Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0334, written 5 Oct 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Oct 2021 |
|---|---|
| Reference | 2021-0334 |
| Deceased | Charlotte Duffield |
| Coroner | Dr Nicholas Shaw |
| Coroner area | Cumbria |
| Category | Other related deaths · Community health care |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Kally Cheema LLB I Senior Coroner! Cumbria Fairfield Stati.on Road , Cockermouth Cumbria CA 13 9PT 5 October 2021 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Adult Safeguarding, Cumbria County Council , Senior Legal Officer, 1 CORONER I am Dr Nicholas Shaw, HM Assistant Coroner for Cumbria CORONER'S LEGAL POWERS 2 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. http://www.leqislation.qov.uk/ukpqa/2009/25/schedule/5/paragraph/7 http://www.leqislation.qov.uk/uksi/2013/1629/part/7/made 3 4 INVESTIGATION and INQUEST An inquest was opened on 1st June 2021 and concluded at a final hearing on 5th October 2021. The short form conclusion reached was one of Self Neglect. CIRCUMSTANCES OF THE DEATH Charlotte Duffield was 40 years old, her body was discovered when police forced entry to her home on 4th February 2021 in response to concerns that Charlotte had not been seen for several weeks. It appeared she had been deceased for a significant period of time. Evidence heard at the inquest suggested that she lived a reclusive lifestyle and was not caring for herself, particularly after her father, with whom she lived, had died 3 months earlier. Due to advanced decomposition a pathologist was unable to determine the exact cause of death, however there were no suspicious circumstances to suggest death was other than natural 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows 5 (1) On 3rd November 2020 Police officers attend Charlotte's home following a telephone call from her aunt expressing concern for her wellbeing. The Officers were concerned about the state of the property, Charlotte's clothing, her lack of emotional response and that she may not have access to money following the sudden loss of her father, Reviewing their report DS Constabulary made a referral to Adult Social Care on 5th November. Evidence seen at the inquest indicates that on receipt of the referral 3 attempts to telephone Charlotte were made on 6th, 9th & 10th November. As there was no reply a letter was sent asking her to contact them. There is a note that her case was discussed at a multidisciplinary meeting on 9th December 2021 but no further action seems to have been taken. of Cumbria (2) Charlotte was referred due to significant concerns for her safety but no safeguarding action seems to have been taken. I am particularly concerned that after her failure to respond to attempted telephone contact no physical effort was made to visit her in person. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you and your organization have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3rd December 2021. I, the coroner, may extend the period. 7 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner. I have also sent it to The Chief Constable, Cumbria Constabulary, Dr and the family of Charlotte Duffield who may find it useful or of interest. , Duke St Surgery, Barrow-in-Furness 8 I am also 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 coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 5 October 2021 9 Signatu~ ~ -
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.
Cumbria County Council People Cumbria Cumbria House 107-117 Botchergate Carlisle CA1 1RD 19 November 2021 Dr Nicholas Shaw HM Assistant Coroner for Cumbria Fairfield Station Road COCKERMOUTH Cumbria CA13 9PT Dear Dr Shaw Re: Regulation 28 Report to prevent future deaths Further to your Regulation 28 report of the 5th October 2021, I write with confirmation of actions taken by Cumbria County Council (CCC). The safety of service users is of the utmost importance to CCC. We take your finding that there were matters giving rise to concern, and your opinion that there was a risk that future deaths may occur, extremely seriously. I wish to assure the Coroner that we proactively review our processes, and that the actions set out in this letter have been in place for many months. It is unfortunate that CCC were not provided the opportunity to present the work undertaken in advance of a Regulation 28 report being issued. Within the Regulation 28 report concerns were raised that the operational response in this situation would leave others at risk if further action was not taken. The report implied that where concerns of self-neglect are identified, or following a referral, a direct face-to-face intervention would be required in order for the council to satisfy its duties. To satisfy ourselves, and offer assurance to yourself, the Council confirms the following steps have been taken: 1. A systematic review of Cumbria Safeguarding Adults self-neglect policy and procedure documentation has been completed to clarify the roles, responsibilities, and duties across the safeguarding system. 2. The operational practice guidance in relation to self-neglect concerns has been reviewed and revised. The guidance reinforces the Council’s position that a face-to-face visit, in order to complete assessment and ensure the safety of the person at risk, must be undertaken to satisfy operational practice requirements and standards. 3. The Council has implemented a countywide operational Safeguarding Adults service, a dedicated safeguarding team providing support across the county, to ensure a consistent and compliant response for all safeguarding concerns, including concerns of self-neglect. 4. This dedicated Safeguarding Adults service is undertaking the delivery of training sessions across all partners to embed the review of self-neglect policy, procedure, and guidance. Serving the people of Cumbria cumbria.gov.uk 5. Finally, a discrete practice learning session is being undertaken with the team directly involved in this case to ensure, from an operational point of view, that there is a clear and unequivocal position on how to respond to self-neglect concerns. I trust the information and confirmation of action detailed in this letter give you assurance that suitable action has taken place to address your concerns. Yours sincerely Executive Director – People (Deputy Chief Executive)
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