Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0321, written 13 Oct 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Oct 2022 |
|---|---|
| Reference | 2022-0321 |
| Deceased | Rebecca Hayward |
| Coroner | Gordon Clow |
| Coroner area | Nottingham and Nottinghamshire |
| Category | Alcohol, drug and medication 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: - Nottingham City Council Copies are to be sent to the other interested persons, namely - - - - - - - Family Nottinghamshire Healthcare NHS Foundation Trust Nottingham Recovery Network Framework Housing Association Rebecca Hayward’s GP Nottingham University Hospitals NHS Trust Hatzfeld Care Home 1 CORONER I am Mr Gordon Clow, Assistant Coroner for the coroner area of Nottinghamshire. 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 12 January 2022 an inquest was formally opened into the death of Rebecca Hayward who died on 13 August 2021. The investigation concluded at the end of the inquest on 13 October 2022. The conclusion of the inquest was the short form conclusion that Rebecca Hayward’s death was alcohol and drug related. 4 CIRCUMSTANCES OF THE DEATH Rebecca Hayward had a history of substance addiction throughout her adult life. She managed to achieve abstinence from alcohol and drugs from March 2020 through to March 2021. Ms Hayward’s recovery from addiction was vulnerable, however, and she was assessed by her substance misuse worker to be unable to avoid relapse if she were to be homeless and accommodated in hostel accommodation. In the weeks leading up to Ms Hayward’s discharge from the care home, her substance misuse worker repeatedly and consistently reminded the professionals involved in Ms Hayward’s care of the need to avoid Ms Hayward being discharged to a hostel and of her view that a discharge to a hostel would result in Ms Hayward’s death from substance misuse. Ms Hayward became homeless on discharge from her care placement on 31 March 2021 whereupon she was accommodated in a hotel. She was provided with hostel accommodation on 5 May 2021. As had been predicted, this led to a relapse into alcohol and, latterly, substance misuse with catastrophic consequences for Ms 1 Hayward’s health and personal safety. On 13 August 2021 Ms Hayward was found deceased at someone else’s property following a period of alcohol and substance misuse. Ms Hayward’s death was a predictable consequence of the effect upon her of becoming homeless on 31 March 2021. 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) Assessments of persons with severe and multiple disadvantage are undertaken by persons with little or no experience or specialist training in homelessness and substance misuse, resulting in inaccurate assessment and plans; (2) Where a person is about to move to a different type of accommodation, Care Act assessments are only extended to include consideration of the individual’s changed care needs in their new environment if the early assessment work identifies eligible care needs in their current circumstances, with the social care provision subsequently being dependant on a re-referral and where such re-referrals are resisted; Other areas of concern existed regarding other issues but plans were in place to address these areas and so I did not have ongoing concerns of a risk of future deaths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 9 December 2022. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting 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 Interested Persons set out above. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. 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, 2 about the release or the publication of your response. 9 Mr Gordon Clow, HMAC 13 October 2022 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.
Head of Adult Safeguarding & Quality Assurance Adult Social Care Children & Adults Nottingham City Council Loxley House Station Street Nottingham NG2 3NG Private and Confidential Mr. Clow HM Assistant Coroner for Nottingham and Nottinghamshire Nottinghamshire Coroner’s Office The Council House Old Market Square Nottingham NG1 2DT 02.12.2022 Dear Mr Clow, RE: Regulation 28 – Report to Prevent Future Deaths I am writing to provide you with a response to the above Regulation 28 report, dated 13 October 2022, following the unfortunate death of Ms Rebecca Hayward. The matters of concern have been reviewed and addressed by the Nottingham City Council Adult Social Care Senior Leadership Team, and Principal Social Workers. We have developed an overarching action plan which provides a comprehensive response to these matters. The plan will be reviewed on a monthly basis, and will be governed by the Senior Leadership Team. Progression of the plan will be evidenced through review of all reports and revised policies, data reporting and qualitative measures which will be incorporated into all revised policies and training programmes. The other areas of concern identified in the Case and Quality Assurance Review submitted by Nottingham City Council in evidence to assist the Inquest will adhere to the same governance arrangements as noted above. I hope that the actions and governance arrangements provide you with assurance of Nottingham City Councils commitment to addressing the issues raised both by yourself, and through the Adult Social Care Case and Quality Assurance Review. Please contact me should you require any further information or updates. Yours sincerely Head of Adult Safeguarding & Quality Assurance
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