Prevention of Future Deaths reports
Regulation 28 report to prevent future deaths, reference 2021-0270. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Reference | 2021-0270 |
|---|---|
| Deceased | Hadley Savory |
| Coroner | Ian Brownhill |
| Coroner area | North East Kent |
| Category | Alcohol, drug and medication related deaths · Other related deaths · Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Kent Hospitals University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
North East Kent Coroners Cantium House 2nd Floor Maidstone Kent ME14 1XD Telephone: New and Current Cases: 03000 410502 General Enquiries: 03000 410503 Email: KentandMedwayCoroners@kent.gov.uk REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Director of Adult Services at Kent County Council 1 CORONER I am Ian Brownhill, assistant coroner, for the coroner area of North East Kent 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 Hadley John Savory was found dead at his home address in Margate on 13 December 2019. An investigation into his death was commenced. The investigation concluded at the end of the inquest on 11 August 2021. My conclusion was that his death was drug related, in addition, a short narrative conclusion was given as explained further under section 4 below. 4 CIRCUMSTANCES OF THE DEATH Hadley John Savory was discharged from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. A multi-agency meeting did not take place prior his discharge from hospital. The plan for Mr Savory’s care, support and treatment in respect of his substance misuse, physical health, mental health and social care needs is unclear. Mr Savory’s presentation declined in the community. Safeguarding referrals were made but no multi agency meetings were convened pursuant to safeguarding duties under the Care Act or as per the Kent and Medway Multi-Agency Policy and Procedures to Support People that Self-Neglect or Demonstrate Hoarding Behaviour. Police made entry into Mr Savory’s home address on 13 December 2019, he was found to be deceased. Toxicological evidence indicated that Mr Savory had taken a lethal dose of methadone. There was no evidence that Mr Savory had intended to take an overdose. 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 are as follows. – (1) There was no evidence of a multi agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs; (2) There was no recording (or available evidence of recording) of attempts to escalate internal disagreements as to which team Mr Savory should have been allocated to. Nor did the evidence establish how internal disagreements as to allocation of cases are recorded; (3) The evidence was not clear as to how eligible care needs under the Care Act are met when a service user is transferring between services. In Mr Savory’s case he was assessed as having eligible needs but no care and support plan was developed; (4) The evidence demonstrated that there was a lack of clarity as to the interrelationship between safeguarding duties under the Care Act and the operation of the Kent and Medway Multi-Agency Policy and Procedures to Support People that Self-Neglect or Demonstrate Hoarding Behaviour; (5) It was unclear as to how information sharing operated in respect of service users who are identified as potentially having fluctuating mental capacity in respect of their care and support needs. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 6 October 2021. I, the coroner, may extend the period. 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 The family of Hadley John Savory The Chief Executive of the East Kent Hospitals University NHS Foundation Trust The Chief Executive of The Forward Trust The Chief Executive of Kent and Medway NHS and Social Care Partnership Trust The legal representatives of the above. In addition, I have sent this to: The Independent Chair of the Kent and Medway Safeguarding Adults Board I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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 coroner, at the time of your response, about the release or the publication of your response. 9 Signature: Ian Brownhill Assistant Coroner North East Kent 11 August 2021
1 response 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.
Mr Ian Brownhill, Assistant Coroner North East Kent Coroners By email only: Adult Social Care and Health Sessions House Maidstone Kent ME14 1XQ Date: 25th November 2022 Dear Sir, Inquest touching upon the death of Hadley Savory Kent County Council response to the Regulation 28 Report to Prevent Future Deaths I am providing this further response to the Regulation 28 Report to Prevent Future Deaths that you issued to Kent County Council (KCC) and following my preliminary response dated 6th October 2021. I apologise for the delay in providing a final response but have been awaiting the conclusion of the review referenced in my first letter in order to fully respond to your matters of concern 1, 4 and 5. I set out below for ease of reference those matters of concern as they appear in your PFD Report together with KCC’s responses. There was no evidence of a multi-agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care, and physical health needs. Multi-agency planning: Having reviewed the records, it appears that there were discussions between agencies and professionals and with Mr Savory himself regarding his discharge from hospital, but it is accepted that there is no evidence of a formal multi-agency planning meeting. It has been identified through review that a multi-agency meeting was required due to the various needs that Mr Savory had and that all agencies needed to joint work to fully consider how these impacted together. Mr Savory required a plan detailing how to support him and all the factors that affected his life. Mr Savory had multiple needs, and these needed to be considered in tandem by all agencies. To support this now, there are multi-agency protocols in place around co- occurring conditions. An ‘Operational Protocol for Co-occurring Conditions (Mental Health and Substance Misuse Disorders)’ has been developed by Kent and Medway NHS and Social Care Partnership Trust (KMPT) with representatives from Kent and Medway Substance Misuse Services (including Forward Trust, Change Grow Live and Turning Point) and KCC Public Health. This protocol was published in November 2021 and states this as its purpose: “This operational protocol is designed to give a clear framework within which all Kent and Medway Substance Misuse Services and Mental Health providers can operate with regard to providing comprehensive service user focused services to those with Co-existing Mental Health and Substance Misuse Disorders (Dual Diagnosis)” When there are disagreements between agencies around decisions being made, the Safeguarding Adults Board (SAB) ‘Resolving Practitioner Differences: Escalation Policy for Referrals and Adult Safeguarding’ can be utilised. This Policy was reviewed and updated in July 2022; the purpose of the policy sets out when and how differences must be addressed: “Members of the Safeguarding Adults Board are clear that whenever a practitioner, agency or service has a concern about the action or inaction of another, this must be addressed, and any challenges conducted in a professional and respectful manner. Practitioners and managers should always be prepared to review decisions and plans with an open mind” Links to the SAB website and policies are provided on the KCC Safeguarding webpage. Multi-agency procedures for safe discharge of patients with concurrent needs: Following the sad death of Mr Savory and due to changes to practice following COVID, KCC updated its ‘Hospital Discharge Service Policy and Operating Model’. This new policy and operating model is designed to support the full implementation of discharge, and to aide this a set of discharge guidance action cards has been developed to summarise responsibilities for key roles within the hospital discharge process. The policy sets out three clear stages of discharge and these provide the need for acute and community health and social care to work in a fully synchronised way to ensure people are discharged in a timely manner but also to ensure that any social care assessments can commence at the first opportunity once a person has been discharged. There will be named leads for each Acute and Community Hospital which will be the KCC Short Term Pathways (STP) Team Manager, supported by the Senior Practitioner and Social Care Discharge Co-Ordinator in the first instance with escalation if required to the area Service Manager within STP. The expectation is that these named leads will attend discharge management meetings and together with health colleagues will provide social care advice and information, guidance as well as influencing and supporting the decision making process of the Multi-Disciplinary Teams (MDTs) for safe discharges of people via Discharge to Assess. People/patients who require social care support/assessment will be identified at the MDTs and accepted as a referral via the Ready to Transfer (RTT) form. This new policy helps to ensure that individuals’ needs are identified and considered pre and post discharge from hospital to ensure that physical and social needs are factored in within the discharge process. The evidence demonstrated that there was a lack of clarity as to the interrelationship between safeguarding duties under the Care Act and the operation of the Kent and Medway Multi-Agency Policy and Procedures to Support People that Self-Neglect or Demonstrate Hoarding Behaviour. In the 3 years following the sad passing of Mr Savory, there has been considerable work undertaken around the area of self-neglect. Kent and Medway Safeguarding Adults Board have recently published their updated ‘Policy and Procedures to Support People that Self-Neglect or Demonstrate Hoarding Behaviour’. Following this update, a briefing was sent to all Adult Social Care staff on 6th October 2022 and the changes were highlighted within that communication. This self-neglect policy now includes clearer categories of low, medium, and high risk. The policy makes clear the need for practitioners to have awareness of different duties and powers provided by legislation and of enforcement powers where necessary. There is also greater clarity around medium risk instances that do not meet the criteria for a Care Act 2014 section 42 safeguarding enquiry and how to manage these. In addition, KCC is currently developing a new self-neglect workflow within Mosaic (KCC information system). It is envisaged that this new workflow can be started at any point during Adult Social Care intervention with the person and will provide a complete summary of all actions taken related to self-neglect. The implementation of this workflow is anticipated by January 2023. KCC has also continued to undertake activities to raise practitioners’ awareness around the important subject of self-neglect and the importance of acting appropriately in response. These have included: • Specific self-neglect and hoarding training courses, • A briefing around a published Safeguarding Adults Review (SAR) concerning self- neglect, • Practitioner events discussing self-neglect with substance abuse and homelessness, • A new self-neglect e-learning course and • A section 11 Care Act briefing about when people decline or refuse an assessment and there are concerns about abuse, neglect, or mental capacity. It was unclear as to how information sharing operated in respect of service users who are identified as potentially having fluctuating mental capacity in respect of their care and support needs. In review, the issue of information sharing appears inter-linked with the multi-agency working comments earlier in this letter. As agencies were not working together to discuss plans and options, they equally were not sharing the information that they each possessed regarding Mr Savory’s fluctuating capacity. Sharing information in this way in addition to breaking down decisions to a micro level should support a better understanding of capacity to make macro decisions such as decisions relating to residence and care. The importance of assessing capacity at a micro level will be added to KCC training and learning resources in relation to capacity assessments. The following measures have already been taken to ensure that appropriate training and learning opportunities regarding mental capacity assessments and addictions are available to KCC practitioners: • There is a Mental Capacity Assessment advanced training course which includes completions of complex capacity assessments. Learning and Development colleagues have confirmed that Information on substance misuse is included in the course content from November 2022, • Within the Adult Social Care Core Skills Programme, ‘Topic 3’ includes an outline on responsibilities within the Mental Capacity Act for social care staff, • All Adult Social Care staff can access on the Safeguarding KNet (KCC intranet) and Kent Academy Training pages the learning from tragedies and • The Strategic Safeguarding Team have recently completed over 40 internal team talks across KCC. As part of these talks, teams were advised of the work that the Strategic Safeguarding Team complete and advised of the resources that are available on KNet and Training pages. T h e n e e d f or a g e n ci e s t o pr o m ot e tr a n s p ar e n c y, a c c o u nt a bilit y, e vi d e n c e of d e ci si o n - m a ki n g pr o c e s s e s, a n d pr o m oti n g a n a p pr o pri at e l e v el of i nt er v e nti o n t hr o u g h a m ulti - a g e n c y a p pr o a c h ar e all k e y a s p e ct s of t h e af or e m e nti o n e d K M S A B ‘ P oli c y a n d Pr o c e d ur e s t o S u p p ort P e o pl e t h at S elf -N e gl e ct or D e m o n str at e H o ar di n g B e h a vi o ur’ w hi c h w a s u p d at e d i n S e pt e m b er 2 0 2 2. I nf or m ati o n s h ari n g s h o ul d b e m or e r o b u st u n d er t h e s e n e w/r e vi s e d p oli ci e s a n d pr o c e d ur e s. I n a d diti o n, K C C r e m ai n c o m mitt e d t o a p pr o pri at e i nf or m ati o n s h ari n g b y c o nti n ui n g t o b e a si g n at or y o n t h e K e nt a n d M e d w a y I nf or m ati o n P art n er s hi p, w hi c h pr o m ot e s o p e n n e s s a n d tr a n s p ar e n c y i n i nf or m ati o n s h ari n g, a s w ell a s a p pr o pri at e g o v er n a n c e a n d s u p p ort, w hi c h a s si st s u s t o s h ar e p er s o n al i nf or m ati o n l a wf ull y, s af el y, a n d s e c ur el y. K C C al s o w or k c oll a b or ati v el y wit h t h e K e nt a n d M e d w a y S af e g u ar di n g A d ult s B o ar d a n d a d h er e t o all m ulti -a g e n c y p oli ci e s s u c h a s t h e K M S A B g ui d a n c e c all e d ‘ A q ui c k g ui d e - l e g al b a si s f or i nf or m ati o n s h ari n g a n d w h at c a n l a wf ull y b e s h ar e d’. T hi s g ui d e w a s u p d at e d i n M a y 2 0 2 2. All st aff m e m b er s wit hi n A d ult S o ci al C ar e r e c ei v e m a n d at or y s af e g u ar di n g a w ar e n e s s tr ai ni n g w hi c h e m p h a si s e s t h e i m p ort a n c e of u n d er st a n di n g t h e C ar e a n d S u p p ort St at ut or y G ui d a n c e f or s af e g u ar di n g. I n a d diti o n, t h er e ar e f urt h er v ari o u s c o ur s e s pr o vi d e d , w hi c h i n cl u d e i nf or m ati o n o n l e g al fr a m e w or k s s u c h a s t h e C ar e A ct 2 0 1 4, M e nt al C a p a cit y A ct 2 0 0 5, H u m a n Ri g ht s A ct 1 9 9 8, a n d t h e D at a Pr ot e cti o n A ct 2 0 1 8. All of t h e s e l e g al fr a m e w or k s will h a v e r el e v a n c e t o a p er s o n’ s w ell b ei n g a n d e m p h a si s e t h e i m p ort a n c e of a p pr o pri at e i nf or m ati o n s h ari n g. I tr u st t h at t h e i nf or m ati o n c o nt ai n e d i n t hi s a n d m y pr e vi o u s r e s p o n s e t o y o ur P F D R e p ort pr o vi d e a d e q u at e a s s ur a n c e t o y o u t h at K C C h a s t a k e n st e p s t o u n d er st a n d a n d a d dr e s s y o ur m att er s of c o n c er n, b ot h i nt er n all y a n d i n p art n er s hi p wit h ot h er a g e n ci e s, a n d will c o nti n u e stri vi n g t o i m pr o v e t h e ar e a s i d e ntifi e d. Y o ur s f ait hf ull y C or p or at e Dir e ct or – A d ult S o ci al C ar e a n d H e alt h
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