Roy Curtis

Mr Tom Osborne 
Senior Coroner 
Milton Keynes  

26 January 2021 

Dear Mr Osborne 

Reply To: 

Direct Line: 

Regulation 28 Prevention of Future Death following the inquest of Mr Roy Curtis 
deceased.  

We acknowledge receipt of the Regulation 28 report following the inquest of Mr Roy Curtis 
that concluded on Wednesday 2nd December 2020.   

You have advised us of your concerns as follows:  

That the procedure for allocating and responding to a referral for an urgent adult 
social care assessment is overly bureaucratic and they are not afforded the priority 
within social services that that they so obviously require.  

Mr Curtis was referred for an urgent Adult Social Care assessment by on 25th September 
2018 following the assessment under the Mental Health Act which resulted in an informal 
admission to the Campbell Centre. Mr Curtis’ benefits had been stopped and he was at risk 
of losing his housing. The referral noted that Mr Curtis was unable to cope independently in 
addressing his current issues and, as a result made plans to end his life. Mr Curtis was not 
allocated a worker until 26 November 2018; the delay was unacceptable.  Following a further 
letter inviting him to an appointment with the Benefits Agency Mr Curtis sadly ended his life.  

Mr Curtis should have been seen and offered an assessment whilst still an inpatient at the 
Campbell Centre, an approach that is now well embedded across health and social care. 
Identifying people who are in patients who need support are in discharge planning meetings 
and is now  straightforward and should not be subject to any delays or unnecessary 
bureaucracy.   

All Adult Social Care (ASC) referrals are channelled  through the MKC Access Team, which  
operates Monday to Friday 8.30am-5pm. Referrals may be submitted by the person with 
needs, a relative, a professional or a member of the public via telephone, email or the online 
form on the Milton Keynes Council Website. 

Each month we receive an average of 500 ASC referrals per month in addition to 
approximately 240 safeguarding alerts.  All referrals are received by the MKC Access Team 
and processed immediately.  It is the response to the referral that is prioritised.  The type of 
referrals that are particularly prioritised are: 

1. 
2. 

3. 
4. 

Where there is a safeguarding concern 
the person cannot leave hospital without a package of care – their needs are 
therefore assessed and planned before discharge, 
An informal carer can no longer be provide support  
The person’s assessment needs have increased.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Outside of office hours the Milton Keynes Council’s Out of hours Social Care responds to 
urgent requests for assistance.  The team operates between 1700 and 0900 and at all hours 
over the weekends and bank holidays.  The Out of Hours team do not complete ASC 
assessment but will deal with urgent matters e.g. a missing person, requests for additional 
care and Mental Health Act assessments.  The Out of Hours Team will complete a referral 
into the Access Team should an adult social care assessment be required.    

Referrals received by the Access Team are sent to social work teams electronically via the 
Adult Social Care client record system; Frameworki. The referrals are reviewed by a Deputy 
Team manager and/or the Duty worker. All our adult social care teams operate a duty social 
work system during office hours. It is these teams that take on any urgent work, for example 
a concern about an individual’s welfare.   Referrals for a social care assessment are 
allocated on the day they are received, and the allocated worker then arranges to make 
contact with the person who has been referred.  We would expect contact to be made with 
the person within 7 days of receipt of the allocated referral.   

It can be challenging and sometimes take time to contact a person referred for an 
assessment.  Our MKC Adult Social Care Practice Guidance has been updated regarding 
how to manage situations where contact has not been possible.  This includes: 

•  Using texts and calls 
•  Visiting the address and leaving a card if there is no response  
•  Visiting both announced and unannounced 
•  Checking in with other professionals e.g. registered GP 
•  Speaking to neighbours  

Where a worker is worried for the person’s welfare the worker will refer to the Thames Valley 
Police for a welfare check.  

Whilst we will always try to complete an assessment within 28 days it often takes much 
longer when we are working with people who are have multiple, complex needs. Our 
assessment begins from the moment we contact the person; however, we may not complete 
an ASC assessment for several months whilst we address immediate needs, develop a 
professional relationship and involve others.  

We recognise that we did not get our response right for Mr Curtis.  We have learnt from his 
untimely death and have reviewed and improved our practice.  There is now a link social 
worker employed to work with the acute mental health hospital ward who is responsible for 
coordinating social care assessments before discharge when needed.  

Where a worker from Adult Social Care fails to make contact with a service user by phone, 
letter or email they will make a home visit. If there are still further concerns, the worker will 
make contact with Thames Valley Police for consideration of a welfare visit.  

We have reviewed the Autism training to include awareness of suicidality and risks, this 
training is mandatory for all ASC staff. 

All our Social workers and Social Work Assistants have a formal supervision meeting every 
four weeks or more frequently for workers new to MKC. Supervision audits are also 
undertaken in addition to reflective case reviews for particularly complex work.  There is a 
requirement at this meeting that managers review actions on caseloads and monitor risks.  

 
 
 
 
 
 
 
  
 
 
 
 We will continue to monitor the practice of our teams, with a focus on learning and improving 
outcomes for vulnerable people. We formally review our performance each month via our 
Adult Leadership Team meeting, with Heads of Service responsible for the performance in 
their area.  This monitoring includes the timelines for assessments and case work review. 

  Yours sincerely 

Group Head Adult Services