Clifford Rose

Executive Office 

12 December 2022 

Mr Tom Osborne 
Senior Coroner for Milton Keynes 
HM Coroner’s Office 
Civic Offices 
1 Saxon Gate East 
Milton Keynes MK9 3EJ 

Dear Mr Osborne, 

Re: Regulation 28: Report to prevent future deaths 

Thank you for your Regulation 28 report dated 20 October 2022, following the Inquest 
into the death of Mr Clifford Rose.  I am writing to provide CNWL’s response to the 
concern that you raised in that report. 

Firstly, we would very much like to extend our condolences to Mr Rose’s family and 
friends. 

The matter of concern was that: 

During the course of the evidence at the inquest it became apparent that detailed 
assessments of the needs of very vulnerable and perhaps elderly patients are 
being carried out over the telephone. In this particular case, it led to the deceased 
confirming that he was able to dress himself and that he was eating and drinking 
regularly. This was far from the correct position. I believe that consideration 
should be given to put in place a system whereby all assessments are carried out 
face-to-face and where appropriate should involve another member of the family. 

Assessments 

We thought it would be helpful to provide more information on the process in which 
referrals to Home First Therapy are managed.  Referrals can be a request for a person 
to be assessed, or provide advice or equipment, and are received from a number of 
sources including acute hospitals, primary care and from patients themselves. All 
referrals are initially sent to the Adult Social Care Access Team (ASCAT) which is a 
single point of access hub managed by Milton Keynes Council. The Council triage the 
referral and if appropriate, forward on referrals to the CNWL Home First Therapy team. 

Once a referral has been received by the CNWL Home First Therapy Team, a senior 
clinician within the team completes an initial triage to ascertain whether it is a routine or 
urgent referral and then allocates it accordingly. 

Trust Headquarters, 350 Euston Road, London NW1 3AX 
Telephone: 020 3214 5700 
www.cnwl.nhs.uk 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
   
 
   
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 All urgent referrals are seen face to face by a Home First Therapist. 

Routine referrals are sent to the OT Practice, which is an independent organisation 
contracted by CNWL to undertake a detailed information gathering from SystmOne and 
any identified carers, friends or relatives (see below) and an assessment of need with 
the patient.  This activity is carried out by Health and Care Profession Council 
Registered Occupational Therapists.  The information gathered enables the Home First 
Team to assign the most appropriate therapist to see the patient in a timely way. Some 
patients require a piece of equipment or advice. However, if the OT Practice recommend 
that a patient is seen face to face then this recommendation is accepted by the Home 
First Therapists and an appointment made at the earliest opportunity. 

Involvement of family members 

As an organisation, involving patient’s family and carers where appropriate, is extremely 
important to us.  We have taken immediate steps to make the process more robust and 
ensure that patients are asked from the beginning of their care journey with us who they 
would like involved in their care. 

We are updating all first contact assessment templates on SystmOne to include a 
mandatory question, ‘Would you like us to involve a family member, carer or friend in 
your care?’, and a section to record the details of any nominated person.  We are also 
adding to these templates another mandatory question, ‘Are you under the care of any 
other services?’ which will help identify patients who are receiving care from different 
providers and what the package of care is.  This will, with consent from the patient, 
enable our teams to gather more information about them, particularly if there are 
concerns about a patient’s vulnerability or possible self-neglect, and escalate 
accordingly. Information gained from communications with family members, carers and 
friends will be considered when triaging the patient. These updates to SystmOne are 
due to be completed by the end of December 2022. 

To ensure that all staff are aware of the changes we have produced a ‘Lessons Learned 
flyer’ which will be shared with them and discussed at team meetings.  We will also be 
sharing the learning and changes at the MKCHS Clinical Oversight Group. This group 
sits monthly. 

Thank you for bringing your concern to our attention.  We hope that this response 
provides some reassurance to both you and Mr Rose’s family that the Trust has taken 
this seriously and that we are taking steps to address the issue raised.  Should you 
have any further questions or concerns, please do not hesitate to contact me. 

Yours sincerely, 

Chief Executive

Service Area 

Mr T Osbourne 

HM Senior Coroner for Milton Keynes 

Ground Floor 

Civic 

1 Saxon Gate East 

Milton Keynes 

Friday 9 December 2022 

Dear Sir  

Re: Regulation 28: Report to Prevent Future Deaths 

Further to the notification you submitted to Milton Keynes City Council (MKCC) on 20 October 
2022, I write to confirm the actions that MKCC are taking in relation to the outcome of the 
investigation and inquest into the death of Mr Clifford William Rose. 

With regard to access to the system one, the healthcare case management system, I have been in 
contact with colleagues at Central and North-West London (CNWL) Healthcare Foundation Trust 
and it has been agreed that a reciprocal arrangement for both organisations to access the 
healthcare (System One) and social care (Liquid Logic) systems will be put in place. We have 
determined that some key teams in adult social care (such as Access and Safeguarding Adults) 
should have “read only” rights to use System One. Similarly, it has been agreed that key teams in 
CNWL will need access to the adult social care Liquid Logic case management system, again, this 
will be on a “read only” basis. 

It is anticipated that the technical issues relating to access will be addressed in early 2023 at the 
latest. 

At the present time the adult social care Mental Health team have access to System One. It is 
proposed that whilst this access is expanded, colleagues in the Access and Safeguarding Adults 
team will liaise with the mental health duty team if they have particular concerns relating to an 
individual’s healthcare provision. 

I would like to reassure you that adult social care teams are now conducting face-to-face 
assessments following referrals for care and support. As you will be aware the Covid-19 pandemic 
impacted on face-to-face visits, however, we are now operating as we were pre-Covid, so face-to-
face assessments are being undertaken. You will appreciate that we do occasionally encounter 

 
 
 
 
 
 
 
 
 
 
 
 
 
 people who are reluctant to have people visit them in their homes, where this is the case, we do 
endeavour to get an insight into their needs and living arrangements. We will always record where 
an individual has declined a face-to-face visit. 

I hope that the information provided above is satisfactory to your needs, If you have any further 
queries please do not hesitate to contact me. 

Yours sincerely 

Head of Access, Hospital and Older People’s Social Work, Safeguarding Adults and DoLS