criteria for urgent action in that Mr Maclean was clearly eligible for an assessment potentially significant harm. under Care and risk Act the at of Officer A’s conduct is currently being addressed through MCC disciplinary procedures. Based on the information provided in the referral by the referrer in respect of Mr Maclean the second officer, Officer B, should have passed it to the Primary Assessment Team for further assessment once he had established that he was unable to make contact. The referral also from indicated Maclean. received consent been had fact Mr in Officer B’s conduct is also being addressed through MCC disciplinary procedures and the officer alternative currently duties on is Actions In response to the concerns raised by the Coroner and the outcome of the management investigation following actions taken: taken place have are the be or to 1. All contacts which have been closed or viewed as non-urgent by Officers A and B have been reviewed. 2. An audit of 20% of all contacts classed as “NFA” (No Further Action) by the Contact Centre between July 2017 and September 2017 is being undertaken 3. Further training will be provided for all Contact Centre staff in respect of the Care Act, safeguarding and consent. This will be arranged immediately and will be provided by MCC’s Assurance Quality Team. 4. The Quality Assurance Team are to undertake regular audits of the work undertaken by the Contact Centre. 5. MCC is currently exploring increasing social work supervision and oversight of the Contact Centre officers 6. MCC has considered the recommendations of the GMFRS report and will continue with the work currently underway to raise the awareness of the services offered by GMFRS among adult social care staff. There are regular meeting between the Community Safety Officer from GMFRS and MCC to ensure that all options for extending considered. partnership working are 7. MCC will be referring this matter to Manchester Safeguarding Adults Board for their Review. the Safeguarding consideration whether criteria Adults meets this for as to a Yours sincerely, Deputy Director of Adult’s Social Service - Manchester City Council
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.