William Lugg

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Po Your ref: Date: 1st Oct 2018 Wigan Investment Centre

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STRICTLY PRIVATE AND CONFIDENTIAL

Wigan
Heather Williams QC WN3 5BA
Assistant Coroner Tel: 01942774394
Inner North London Poplar Coroner's Court Fax: 01942 774526
127 Poplar High Street DX: 322401 Wigan 11
Tower Hamlets PS
London FES

E14 0AE

Dear Madam Coroner

RE: Response to Regulation 28 Report to Prevent Future Deaths
Inquest touching upon the death of William Lugg

We act on behalf of Careworld London Ltd in relation your report to prevent future deaths, dated 25'
June 2018. The report was sent to vot Director of Careworld London Ltd and
HR ez: of Service at Careworld London Ltd. This response is provided on behalf of Careworld

Further to your report, it is noted that 6 matters of concern have been identified:

1. Tower Hamlet's Failed Visits Procedure was poorly understood and not followed by Careworld
staff, in particular (though not limited to): (a) the appropriate means of alerting Tower Hamlets
to failed care visits that occurred during a weekend; and (b) use of the Tower Hamlets’ pro
forma Failed Visit Record;

2. Careworld’s own Failed Visits Procedure does not mirror or reflect aspects of Tower Hamlet's
prescribed procedure;

3. Vital information regarding the identity of and contact details for the only other keyholder to the
premises in this instance was not clearly recorded by either Tower Hamlets or Careworld;

4. No adequate record of calls from a carer to the Careworld Care Co-ordinator regarding failed
visits was made, leading, in turn, to inaccurate information regarding the client's welfare being
disseminated to Tower Hamlets by another member of Careworld staff;

5. Neither Tower Hamlets or Careworld’s Failed Visits policy gives any / any sufficient
prominence to the possibility of involving the police if other attempts to confirm the individual's
welfare following a failed visit have proved unsuccessful;

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6. The absence of a clear / clearly understood system for the Adult Social Care Team to use on

a Monday morning for assessing and deciding the priority of referrals from the Out of hours

service made over the weekend (and for recording this decision-making).

We respectfully submit that the matters of concern so identified have been addressed in the following

ways:

(iii)

(iv)

(vi)

Careworld London has designed and implemented a new Action Plan, a copy of which
is appended to this letter as Appendix A.

The Failed Visits policy itself has been updated - a copy is at Appendix B - and all
Careworld London staff (both office staff and care workers) have been re-trained in
respect of the content of the revised policy and in respect of the fundamental
principles involved in safeguarding adults. All such training was completed by 3
August 2018.

Appended to this letter as Appendix C is a copy of the written module that formed the
basis for the training. It will be seen that the key objectives of the training were to
ensure that all staff are in a position to recognise their responsibility for the safety and
security of all service users, to ensure that there are clear escalation procedures in
place for those occasions when “no reply” is obtained, and to ensure that effective
mechanisms for communication within and between all relevant agencies are in place
to address and resolve “no reply” incidents.

We are confident that these steps effectively address the concern expressed as
Matter of Concern 1 above, namely the poor understanding and adherence to the
Failed Visits policy by Careworld London staff;

The revisions to the Careworld London “Failed Visits” policy and procedures are
specifically designed to ensure that they do now “mirror and /or reflect” the policies
and procedures followed by the relevant local authorities with whom we work (See
Matter of Concern 2 — above). It is recognised that a disjoint between differently
designed policies operated by different agencies had created potential for difficulties
in the past. Careworld London no longer works with Tower Hamlets but does provide
services to the Hackney Children, Adults and Community Health Department. There
has been liaison between Careworld London and Hackney and we attach by way of
evidence (at Appendix D ) a letter dated 9 August 2018, demonstrating the manner in
which information on policy is now exchanged with a view to ensuring that procedures
and practices operate together effectively.

Concern about the recording of “vital information regarding the identity of and contact
details for the other keyholders to the premises” (Matter of Concern 3 — above) has

(vii)

(viii)

been addressed. It will be seen from the Action Plan that such details in respect of all
664 service users have now been updated. Dedicated scheduling software has now
been put in place to ensure that such information is accurately recorded, up-to-date
and accessible to all those who have need of it. Without wishing to descend into too
great particularity, we append to this letter as Appendix E screenshots from the
software used, that we hope give an indication of the way in which such records are
now maintained;

Concern relating to the “inadequate recording of calls from carers” (Matter of Concern
4 — above) has been addressed. It will be noted from the Failed Visits policy that if
Para 3 of the policy becomes applicable, the relevant carer is required to immediately
contact office staff for advice and direction. Pursuant to Para 4, office staff are then
required to contact, in this order (a) the service user; (b) relatives (in particular any
recorded key-holder); the warden or alarm control; (d) the Emergency Duty Team.
Further it will be noted from the Action Plan that office staff are required to record and
keep note of all such communications;

Concern relating to “insufficient prominence of the possibility of involving police”
(Matter of Concern 5 - above) has been addressed. It will be noted from the Failed
Visits policy that if Para 6 becomes applicable, “office staff should contact the police
immediately and both office and care staff should wait at the premises until the police
arrive and gain access”.

If you have any continuing concerns, we of course remain more than willing to consider and address

them.

Please acknowledge safe receipt.

C\

Yours faithfully

Stephensons Solicitors LLP

x

IN THE MATTER OF THE INQUEST  

TOUCHING UPON THE DEATH OF WILLIAM LUGG 

Response from the London Borough of Tower Hamlets to the Coroner’s 

Regulations 28 Prevention of Future Deaths Report 

Introduction 

1.  This  is  the  response  from  the  London  Borough  of  Tower  Hamlets  (‘the 

Council’)  to  the  Coroner’s  Regulation  28  Prevention  of  Future  Deaths 

Report dated 25 June 2018 following the inquest into the death of William 

Lugg (‘WL’). 

2.  On 12 March 2018 an investigation was commenced into the death of WL, 

aged  68  years old. The  investigation  concluded at  the end  of  the inquest 

on 20 June 2018. The inquest found that WL died on 6 March 2018 at his 

residence at 

 following an 

unwitnessed fall when he was ascending the stairs at that address, which 

occurred  on  /  by  the  morning  of  3  March  2018.  The  conclusion  of  the 

inquest was a narrative one. The medical cause of death was found to be 

head injury. 

The narrative conclusion of death is as follows: 

“…Mr Lugg lived alone and had not left his residence for several years. He 

suffered  from  severe  depression.  He  was  under  the  care  of  the  Tower 

Hamlets  Adult  Social Care  Team  and  received  daily  care  visits from  staff 

employed  by  the  Careworld  London  care  agency  and  also  Meals  on 

Wheels. From the morning of 3 March 2018 onwards, the Careworld carer 

and  the  Meals on Wheels personnel received  no  answer upon  their  daily 

1 

 
 
  
 
 
 
 
 
 
 
 
 attendances at the premises. This was unusual. Careworld did not contact 

the Tower Hamlets Out of hours service or the police over the weekend of 

3  –  4  March  2018.  They  conveyed  inaccurate  information  to  Tower 

Hamlets on 4 and 5 March 2018. The premises were not attended until 6 

March 2018 by Tower Hamlets Adult Social Care Staff, when police were 

contacted  for  the  first  time.  Once  entry  was  gained,  Mr  Lugg  was 

discovered, deceased, having fallen down the stairs. It is not clear whether 

or not earlier intervention, following the fall, would have saved him…”. 

Response to Concerns 

3.  The  Council  has  carefully  considered  each  of  the  matters  of  concern 

raised  by  the  Coroner  and  this response addresses each  concern  in  turn 

setting out the action taken or proposed to be taken, along with a timetable 

for the actions.  

4.  Following the death of WL and prior to the inquest conclusion hearing on 
20  June  2018  the  Council  commenced  a  safeguarding  enquiry  on  3  May 

2018  and  a  referral  was  made  for  a  Safeguarding  Adults  Review  on  9 

March  2018  with  a  view  to  learning  lessons  from  this  case.  The  Coroner 

will  recall  that 

,  Team  Manager  for  the  Assessment  and 

Intervention  Team  (Adult  Social  Care)  provided  both  written  and  live 

evidence about the steps that are being taken.  

a)  Tower  Hamlets  Failed  Visits  Procedure  was  poorly  understood 

and  not  followed  by  Careworld  staff,  in  particular  (though  not 

limited to): (a) the appropriate means of alerting Tower Hamlets to 

failed  care  visits  that  occurred  during  a  weekend;  and  (b)  use  of 

the Tower Hamlets pro forma Failed Visit Record; 

5.  The service specification against which commissioned home care services 

are  to  be  delivered,  and  which  forms  a  core  element  of  the  contract 

between  the  Council  and  commissioned  providers,  includes  explicit 

2 

 
 
 
 
 
 
 
 reference to the importance of compliance with the Failed Visits Procedure 

as follows:- 

12.8 

Failed Visits 

12.8.1 

The Council has revised and updated its Failed Visits Policy and 

Procedures  with  effect  from  January  2016.  This  Policy  and  Procedure 

document  is  annex  02  to  the  service  specification  and  must  be  complied 

with at all times. 

12.8.2 

For the absence of doubt, a failed visit is defined as a planned 

visit  that  has  not  been  cancelled  or  changed  by  the  Council  or  service 

user,  and  for  which  the  care  worker  or  other  professional  scheduled  to 

undertake the visit has been unable to gain access to the service user. 

6.  The  Failed  Visits  Procedure  that  was  current  at  the  time  the  Council 

entered  into  its  contract  with  Careworld  was  included  with  the  service 

specification  and  its  importance  has  been  the  subject  of  discussion  in 

home care provider forums that Careworld participated in on a number of 

occasions. Other commissioned home care providers have confirmed that 

they  have  no  difficulty  in  understanding  and  operationalising  the  Failed 

Visits Procedure. 

7.  The service specification referred to above also makes clear, in section 11, 

which relates to workforce issues, “the service provider will ensure that as 

a  minimum” a  range  of  workforce  competencies  are  maintained  including 

the following:- 

  All employees are competent and trained to undertake the activities for 

which they are employed and responsible; 

  All employees are aware of their Safeguarding responsibilities both for 

Children and Adults; 

3 

 
 
 
 
 
 
 
 
   All  employees  are  aware  of,  familiar  with  and  can  operationalise  the 

Provider’s policies and procedures. 

8.  It  is  the  Council’s  view,  that  the  requirement  both  to  comply  with  the 

Council’s  Failed  Visits  Procedure  and  to  ensure  that  care  staff  are 

competent in complying with the said procedure is clearly specified. 

9.  Since  the  inquest  the  Council  has  confirmed  with  all  providers  that  they 

have  a  copy  of  the  current  Failed  Visits  Procedure  and  those  providers 

have  also  been  consulted  on  the  proposed  revisions  to  the  Procedure 

referenced elsewhere in this response. 

10. The  Council  has  reviewed  its  contractual  relationship  with  Careworld  in 

response to a range of concerns, including those relating to conduct in the 

provision  of  care  to  Mr  Lugg,  and  following  Mr  Lugg’s  death.  Non-

compliance  with  the  Failed  Visits  Procedure  in  a  number  of  cases  has 

been one of the themes identified as a result of this review. 

11. Based  on  the  findings  from  this  contract  review  process  the  Council  has 

determined  to  terminate  our  contract  with  Careworld  and  the  termination 

notice  has  now  been  served.  All  care  services  provided  by  Careworld  in 

Tower  Hamlets  are  therefore  being  transferred  to  other  commissioned 

providers on 20 August 2018. 

b)  Careworld’s own Failed Visits Procedure does not mirror or reflect 

aspects of Tower Hamlets’ prescribed procedure; 

12. The  service  specification  referred  to  above  includes,  in  section  12,  the 

following requirement: 

12.4 

It  is  for  service  providers  to  ensure  that  the  content  of  their 

policies  and  procedures  is  accurate,  up  to  date  and  reflects  the 

requirements  of  the  contract,  service  specification  and  all  relevant 

legislation and regulatory requirements. The Council will, as part of the 

4 

 
 
 
 
 
 
 
 
 
 ongoing  contract  management  process,  expect  to  review  a  sample  of 

policies and procedures to ensure compliance with these requirements. 

There  are  also  a  number  of  specific  policies  and  procedures  the 

Council wishes to draw specific attention to, either to provide additional 

commentary on  content  or to  make  explicit the  requirement  to  comply 

with existing Council policies and procedures. These are listed below. 

The Failed Visits Procedure is one of five policies and procedures that is 

explicitly  referenced  here  and 

the  reference 

is  reproduced  above 

(paragraph 12.8). 

c)  Vital  information  regarding  the  identity  of  and  contact  details  for 

the only other keyholder to the premises in this instance was not 

clearly recorded by either Tower Hamlets or Careworld; 

13. The  section  42  safeguarding  enquiry  into  the  death  of  Mr  Lugg  is  almost 

complete but  has not yet been concluded due to a subsequent allegation 

of financial abuse which is still being investigated.  However, some of the 

key findings are shared in this report.   

14. The  enquiry  recognises  that  the  neighbour  being  an  emergency  contact 

and key holder was not discussed between Mr Lugg and the social worker 

and that therefore there is no record of the neighbour’s details on the Adult 

Social Care file.   

15. The  Careworld  care  plan  signed  on  26  January  2018  does  detail  the 

neighbour as Mr Lugg’s emergency contact.  Although Careworld had this 

information on file, it was not shared with the carer when he was trying to 

locate Mr Lugg. 

16. The  safeguarding  enquiry  report  recommends  that  social  workers  and 

senior  practitioners  should  ensure  that  up-to-date  front-sheet  information 

including relationships, emergency contacts, key holders, key safe details, 

warnings and information about mobility issues is  kept updated.  This will 

5 

 
 
 
 
 
 
 
 
 ensure that accurate information is captured by the Adult Social Care and 

is accessible when it is needed. 

17. The  Council’s  Failed  Visits  Procedure  has  been  reviewed  and  following 

consultation, including with our provider services, it is being revised.  The 

revised policy will be signed off and formally launched with the Adult Social 

Care and commissioned providers in August 2018.   

18. The revised policy addresses the above recommendation.  It now includes 

a  section  on  “being  prepared”  which  highlights  the  importance  of  good 

record-keeping.  This section in the procedure aims to ensure that services 

that  may  encounter  a  “failed  visit”  situation  are  equipped  with  the  right 

information to enable them to act quickly and effectively.  This includes, for 

example, the requirement to hold essential information such as the names, 

addresses  and  telephone  numbers  of  emergency  contacts,  family  and 

friends,  the  nearest  key  holder,  any  mobility  issues  and  whether  the 

person  is  known  to  leave  their  property  or  not.    The  procedure  requires 

that this information be accessible to those who may need it, any time, day 

or night.  

d)  No  adequate  record  of  calls  from  a  carer  to  the  Careworld  Care 

Co-ordinator regarding failed visits was made, leading, in turn, to 

inaccurate 

information  regarding  the  client’s  welfare  being 

disseminated to Tower Hamlets by another member of Careworld 

staff; 

19. As  noted  above,  Careworld’s  conduct  in  relation  to  the  care  of  Mr  Lugg 

and following his death, is one of a number of factors that have led to the 

Council  determining  that  it  is  necessary  to  terminate  our  contract  with 

Careworld and the notice of termination has been served. 

e)  Neither  Tower  Hamlets  or  Careworld’s  Failed  Visits  policy  gives 

any sufficient prominence to the possibility of involving the police 

6 

 
 
 
 
 
 
 
 if  other  attempts  to  confirm  the  individual’s  welfare  following  a 

failed visit have proved unsuccessful; 

20. The  Council’s  revised  Failed  Visits  Procedure  now  includes  a  one-page 

checklist which makes more prominent  the requirement to call the Police 

in  an  emergency  situation,  following  some  quick  checks  to  locate  the 

person:- 

“…If you suspect the person is at risk of serious harm or is critically unwell 

you should all 999 immediately…”.   

This statement is included, in highlighted colour, at the end of a one-page 

checklist and repeated a further twice throughout the process document.  

21. Moreover,  the  procedure  now  places  emphasis  on  any  individual  taking 

the  responsibility  to  call  the  Police;  if  their  assessment  of  risk  indicates 

there may be a need to.  There is still a requirement for information to be 

passed  to  senior  staff  members  and  to  the  local  authority,  and  in  most 

cases the decision as to whether to call the Police will be made by a more 

senior  officer.    However,  the  procedure  does  not  exclude  any  officer, 

including carers, from calling the Police in an emergency situation. 

f)  The  absence  of  a  clear  /  clearly  understood system  for  the  Adult 

Social Care Team to use on a Monday morning for assessing and 

deciding  the  priority  of  referrals  from  the  Out  of  Hours  service 

made over the weekend (and for recording this decision-making). 

22. The Assessment & Intervention Team (Adult Social Care) has reviewed its 

service  delivery  model  and  now  has  additional  resources  to  cover  the 

referral  processing  section.    A  First  Response  Officer  is  dedicated  to 

managing the email referrals between the hours of  9am – 5pm, every day.  

This enables any urgent referrals to be picked up immediately.  The officer 

prioritises  the  Emergency  Duty  Team  (Out  of  Hours)  reports  and  other 

failed  visit  reports  each  morning,  including  after  a  weekend.    Any  such 

7 

 
 
 
 
 
 
 
 
 reports  are  saved  onto  the  social  care  database  (Framework-i)  and 

emailed  to  the  allocated  officer.  The  First  Response  Officer  will  speak  to 

the  allocated  officer  or  in  their  absence  their  supervisor,  directly,  to  alert 

them to the report.  Where there is no allocated officer, the First Response 

Officer will speak to the relevant team’s duty section immediately, who will 

in  turn  act  upon  the  report.  The  team  has  updated  their  procedures  to 

reflect this. 

23. The  Referral  Processing  section  in  the  Assessment  &  Intervention  Team 

ran a practice session on 2 August 2018 where they looked at the lessons 

learned from Mr Lugg’s case and implementing the new procedure for their 

section.   

Other Steps: 

24. In  addition to  the  concerns  as  raised  by  the Coroner,  as  per the Witness 

Statement  of 

  Team  Manager  dated  24  May  2018,  the 

Council also notes the following learning points from this case:- 

i) 

Given  Mr  Lugg’s  history  and  his  persistent  lack  of  engagement  – 

there is a question as to whether his mental capacity regarding his 

personal  care,  access  to  health  services  should  have  been 

assessed. I note, however that the social worker in her assessment 

did  note  that  an  Independent  Mental  Capacity  Advocate  (IMCA) 

was not required, indicating that this was at the forefront of her mind 

but that there was sufficient evidence to  presume he had capacity.  

Indeed,  to  support  her  decision  regarding  the  presumption  of 

capacity and recognising that Mr Lugg did need some support, the 

social worker ensured the presence of an advocate in the form of a 

Tenancy Advisor / advocate during her assessment.   

Nonetheless, despite the explanation by the social worker as to why 

a  mental  capacity  assessment(s)  was  ruled  out,  there  remains  a 

concerning  pattern  of  Mr  Lugg  continually  declining  support 

8 

 
 
 
 
 
 
 
 especially  around  his  personal  care.  There  is  no  evidence  of  any 

discussions  with  him  about  the  implications  of  this  or  whether  he 

had  any  insight  into  the  repercussions  of  his  behaviour  continuing 

over an extended period of time and the potential risks to his health 

and well-being. 

ii) 

There  was  a  gap  between  November  2017  and  February  2018 

during  which  there  was  no  allocated  social  worker  to  Mr  Lugg.  In 

hindsight, this should have been considered more carefully. Whilst I 

note  that  there  were  no  incidents  or  concerns  raised  regarding  Mr 

Lugg’s  care  over  that  time,  consideration  should  be  given  to  Mr 

Lugg’s  history  of  non-engagement  and  the  need  for  continual 

support and monitoring. In future, service users who are vulnerable 

and need continual support will remain allocated to a worker until a 

clear plan of support is identified.  

iii) 

The  internal  interaction  between  the  monitoring  services  from 

Commissioning  and  the  social  work team  needs  to  be  reviewed  to 

ensure  that  there  is  a  more  robust  way  of  communication.  In  this 

instance,  I  am  of  the  view  that  the  monitoring  officers appeared  to 

carry out their visits with no liaison or feedback to the social worker.  

iv) 

The  care  agency,  over  the  period  between  the  3rd  and  the  6th 

March  2018,  appeared  to  have  sent  emails  to  the  ‘Adultcare’  and 

‘Brokerage  Duty’  emails  which  are  only  accessed  during  the 

working  week  (Monday  to  Friday  between  9am  -  5pm).    The  care 

agency and Meals on Wheels would have been required to contact 

the  Out  of  Hours  Emergency  Duty  Service  in  the  event  of  a  failed 

visit  as  well  as  copying  in  the  emails  of  Adultcare  and  Brokerage. 

The  Out  of  Hours  Emergency  Duty  Services  have  a  social  worker 

on  call  that  can  provide  support  and  advice  in  the  event  of  an 

emergency  to  include  where  there  has  been  a  failed  visit.  This 

procedure  appeared  not  to  have  been  followed  in  this  case.  Our 

9 

 
 
 
 
 
 Brokerage Team now reminds care agencies of the contact details 

for our Out of Hours Emergency Duty Service. 

v) 

The  care  providers  are  required  to  follow  a  Failed  Visit  Procedure 

which  requires  them  to  check  with  various  agencies  such  as  the 

hospital,  police,  and  next  of  kin  while  also  alerting  the  local 

authority. As this does not appear to have been fully implemented in 

this  case,  the  local  authority  now  ensures  care  providers  are 

conversant with the Failed Visit Procedure. 

25. A safeguarding review is ongoing and the findings and  recommendations 

will  return  to  the  multi-agency  group  for  agreement  once  the  full 

safeguarding enquiry is concluded. 

26. As  set  out  in  this  report,  some  immediate  actions  have  been  taken  in 

relation  to  the  early  learning  in  this  case.    Additionally,  Tower  Hamlets 

Adult Social Care has been making improvements in areas of practice that 

address some of the areas of concern in this case. For example: 

  Piloting  a  new  carers’  assessment  and  raising  the  profile  of  carers  in 

the borough 

  Developing  a  single  point  of  access  for  health  and  social  care  which 

includes a review of the Out of Hours service.  This will cover how the 

service  is  accessed  as  well  as  case  recording  which  is  accessible  to 

those who need to see it. 

  Revision of the Tower Hamlets Adult Social Care Failed Visits Policy & 

Process  which  now 

includes  emphasis  on  keeping 

front-sheet 

information  up-to-date,  fewer-hand-offs  and  highlights  the  importance 

of calling the Police if serious harm is suspected.  This will be followed 

by a formal launch of the new policy and process with both Adult Social 

Care staff and our commissioned providers. 

  A  review  of  the feedback  loop  between  the quality  monitoring  team  in 

Commissioning and Adult Social Care teams. 

10 

 
 
 
 
 
 
   The  Council  has  determined  to  terminate  our  contract  with  Careworld 

and the termination notice has now been served. 

27. We  have  reported  this  case  to  the  Safeguarding  Adults  Board  (‘SAB’) 

subgroup.  There will be an independent learning review as a follow up to 

the section 42 enquiry which will take into consideration other cases where 

there are similar themes in learning.  Whilst more immediate actions have 

been  taken  in  relation  to  the  learning  in  this  case,  the  full  findings  and 

recommendations  of  the  independent  review  will  be  reported  to  the 

Safeguarding Adults Board and any further recommendations followed up.   

Conclusion 

28. I  hope  that  the  above  addresses  the  concerns  raised  in  the  Coroner’s 

report. The Council remains committed to learning lessons from untoward 

incidents  and  continually  improving  the  care  provided  to  the  most 

vulnerable sections of our community for whom we are responsible. 

Signed:   

Date: 

Corporate Director Health, Adults and Community 

London Borough of Tower Hamlets  

11 

16th August 2018