Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0201, written 8 Oct 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Oct 2020 |
|---|---|
| Reference | 2020-0201 |
| Deceased | May Miller |
| Coroner | Jacqueline Devonish |
| Coroner area | Suffolk |
| Category | Care Home Health related deaths · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) Director, Suffolk Safeguarding Partnership (2) , Director, The Limes, Sheltered Housing, London Road, Halesworth 1 CORONER I am Jacqueline Devonish, Area Coroner, for the coroner area of Suffolk. 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 INVESTIGATION and INQUEST On 26 June 2020 I commenced an investigation into the death of 95 year old May Adalaid Miller. The investigation concluded at the end of the inquest on 7 October 2020. The conclusion of the inquest was that; May Miller died from natural causes precipitated by a violent assault on 9 February 2020, as she slept at her residential care home. 4 CIRCUMSTANCES OF THE DEATH This was a very sad death indeed. May Miller, although frail by virtue of her age, was well and happy when she became a resident of Beech House Residential Care Home on 4 February 2020. Whilst in her room asleep on 9 February, 5 days after she arrived at the home, she was attacked by another resident, with his walking stick. He beat around her head and face. There were defensive injuries to her arms and legs. The Beech House staff heard her screams and attended immediately. Another resident also raised the alarm by pressing the alarm in her own room opposite. , aged 89, On arrival of the carers, Mr had happened. It was thought that he was suffering from dementia with periods of lucidity and other periods of hallucination. There had been no assessment. was standing in the corridor, unable to recall what had resided at their A Warden from the Limes gave evidence that Mr independent living facility (in a property he purchased) between 16 June 2019 and 4 February 2020 before moving to Beech House. Upon initial assessment the Warden found him belligerent and aggressive and felt there was something not quite right. There was no formal procedure for vetting or assessment except the request for a GP report. Nonetheless, the Limes accepted his application for residency when it went to a committee for consideration. His behaviour deteriorated and appeared to be aggressive and sexually motivated, causing the Warden to feel unsafe. She subsequently stopped visiting him alone, and later, not at all. ’s daughter gave evidence that her father had had a social worker but had Mr declined a mental health assessment. He had episodes or paranoia but there had been no signs of physical aggression or violence. Prior to approaching Beech House she had applied to Holmwood, Bungay who had refused to accept him due to his declining condition. Beech House’s evidence was that they had not been made aware of this information, and could not request information from any professional sources since he was arriving from an unregistered facility. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you; The MATTERS OF CONCERN as follows:- In light of the data sharing and confidentiality requirements under GDPR, the GP was unable to disclose full information to the Limes or to Beech House about any previous conduct or assessments of asked to sign a letter giving consent to disclosure to other agencies before or after the residency. It was not known whether the GP could have been the central point of contact for all investigative agencies and the Care Homes. . At no time was the family of Mr It was established during the evidence that multiple investigative agencies may have been aware of Mr s risk factors but that due to his not having been admitted to Beech House from a registered facility, that information sharing was not possible. Had there been in place a system for sharing safeguarding information with the Limes and Beech House, there may have been an opportunity to safeguard May Miller. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you or 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 3 December 2020. I, the Area Coroner, may extend the period if I consider it reasonable to do so. 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 the following Interested Persons: 1) 2) 3) 4) CQC , family , Warden at the Limes , Director, The Partnership in Care Limited (Beech House) I am 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 Area Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Signed Jacqueline Devonish Dated 8 October 2020
2 responses 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.
May Miller - REGULATION 28 REPORT TO PREVENT FUTURE DEATHS This report has been prepared by Council and Chair of the Safeguarding Adult Review Panel on behalf of Director People Services, Suffolk County Council , Head of Safeguarding Adults, Suffolk County , Executive The preparation of the report included discussion with , author of the , Professional Advisor to witness statement offered to the inquest hearing and the Safeguarding Partnership and lead professional for the May Miller Safeguarding Adults Review. 1. Matters of Concern: Coroner findings. In light of the data sharing and confidentiality requirements under GDPR, the GP was unable to disclose full information to the Limes or to Beech House about any previous conduct or assessments of . At no time was the family of Mr other agencies before or after the residency. asked to sign a letter giving consent to disclosure to It was not known whether the GP could have been the central point of contact for all investigative agencies and the Care Homes. It was established during the evidence that multiple investigative agencies may have been aware of Mr House from a registered facility, that information sharing was not possible. ’s risk factors but that due to his not having been admitted to Beech Had there been in place a system for sharing safeguarding information with the Limes and Beech House, there may have been an opportunity to safeguard May Miller. 2. Decision to undertake a Safeguarding Adults Review The purpose of a SAR is described in the statutory guidance as to ‘promote effective learning and improvement action to prevent future deaths or serious harm occurring again’. The aim is that lessons can be learned from the case and for those lessons to be applied to future cases to prevent similar harm re-occurring. Further information regarding SARs can be found https://www.suffolksp.org.uk/working-with-children-and-adults/adults/safeguarding-adults- reviews/ On 30 June 2020, the Safeguarding Adult Review Panel (SARP) received a referral for consideration for a Safeguarding Adults Review. Thereafter discussion was held with the deceased’s family with regards to the proposal to undertake a Safeguarding Adult Review and its intended purpose. On 14 October 2020, the agreed to proceed as a full SAR Review in Rapid Time. The Review in Rapid Time is a pilot project delivered by the Social Care Institute for Excellence, with Local Authorities participating voluntarily. COVID-19 has created a new urgency to identifying and sharing learning from certain cases, and this project looks to align the timescales of completing adults’ reviews in the same way as serious safeguarding incidents involving children (15 working days) As part of Department of Health and Social Care’s COVID-19 Action Plan for Social Care, SCIE has worked with Safeguarding Adults Boards to develop and test a new model for conducting SARs In Rapid Time. 3. Terms of reference: Themed learning points to be included in the SAR The Review Group set up meeting with relevant leads will be held on 19 November 2020, where the key themes for the SAR will be defined. However, from the safeguarding investigation report undertaken by Adult and Community Services, it is thought that the key themes will be as follows: a) Assessment and admission of customers to care settings who are self-funding. To identify barriers to robust information sharing across partner agencies with regards to safeguarding concerns and wider risk factors. This is to include any barriers to information sharing between housing providers and care providers in the placement of an adult who may pose a risk to others. b) Responses to older people with dementia who have high additional needs in a crisis situation, and appropriate placements of those people c) Availability of hospital and community beds for older people with dementia who have mental health needs d) Who should undertake mental health act assessments under the Mental Health Act 1983, when they should undertake them, and when particular agencies should/can request them. 4. Timeframe It is anticipated that the review will be completed by mid-December 2020, after which it will be presented to the SARP for further critique and development of the action plan. Full sign off will be undertaken by the SAB in February 2021 Any urgent matters arising from the review and action plan will be addressed with relevant senior leaders before February.
The Limes Residents Association Limited
The Garden Room ‘The Limes’, 41 London Road
Halesworth, Suffolk IP19 8LT
26.10.2020
Senior Coroner’s Officer
Beacon House, Whitehouse Road
Ipswich, Suffolk IP1 5PB
Inquest Touching the Death of May Adalaid MILLER
Dear Julie.
The Limes comprises 30 properties owned on a leasehold basis.
The owners of the properties are encouraged to live independently
and previously any concern the warden may have had on a
resident has been passed on to their families who it has been
expected would discuss their relatives needs with professional
agencies, care homes etc.
We believed this to have happened in this case.
We employ a warden who lives on site but her role is limited to that
of a good neighbour. The warden would normally visit each
resident once a week. If required this is increased but we are not
a care home and any daily care needs would need to be arranged
by the wider family.
Prospective residents are interviewed by the warden and the
manager. A letter of suitability is always obtained from the G.P. but
they seemed to be bound by confidentiality and the information is
received is very limited.
We have always taken the view that it’s up to the care home to
consider the suitability of a resident? and undertake an
assessment prior to admission. On admission I would have
expected given their lack of information that an assessment would
have started straightaway. Had we been approached by Beach
House we would have shared what knowledge we had.
In light of the above case and on reflection the following changes
will be made to our working practice. The residents will be
informed of the changes to our policy immediately by letter and our
handbook will also be amended to reflect the changes.
On hearing that a resident is considering a move into
residential care, contact will be made immediately with the
receiving care home and all information will be shared.
This would initially be by phone (warden) and would always
be followed up in writing (manager)
I will also be writing to our local Social Services and G.P. practice
and invite them to a coffee morning with the intention of building up
a working relationship. Initially I would like to see this happen twice
yearly. I would hope that from this clearer communication was
possible and advice and support forthcoming when requested.
Company Secretary and Manager
The Limes Residents Association Limited: Company registration number: 2682550. Registered in England.
Registered Office: The Garden Room, ‘The Limes’, 41 London Road, Halesworth, Suffolk IP19 8LT
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