Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0326, written 4 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 | 4 Oct 2022 |
|---|---|
| Reference | 2022-0326 |
| Deceased | Reginald Cauthery |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| Category | Community health care and emergency services related deaths · Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 6 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Coroner ME Hassell HM Senior Coroner Inner North London REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Jeremy Quin MP, Minister of State for Crime, Policing and Fire Home Office 2 Marsham Street London SW1P 4DF 2. Rt Hon Therese Coffey MP Secretary of State for Health and Social Care Department of Health and Social Care 39 Victoria Street London SW1H 0EU Chief Executive Care Quality Commission 2 Redman Place Stratford London E20 1JQ Chief Executive Officer Telecare Services Association Suite 8 Wilmslow House Grove Way Wilmslow SK9 5AG 3. 4. 5. Managing Director UK Telehealthcare 11 Westfield Park Ryde PO33 3AB 6. Executive Director CECOPS 71 Church Street Great Missenden HP16 0AZ. 1 CORONER HM Assistant Coroner Sarah Bourke Inner North London Poplar Coroner’s Court 127 Poplar High Street London E14 0AE 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 9 March 2022, Senior Coroner Hassell commenced an investigation into the death of Reginald Cauthery, aged 82 years. The investigation concluded at the end of the inquest on 19 August 2022. The conclusion of the inquest was that the medical cause of Mr Cauthery’s death was: 1a) Multi organ failure; 1b) 36.5% burns to the body; 2) chronic obstructive pulmonary disease, cardiac failure, and ischaemic heart disease. I returned a short form conclusion of Accident which stated as follows: Mr Cauthery was identified as having an increased fire risk due to smoking. As he was frail, his ability to react to and escape a fire was significantly reduced. Smoke alarms were fitted at his home, but these were not connected to the telecare monitoring system in his home. A smouldering fire started in the electrical motor of his bed on 21 February 2022. The smoke alarms activated but the Fire Brigade was not contacted for at least 10 minutes after the alarm first went off. Mr Cauthery sustained extensive burns and died in hospital the following day. 4 CIRCUMSTANCES OF THE DEATH Mr Cauthery was frail with limited and deteriorating mobility. He had some problems with alcohol and used medication which made him sleepy. He lived alone with the support of carers and family members. In July 2020, he was discharged from hospital with a motorised bed. Mr Cauthery’s bed was serviced in accordance with the Manufacturer’s servicing schedule and no faults were ever reported. Additionally, a telecare pendant alarm system was fitted in his flat. The system was linked to a call centre which would alert relatives in the event of a call. In September 2020 a person-centred fire risk assessment found that Mr Cauthery’s mobility was limited to transferring between his bed and his commode. The assessment also found that he was at increased risk of fire due to smoking in bed and that he would be less able to react to fire or escape due to his poor mobility. The Fire Service undertook a Home Fire Safety Visit and fitted smoke alarms. Mr Cauthery was also issued with fire retardant bedding. The smoke alarms were not connected to the telecare system. His carers were of the view that Mr Cauthery needed to be supervised at night, but Mr Cauthery did not agree. A Care Act assessment carried out in December 2020 noted factors relevant to fire risk and referred to an incident when the smoke alarm had triggered due to Mr Cauthery falling asleep whilst smoking. The assessment did not review the telecare arrangements. In December 2021, the Fire Brigade were called to a small fire at Mr Cauthery’s flat which was caused by smoking materials. The Fire Brigade made a safeguarding referral. The Local Authority decided to refer Mr Cauthery to a Complex Case Management Social Worker but there were no changes to his care package or the equipment provided. The telecare arrangements were not reviewed. Around 9pm on 20 February 2022, a neighbour thought they could hear a car alarm going off. At approximately 9.30 pm the neighbour realised that the alarm was coming from Mr Cauthery’s flat. The neighbour could not smell smoke but made further checks and saw smoke coming from Mr Cauthery’s window. The neighbour made a 999 call at 9.38 pm. Around the same time, telecare records show that Mr Cauthery pushed his pendant alarm. The telecare call was not answered until 9.41 pm. The telecare call handler did not make a 999 call until 9.47 pm as they spent several minutes trying to obtain confirmation that the smoke alarm was going off from Mr Cauthery and his nominated relative. The Fire Brigade arrived on scene at 9.43 pm. Firefighters entered the property and found Mr Cauthery lying on the floor next to his bed. Mr Cauthery was the only person in the property. Mr Cauthery sustained full thickness burns to his face, torso, arms, and legs which affected 36% of his total body surface area. Mr Cauthery died the following day. An investigation was carried out by the London Fire Brigade who found that the fire was most likely to have been a smouldering fire within the motor unit for his bed mechanism. Had the fire instead been started by a lit cigarette, this would also have been a smouldering fire. In either event, smouldering would have generated smoke for several minutes before a flame developed. 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 review of the telecare service provided to Mr Cauthery despite the agencies working with him being aware of his increased fire risk and deteriorating mobility. (2) The ability of frail and vulnerable people to get urgent help in a fire situation will often depend upon other people recognising that a smoke alarm has triggered and calling the Fire Brigade. This raises particular problems if the person lives alone and their smoke alarm is not connected to their telecare system. (3) If Mr Cauthery’s smoke alarm had been connected to his telecare system, the call would have been answered as a priority. In addition, the call handler would not have spent several minutes seeking confirmation that the smoke alarm was going off before making a 999 call. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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, namely by 5 December 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: • Family of Reginald Cauthery • London Borough of Hackney • London Fire Brigade • Best Choice Global Limited • Millbrook Healthcare Group 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. Sarah Bourke HM Assistant Coroner 4 October 2022
6 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.
From Lord Markham CBE Parliamentary Under-Secretary of State 39 Victoria Street London SW1H 0EU 15 June 2023 Ms Sarah Bourke HM Assistant Coroner Inner North London Coroner’s Court 127 Poplar High Street London E14 0AE Dear Ms Bourke, Thank you for your letter of 4 October 2022 to the Rt Hon Thérèse Coffey MP, the then Secretary of State for Health and Social Care, about the death of Mr Reginald Cauthery. I am replying as Minister with responsibility for the use of technology in healthcare. I am sorry for the delay in replying. First, I would like to say how saddened I was to read of the circumstances of Mr Cauthery’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Telecare services are provided by local authorities, housing associations, the third sector and by commercial organisations. Not all local authorities provide or commission telecare services, but telecare is an intervention linked to the Care Act of 2014 and that Act’s responsibilities of preventing, reducing, or delaying the development of care and support needs or in meeting individual eligible needs for care and support. Where local authorities are commissioning telecare services, they will agree their own contracts in doing so, including how telecare devices should be maintained and their use reviewed. This Department published the “What Good Looks Like" framework for adult social care on 16 May. It is available on GOV.UK. The framework has been developed as part of Department of Health and Social Care and NHS England guidance to support health and care organisations with digitisation. The What Good Looks Like framework aims to bring together the needs of local authorities and care providers into one coherent guidance document that helps them to understand what they need to do to work well digitally. Within this publication we have reminded local authorities to consider, or re-examine alongside other interventions, the role technology enabled care can provide in maintaining independence of people in their own homes as care needs are reviewed, and how other preventative devices may need to be linked in, such as a compatible smoke detector where a person has deteriorating mobility and there is an increased fire risk. Also issued on 16 May by this Department was an updated Adult Social Care Digital Skills Framework to help support the development of digital skills across the adult social care workforce. It can be used by social care employers to help with planning staff training, or by individuals for their personal development. This updated framework will support social care workers to understand the importance of, and develop the skills to regularly review, how technology is used to support care within people’s care plans. Further information can be found at www.digitalsocialcare.co.uk/digital-skills-and-training/digital-skills-framework. I hope this reply is helpful and apologise once again for the long delay in replying. With my very best wishes, LORD MARKHAM CBE
Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA www.cqc.org.uk HM Coroner ME Hassell Inner North London Poplar Coroner’s Court 127 Poplar High Street London E14 0AE 26 January 2023 Dear HM Coroner Hassell Regulation 28 Report following the inquest into the death of Reginald Cauthery We write further to the Regulation 28 report received on 16 December 2022 made following the inquest into the death of Reginald Cauthery. We are sorry to learn of the tragic death of Reginald Cauthery and the matters of concern as follows: 1) There was no review of the telecare service provided to Mr Cauthery despite the agencies working with him being aware of his increased fire risk and deteriorating mobility. 1. (2) The ability of frail and vulnerable people to get urgent help in a fire situation will often depend upon other people recognising that a smoke alarm has triggered and calling the Fire Brigade. This raises particular problems if the person lives alone and their smoke alarm is not connected to their telecare system. 2. (3) If Mr Cauthery’s smoke alarm had been connected to his telecare system, the call would have been answered as a priority. In addition, the call handler would not have spent several minutes seeking confirmation that the smoke alarm was going off before making a 999 call. We have contacted the regulated provider, Best Choice Global Limited provider and discussed lessons learnt with them. The regulated provider was reliant upon telecare ‘experts’, fire service and commissioners to ensure the telecare equipment was appropriately linked to the fire service. However, the matters of concerns highlighted in the Regulation 28 report relate to services outside our scope of regulation. We do not regulate the fire service or the telecare service and therefore we have no powers to prevent future deaths in relation to these services. If you identify any further assistance that the CQC is able to provide, please do not hesitate to contact us with any questions. Yours sincerely Interim Deputy Director - London
Rt Hon Chris Philp MP Minister of State for Crime, Policing and Fire 2 Marsham Street London SW1P 4DF www.gov.uk/home-office Sarah Bourke HM Assistant Coroner Inner North London St Pancras Coroner's Court Camley Street London N1C 4PP December 2022 Dear Sarah Bourke Regulation 28: Report to prevent future deaths I am writing in response to your report, sent on 13 October, concerning the death of Mr Reginald Cauthery, issued under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. First, I would like to offer my sincerest condolences to the family and friends of Mr Cauthery. You have asked me to respond, in my capacity as Minister of State for Crime, Policing and Fire, to your concerns regarding the function and use of the telecare system and its connection to smoke detection alarms. I note the inquest concluded that Mr Cauthery died from a fire at his own home, which was likely to have been caused by a fault in his mechanised bed. The Home Office is responsible for the Regulatory Reform (Fire Safety) Order 2005, which applies to existing non-domestic premises and the common parts of multi-occupied residential buildings. It does not apply to individual homes. The Fire Safety Order places certain duties on the person responsible for the premises (usually the owner, landlord or employer) to ensure its fire safety. It is Local authorities that have a duty under the Housing Act 2004 to take enforcement action if they identify seriously hazardous conditions - including fire - in residential accommodation. This is assessed using the Housing Health and Safety Rating System risk assessment tool. Under the FSO, Fire and rescue services do not have statutory powers to enforce changes to telecare systems. Further, fire and rescue services (FRSs) do not install or maintain telecare systems and have no capability to link them to smoke alarms. Such work must be undertaken by telecare engineers. The Fire and Rescue Services Act 2004 requires FRSs to undertake community fire safety activity to the extent they consider it reasonable. As part of their fire prevention function FRSs provide home fire safety checks which includes educating individuals on fire safety measures in their homes. Local agencies are best placed to consider the care packages and equipment, including telecare systems, that are required to support vulnerable people. Officials from my Department have sought information from London Fire Brigade (LFB) on its policy regarding telecare systems. LFB confirmed that where telecare systems are installed it advises all care providers and support workers that the systems should be linked to smoke alarms as standard. To ensure that lessons from this case are learned, the Home Office will be sharing information from this case with the National Fire Chiefs Council (NFCC), which drives improvement and development throughout the UK FRSs. We will encourage it to disseminate the findings from your Regulation 28 report and ask FRSs (as part of their fire safety checks) to continue highlighting the importance of linking telecare systems to smoke alarms to help inform local agencies and carers about using them effectively. Rt Hon Chris Philp MP Minister of State for Crime, Policing and Fire
IN THE INNER NORTH LONDON CORONER’S COURT AND IN THE MATTER OF A REGULATION 28 REPORT TO PREVENT FUTURE DEATHS IN THE MATTER TOUCHING UPON THE DEATH OF THE LATE REGINALD CAUTHERY SUBMISSIONS ON BEHALF OF THE LONDON BOROUGH OF HACKNEY 1 This matter concerns the circumstances of the death of the late Reginald Cauthery, which were investigated by Senior Coroner Hassell, leading to an inquest on 18th and 19th August 2022 (‘the Inquest’) in which His Majesty’s Coroner (‘HMC’) recorded a conclusion that primary cause of death multi organ failure as a result of 36.5% burns to the body. Those burns were the result of a fire that was found to have started in Mr Cauthery’s bed on 20th February 2022. 2 These submissions are made on behalf of Council of the London Borough of Hackney (‘the Council’) in response to HMC’s report of 4th October, 2022, made pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, with the objective of reducing the risk of future deaths (‘the PFD Report’). The report was not received until 29th December 2022 and HMC’s officer kindly extended the date by which the Council could reply until 31st January, 2022. The Council apologises for the slight delay in its submission and the short extension kindly given by HMC’s officer. 3 The Council was a properly interested party (‘PIP’) in the Inquest because of its responsibility for commissioning and providing care to Mr Cauthery. At the outset, the Council and those social workers and officers who have been engaged in this case extend their deepest sympathy to Mr Cauthery’s family for his sad death. 4 The circumstances of Mr Cauthery’s death are set out in part 4 of the PFD Report and are not repeated. 5 At part 5, HMC set out the following matters of concern: (1) There was no review of the telecare service provided to Mr Cauthery despite the agencies working with him being aware of his increased fire risk and deteriorating mobility. (2) The ability of frail and vulnerable people to get urgent help in a fire situation will often depend upon other people recognising that a smoke alarm has triggered and calling the Fire Brigade. This raises particular problems if the person lives alone and their smoke alarm is not connected to their telecare system. (3) If Mr Cauthery’s smoke alarm had been connected to his telecare system, the call would have been answered as a priority. In addition, the call handler would not have spent several minutes seeking confirmation that the smoke alarm was going off before making a 999 call. 6 The Council notes that HMC, in making her findings and in expressing her concerns about the circumstances of Mr Cauthery’s death has expressly not made any findings about the civil liability of any party, which is not the function of an inquest. Similarly, nothing in this reply or in the document exhibited with it should be taken as an admission of civil liability in respect. While the Council does accept that its procedures could and should be improved to reduce the risk of these sad circumstances recurring, that does not and should not be taken as equating to such an admission. 7 Following the hearing and service of the PFD, the Council’s officers and social workers engaged in this case considered with their legal representatives ways in which HMC’s above concerns can be addressed so as to reduce the risk of future deaths from fire; and particularly fire caused by vulnerable persons, particularly those such as Mr Cauthery who are at greater risk. In his case, it is recognised that the following increased his risk individually and (particularly) conjunctively: that he was bed-bound; that he was a heavy smoker; that he drank heavily. 8 These discussions led to the Council setting out a number of ways in which it might address its procedures and guidance that could reduce the risks to vulnerable individuals such as Mr Cauthery. The procedures and guidance are those that are set out in the Council’s ‘Mosaic’ system. 9 The Council attaches a table in which it sets out, by column, its identification of what could be done better, learning from the circumstances of Mr Cauthery’s death, the action it intends to take and the time-frame for that action. 10 The Council hopes that HMC can be assured that its officers, staff and agents have taken careful account of the circumstances of Mr Cauthery’s death, the evidence considered in the Inquest and her concerns. It is submitted that the changes to their procedures and guidance will have the effect of reducing the risk to vulnerable people in Mr Cauthery’s situation and of deaths in particular. 2nd February, 2023 Field Court Chambers, 5 Field Court, Gray’s Inn, London WC1R 5EF
HM Assistant Coroner Sarah Bourke Inner North London Poplar Coroner’s Court 127 Poplar High Street London E14 0AE Chief Executive Officer TEC Services Association C.I.C. Suite 8, Wilmslow House Grove Way Wilmslow SK9 5AG Date: 4th December 2022 Ref: Mr Reginald Cauthery – Regulation 28 Report to Prevent Future Deaths. Dear Ms Bourke, I am writing in response to the above Regulation 28 Report to Prevent Future Deaths, where you have asked the TEC Services Association C.I.C. (TSA) to provide details of action taken, or proposed to be taken, following the sad death of Mr Cauthery. About the TSA TSA is the industry body that works to drive the transformation of the TEC sector through strengthening Partnerships, Data and People, whilst recognising and responding to demand, scope and opportunities in Technology Enabled Care. We endeavour to ensure the Quality and safety of TEC by setting and developing standards and providing independent and trusted audit and certification, which is managed by our wholly owned subsidiary company, TEC Quality Ltd, a United Kingdom Accreditation Service (UKAS) accredited certification body. We provide support and knowledge-share to members looking to improve the delivery of TEC services, grow their business or strengthen their impact on the TEC sector. Introduction I have read and noted the circumstances and the points you have highlighted regarding the incident provided in your report and requested that TEC Quality Ltd (mentioned above) investigate this matter, TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75 in their capacity as our quality and safety standards body. This investigation was necessary, to fully understand the circumstances of the incident and to take the views of the main parties involved in the incident into account before we were able to make recommendations on actions to be taken. The organisations we were able to discuss the case with were: • London Fire Brigade (LFB) • Millbrook Healthcare (MH) • Appello Monitoring (AM) It has not been possible to arrange discussions with the other parties listed in your report. The details of these discussions that took place are documented below: Discussion with London Fire Brigade TSA and TEC Quality have had a working relationship with the National Fire Chiefs Council (NFCC) for many years and already work collaboratively with them. The same can be said for TSA and LFB and clearly, we will continue this relationship. With regard to this particular incident, TEC Quality met with two representatives from LFB, who were responsible for investigating fire deaths in the London Boroughs and one member of staff who has knowledge of TEC. This discussion highlighted the following: • LFB confirmed that the TEC solution provided, consisted of an alarm unit and pendant trigger and that no linked smoke detection had been provided. • There had been at least two incidents where LFB had been required to intervene at Mr Cautherys home and a Safeguarding referral was also made. • As a result of the incidents, LFB did conduct home fire safety assessments, which noted that Mr Cautherys mobility had become limited and installed battery-operated smoke detection because of the incidents. However, these were stand-alone detectors and not linked to a monitoring centre. In addition, they recommended fire retardant bedding. In this instance, the only point of referral has been to LBH. • • • Often, LFB does not know which TEC services are contracted to provide the TEC services in the areas they cover; therefore, it is unclear to whom these types of incidents should be reported, other than the local authority Adult Social Care service. • During the discussion we pointed out to LFB, that following an incident like this, Fire Services utilise “Fire Industry Experts” to provide independent advice. However, TSA are never informed TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75 of such incidents and we believe that where TEC is involved and potentially contributed to a death, or injury that TSA should be advised, so that we can investigate the circumstances from a TEC perspective. We also advised LFB of an initiative we are currently working on with Ambulance Services, where we have developed a national call-handling Pathway Decision Support Tool, which will provide consistency and guidance for TEC operators, to determine the correct health response for their service users, should this be Ambulance, Urgent Community Response (UCR), or other NHS pathway. Colleagues from LFB thought this was a good idea and said they would be supportive of a similar approach for Fire Services. All parties on the call felt that the meeting had been beneficial and have committed to further, regular meetings every quarter, to help with liaison and support to try to eliminate similar occurrences. Discussion with Millbrook Healthcare (MH) With any TEC installation, the solution must be reviewed at least annually, to ensure that it still meets the service users’ needs, which may have declined since the first installation. TEC Quality met with three members of staff from MH, who included the Head of Governance and two managers from the TEC team. The following main points were noted from these discussions: • MH had conducted the original assessment for TEC for Mr Cauthery, but at the time, he was able-bodied and assessed as having the ability to leave the property unaided in the event of a fire. It was assessed that he would also understand what actions needed to be taken, in the event of a fire being discovered. Therefore, he was assessed as not requiring any form of linked fire detection. • Since the original assessment, it would appear that Mr Cauthery’s condition deteriorated to such an extent, that he became bedbound. • MH confirmed that the contract with Hackney did not include any reassessment and therefore there were no opportunities for them to revise the TEC solution provided to Mr Cauthery. • MH also confirmed they had not been informed of the incidents reported by LFB. • At the time of the incident, MH did not conduct the “Monitoring” element of the contract and this was in transition to their monitoring centre. Under these circumstances, alarm units need to be reprogrammed to alert the new centre in the event of an alarm, but MH stated they had been unable to contact Mr Cauthery, to conduct the reprogramming exercise. MH advised that the monitoring company at the time of the incident was Appello Monitoring (AM). TEC Quality contacted Appello and the details of the discussion with them can be seen in the next section. TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75 • MH stated that they have since written to LBH, to offer their Occupational Therapy services to conduct reassessments of the TEC customers, if LBH is unable to conduct them. • MH confirmed that they had no contact with Best Choice Global Limited, who provided direct care for Mr Cauthery. Discussion with Appello Monitoring Your report indicated that there was a six-minute delay from the alarm unit is activated until a response was made by an operator at AM. A meeting was requested with AM, to understand the circumstances of the call and to ascertain if there had been an inordinate delay in response. At the meeting, we discussed an investigation that had already taken place into the circumstances of the call. These are summarised below: • An alarm call was received at AM which had been triggered by the pendant and not a smoke detector, as has already been established. • The operator found it difficult to establish clear communication with Mr Cauthery and made several attempts to ascertain the circumstances of the call. • They tried to contact the resident on their mobile phone to see if this was any clearer, but could not get the resident to answer. • Trying to make contact the operator thought they heard the resident saying, “I am boiling”, but did not associate this with a possible fire. This was repeated several times. • The operator also tried to contact the nominated contacts for Mr Cauthery, but without success. • When we asked, AM advised that an alarm could be heard in the background, but the operator could not be certain that this was from a smoke detector, or another form of alarm, such as a burglar alarm, or car alarm. This is a similar statement to that of the neighbour, who thought it was a car alarm that had been activated. • Upon trying all avenues available to them, the operator contacted the Ambulance service and requested attendance, surmising that this was a medical emergency, rather than a fire. • The Ambulance Service then confirmed that they had already been contacted by another source and that the Fire Service were also en route to the property, due to the fire. We discussed learning opportunities with AM, who agreed that in hindsight and considering that an alarm could be heard and with the resident’s comments, a better response for Mr Cauthery may have been to contact the fire service, rather than the ambulance. TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75 AM are now amending their procedures for operators, to say that if future calls are received, where an alarm can be heard in the background and there is no clear information from the resident, or a carer on-site, that the noise is from something other than a smoke alarm, they are to contact the fire service immediately. Conclusions From the details of your report and the discussions we have had with service providers involved in the service delivery for Mr Cauthery, I can make the following conclusions: • The TEC solution installed was functioning and the trigger device was being worn, evidenced by the trigger alarm received by the alarm receiving centre. • No reassessment of the TEC requirements was conducted following the incidents reported by LFB and it is possible that none were conducted since the first installation. • His carers recommended that Mr Cauthery needed to be supervised at night, but Mr Cauthery did not agree. • As you have pointed out in your report, despite indicators and opportunities to install linked smoked detection, these opportunities were missed. • LFB identified in their investigation that this was a smouldering fire, which would have generated smoke for some time. It is likely that if linked smoke detection had been installed, this could have enabled a much quicker response by the alarm receiving centre in alerting the fire situation to LFB. • There was little and possibly no communication between the various agencies as a collective who had a role to play in the solution provided to Mr Cauthery. • Each agency appears to have been working in accordance with its own individual contractual requirements, but not as a collective of care. I consider that depending on the contractual relationships, this should have been coordinated by LBH as the commissioner of the TEC service and is likely to have assisted in determining the care provision prescribed. TSA Comments and Actions On this occasion and from our discussions, we could not see any evidence that the TEC services involved, were at fault in any specific way, but we do feel that the disjointed way of working between agencies is a significant factor in this case. However, we do believe that lessons can be learnt. TSA already has a set of standards called the Quality Standards Framework (QSF), which we audit service providers against, utilising our Certification Body, TEC Quality Limited. This framework is designed to ensure that these kinds of errors are minimised. We try to encourage commissioners to TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75 specify the QSF in tenders and that procurement bodies do the same. However, this is not a mandatory scheme for the sector and is voluntary in nature. The QSF modules cover assessment and reassessment and our auditors check that processes are in place to ensure that service providers conduct risk assessments and re-evaluate service user needs, especially after any incidents. Commissioners need to understand that the assessment of the need for TEC is an iterative process and needs the correct level of funding and service provision. This is an important element of any TEC solution. TSA will continue to promote that the QSF is cited by commissioners and will continue to ongoing work to raise the profile of the QSF and why it is so important that these standards are followed and to minimise the risk of incidents such as Mr Cauthery happening in the future. In addition, TSA represents the TEC sector on British Standards Institute (BSI) working committees, to develop standards in public safety in TEC. We are currently working on a new British Standard with one of these committees, which will be called “BS 8684 - Technology enabled care – Assessment of user needs and risks, system design, installation and maintenance – Code of practice” and is aimed to specifically reduce the risks identified in this case. This development work will likely continue into 2023, but when it is complete, we will also be implementing this requirement within our QSF, which our auditors will then audit against to ensure it is implemented by certified TEC installation companies. This inclusion will most likely be achieved in our programmed review in September of next year. There is also an existing British Standard called, “BS 5839: Fire Detection and Fire Alarm Systems for Buildings” which we quote as a normative reference within the QSF, to ensure that appropriate smoke/fire detection is assessed for and installed and in line with the fire risk assessment. As mentioned earlier in this response, TEC Quality will now arrange for quarterly meetings with LFB, so that incidents are made known and so that we can support the investigation, to advise on corrective and preventative action. The collaboration with NFCC will also continue as a standing arrangement. As stated in the discussion with AM, they are amending their operational procedures should alarms be heard in the background of a call, but we will also be issuing guidance to the same effect for all our certified monitoring organisations. This guidance will be issued by the end of November this year. Once our work on the Ambulance Pathway Decision Support Tool is complete, we will commence work on a similar tool for Fire Call Handling, with the support of NFCC and LFB if they are willing to do so. It must be recognised that it is likely that such a tool would not be available for use by service providers TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75 until 2024. This is because of the development requirements, testing, training, evaluation and documentation development that will be required for such a project, which is our experience with the Ambulance tool. The Pathway Decision Support Tool forms part of our national work with NHS leaders, where TEC Responders are now a pivotal part of the NHS Going Further for Winter plans. NHS chief executive Amanda Pritchard has written to all Integrated Care Boards (ICBs) urging them to commission QSF- certified TEC Responder Services to work with Urgent Community Response teams and free up around 55,000 ambulance trips each year. A similar initiative to that of the NHS, driven by Coroners like yourself, Directors of Adult Social Care and the Home Office, needs to demand that TEC Services are verified for quality and safety through audit and the endorsement of the TSA Quality Standards Framework. This will help to avoid similar situations to that of Mr Cauthery. I hope this demonstrates that we are doing all we can to learn and change behaviours following such sad incidents, and that you can also help us. If you require further information, please do not hesitate to contact me. Yours faithfully, Chief Executive Officer TEC Services Association C.I.C. TSA Suite 8, Wilmslow House, Grove Way, Wilmslow. SK9 5AG Tel: 01625 520320 | Email: admin@TSA-voice.org.uk | www.TSA-voice.org.uk | Twitter: @TSAvoice TEC Services Association C.I.C. Registered in England & Wales No.11116454. VAT Registration No: 284 9061 75
UKTelehealthcare The Vista 11 Westfield Park Ryde PO33 3AB Tel: 020 80049229 RE: Reginald Cauthery (died: 21.02.22) Dear Mrs Mazepina, I have read your attached documentation and can confirm that we would always recommend to our members and the wider Technology Enabled Care (TEC) sector to provide monitored smoke detectors, rapid heath detectors and fire detectors to elderly and vulnerable service users. We worked on a number of recommendations with London Fire Brigade in 2003 which remain relevant today and I have attached a slide set giving details of the joint recommendations. Please do not hesitate to contact me if I can be of any further assistance. Managing Director VAT Reg No: 937691283 London Telecare Ltd. trading as UKTelehealthcare. Registered in England No. 05591564
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