Colin Gumm

By email  
Mr P Cooper 
HM Coroner for Lincolnshire 
The Myle Cross Centre 
92 Macauley Drive 
Lincoln 
LN2 4EL 

Head of Safeguarding 
Adult Care & Community Wellbeing 
Lincolnshire County Council  
County Offices 
Newland 

20 June 2023                                                                      

Dear Mr Cooper                                                                              

REGULATION 28 REPORT – COLIN ROBERT GUMM 

Thank  you  for  your  letter  dated  27th  April  2023  enclosing  your  Regulation  28  Report 
following the inquest investigating the death of the late COLIN ROBERT GUMM.  As 
required  under  Section  7  of  your  report,  we  have  now  considered  your  points  and 
respond accordingly. 

Conclusion of the Inquest  

"The  deceased  (who  was  a  vulnerable  adult  upon  a  care  package)  died  on  27th 
November  2021  at  Lincoln  County  Hospital,  Greetwell  Road  Lincoln  where  he  was 
admitted having been found in a collapsed state by his carers that day. Sadly despite 
treatment his condition deteriorated and he passed away the same day. A safeguarding 
referral was subsequently made." 

Your concerns  

Your concerns listed in the report are: 

1.  Adult  Social  Care  were  first  involved  in  2017  due  to  the  deceased  self-
neglecting. It is recorded assessments were not able to be completed.  

The  coroner  had  evidence  within  the  safeguarding  statement  that  the  recorded 
assessments were not able to be completed due to the individual's lack of engagement 
with the authority. Where an individual has capacity to refuse to engage with a service, 
they are entitled to do so. LCC are not able to force an individual to accept services or 
an assessment.  

2.  It was not until April 2021, 3 years later and despite care packages being in 
place  and  funded  by  Lincolnshire  County  Council,  that  the  deceased 
became known again to Adult Social Care where it was deemed necessary 
to provide ongoing support of the Wellbeing Team and Adult Social Care 
_________________________________________________________________________________ 
County Offices, Newland 
Lincoln LN1 1YL 

www.lincolnshire.gov.uk                                                         

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 until his passing in November 2021. This was as a result of a referral from 
the GP.  

3.  What happened in those 3 years by way of observations upon the deceased 
by safeguarding and if none shouldn't there have been something in place? 
Nothing  has  been  evidenced  to  date.  Shouldn't  measures  have  been  in 
place to review/or monitor?  

This factual basis is incorrect. There were no packages of care provided or funded by 
Lincolnshire County Council (‘LCC’) between 2017 and April 2021.  Furthermore, there 
was never any doubt about Mr Gumm's capacity to make his own decisions about his 
own care and support and in fact he made his own private arrangements. As LCC were 
not involved in the commissioning of any care for him, LCC would only become involved 
if  a  safeguarding  concern  was  raised  or  if  he  had  changed  his  mind  about  wanting 
support and was eligible for that support.  Aside from the referral already referred to in 
the  safeguarding  statement,  there  were  no  safeguarding  referrals which  came  to  the 
attention of LCC in those 3 years. So, in summary there would not have been, nor should 
there have been, observations of him by safeguarding nor reviews of his care as this 
was not the responsibility of LCC.  

He did however have significant health issues so he will have been in touch with health 
services to support his health care. 

On 14.4.21 a concern was raised by a Census volunteer (gathering information for the 
national  census)  that  they  had  visited  Mr  Gumm  several  times  and  could  not  get  a 
response. As a result, police carried out a welfare check and confirmed his safety. As 
Mr  Gumm  could  not  be  contacted  by  telephone  due  to  his  telephone  line  being 
disconnected, a duty officer arranged to visit. At the home visit, Mr Gumm declined an 
assessment, but the worker gave him advice and information and a referral was made 
to the Wellbeing Service for a benefits check and for assistance with shopping, cleaning 
and a key safe. A referral was also made to Age UK. Some information was provided 
verbally,  and  some  information  was  posted.  It  was  noted  that  he  had  terminal  blood 
cancer. The Wellbeing service at LCC supported with information about cleaning and 
shopping  services;  applying  for  an  Attendance  allowance;  and  telecare  equipment. 
Wellbeing  also  identified  that  he  would  benefit  from  a  stair  rail.  Wellbeing  was  to 
complete  a  follow  up  call  but  due  to  disengagement  contact  was  closed  on  27/4/21. 
There  was  no  concern  about  Mr  Gumm’s  capacity,  and  he  was  therefore  entitled  to 
refuse an assessment and/or services. He was also noted to be a self-funder.  A self-
funder is someone who has resources over the capital threshold limit and who is not 
entitled to state support.  

There  were  further  examples  of  Mr  Gumm  making  an  active  choice  to  refuse 
assessments  and  or  services.  Some  of  these  and  other  related  information  are 
documented below: - 

  12/5/21 a needs assessment was started by ASC and wellbeing hub but was not 
completed as Mr Gumm had said that he wishes to attend hospital appointment 
before deciding if he would like support. 

  27/05/21 Mr Gumm declined a falls assessment. 

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   28/05/21  As  a  result  of  Covid  arrangements  Mr  Gumm  was  provided  with  2 
weeks of funded care by health. After that arrangement Mr Gumm declined to 
have care either private or brokered through LCC. It is recorded that there were 
no concerns about Mr Gumm’s mental capacity to decline care and he had insight 
into his needs. 

  01/06/21  Mr  Gumm  was  taken  to  A&E  following  a  fall.  He  consented  to  ASC 
contacting  agencies  on  his  behalf  to  arrange  a  private  care  package.    The 
private care package was identified but postponed due to admission to hospital 
for treatment.  

  12/06/21 Mr Gumm was discharged home with private care via Amber Care. 

  06/07/21  ASC  received  a  Lincolnshire  Fire  and  rescue  notification.  Mr  Gumm 

accepted the installation of x3 smoke detectors and a CO2 detector. 

  07/07/21 Home visit was undertaken by wellbeing and identified rails for around 

the property. 

  09/07/21 – A review was completed by hospital social work team with Mr Gumm 
who said “Amber care are fantastic”. He declined to have a needs assessment 
but said maybe a call from area team in the future. It was highlighted that the 
boiler was not working. A neighbour offered to contact the engineer for Mr Gumm. 
A Wellbeing referral made by fire service for a financial review re benefits. 

  02/08/21  Mr  Gumm  was  admitted  to  hospital  20/07/21  following  a  fall  and 

fracturing right femur. 

  On discharge Mr Gumm decided to go to a care home. He was self-funding his 
care  as  above  the  financial  threshold.  A  placement  was  found  at The  Laurels 
care home which Mr Gumm agreed to. 

  10/08/21 Mr Gumm was discharged to The Laurels, which he was self-funding.  

  23/08/21 hospital social work team called and spoke to Mr Gumm who declined 

an assessment. 

  27/08/21 The OT at the GP surgery made a new contact to ASC. Mr Gumm was 

stating he wished to return home and was needing some support. 

  13/09/21  The OT arranged equipment. A Needs assessment was offered, Mr 

Gumm declined but asked for support to be arranged privately. 

  14/09/21 – Agencies were contacted, and Bluebird Care had capacity. Mr Gumm 

agreed to them visiting him to see if they could meet his needs.  

  16/09/22 The Laurels was due to close. A needs assessment was completed by 
agreement  in  order  that  Mr  Gumm  could  move  elsewhere.  A  placement  was 

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 found for  him at  Homer  Lodge  in  Lincoln.  Once  again  this  was  a  self-funded 
placement.  

  22/09/21 A Needs assessment and moving and handling plan were emailed to 
Bluebird  Care  for  their  information.  Confirmation  was  received  from  Bluebird 
Care that they could meet needs.  
ASC spoke to Mr Gumm over the phone, and he said Bluebird Care visited the 
day before and could meet his needs but were unable to start for 2 weeks.  

  24/09/21 Confirmation form Bluebird care could start on 05/10/21. 

Mr Gumm did not receive any commissioned care from LCC. He refused most attempts 
to assess him, and he refused services deciding (with capacity) to commission his own 
care arrangements.  

3.  EMAS make their own safeguarding referral on 29th November 2021 as he 
appeared  to  them  on  the  one  time,  they  saw  the  deceased  that  he  was 
underweight and showing signs of clinical dehydration. If they were able 
to observe this why is no one else in Adult social care making the same 
assessment during his lifetime. 

Adult social care was not involved in the provision of Mr Gumm’s care and therefore had 
no opportunity to be sighted on it unless a referral of a safeguarding nature was made. 
No  such  referral  was  made.  Bluebird  Care  was  the  agency  providing  his  privately 
arranged care.  

4.  After  his  death  LCC  decide  to  undertake  a  s.42  assessment  under  the 

categories of neglect and acts of omission.  

5.  The outcome from the "limited information gathered" was that no risk was 
identified  and  no  action  taken.  Despite  the  toxicology  report  still  to  be 
received  the  enquiry  was  closed  and  never  reopened.  As  a  result  no 
appropriate action was taken to mitigate any risk to others.  

The  evidence  before  the  coroner  confirmed  that  the  safeguarding  referral  was 
reviewed  by  the  Adult  Safeguarding  Team  to  establish  whether  the  criteria  for  a 
Safeguarding enquiry under Section 42 of the Care Act 2014 ("s.42") was met. S.42 
of the Care Act is detailed below. 

 Enquiry by local authority 

(1) This section applies where a local authority has reasonable cause to suspect that 
an adult in its area (whether or not ordinarily resident there)— 

(a)has needs for care and support (whether or not the authority is meeting any 
of those needs), 

(b)is experiencing, or is at risk of, abuse or neglect, and 

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 (c)as a result of those needs is unable to protect himself or herself against the 
abuse or neglect or the risk of it. 

(2) The local authority must make (or cause to be made) whatever enquiries it thinks 
necessary to enable it to decide whether any action should be taken in the adult’s case 
(whether under this Part or otherwise) and, if so, what and by whom. 

(3) “Abuse” includes financial abuse; and for that purpose “financial abuse” includes— 

(a)having money or other property stolen, 

(b)being defrauded, 

(c)being put under pressure in relation to money or other property, and 

(d)having money or other property misused. 

 Mr Gumm had sadly died and therefore this ended the Local Authority's legal duty to 
take steps to safeguard Mr Gumm under s.42. However, the Safeguarding Team did 
progress with a s.42 enquiry (although it should have been recorded as a non s.42 
enquiry at that time) to seek wider assurance in relation to the care providers involved 
and any potential wider risks. (LCC’s processes in relation to s.42 enquiries and more 
generally  is  explored  below  in  the  section  on  action  by  LCC).  Proportionate 
enquires/fact-finding was undertaken (in so far as the council were able to do so given 
the circumstances) and no concerns were identified in relation to the services provided 
to the deceased.   

Whilst the toxicology report had not been received at the time the safeguarding enquiry 
was closed, as no concerns were identified about the service provided by the provider, 
the  outcome  of  the  toxicology  report  would  have  had  no  bearing  on  whether  the 
safeguarding  enquiry  should  have  been  re-opened  for  the  reason  set  out  in  the 
following paragraph.  

LCC  would  reiterate  that  as  LCC  were  not  providing  care  to  Mr  Gumm.  Mr  Gumm, 
throughout any contact LCC had with him, had capacity to make his own choices.  It 
was open to Mr Gumm therefore to make  informed life choices to drink alcohol if he 
wanted to do so. Without any evidence to suggest that this was not a free choice, the 
carers  would  have  no  legal  jurisdiction  to  intervene.  Furthermore,  this  was  a  home 
environment not a care home setting. There was nobody else to safeguard in his home.  

6.  Conflicting evidence was provided by Bluebird Care that: 
Registered Manager (02/02/23 – "the only drink we pour for him is water, we 
never poured alcohol for him" 
26th November 2021 14.24 from carers log – "water and whisky provided on 
top of ongoing medication”. 
EMAS report (12.4.22) "bottles of alcohol were found by his bed and enquired 
with the carers, however they believed that he doesn't drink a lot as he was 
unable to pour on his own”. 

We can only reiterate that LCC was not providing care to Mr Gumm at the time. LCC 
are not therefore in a position to determine whose evidence can or should be believed 

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 nor could LCC judge whether Mr Gumm was capable or not of pouring his own drink or 
whether  he  was  asking  carers  to  do  so  as  a  capacitated  person.    Reopening  the 
safeguarding enquiry would not have given LCC the ability to make such determinations. 
As this care was in his own home there was not deemed to be a risk to anyone else.  

7.  Instead  the  s.42  reporter  according  to  the  live  evidence  of  the  principal 
practitioner  of  the  Adult  safeguarding  team  of  the  day,  appears  to  have 
collated only limited information and closed the enquiry down prematurely 
without  looking  at  material  documents  or  even  awaiting  the  toxicology 
report.  At  the  very  least  it  should  be  reopened  to  see  if  there  was  any 
missed opportunities from which lessons could be learnt and future deaths 
prevented  and  to  embody  the  whole  purpose  of  a  s.42  assessment  in 
deciding what action to take and protect the person in question. It being 
reiterated that this assessment was only commissioned after the deceased 
had been passed away.  

The s.42 reporter had made enquiries which determined that there was nothing which 
had led her to be concerned about how the provider had operated. For the reasons set 
out in paragraph 6 above, even awaiting the toxicology report, would not have allowed 
her  to  determine  from  these  particular  circumstances  that  the  provider  had  acted 
inappropriately. 

Actions taken 

LCC has already reviewed its safeguarding processes in relation to matters where the 
safeguarding concerns are raised when the adult is deceased. 

Pursuant to LCC’s duties under s.42, a Local Authority is not required by law to carry 
out enquiries for those individuals who do not meet the criteria for safeguarding as set 
out in this section of the Act. In particular, the care act duty can have no application to 
a deceased individual as the purpose of the enquiry is to decide what action is to be 
taken in relation to the individual and by whom. In some cases, LCC may have had 
a  safeguarding  referral  during  the  individual’s  life  and  appropriate  information  about 
LCC’s safeguarding actions will be provided to the coroner.  

In  other  cases,  the  safeguarding  team  may  have  had  no  involvement  during  the 
individual’s  lifetime  but  may  have  been  notified  on  death.  In  these  cases,  it  is  not 
appropriate to undertake a s.42 enquiry.  

However, if necessary, limited fact-finding enquiries will be made by the safeguarding 
team  in  order  to  ascertain  whether  further  consideration  of  potential  risk  to  others  is 
required.    This  information  is  shared  with  the  Commercial  Team  and,  if  appropriate, 
CQC, who will consider the information and decide any assurance actions, which may 
include if appropriate, a visit to the provider.  Every contract for services with the council 
has its own contracts officer allocated to that provider. In the first instance, depending 
on the circumstances, it is likely that the contracts office will visit. However, the council 
also has significant other quality assurance methods which may be used to monitor and 
improve services and work with the regulator who has the power to take formal action 
or in the worst-case scenario work  with the regulator,  who has the authority to close 
down an unsafe provision.    

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 Service Quality Reviews Meeting 

These are monthly standing operational strategic review meetings. It is a multi-agency 
forum which monitors any provider who may be deemed to be high risk. In attendance 
at  these  reviews  amongst  others  are  usually  the  Commercial  team,  LCC  Adult 
Safeguarding  Team,  Health,  CQC,  Health  protection  (public  Health  –  LCC),  NHS 
Continuing  Health  care  etc.  The  provider  will  not  be  removed  from  this  operational 
review until necessary improvements have been made. In addition, a fortnightly meeting 
takes  place  attend  by  LCC  Adult  Safeguarding  Team,  LCC  Contracts  Team 
(Commercial Team), ICB and CQC.  

Quality and Safeguarding Board   

This is a board comprising senior officers within the Council that will review any serious 
risks and agree and seek assurance regarding any appropriate action.  

Meetings with CQC  

The Head of the Commercial team also meets with CQC on a regular basis to discuss 
any cases of concern and facilitates any appropriate action.  

Whilst  therefore  information  may  not  be  provided  by  the  safeguarding  team  in  these 
cases, the council has a tried and tested approach to the considering whether or not 
any other individuals may be at risk. If during this due diligence the council identifies an 
individual  who  is  at  risk,  a  safeguarding  referral  is  then  made  to  the  council  to  see 
whether the individual meets the criteria for the opening of a s.42 enquiry. 

We want to take the opportunity to reassure the coroner that whatever the process has 
been called, LCC are satisfied that appropriate assurances have been undertaken to 
see  whether  action  does  need  to  be  taken  by  the  wider  council  as  a  result  of  an 
individual’s death.  

 Yours sincerely  

Head of Safeguarding  

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