Netlyn Robinson

Office of the Senior Coroner for the 
county of West Yorkshire (Eastern 
District) 
Coroner’s Office and Court 
71 Northgate 
Wakefield 
WF1 3BS 

Deputy Director 
Social Work & Social Care Service 
Adults and Health 
Merrion House 
Merrion Centre 
LEEDS 
LS2 8BB 

10 August 2021 

Dear Sir/Madam, 

Regulation 28: Report to prevent future deaths – Leeds City Council 

I am writing in response to your letter dated 24 June 2021, and the enclosed Regulation 28 Report to 
Prevent Future Deaths regards the death of Ms. Netlyn Mae Robinson. I note that you made this 
representation following the inquest which concluded on 22 June 2021. We have reviewed your 
comments and have undertaken an internal review following receipt of this report and can confirm that 
Leeds City Council has taken immediate action on a number of the issues raised and has a clear plan in 
place to address those for which there is a longer timescale. Please see attached action plan.  

The council takes this matter very seriously and is endeavoring to learn from the insights your report 
allows, following the sad death of Ms. Robinson. 

Deputy Director – Social Work and Social Care Services 

www.leeds.gov.uk 

general enquiries 0113 222 4444 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 Matter of concern 
raised by coroner 
1. In evidence it became 
apparent that there was no 
falls pendant or alarm pro-
vided on Mrs Robinson’s 
return home despite her 
previously having one 
when last at home. There 
appeared to be no process 
in place to check whether 
there was a fully opera-
tional alarm system in 
place when needed. Fur-
ther that Mrs Robinson  
was not consulted about 
the lack of an alarm until 
she arrived home thus no 
process in place to provide 
a person with relevant in-
formation in order that 
they are able to decide 
whether or not to return to 
their home address with-
out any form of alarm.  

2. The telephone line was 
not connected. There ap-
peared to be no process in 
place to check that tele-
phones are working and 
that a vulnerable person 

Regulation 28 Report – Action Plan 

Action to be taken 

Action to be taken by 

Lessons Learnt Training Session (applies to points 1-6)   

•  The Mental Health Unit (MHU) to be provided with ‘Lessons Learned’ 
training session which will cover all points raised by the Regulation 
28 Notice and mitigate risk of identified issues occurring in the fu-
ture.  

•  Training to include specific focus on telecare pendent alarms and 

other telecare services. This will include the need to consider refer-
ring for telecare at the start of the discharge planning process where 
the need for equipment is identified; making a note of existing 
equipment at the point of admission to residential care or hospital; 
checking that equipment is in place prior to discharge; testing of 
equipment on discharge; ensuring capacity and decision-making is 
recorded where a service user chooses to return home without rec-
ommended equipment in place and in working order.  

•  Training to also include advising staff of other agreed actions (dis-
charge checklist, Conversation Record pro-forma, Coroner’s Court 
process/protocol) and implications for practice moving forward. 

Discharge Checklist/Crib Sheet (applies to points 1,2,3,4,6) 

•  Task and finish group to be established to develop a discharge check-
list/crib sheet to be used where a person is returning to a private res-
idence following an extended stay in hospital or residential care. 
•  Checklist will include the need for all utilities to be checked to estab-
lish they are in working order, prior to discharge where practicable, 
including that there is a working telephone line. 

•  Checklist will include the need to consider referral to fire service 
where smoke alarms and CO detector are not in place or are not-
working. 

Training to be developed by Safeguarding 
and Risk Manager (SARM), Team Manager 
(TM) and Service Delivery Manager  SDM) 
and delivered to all staff within the Mental 
Health Unit as a matter of priority prior to 
extending to wider social work teams. 

Discharge checklist/crib sheet to be devel-
oped by Task and Finish group. Group to be 
convened by Safeguarding and Risk Man-
ager and to include Senior Social Worker 
representative from each team. Group to 
be chaired by Service Delivery Manager. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Regulation 28 Report – Action Plan 

•  Checklist will include the need to consider environmental visit/as-
sessment and referral for OT assessment where felt necessary.  
•  Checklist will include recommendation that where indicated as re-

quired a social worker attends the property on the day of discharge, 
with service user’s consent, where family/informal support are not 
able to assist. This intervention will include checking that utilities, 
smoke alarms and telecare equipment are working and that the ser-
vice user is orientated to the property if they have been away from 
home for an extended period.  

MHU Emergency Telephone (applies to point 1) 

MHU Emergency Phone to be purchased by 
SDM from MHU budget.  

•  The Mental Health Unit to purchase ‘pay as you go’ mobile phone 
which can be provided to service users on a temporary basis in the 
event home phone or personal mobile isn’t working and/or where 
required telecare equipment isn’t in place at the point of discharge. 
Provision of the emergency telephone will be considered as part of 
the risk assessment/care needs assessment processes already in 
place where discharge to private residence is being planned. 

Conversation Record Pro-Forma Guidance Notes (applies to points 1,5,6)  

•  Task and finish group to be established to develop guidance notes 

for the Conversation Record pro-forma. This will be uploaded to the 
MHU Sharepoint site and MHU staff will be directed to consider us-
ing the pro-forma when undertaking assessments. There will be a 
particular focus on using the pro-forma for newly qualified social 
workers. 

•  Pro-forma guidance to include need to record and consider medical 

diagnoses and any specific support/interventions required to man-
age health conditions.  

has the ability to call for as-
sistance (emergency or 
otherwise) or communicate 
with friends/relatives. 

3. With a lack of alarm or 
phone line there was still 
no risk assessment as to 
how an alarm could be 
raised. 

4. The heating was not 
working/turned on and 
again there appeared to be 
no process in place to 
check premises had heat-
ing, running water, or 
smoke alarms and there-
fore was not fit and safe for 
a vulnerable person to re-
turn to. 

5. The social worker stated 
he had been trained on the 
job to risk assess. He had 
never been shown a check 
list for the numerous issues 
that need to be checked 
prior to allowing a vulnera-
ble person to be returned 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Regulation 28 Report – Action Plan 

home. This included check-
ing on current medical 
needs (although Mrs Rob-
inson did not have any re-
ported issues regarding 
eating, chewing, swallow-
ing, the question was not 
asked by the social worker 
ensuring her safe return 
home). 

6. It was acknowledged 
that the home was owned 
by Mrs Robinson, however, 
there appeared no process 
in place to outline what so-
cial services would and 
would not do to ensure 
that Mrs Robinson’s prem-
ises were suitable.    

•  Pro-forma guidance to include need to consider equipment/telecare 
needs and consideration of referral to other professionals including 
Occupational Therapy or specialist health services such as SALT. 
•  Pro-forma guidance to include undertaking a risk assessment as part 
of the wider assessment process. This will include highlighting identi-
fied risks, proposed risk management plans and service users’ views 
on identified risks. This will also include the need to document where 
advice is given around risk management but declined by the service 
user. Where risk management/mitigation advice is declined, there 
will be a requirement that mental capacity around this decision is 
formally assessed and documented.  

Coroner’s Court Process/Protocol (applies to point 5) 

•  A process/protocol will be developed in consultation with LCC Legal 
to be used where social workers are required to give evidence at an 
Inquest.  

•  The protocol will include the need for involvement from Team Man-
ager/SDM when reviewing written statements to ensure they accu-
rately reflect the work undertaken in a particular case. 

•  The protocol will include a discussion with the social worker giving 
evidence around what to expect when attending the Inquest, the 
purpose of the Inquest and their role within the process as a witness.  

•  The protocol will still apply where a social worker has left Leeds City 
Council and there will be an agreed expectation that their most re-
cent Team Manager/SDM support the agreed process. 

Conversation Record pro-forma guidance 
to be developed by Task and Finish group. 
Group to be convened by SARM and to in-
clude Senior Social Worker representative 
from each team. Group to be chaired by 
SDM with SARM deputising where re-
quired. 

SDM/SARM to liaise with LCC Legal repre-
sentative to develop Coroner’s Court Pro-
cess/Protocol. Protocol to be communi-
cated to all Team Managers once com-
pleted and training to be provided if neces-
sary/required.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Regulation 28 Report – Action Plan