Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0258, written 19 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jul 2023 |
|---|---|
| Reference | 2023-0258 |
| Deceased | Sylvia Pollitt |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: L&Q Group Housing 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 2nd December 2022 I commenced an investigation into the death of Sylvia Pollitt. The investigation concluded on the 16th June 2023 and the conclusion was one of Narrative: Died from hypothermia when her request for an engineer visit when she had concerns about her boiler did not happen and non-contact with her was not escalated. The medical cause of death was 1a) Gastro-intestinal haemorrhage; 1b) Acute Gastric Erosions; 1c) Hypothermia 4 CIRCUMSTANCES OF THE DEATH Sylvia Pollitt was an elderly resident of a property owned by L&Q. She called them to highlight a concern with her boiler. The call was passed to Liberty who were subcontracted to provide gas services. They were unable to contact her and closed the call down, They should have escalated the situation. On 1st December 2022 Sylvia Pollitt was found in her home address 1 Seamons Walk. Post mortem examination found she had died from complications of hypothermia. 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 will 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 The inquest heard evidence that under the SLA between the Housing Association and Liberty if there is non-contact following a referral then this should be escalated back to the Housing Association so that they can carry out welfare checks and assess the position further. Carrying out of welfare checks for vulnerable adults ensures that they are safe and well. That did not happen in Mrs Pollitt’s case. The evidence before the inquest was that the Housing Association had: 1. No audit system which enabled it to know if this issue of non-escalation by Liberty was a one off or a frequent issue. They had only become aware of the non-contact in this instance following Sylvia Pollitt’s death. 2. No system where they captured/monitored the outcome of each referral to their subcontractor e.g. non-contact; successful attendance. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 13th September 2023. 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 namely may find it useful or of interest. on behalf of the Family, who 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. 9 Alison Mutch HM Senior Coroner 19.07.2023 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Alison Mutch, HM Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG By e-mail Copy of response sent to Thomas Teague KC - HM Chief Coroner 11th September 2023 Dear Madam Re: Regulation 28, Report to Prevent Future Deaths – Report into the death of Sylvia Pollitt We acknowledge the Regulation 28 report to Prevent Future Deaths and your comments contained therein. We thank you for highlighting the areas of concern in the process both during the inquest and in your report, and we wish to provide assurances that we have taken very serious regard of these and have carefully considered and commenced implementing the steps that are required to be taken to seek to prevent such circumstances occurring again. We also confirm that we also took immediate action following the inquest and prior to the report in self-referring ourselves to the Regulator for Social Housing in order to formally track our mitigating actions. Action taken to prevent future deaths We acknowledge the two main concerns raised in your report, being the Housing Association (L&Q) had – 1. No audit system which enabled it to know if this issue of non-escalation by Liberty was a one off or a frequent issue. They had only become aware of the non-contact in this instance following Sylvia Pollitt’s death. 2. No system where they captured/monitored the outcome of each referral to their subcontractor e.g. non-contact, successful attendance. We confirm that we have undertaken a full and thorough robust review and aim to show how we have mitigated these concerns and others raised by ourselves through the process. Head Office 29-35 West Ham Lane Stratford, London E15 4PH T. 0300 456 9998 E. info@lqgroup.org.uk lqgroup.org.uk Registered Office: 29-35 West Ham Lane London E15 4PH Social Housing Regulator (L4517) Registered Society (30441R). L&Q is an exempt charity. To provide some context, we would like to highlight that Mrs Pollitt’s death occurred during a transition phase for L&Q and the previous Trafford Housing Trust (“THT”), this was as the two entities were integrating, a process which completed on 31st March 2023. The processes in place at the time were those of THT. This is not intended to avoid any ownership of the incident on our part, it is to provide the context. We have since aligned the L&Q property services and building compliance policies and processes, which includes the gas safety and contractor management processes. This shall, as we will hopefully demonstrate, now provide greater control and will prevent future deaths from these incidents occurring. With respect to your concern 1 – As soon as we were aware of the incident and the inquest, we immediately reviewed every other gas repair request which had been closed by Liberty outside of the agreed SLA and without reference back to L&Q. We took note of your comments regarding us ‘not knowing what we did not know’ and ensured that this review of the gas repair process included identifying ‘what we did not know’. This included a review of calls received by L&Q and transferred to Liberty, calls received with Liberty, tracing of jobs through Liberty and the L&Q system, and consolidation of the records held by each. Through this we were able to confidently identify all repair cases including those that had been closed both with or without direct reference back to L&Q and were able to identify reasons for all closures. No similar issues to Mrs Pollitt’s situation were identified. Gas safety in L&Q and THT had recently been audited by our independent auditors Mazars in April 2023, which included the process of alignment of the contractual arrangements and a thorough audit of the gas repairs process. This, together with regular contract management meetings confirmed that the circumstances of Mrs Pollitt’s case - where a repair had been aborted by Liberty without any escalation back to L&Q and where L&Q had not subsequently identified the repair - were not and had not been replicated elsewhere. With respect to your concern 2 – Following the inquest and prior to your formal recommendations contained within this Regulation 28 Prevention of Future Deaths report, we had immediately put in place additional processes and checks. This included aligning the process of the former THT with that of L&Q where all calls of this nature are recorded by and within the central call centre prior to being passed to contractors, ensuring that a comprehensive record of all repairs is tracked and managed through our internal housing management system. The previous THT process was to transfer the resident call directly to the contractor, in this incident Liberty. This ensures that no longer can any calls of this nature ‘fall through the gaps’ and there is a clear auditable trail for every repair. 2 That notwithstanding, we have subsequently instituted weekly meetings with Liberty to review every single job raised to trace all those in progress, overdue, completed and requested to be aborted. A full Work In Progress (WIP) report is produced by Liberty which is reconciled against the list held by L&Q and is reviewed by the Gas Compliance Manager weekly to ensure every single repair is accounted for. No jobs are permitted or are possible to be aborted directly by Liberty without reference back to L&Q and the report records all reasons for no access and dates of escalation back to L&Q. All cases of incomplete and requested aborted jobs are automatically followed up by the L&Q gas team to make contact with the resident and if this is unsuccessful, they are immediately passed to the housing management team to make an in-person welfare check. With respect to the ongoing relationship with Liberty, their contractual arrangements are currently under review. We, again, re-iterate that we have taken this very seriously and have welcomed the opportunity to improve. We have personally expressed our condolences to Mrs Pollitt’s family and our regret and remorse for the incident. Yours faithfully Executive Group Director, Property Services For and on behalf of London & Quadrant Housing Trust 3
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