Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0206, written 22 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jun 2023 |
|---|---|
| Reference | 2023-0206 |
| Deceased | Lucy Walles |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Suicide (from 2015) |
| Organisation named | Berkshire Healthcare NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1) The Chief Executive of Reading Borough Council 2) Chief Executive of Berkshire Healthcare NHS Foundation Trust 1 CORONER I am HEIDI J CONNOR, Senior Coroner for Berkshire for the coroner area of Berkshire 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 I conducted an inquest into the death of Lucy Anne Walles, which concluded on 16th June 2023. I recorded a conclusion of suicide. I concluded that her cause of death was : 1a Traumatic brain injury 2 Polytrauma 4 CIRCUMSTANCES OF THE DEATH Lucy was born on 17th November 1997. She was 24 at the time of her death. Her death in hospital on 23 February 2022 happened after she jumped f on 16 February 2022. The key facts for the purposes of this report are as follows: Lucy had mild learning disabilities but had capacity to make her own decisions and go out alone. She needed support with everyday tasks and remembering to do things. Borough Council. A support worker was provided by a care provider (Dimensions). Lucy lived in supported accommodation in Reading, funded by Wokingham Mental Health Support: Lucy had some interactions with mental health services over the years, and we focused on her most recent contacts. Lucy was under the care of the Crisis Home Resolution and Treatment Team (CRHTT, hereafter referred to as ‘the crisis team’) between 11th January and 2nd February 2022, after an overdose. She was discharged from mental health services with a recommendation to refer herself to a group called SUN (Service Users Network). She had been told at that point that she did not meet the criteria for the learning disabilities team and was advised to speak to her GP herself from that point. She saw a mental health practitioner based at her GP surgery on 15th February, indicating that she had thoughts of jumping from a particular bridge in Reading. The crisis team was contacted. Their advice was that, Lucy had Regulation 28 – After Inquest Document Template Updated 30/07/2021 been discharged recently from the service, and that she did not meet the criteria for being taken on by them. The recommendation for Lucy to refer herself to the SUN group remained. They did not speak to Lucy at that point. They did not offer her support from other mental health teams. Safeguarding referrals: There was at least one earlier safeguarding referral, but we focused on those in the last 12 months of Lucy’s life. A safeguarding referral was sent to Reading Borough Council in May 2021 following an incident where Lucy took too many sleeping tablets. This report referenced Lucy’s past history of deliberate self-harm. The evidence suggests that this was not reviewed by Reading Borough Council for almost 3 months – in August 2021 – when it was deemed to be an inappropriate referral on the basis that it did not describe abuse or neglect. Between 10th and 20th January 2022, 3 separate safeguarding concerns were raised with Reading Borough Council. These are referred to below. On the 10th January 2022, a safeguarding referral was made regarding an overdose of Nurofen tablets. On the 18th January, there was an update on the above referral, but this related to additional incidents, including ingestion of bleach. When this was followed up by telephone (with the person who had made the referral) RBC’s record of this conversation includes the following: Lucy has allegedly done a few more self-harm attempts…she is making several threats of suicide ( . Today she tried to …her mental health seems to be deteriorating…Dimensions believe she needs more support than what they can provide as they are not mental health skilled professionals. Subsequent to the referrals on 10th and 18th January, a social worker recorded that she did not think that Section 42 [of the Care Act] criteria were met. She also concluded that there was “robust support from agencies involved and appropriate measures have been taken to address risks posed by her threats of self-harm. No serious harm has occurred to Miss Walles”. On 20th January, South Central Ambulance Service Centre made a safeguarding referral. This referral relates to a previous overdose, and mental health deterioration. The report said that Lucy had told them she did not want to be here anymore. During all of these safeguarding referrals, Lucy was not contacted at all. It appears that the only information taken into account in reaching conclusions was the initial safeguarding report itself and information on Reading Borough Council’s computer system (Mosaic). These would have included earlier safeguarding reports. After the third safeguarding concern was raised by the ambulance service, no review or action took place before the tragic events of 16th February 2022. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) The concerns arising out of this investigation and inquest relate to the following key areas, Regulation 28 – After Inquest Document Template Updated 30/07/2021 a) Safeguarding b) Mental health provision c) Inter-agency communication – particularly where there is some doubt over who should provide additional support needed by a person. We heard in evidence that in the months after Lucy’s death, a Safeguarding Adults Board considered the case, but did not consider that a Safeguarding Adults Review (‘SAR’) should be undertaken. Evidence from Wokingham Borough Council was that they were not at that time aware of the number of safeguarding referrals that had been made. A decision was made (some six days before the inquest) that a SAR will now be conducted. The evidence of the Assistant Director of Adult Social Care was that this is likely to be completed within 1-3 months after the inquest. I have set out the issues / concerns that I have for each of the two recipients of this report, below. Reading Borough Council 1) Time scales for review and triage of safeguarding referrals. 2) Requirements to speak to the individual about whom safeguarding concerns have been raised. 3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry. 4) Systems for making other involved agencies aware of safeguarding referrals and concerns. 5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training. 6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ? 7) Whether they consider that the resourcing of this service is adequate and safe. 8) Systems for auditing, and what will happen if the auditing reveals ongoing issues. Berkshire Health Care 1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference? Specifically: a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February? b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February? 2) Do they consider that resourcing of these services is adequate and safe? 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE Regulation 28 – After Inquest Document Template Updated 30/07/2021 A response to a regulation 28 report is usually required within 56 days of the date of the report. Given the forth coming SAR, and in order to maximise the benefit of both of these investigations, I indicated at the inquest that I would allow a 4 month time period for this response, namely by 22/10/2023. 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 Lucy’s family. I have also sent this report to the following recipients, who have an interest in this matter: 1. Legal representative for Wokingham Borough Council. 2. Legal representative for Dimensions. who may find it useful or of interest. 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 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 about the release or the publication of your response by the Chief Coroner. 22/06/2023 9 Dated: 22/06/2023 HEIDI J CONNOR Senior Coroner for Berkshire for Berkshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 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.
PRIVATE AND CONFIDENTIAL Heidi J Connor Senior Coroner for Berkshire for Berkshire Coronor’s Office Reading Town Hall Blagrave Street Reading RG1 1QH London House London Road Bracknell Berkshire RG12 2UT 04 October 2023 RE: Inquest touching the death of Lucy Anne Walles Dear Madam I write in relation to the above inquest which concluded on 16th June 2023. On 22nd June 2023 you made a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Your report was sent to Reading Borough Council and Berkshire Healthcare NHS Foundation Trust. I am writing to provide you with the Berkshire Healthcare response to your concerns. 1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference? NHS Trusts are changing and improving the way mental health services are provided in the community to support people with mental illness. In Berkshire Health Care we are calling this programme of work “One Team”. This transformation of services is happening across the country following the publication of the Community Mental Health Framework for adults and older adults by NHSE. The new ways of working will improve mental health services so that GPs, mental health teams, local authority and other support organisations in the community work better together so that patients can receive the care they need in a timely way without having to navigate confusing systems. This programme of work is ongoing and is expected to be implemented by September 2024. This work will make a difference by providing: • Clear care and safety plans to address target problems and safety concerns. • A named worker which provides an opportunity to build trust and a meaningful connection as well as clarity and oversight on plans. • Connection with meaningful activities. • An opportunity to create or fulfil personal hopes and aspirations. • Feedback opportunities so that outcomes can be measured. • Better support in the community through the availability of a wider system of support to reduce reliance on crisis services. Instead of teams of mental health professionals, teams will be multi-agency teams, consisting of colleagues from social care and health working alongside the Voluntary, Community and Social Enterprise (VSCE) sector,. They will also include people with lived experience. This approach broadens the support available for people with any level of mental health need. Multi-agency and multi-disciplinary forums will ensure information is not lost or misunderstood and holistic, trauma informed care plans are collaboratively created. This mechanism will also ensure needs are being met by the most appropriate service and expectations are realistic and clear. Specifically: a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February? b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February? At the time Lucy was discharged from CRHTT on the 2nd of February 2022, she had a 16 hours per week of community support in place provided by Adult Social Care (ASC) with a planned move to accommodation with support available 24/7. Lucy also had access to the Service User Network (SUN) which provides group support, and Shout (which provides support with stress, anxiety, suicidal thoughts, and links to many other sources of support for example autism and mental health, bullying, relationships). A Pharmacist review of medication was planned for 17th February 2022. In the new model the following additional support could also be offered in combination with the package from adult social care and this would avoid the need for a crisis team referral on 15th Feb 2022: • Mental Health Integrated Community Service (MHICS) This team is now in place and provides specialised mental health support within the community, focussing on recovery and resilience. This is a multidisciplinary team set up to support people with significant mental illness via direct from services including referral from primary care (Additional Role Reimbursement Scheme (ARRS) worker could refer, ARRS workers are mental health practitioners working in the GP surgery). The aim is to provide early intervention to prevent escalation to services for serious mental illness. • Elmore complex needs floating support service. This is a charity we have commissioned to provide support to people with a wide range of complex needs, who are at risk of falling between the gaps of existing services. Alongside the Trust’s existing offer Elmore provides innovative ways to build trust, increase patients’ engagement with relevant agencies and deliver support tailored to the people who need it. The target group is those who have multiple support needs and complexity. For example, homelessness and rough sleeping, substance misuse, offending, physical disability, self-harm, learning difficulties, domestic abuse, sex working, or experience of abuse and neglect. A motivated team, with wide ranging expertise has been identified to work as part of our personality disorder pathway to provide this individual support. Patients may have very chaotic lives and be distrustful of statutory agencies. Elmore is essential in building the trust required to engage, and maintain that engagement, with other agencies that can provide much needed support. Elmore are now able to accept referrals. • Managing Emotions Programme (MEP) This is part of the personality disorder pathway. The Managing Emotions Programme is a range of courses designed to equip people with the tools and skills needed to manage overwhelming emotions more effectively. This programme is running. • Outreach workers These workers are able to offer short term support and safety planning to those who do not meet threshold or who are unable to access community mental health teams and/or psychological therapy. Will be fully operational by December 2023 • Integrated Multi-Disciplinary Team Complex cases can be discussed to enable a clear formulation of risk and needs. This forum will ensure the person gets the most suitable pathway and care plan to enable the patient to achieve their personal and treatment goals. It is also a place where important information can be shared across agencies pathways, for example,the ARRs worker could present a case here to ensure the correct pathway is in place, adult social care staff can attend to share any concerns. This function will be operational by December 2023. 2) Do they consider that resourcing of these services is adequate and safe? Resourcing remains an issue for all Mental Health Trusts due to the national shortage of qualified mental health practitioners, particularly nurses and psychiatrists. Fewer people want to work in mental health services, and this poses a problem in terms of recruitment and retention. In addition, demand for mental health services is greater than it was previously. The trust has a number of initiatives in place to address these issues: • The reconfiguration of community mental health services as part of the One Team project seeks to ensure the resources we have are being utilised in the right place. Significant changes have already been made to bring the East and West services together to improve resilience and make best use of staff resources and expertise. The leadership of these services is currently under review with the aim of ensuring the right level of operational support is in place, and that staff can be mobilised across the whole of Berkshire, reducing unwanted variation and moving resource around as required making services safer. • Case load reviews - Historically in all mental health services, patients would remain on CMHT caseloads for many years, which can impact significantly on safety as thresholds for acceptance and waits for CMHT due to capacity are directly linked to this. The review will increase resources available by ensuring people are on the correct pathway and receiving the correct evidence based treatment and support. • A Nurse consultant network is also now in place; these are senior specialist roles that attract mental health nurses by providing an opportunity to practice in a senior clinical role, as well as having protected time to focus on education and research and a clear development pathway. The Nurse Consultants can also intervene when there is complexity, which helps with resourcing as staff are supported with caseload capacity and complexity. Nurse Consultants also have a role to play in monitoring workforce capacity to ensure safety. • Increasing the support, skills and knowledge by offering training and supervision to the primary care workforce so they can care for people with mental health problems. • Utilising professional nurse advocates to provide staff with restorative supervision through dedicated staff trained as professional nurse advocates on a monthly basis, to reduce staff turnover as a result of burnout. • Human Resource initiatives to focus on recruitment include targeted recruitment, apprenticeship schemes, linking with universities, using social media and recruitment campaigns. The resourcing of mental health care remains a challenge. However, patient safety is at the heart of everything that we as a Trust do, and we feel that the initiatives we have implemented, and which are ongoing will optimise the deployment of available resources to ensure we support and safeguard our patients as best we can. We are aware that further learning may arise from the ongoing Safeguarding Adults Review (‘SAR’), we are working closely with the panel and will respond to the recommendations. Yours Sincerely Chief Operating Officer
Executive Director for Communities and
Adult Social Care
Civic Offices,
Bridge Street, Reading, RG1 2LU
Date: 24 November 2023
Ms Heidi J. Connor
Senior Coroner for Berkshire
Reading Town Hall
Blagrave Street
Reading RG1 0QH
Dear Madam,
Re: Regulation 28 Response regarding Ms Lucy Anne Walles
I write in relation to the matter raised in your Regulation 28 letter to Reading Borough
Council in respect of the above inquest which concluded on the 16th of June. I am writing
to provide you with Reading Borough Council’s response to your concerns, listed below
under each query.
1. Timescales for review and the triage of safeguarding referrals
The Safeguarding team at Reading Borough Council manages most of the safeguarding
referrals (around 80%) which come into the Council through the Council’s Customer Contact
Centre. If the individual referred has care and support needs and is already known to Adult
Social Care Services, the referral is passed directly to the team involved and this accounts
for the remaining 20% of referrals that come through this route.
For those referrals coming into the Safeguarding team, they are screened, and a named
Safeguarding worker is assigned if the referral requires consideration under safeguarding
procedures. When a Safeguarding contact is received which is the responsibility of a
neighbouring authority, as in Ms Lucy Anne Walles’ situation, the safeguarding team will
contact them to inform them and pass on the details. The timescales for the management
of the contact and referral process are set out as guidance on the Berkshire Safeguarding
Policy and Procedures and Reading Borough Council, along with all the other Local
Authorities covered by the West of Berkshire Safeguarding Adults Board, follow these
procedures.
Following the death of Ms Lucy Anne Walles and the lack of timeliness of an appropriate
safeguarding response to safeguarding contacts in this case, improvements have been made
to the safeguarding service in Reading. Those relating to the resourcing of the service, are
referred to below. In relation to improvements in processes, where a safeguarding contact
contains information which may indicate the individual has suicidal ideation or is at risk of
significant self-harm, a priority flag is added at the point of contact on the client recording
system for the Safeguarding Team’s attention, or the responsible adult social care team
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who are dealing with the case. This priority flag highlights the urgency of the case for those
allocating work and can be removed or added during further assessment of the individual.
This change in process has been required to strengthen the management of high-risk
safeguarding referrals, particularly given the volume of safeguarding contacts received,
and the resource limitations on the safeguarding team referred to below.
The other improvement in process in the management of safeguarding contacts through the
Customer Contact Centre and the Safeguarding Team is that, since the creation of a
dedicated senior Safeguarding Lead role for Reading in June this year, there are daily
consultations between the Safeguarding Team and the Customer Contact Centre to ensure
appropriate referral processes are followed and there is priority flagging of high-risk
safeguarding referrals.
The indicative timescale for a member of the safeguarding adults team to triage the referral
of a safeguarding concern is within one working day as indicated in the guidelines.1
2. Requirements to speak to the individual about whom Safeguarding concerns have
been raised.
The practice standards for safeguarding in this area are supported by the Making
Safeguarding Personal (MSP) initiative led by the Local Government Association and Reading
staff are required to follow these standards. Individuals who are the subject of safeguarding
concerns should always be made aware about the nature of any safeguarding concern, so
they are fully appraised of what information is being shared about them and any actions
which are likely to be pursued on their behalf. They should also be given opportunities to
express their wishes and feelings. Only in exceptional circumstances where dialogue would
increase the risks to them or to others, or where the individual lacks mental capacity,
should this not be a requirement and in the latter circumstance, those with power of
attorney, who are able to act in the best interests of the individual, should be fully
consulted. In the circumstances surrounding Ms Lucy Anne Walles death, Lucy was not made
aware by the Council when safeguarding concerns were raised on her behalf and this did
not follow the requirements of best practice required in MSP.
There has been significant tightening up of practice by the safeguarding team to ensure
individuals are personally contacted about safeguarding referrals and these
that
improvements are the subject of greater monitoring and audit in safeguarding cases. The
Safeguarding Lead and two senior social workers in the safeguarding team ensure that no
safeguarding concern is closed without the individual being contacted.
3. Training around section 42 and when a report meets the threshold for neglect or
abuse. This training should also consider what options are available if a concern
does not meet the threshold for a section 42 enquiry.
Reading Borough Council adopts a comprehensive approach to safeguarding training as
outlined below:
All staff in Adult Social Care undertake Level 1 training which focusses on safeguarding
awareness and the identification and reporting of abuse and neglect. This includes the
1 https://berkshiresafeguardingadults.co.uk/p/4-adult-safeguarding-procedures/43-responsibilities
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requirements for Section 42 enquiries. This is mandatory training and compliance is
monitored by the Council. This training is delivered throughout the year.
Level 2 training is aimed at all Adult Social Care front-line staff and external partners such
as care home managers and familiarises attendees with the Berkshire West Safeguarding
Procedures including use of the procedures, the requirements of “Making Safeguarding
Personal”, conducting safeguarding investigations as part of an enquiry, and the legal
frameworks including deprivation of liberty and the Mental Capacity Act. Level 2 is
mandatory for all staff who undertake any role in safeguarding enquiries and is delivered
throughout the year.
Level 3 training is aimed at staff who manage safeguarding enquiries, for example Senior
Social Workers and Managers, and those who work in specialised roles which involve
safeguarding. It is mandatory for such staff and must be refreshed within 3 years.
Attendance is monitored departmentally and is reported to the West Berkshire Safeguarding
Adults Board.
All three levels of training are run at regular intervals throughout each year and all three
levels of training cover what options should be considered if a concern does not meet the
section 42 enquiry threshold.
There is also a “Safeguarding for Managers” Course which is run twice a year for relevant
managers which looks in more depth at best practice in supervising safeguarding cases,
managing risks and lessons from research and from Safeguarding Adult Reviews.
In addition to the core training offer outlined above Assistant Directors in Adult Social Care
and the Safeguarding Lead are now providing tailored safeguarding training for Managers to
ensure that all senior staff have a consistent approach to safeguarding contacts, referrals
and enquiries and are appraised of best practice guidance. All Social Care practitioners
have access to the training materials and briefing notes produced by the Safeguarding
Adults Board following Safeguarding Adult Reviews (SAR) reports and are given
opportunities to attend learning events for SAR recommendations. The SAR findings for Ms
Lucy Anne Walles (under the title “Bree” SAR) and the recommendations therein will be
the subject of learning events.
4.
Systems for making other agencies aware of safeguarding referrals and concerns.
The West of Berkshire Safeguarding Adults Board require Pan Berkshire policies and
procedures to be followed in respect of all safeguarding cases which are either related to
Reading residents, or to individuals receiving services in Reading. These policies and
procedures set the expectation that the outcome of a Safeguarding Concern is required to
be communicated to the referrer, with the persons consent wherever possible. Other
appropriate action may also be considered for example if the individual is presenting with
care and support needs this information would be passed to the appropriate team to assess.
Where the Concern is progressed to a Safeguarding Enquiry the Agencies involved are
consulted as part of that Enquiry and over any care and protection plan which is then
developed.
In the case of Ms Lucy Anne Walles, there had been multi agency discussions led by
Wokingham as the responsible Local Authority for the case, but the safeguarding referrals
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were received by Reading which did not trigger a multi -agency meeting to consider the
collective risks.
The West of Berkshire Safeguarding Adults Board is currently working on strengthening and
standardising of the guidance in the procedures, particularly the multi-agency processes
being used across the local authorities.
The SAR author has identified this as a gap and has already begun to discuss with
representatives from the Safeguarding Adults Board the lack of an agreed and shared multi-
agency risk assessment in respect of Ms Lucy Anne Walles and Reading Adult Social Care is
fully involved in the consideration of recommendations and on improving transparency and
clarity in this regard.
5.
In relation to the above points, whether RBC should reflect the above changes in
formal (written) policy, as well as delivering training.
All policy changes in respect of processes and policies relating to safeguarding in Reading
are subject to approval by the West of Berkshire Safeguarding Adults Board, in which
Reading is a key statutory agency partner and follow the Pan- Berkshire policies and
procedures used by all agencies.
The tri- borough arrangements for safeguarding agreed by the Board require consistency
of processes and procedures across the Board footprint and therefore Reading only
changes formal policy, when agreed through the Safeguarding Adults Board. Revisions and
associated amendments of the pan Berkshire procedures are instigated for several reasons
including the recommendations of Safeguarding Adults Reviews, best practice guidance,
and changes in national safeguarding policies.
Training on Adult safeguarding for Council staff (content outlined above) is delivered
locally through the Organisational Development Team, coordinated by a dedicated
Workforce Development Officer for Adult Social Care, the Principal Social Worker and
Principal Occupational therapist and other senior staff in the Adult Social Care service. In
addition, the Safeguarding Adults Board delivers training and learning events on a range
of matters relevant to safeguarding practice and the learning from Safeguarding Adults
Reviews and thematic safeguarding reviews. The Board also has a responsibility to monitor
the delivery of multi-agency learning on matters related to adult safeguarding.
As part of the improvement work being undertaken this year to improve the performance
of safeguarding in Reading, Senior Managers in Adult Social Care in Reading have
undertaken workshops with all the managers engaged in safeguarding, to strengthen their
understanding of the safeguarding processes and the requirements of best practice which
we are seeking to deliver as outlined in point 3.
6.
Improving the interaction between agencies involved and consideration of the
threshold for arranging joint meetings to discuss service users, whether they meet
Section 42 thresholds or not. The evidence we heard is that this is being actively
encouraged. Should there be written guidance about this somewhat subjective
issue?
Multi agency meetings occur as part of the safeguarding processes. However, multi-agency
meetings are arranged to discuss many forms of risk and the care and support needs of
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individuals, not only those who meet the section 42 threshold. When the threshold for
Section 42 enquiry is not judged to have been met, any agency can refer for a Multi-Agency
Risk Meeting (MARM) or the lead authority can call a MARM meeting, and this is outlined
in the procedural documentation for the West of Berkshire Adult Safeguarding Board.
7. Whether the resourcing of the service is adequate and safe?
Safeguarding services in Reading, in line with all other parts of the UK have been
experiencing and continue to experience increases in the number of reported safeguarding
concerns, which have resulted in significant service pressures over the last three years. In
20/21 for example there were 1598 concerns reported to Reading, whereas in 21/22 this
had risen to 2969. There have been difficulties in recruiting and retaining permanent staff
to work in safeguarding, in part because of national workforce shortages, but also because
of the high-level demands in skills and experience needed to work with very vulnerable
individuals in crisis situations.
The Council continues to review the required organisational structure to see which is best
able to meet the increased demand in order to deliver adequate and safe resourcing of
adult safeguarding in Reading and has made changes as a result.
Following the appointment in June 2023 of a Senior Safeguarding lead, 3 additional full
time safeguarding staff were appointed, and this has provided a 30% increase in dedicated
staff resource for managing safeguarding referrals. The Senior Safeguarding Lead is
accountable to, and works with, the Assistant Director for Safeguarding, Quality and
Practice. This has strengthened the managerial oversight of the delivery of the
safeguarding service and continues to report performance of safeguarding to the
Departmental Management Team, led by the Executive Director.
These increases in safeguarding resources described above have been delivered despite
resource pressures effecting the Council, in recognition of the importance of safeguarding
for the residents of Reading. However, workforce challenges in social care are being felt
by all Local Authorities in the UK at the current time particular in respect of shortages of
skilled and experienced staff throughout the adult care service which continue to
challenge the resourcing of safeguarding systems across health and social care.
8. What are the systems for auditing and what happens if auditing reveals on going
issues?
As noted earlier the West of Berkshire Safeguarding Adults Board provides the framework
policies and procedures for all safeguarding in Reading and staff must adhere to those and
operate to those, with due regard to the requirements for safeguarding set out in the Care
Act (2014) and other legislation and guidance. Any issues identified with the procedures
and policies are picked up through the SAB as described in 5 (above) and any individual
skills deficits with individual workers are addressed through managerial oversight and
guidance as work is subject to auditing of cases and worker supervision which has been
strengthened in Reading in the last 6 months. Themes from audits and the learning from
them are shared with staff in “Learning Together” sessions which are led by the Principal
Social Worker and Principal Occupational Therapist.
Learning from SARs and other reviews of Safeguarding are overseen by the Safeguarding
Review Panel of the SAB and recommendations from that panel to commission external
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reviews, thematic learning reviews, appreciative enquiry, training and other forms of
learning from practice, are made to the Board and supported by senior representatives
from the 3 Councils and partner agencies. The “Bree” SAR will form the basis of learning
events and other opportunities for dissemination of recommendations for improvements
in safeguarding and support of vulnerable individuals at risk of suicide.
In June this year the creation of a senior management post to lead safeguarding practice
in Reading, is enabling challenges in the delivery and resourcing of effective safeguarding
to be brought to the attention of senior managers in Adult Social Care and in the wider
Council. The postholder also oversees the work of the Safeguarding Team, undertakes
auditing and reviewing of safeguarding cases and provides expertise in management of
complex Section 42 enquiries.
In July 2023 Adult Social Care in Reading introduced a Quality Assurance Framework for
the service which includes an audit programme which supports auditing of safeguarding
referrals, not just at team level but also incorporating wider auditing by managers and
some external commissioned audits undertaken by specialists. The individual learning
from these audits is fed back to workers and their managers and any themes for learning
which emerge, form the subject of workshops with appropriate staff. This Quality
Assurance Framework systematises case audit in a more thorough form from previous
auditing activity and allows for more rigorous consideration of any gaps in processes,
policies or practice skills. The Departmental quality assurance process is led by the
Executive Director under the title “Striving for Excellence” which is following the
framework provided for inspection of adult social services by the Care Quality Commission
(CQC), who are in the process of inspecting all local authority adult social care services.
This includes the performance, delivery and outcomes of safeguarding services as a key
part of their inspection.
The explanation outlined above under each point aims to provide reassurance around
progress in relation to the specific actions that were for the Council to address. In overall
conclusion the Council will continue to work to improve its response to safeguarding
concerns drawing on support from agency partners represented on the Safeguarding Adults
Board and will give full consideration of recommendations from the Safeguarding Adults
Review concerning the tragic death of Ms Lucy Anne Walles. The findings of the
Safeguarding Adults Review will contribute to the improvement work particularly in
respect of how we respond across health and social care services to vulnerable people at
risk of abuse, neglect and harm and those at risk of suicide.
Yours sincerely
Executive Director of Communities and Adult Social Care Services
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