Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0033, written 2 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Feb 2022 |
|---|---|
| Reference | 2022-0033 |
| Deceased | Carol Cole |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | Mental Health related deaths · Suicide (from 2015) · Police related deaths · Other related deaths · Alcohol, drug and medication 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. , Chief Executive of Dorset Council , Chief Constable of Dorset Police 1 CORONER I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset 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 the 20th May 2020, an investigation was commenced into the death of Carol Patricia Cole, born on the 21st November 1951. The investigation concluded at the end of the Inquest on the 21st January 2022. The Medical Cause of Death was: Ia Combined overdose II Ischaemic Heart Disease The conclusion of the Inquest was suicide. 4 CIRCUMSTANCES OF THE DEATH On the 15th May 2020 the deceased, who was prescribed and medication, and who had a history of depression, unstable personality disorder and previous overdoses of medication, was found in a collapsed and , unresponsive condition in the bedroom at her home address at Weymouth. 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 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: 1 1. During the inquest evidence was heard that: i. Following attendances upon Mrs Cole by officers from Dorset Police in the days and weeks leading up to her death, two Public Protection Notice (PPN) were submitted to the Multi Agency Safeguarding Hub (MASH) within Dorset Police. The first of these PPNs raised concerns about Carole’s mental health. ii. When a PPN is received by the team within MASH, they forward the PPN onto the relevant agencies, or people, who can provide support to the individual, or take action. One of those to whom this can be shared is the person’s General Practitioner (GP). iii. iv. v. vi. In Dorset there are 2 Local Authorities that cover the County, BCP Council and Dorset Council. If MASH receive a PPN about a resident in the BCP Council area the current arrangement is that MASH send the PPN directly to the GP as required. If they receive a PPN about a resident in the Dorset Council area the current process is that they do not send it directly to the GP but send it directly to the Dorset Adult Access team at Dorset Council, who will then send it to the GP. At the time of her death Carole resided within the Dorset Council area. A PPN was submitted to MASH regarding Carole on 25.4.20 which raised concerns regarding her mental health. The MASH team determined the PNN should be shared with the Dorset Adult Access team to share with the GP in line with the process. At the Inquest the representative from the GP surgery confirmed there was no record of the PNN being received by them, which led to a missed opportunity for Carole to be assessed by her GP. The process currently in place, which I understand has been agreed by both Dorset Council and Dorset Police, of preventing the MASH team from sending the PNN directly to the GP, may result in the GP not being informed of the contents of the PPN which may result in a person not receiving an assessment, support or treatment. I am not aware of a reason why the MASH team cannot send it directly to the GP, as they do for those residents in BCP council area, to avoid such missed opportunities to take action which may lead to a future death. 2. I have concerns with regard to the following: i. There could be missed opportunities to share PPNs relating to residents within the Dorset Council area with agencies or professionals due to the current processes in place between Dorset Police and Dorset Council which could lead to a future death. I therefore request that Dorset Police and Dorset Council review their current processes in place regarding the sharing of PPNs by MASH, especially to General Practitioners for the residents within the Dorset Council area. 2 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/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, 30th March 2022. 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 and to the following Interested Persons: (1) Mrs Clough’s family (2) Dorset County Hospital NHS Foundation Trust 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. 9 Dated Signed 2nd February 2022 Rachael C Griffin 3
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.
Chief Executives Office Dorset Council County Hall Colliton Park Dorchester DT1 1XJ www.dorsetcouncil.gov.uk Date: 29/03/2022 Rachel C Griffin Senior Coroner The Coroner’s Office for the County of Dorset Bournemouth Town Hall Bournemouth BH2 6DY Dear Madam, Regulation 28: Prevention of Future Deaths Report Response Deceased: Carole Patricia Cole I am writing in response to the Regulation 28 report which was issued to both the local authority and Dorset Police regarding Carole Patricia Cole. I know that you will share a copy of this response with Mrs Cole’s family and I would first like to express my condolences for their loss. During the inquest, evidence was heard regarding the process for sharing Public Protection Notices (PPNs). The Regulation 28 report raised a specific concern in that: i) There could be missed opportunities to share PPNs relating to residents within the Dorset Council area with agencies or professionals due to the current processes in place between Dorset Police and Dorset Council which could lead to a future death. The request was made that Dorset Police and Dorset Council review their current processes in place regarding the sharing of PPNs by MASH, especially to General Practitioners for the residents within the Dorset Council area. We reviewed the current PPN process with Dorset Police and Bournemouth, Christchurch and Poole (BCP) Council between 16/02/2022 and 16/03/22. This involved members of the operational management team at Dorset Council and Bournemouth, Christchurch and Poole (BCP) Council and Dorset Police Public Protection Unit meeting to analyse current steps in the process. This identified the following areas of improvement: i) When a PPN is received by the Multi-Agency Safeguarding Hub (MASH) within Dorset Police, information is shared differently depending on whether the person is a resident of Dorset Council local authority area or BCP. If the person is resident of the Dorset Council area the MASH team share PPNs with the Adult Access Team who then share them with the GP and other relevant organisations. If the person is a resident of the BCP area MASH share directly with GPs. This was raised as a matter of concern within the Regulation 28 report. When a PPN is received into the Adult Access Team and a person is known or open to an Adult social care team, the PPN is passed to the relevant team to share with relevant agencies or professionals. Having different internal process for people known or not known to Adult Social Care could result in a delay in sharing PPNs. The following actions were identified: i) ii) iii) iv) Amend the current process of sharing PPNs between Dorset Police and Dorset Council to align with BCP processes. This requires work to ensure the MASH has adequate capacity and access to up-to-date information about a person’s GP. To have an immediate impact on the current process, Dorset Council will provide additional staffing resources to MASH to assist with the sharing of PPNs to GPs to allow time for a wider system review of MASH to be completed. The plan is to complete recruitment by end of May 2022. A meeting has been arranged between Dorset Council, Dorset Police MASH, BCP and health partners including GP safeguarding leads in April 2022 to discuss current PPN sharing processes, including what is working well and areas for improvement. This was the earliest opportunity to do so, so that all parties could be represented. Share learning from the Regulation 28 report at Dorset’s Safeguarding Adult Review in April 2022 and seek approval to align a full partnership review of PPN sharing within Adult MASH with the Children’s MASH review which will take place in July 2022. Amend Dorset Council’s internal process so that the Adult Access Team forward PPNs to relevant agencies or professionals regardless of whether the person is known or not known to Adult Social Care. This was immediately actioned and implemented on 25/02/22. I hope the above information provides assurance to the Chief Coroner that Dorset Council has taken the matter with due concern and an ongoing commitment with Dorset Police and wider partners to finding a resolution to this issue and in turn mitigate the risk of future deaths to the residents of Dorset. We would like to propose that we provide a further update after the wider system review in July 2022. Your sincerely Chief Executive Dorset Council
Mrs Rachel C Griffin
Senior Coroner
Coroner's Office
County of Dorset
Town Hall
Bournemouth
BH2 6DY
Chief Constable
Dorset Police
Force Headquarters
Winfrith
DORCHESTER
DT2 8DZ
30 March 2022
Dear Madam,
Regulation 28: Prevention of Future Deaths Report Response
Deceased: Carole Patricia Cole
I write in respect of the above-mentioned report of 2 February 2022 (“the Regulation
28 report”).
Firstly, I would like to express condolences on behalf of myself and Dorset Police to
the family and friends of Carole.
Secondly, I thank you for sending a copy of the Regulation 28 report that was made
during the inquest into Carole’s death. As you would expect, we welcome any such
opportunities for Dorset Police to consider whether there are any improvements that
can be made to how we work.
In the Regulation 28 report, you confirm that the matter of concern that you wish to
raise is that there could be missed opportunities to share PPNs relating to residents
within the Dorset Council area with agencies or professionals due to the current
processes in place between Dorset Police and Dorset Council which could lead to a
future death.
You therefore requested that Dorset Police and Dorset Council review their current
processes in place regarding the sharing of PPNs by MASH, especially to General
Practitioners for the residents within the Dorset Council area.
The review took place between 16/02/2022 and 16/03/2022 with partners from Dorset
and BCP Adult Social Care. This confirmed the process of sharing PPNs between the
Police and BCP Council and Dorset Council differs. It has been acknowledged that
the existence of two different systems can present a risk to safeguarding and the
consistency of one process would be preferable.
The review also identified that for the Police to carry out the sharing of PPNs to GPs
there would be a requirement for Police to have access to the Dorset Care Record
which it currently does not have.
On occasions officers will attend an incident whereby the GP is unknown or recorded
incorrectly therefore it is necessary to confirm the correct GP details utilising the
Dorset Care Record to ensure personal information is not being passed to the incorrect
surgery.
Identification of this risk has prompted a further review with Health partners which is
scheduled to commence on 12 April 2022. Police, Health and Social Care will work
together to review the current process, what is working well and where improvements
can be made based on national best practice from other areas.
On 28 March 2022, it was agreed that Dorset Council will fund a member of staff from
Adult Social Care to co-locate with Dorset Police in the MASH. This role would be
responsible for sharing with GPs and have access to the Dorset Care Record. In the
interim I am aware that the Dorset Adult Access Team promptly streamlined their
working practices in February 2022 to overcome the issue that resulted in the failure
to share the PPN with the GP in the case of Ms Cole.
The learning from the Regulation 28 report has been passed to the Safeguarding Adult
Review Board for further discussion and to secure partnership commitment to
delivering the findings of the review.
As you would expect, correspondence from yourself is taken most seriously by myself
and we will continue to work with our partner agencies to ensure that our processes
are appropriate, proportionate and minimise any risk of missing opportunities to
safeguard our residents.
Thank you again for your consideration and questioning of the Force through the
Regulation 28 procedure and copying the report to us. I trust this response provides
you with the further information that you require. Please do contact me should you
wish for further clarification or information.
Yours sincerely
Chief Constable
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