Jacob Sulaiman

RESPONSE TO REGULATION 28 CORONER’S REPORT 
TO PREVENT FUTURE DEATHS 

1 

THIS RESPONSE IS MADE ON BEHALF OF 

London Borough of Camden 

2 

THIS REPORT IS BEING SENT TO 

Sarah Bourke, Assistant Coroner for the coroner area of Inner North London 

3 

CORONER’S LEGAL POWERS 

Coroners and Justice Act 2009 and Regulations 28 and 29 of the 
Coroners (Investigations) Regulations 2013  

4 

INVESTIGATION AND INQUEST  

On 12 December 2017, Assistant Coroner Heather Williams commenced 
an investigation into the death of Jacob Sulaiman aged 65. The 
investigation concluded at the end of the inquest on 6 July 2018.  

In relation to how, when and where Mr Sulaiman came by his death, the 
investigation found that:  

Mr Sulaiman sustained carbon monoxide poisoning after a fire started in 
his bedroom. He died at his home on 8 December 2017.  The medical 
cause of death was:  

1a carbon monoxide poisoning  
1b inhalation of products of combustion  

The coroner concluded that Mr Sulaiman’s death was the result of an 
accident.  

5 

CIRCUMSTANCES OF DEATH 

The circumstances of death are set out in the Coroner’s Regulation 28 
Preventing Future Deaths Report  

6 

CORONER’S CONCERNS 

(1)  Response  officers  from  Careline  visited  Mr  Sulaiman  twice  during  the 
night of 7/8 December 2017. It is not usual practice to leave a written record 
of those visits in the property.  

(2)  In  addition,  Mr  Sulaiman  made  a  number  of  calls  to  Welbeing,  which 
were referred to response officers for guidance.  

(3)  Response  officers  only  know  about  calls  made  to  Welbeing  if  the 

 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
  
 
 
 
 
 
 information  is  placed  on  the  shared  database.  Response  officers  did  not 
know the outcome of the paramedics’ visit in the early hours of 8 December 
when they visited at 3.40 am.  

(4)  Information  regarding  the  nature  and  number  of  recent  contacts  with 
Welbeing  is  not  easily  accessible  to  response  officers  dealing  with  an 
emergency call out.  

(5) From the evidence before me, it is evident that the services which visited 
Mr Sulaiman on the night of 7/8 December 2017 had an incomplete picture 
of  the  number  of  other  services  that  Mr  Sulaiman  had  contacted  and  his 
presentation  at  those  times.  In  particular,  had  the  London  Ambulance 
Service had more information regarding the nature and number of calls that 
Mr Sulaiman had made to Careline, this may have had some bearing on the 
steps  taken  to  assess  his  mental  capacity  and  how  Mr  Sulaiman  was 
managed.  

7. 

RESPONSE 

(1)  Response  officers  from  Careline  visited  Mr.  Sulaiman  twice  during 
the  night  of  7/8  December 2017.  It  is  not usual practice  to  leave  a 
written record of those visits in the property; 

In  the  first  visit,  the  Response  Officers  were  called  as  Mr  Sulaiman  had 
fallen  and  they  supported  him  back  to  bed,  as  he  was  not  injured.  The 
second visit was requested when Mr Sulaiman’s alarm was triggered and he 
did not answer. Response Officer’s found that he was safely in bed asleep. 
Neither  of  these  visits  were  out-of-the-ordinary  for  Careline  Response 
Officers.  At the first visit Mr Sulaiman did talk of his passport and wanting to 
go to the airport, however he was redirected to get some rest in bed as the 
hour was late. 

The visits were recorded on the Careline client database and the recording 
procedure is outlined below.   

(2)  Mr.  Sulaiman  made  a  number  of  calls  to  Welbeing  which  were 

referred to response officers for guidance; 

The calls were triaged by Welbeing and were passed to Careline response 
Team  when  action  was  required,  such  as  a  visit.  There  were  no  calls 
between  Welbeing  and  Careline  for  ‘guidance’  –  although  there  were  two 
‘for  information’  to  let  Careline  know  the  emergency  services  had  been 
called.  First the LAS service at 23.10 and later LFB at 07.57 the following 
morning.  There were three calls from Welbeing to Careline to request visits, 
two  of  which  resulted  in  visits  at  22.59  and  04.35.  During  the  third  call, 
Welbeing call handler and Careline Response Officers mutually agreed that 
as Mr Sulaiman had not fallen and was mobile enough to reach his entrance 
hall,  a visit  was  not  required.  Both  the Welbeing  call  handler  and  Careline 
Response Officers were aware of Mr Sulaiman’s desire to go to the airport 
and they agreed to redirect him and asked him return to his flat, due to the 
hour – 05.30am. 

       (3)  Response  officers  only  know  about  calls  made  to  Welbeing  if  the       
information  is  placed  on  the  shared  database.   Response  officers  did  not 
know the outcome of the paramedics visit in the early hours of 8 December 

 
 
 
 
 
 
 
 
 
 when they visited at 3.40am; 

Welbeing pass on information to response officers when there is likely to be 
a need for a visit.  A call that does not result in a visit is not routinely passed 
on to Careline, as no action from them is required.   

When  LAS  are  called,  they  do  not  routinely  report  back  to  Welbeing, 
however  in  the  case  of  Mr  Sulaiman,  his  community  alarm  made  contact 
with  Welbeing  while  LAS  were  still  in  attendance  and  the  paramedic 
confirmed  to  Welbeing  that  was  Mr  Sulaiman  had  no  medical  needs  that 
required taking him to hospital. 

       (4)      Information  regarding  the  nature  and  number  of  recent  contacts 
with Welbeing  is  not easily  accessible  to  response officers  dealing with an 
emergency call out; 

Please see answers to paragraph 8 below.  The service will be changing to 
address these gaps. 

       (5)  From  the  evidence  before  the  Coroner,  the  Coroner  considered  it 
was  evident  that  the  services,  which  visited  Mr.  Sulaiman  on  the  night  of 
7/8,  December  2017  had  an  incomplete  picture  of  the  number  of  other 
services  that  Mr.  Sulaiman  had  contacted  and  his  presentation  at  those 
times.  In  particular  had  the  London  Ambulance  Service  had  more 
information regarding the nature and number of calls that Mr. Sulaiman had 
made  to  Careline,  this  may  have  had  some  bearing  on  the  steps  taken  to 
assess his mental capacity and how Mr. Sulaiman was managed. 

It  is  correct  to  say  that  none  of  the  individuals  attending  Mr  Sulaiman’s 
property on the night of his death had a full picture of all the calls  that day, 
however, Welbeing were aware of, and coordinated the responses, whether 
they were remotely or in person. 

The  main  concern  of  Response  Officers  and  LAS  in  attendance  were 
related  to  his  physical  health  and  his  repeated  falls.    Mr  Sulaiman  was 
reported to be quite fixed on his plans to travel to the airport and return to 
The Netherlands.  He was however able to be redirected to return to his flat 
and there was no evidence that he lacked capacity. During the night, none 
of  interactions  with  Mr  Sulaiman  were  such  as  to  require  intervention 
relating to his mental health.   

8 

ACTION TAKEN/TIMESCALE 

The following  response  sets  out current practice (and  practice  as  it  was  in 
December  2017).    There  have  since  been  identified  improvements  to  the 
service, which are outlined below and are already underway.  

Unlike Domiciliary Care providers who visit regularly to  support people with 
practical  care  tasks  and  record  their  activity,  Careline  Response  Officers 
visit  on  an  ad  hoc  basis  following  a  connection  to  Welbeing.  There  is  no 
written record left in the individual’s home.    

A  Careline  call  can  be  triggered  by  way  of  an  individual  pressing  their 
emergency call button, on the Careline unit in their residence, or if a sensor 
detects a fall etc.  

 
 
 
 
 
 
 
 
  
 
 
 The call handler at Welbeing will triage the call and make a decision if the 
Response Team are required to visit. 

A  visit  by  the  Response  Team  is  recorded  on  the  local  customer  records 
management system held by Careline.  

In  the  case  of  Mr  Sulaiman,  who  lived  in  Sheltered  Housing,  a  message 
would be left by the Response Team for the Scheme Manager to follow up 
on the next day’s shift. For people in Sheltered Housing, Careline Response 
Team provides out-of-hours support only. 

The Welbeing  call  handlers  do  not  call  the  Response  Team  for  guidance, 
but rather when action is required.  As above, they triage the call and make 
contact with the individual to find out why the sensor has been triggered.  In 
many calls, the person just requires reassurance. In some it is evident that a 
call is required to be made directly to the emergency services and the call 
handler will do this – without any reference to the Careline Response Team. 

If the individual is distressed or is in need on non-medical assistance (e.g. 
fallen and needs help  to get  up)  the  call handler  will  make  the  decision  to 
contact the Response Team to despatch them for a visit. 

If the emergency services have already been called, the Careline Response 
Team do not attend.  There are occasions when the Response Team attend 
and  make  a  further  decision  to  call  emergency  services  when  they  are  on 
site. 

The current system is not joined up as the call handing and response teams 
are separate services run by different organisations.  Welbeing record their 
calls  and  Careline  record  their  response.    When  there  is  an  issue  the 
Welbeing records are requested by Careline. 

The Careline records are updated by the Response Officers who go out on 
the visit. Where follow-up is required from Adult Social Care, this is flagged 
on a further database. 

If there have been multiple calls received, Welbeing will have access to that 
record and be able to see it when they open the individual’s file.  This is a 
similar picture in Careline.  If either make a decision to call the emergency 
service as a result, they would be expected to pass on this information. 

There  is  currently  no  feedback  mechanism  for  the  London  Ambulance 
Service to update Wellbeing or Careline. 

In  2017,  Camden  Council  made  the  decision  to  end  the  contract  with 
Welbeing and to bring the call handling function back in house (It had been 
outsourced approximately 10 years earlier). 

The decision was made, as it was believed that quality would be improved, 
as potential gaps in the service would be eliminated, if it was joined-up and 
one  organisation  would  be  responsible  for  the  triage  and  despatch  of  the 
Response Team.  

In preparation for this move, a new IT platform was required to support the 

 
 
 
 
 
 
 
 
 
 
 
 
 
 records management and mobile working, to ensure recording is timely and 
complete. 

This change is  well underway, migrating records to the new IT system and 
training  staff,  so  that  it  will  be  in  place  before  the  end  of  2018.  As  part  of 
working  practices,  there  will  be  a  checklist  for  referring  to  the  emergency 
services, including ensuring that a full history is given to London Ambulance 
Service  when  a  call  is  made.    Careline,  which  will  now  have a  full history, 
will pass on all the information to LAS call centre, to be recorded as a part of 
the callout. 

A  Safeguarding  Adults  Review  (SAR)  is  a  multi-agency  review  process 
which  seeks  to  determine  what  relevant  agencies  and  individuals  involved 
could have done differently that could have prevented harm or a death from 
taking place. 

In  the  London  Borough  of  Camden,  we  have  a  SAR  review  panel,  which 
considers whether referrals meet the requirements for a SAR.  Following the 
concerns  raised  by  the  Coroner,  we  feel  it  appropriate  that  a  referral  is 
made to the SAR panel for Mr Sulaiman’s case to be reviewed.  We want to 
review the case to determine whether or not it meets the threshold for SAR 
or any further work outside the SAR processes that will lead to better multi-
agency working.   

The London Ambulance Service is represented on the Adults Safeguarding 
Board and we would expect them to participate in any SAR.  In addition, the 
senior  manager  responsible  for  the  Careline  service  has  already  made 
contact with LAS to begin discussions about how information could be better 
shared in future. 

9 

THIS RESPONSE HAS BEEN PREPARED BY 

10 

DATE OF RESPONSE 

3rd October 2018