Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0286, written 14 Sep 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Sep 2022 |
|---|---|
| Reference | 2022-0286 |
| Deceased | Diane Austin-Martin |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Health and Social Care 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 23rd March 2021 I commenced an investigation into the death of Diane Austin-Martin. The investigation concluded on the 29th July 2022 and the conclusion was one of Narrative: Died from natural causes contributed to by neglect. The medical cause of death was 1a) General debility from multiple sclerosis exacerbated by urinary tract infection, pressure ulcerations and low body mass index 4 CIRCUMSTANCES OF THE DEATH Diane Margaret Austin-Martin was a vulnerable adult with significant health issues including multiple sclerosis. She had significant care needs. She moved to Stockport. The Social Services team in Northern Ireland who had been working with her did not notify Stockport Metropolitan Borough Council of the move or seek to make robust enquiries to ensure the private care in Stockport would be appropriate. She was therefore not visible to Stockport Social Services. A claim was made and accepted by the Department for Work and Pensions for care support for her. Regular payments commenced. There was no evidence of any quality assurance in relation to the care provided. She was seen once by the GP. An attempt to refer to secondary care was unsuccessful and she was never seen or assessed by Multiple Sclerosis Services. Her carers were the people she lived with. The level of care was wholly inadequate to meet her needs. On 22nd March 2021 when police attended the address she was found to have multiple pressure ulcers and be severely underweight. She was found in filthy, squalid living conditions. 1 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. The inquest heard evidence that there was no clear mechanism to ensure that Social Services were aware of her move despite her vulnerability having being identified whilst she resided in Northern Ireland. As a consequence Social Services were unsighted as to her being resident in Stockport; 2. DWP were aware of her presence and payments were made recognising her needs but there was no mechanism to ensure that the care provided was of an appropriate quality; 3. The inquest heard that where a private care arrangement exists as in this case there is no mechanism to ensure that the care is of a sufficient and appropriate quality in contrast to a resident of a care home; 4. After her initial claim for payment and her initial GP visit she dropped out of sight of agencies until she was found. 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 9th November 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 namely may find it useful or of interest. on behalf of the Family, who I am also under a duty to send the Chief Coroner a copy of your response. 2 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 Alison Mutch HM Senior Coroner 14.09.22 3
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.
From Helen Whately Minister of State for Social Care 39 Victoria Street London SW1H 0EU Alison Mutch Senior Coroner for the Coroner Area of Greater Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG 12 June 2024 Dear Ms Mutch, Thank you for your letter of 14 September 2022 to the then Secretary of State for Health and Social Care at the time Thérèse Coffey, about the death of Diane Austin- Martin. I am replying as Minister with responsibility for social care. Firstly, I would like to say how saddened I was to read of the circumstances of Ms Austin-Martin’s death, and I offer my sincere condolences to her family. I am grateful to you for bringing these matters to my attention. Your first concern referred to the lack of a mechanism to ensure that Social Services were aware of her move despite her vulnerability having been identified whilst she resided in Northern Ireland. Having made enquiries to the Department of Health Northern Ireland (NI), we can advise that there are general duties about making necessary services available under the HPSS (NI) Order 1972 and the Chronically Sick and Disabled Persons (NI) Act 1978. There is also the NI policy ‘Adult Safeguarding: Prevention and Protection in Partnership: 2015’. Paragraph 14.2 of this policy references information sharing for safeguarding purposes. The use of these pieces of legislation would depend on an individual assessment of need. NI officials have advised that it would be good practice to offer support and guidance to someone moving and make referrals in accordance with an assessment of need at this point. In relation to the second and third concerns you raised, adult safeguarding is particularly relevant. Given that it is good practice for a local authority’s Safeguarding Adults Board (SAB) to work with coroners, you may wish to write to the local SAB for further information about this case, including whether the SAB has considered a Safeguarding Adults Review (SAR). 1 Adult safeguarding is relevant because local authorities have a duty, under the Care Act 2014, to make enquiries when they suspect that an adult with care and support needs is a) at risk of abuse or neglect and b) unable to protect themselves as a result of those needs. You were concerned that there is no mechanism to ensure that domiciliary care is of a sufficient and appropriate quality, in contrast to regulation of care homes. While it is correct that CQC does not inspect unregulated home care settings, local authority adult safeguarding duties do provide a mechanism by which to investigate private home care arrangements if the quality of care puts the cared-for person at risk of harm. According to the care and support statutory guidance, safeguarding adults with care and support needs is everyone’s business and multi-agency working is vital. Local authorities must co-operate with such other agencies or bodies as it considers appropriate in the exercise of its adult safeguarding functions, including primary and secondary healthcare services. This is described in section 6(7) of the Care Act 20141, and those partners must also co-operate with the local authority in the exercise of their functions relevant to care and support including those to protect adults. This means that, if a local authority conducts a safeguarding enquiry and finds that action must be taken to protect the adult in question, local partners must cooperate and lead on that action when required. In addition, the Care Act 2014 requires each local authority to set up a Safeguarding Adults Board (SAB). SABs are required to carry out a Safeguarding Adult Review (SAR) of a case involving an adult in its area with needs for care and support in circumstances where an adult has died, and the SAB knows or suspects the death resulted from abuse or neglect (whether or not they knew this at the time of death). Your fourth and final concern noted that Ms Austin Martin dropped out of sight of agencies. NHS England has noted that there are robust processes in place across the Stockport GP population around the management of newly registered patients. The expectation is that following registration, an initial appointment will be offered to the patient which would include an assessment of medical needs, the prescribing of medications, and a plan agreed for how care will be managed moving forward and when any regular medications will be reviewed. The GP Practice where this patient was registered, have confirmed that Ms Austin-Martin was seen at a face-to-face consultation on 6th November 2019 shortly after registering on 30th October. She was identified to have Multiple Sclerosis (MS) and asthma requiring ongoing management with medications, that were duly prescribed and a follow up with local MS service (a referral was created to this effect) had been arranged. She was advised to book in for an asthma review with the practice nurse alongside being offered (but declined) a seasonal influenza vaccination. As far as the practice were aware, appropriate follow up and referral had been initiated following her initial consultation to address her long-term conditions and medication requirements. NHS England has confirmed that this is within the level of expectation of when a new patient registers with a GP in Stockport and on this occasion all appropriate steps appear to have been taken to complete her initial registration assessment and to 1 https://www.legislation.gov.uk/ukpga/2014/23/section/6/enacted address her long-term conditions and medication requirements with appropriate follow up planned. NHS England have advised they are seeking further clarity on why the annual reviews for Multiple Sclerosis did not take place. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, HELEN WHATELY
See every Prevention of Future Deaths report matching Alison Mutch, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.