Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0297, written 17 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Aug 2023 |
|---|---|
| Reference | 2023-0297 |
| Deceased | Shirley Ashelford |
| Coroner | Christopher Williams |
| Coroner area | London Inner (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 (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Medicine Healthcare products Regulatory Agency (MHRA)
2. London Borough of Southwark (Occupational Therapy Service and
Asset Management Team).
3. Prism Medical UK Ltd.
4. Bureau Veritas UK Ltd.
5. His Honour Judge Thomas Teague KC, The Chief Coroner for England,
and Wales.
1
CORONER
I am Christopher Williams an Assistant Coroner, for the Coroner Area of Inner London
South (Southwark Coroners Court).
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 the 27th July 2021 an investigation commenced into the death of Shirley Frances
Ashelford, born 30th June 1961, and who died on 20th July 2021.
The investigation concluded at the end of the inquest on 9th August 2023.
The medical cause of death was:
1(a) Asphyxia
1(b) Chest compression with suspension from Mobility Body Hoist Harness
II Multiple Sclerosis.
I recorded the following factual findings in Box 3 of the Record of Inquest:
At the time of her death Shirley had secondary progressive multiple sclerosis,
diagnosed in 2000, which severely restricted her mobility.
Despite her condition, preventing her from standing up and walking, she was
determined to live as independently as possible sharing a home with her husband.
Her daily routine was to wake at 06:00 am, and call her husband between 07:00 and
07:30 am, to assist her getting dressed.
On the morning of the 20/7/21 whilst she was transferring from her bed to a mobility
scooter, using a mechanical ceiling hoist, the lowering mechanism failed leaving her
suspended with her feet off the floor in the hoist chest harness.
1
The harness tightened causing compression of the chest which, in combination with
respiratory weakness caused by multiple sclerosis, led to fatal asphyxia.
Her husband awoke at about 08:00 am, when he did not hear his usual alarm call,
and discovered her unresponsive in the hoist harness.
Despite attempts at resuscitation she was pronounced dead after the arrival of the
ambulance service.
Based on those factual findings my Conclusion in Box 4 of the Record of Inquest was:
Misadventure
4
CIRCUMSTANCES OF THE DEATH
Shirley was aged 60 at the time of her death. Following a diagnosis of multiple
sclerosis, in 2000, her mobility slowly declined, eventually losing the ability to stand
and walk and becoming reliant on a mobility scooter.
In February 2003 she referred herself to the London Borough of Southwark
Occupational Therapy (OT) Services who over the years arranged adaptations to her
home to assist with her declining mobility.
She was provided with a powered transverse hoist to transfer her from her bed to a
mobility scooter.
The hoist was a Freeway Transactive Xtra, serial No. TXD23090, Manufactured by
Prism Medical UK. It consisted of a motor which moved along an H-track frame,
installed in the ceiling, above the bed. Attached to the motor was a harness consisting
of 2 lines which attached to the front and back of a sling which fitted around the chest
area. The sling was a Liko Mastervest MOD 64.
The sling/harness was designed to tighten around the chest when put under weight to
prevent a user sliding through it. When the hoist was working correctly Shirley would
only be suspended for a matter of seconds before her feet encountered the floor when
transferring to the scooter.
She operated the hoist using a handheld control which had 6 buttons for movements
in every direction, up/down, left/right, and forwards/backwards.
The local authority employed an independent contractor, Higher Elevation Ltd to
maintain the working of the hoist. The contractor’s attendance was organised by the
local authority Asset Management Team (AMT). Higher elevation produced visit report
sheets which they sent to the AMT. The AMT in turn did not provide the visit reports to
the OT department.
In the months leading up to her death Shirley reported problems with the hoist getting
stuck when trying to lower it and causing her to be suspended in mid-air. This was
documented in emails to her Occupational Therapist (OT). On the 25/3/21 she
described being trapped in the hoist for 5 minutes and stating “… the pain all this is
causing me is immense and the damage to my condition is noticeable…” .
On the 9/4/21 she emailed her OT describing the hoist lowering problem as being
occasional and that it worked normally most of the time. On the same day Higher
Elevation advised the AMT that the hoist should be replaced. This was not
communicated to the OT team by the AMT.
On the 30/6/21 Bureau Veritas UK Ltd, a private company, commissioned by the
London Borough of Southwark, performed a 6 monthly inspection of the hoist, and
reported no defects, which could become a danger to persons, were present. That
report was made to the AMT but not to the OT department. The report does not
2
indicate that Bureau Veritas was aware of the reports Shirley had made to the OT,
and the Higher Elevation report of 9/4/23.
On the morning of 20/7/21 Shirley’s husband found her suspended in the hoist
halfway between the bed and mobility scooter in an upright position with her feet
about 2 inches off the floor.
He manoeuvred her above the scooter using the hoist handheld control, which
although unable to lower, was still operating in the horizontal plane. He then used a
knife and scissors from the kitchen to cut the harness lines to lower her onto the
scooter and called the ambulance. It is significant that he did not use a red emergency
cord, located on the hoist unit underside, to lower her. He revealed at the inquest that
he had not received training on its use.
He then attempted to perform CPR whilst she was on the scooter because he could
not move her onto the floor by himself. The ambulance service attended about 10
minutes later and pronounced life extinct. Rigor-mortis was noted.
An initial Post-Mortem report, 3/11/21, considered that positional asphyxia was
possible due to the presence of petechial haemorrhages of the sclera but the
pathologist,
Unascertained. A neuropathologist had also been unable to identify a cause of death.
, was only able to offer the cause of death as 1(a)
A second pathologist,
description of the position in which Shirley was suspended in the hoist and concluded
in a report 2/5/23 that the harness tightened causing compression of the chest which,
in combination with respiratory weakness, from multiple sclerosis, led to the fatal
asphyxia.
, was provided with a diagram and
When submitting his report
publications of studies of deaths caused by straps and harnesses in different settings
to illustrate his finding as to the cause of death. The Pathology Report and medical
publications are attached.
provided me with several medical
Based on the pathology findings I ruled out ‘natural cause’ on the basis that chest
compression from a mobility hoist harness was not a natural event but the failure of a
piece of manufactured equipment. I recorded a conclusion of Misadventure because
death resulted from an unintended mechanical failure of the hoist to lower and the
unforeseen increasing pressure on the chest area caused by the sling restricting
Shirley’s breathing movements.
5
CORONER’S CONCERNS
From the evidence I received, at the inquest, there are 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.
During the inquest I heard evidence of the following matters:
• Shirley was an unusual local authority OT service user because she operated
her hoist and sling mainly without the assistance of a carer because she
wanted to maintain her independence and dignity as much as possible.
Because she had mental capacity the OT service respected her wishes.
• Shirley’s husband who was the main carer at the time of her death did not
receive any training from the local authority in safe usage of the hoist and in
particular use of the red emergency pull cord. It was not clear whether Shirley
had received any training on the use of the red pull cord when she was
3
provided with the hoist because there was no paperwork confirming training
had been delivered.
•
I found that when Shirley was suspended in the hoist, she did not use the red
pull cord, on the underside of the hoist unit, because it had not lowered and
because her husband was able to use the hand control to manoeuvre her
toward the scooter. He would not be able to do this if the red cord had been
pulled because the electric power would switch off.
• Higher Elevation reported inspections of the hoist to the AMT but not to the
OT department. The AMT, in turn, did not share those reports with the OT
department.
• The Inspection by Bureau Veritas 30/6/23 only reported to AMT but not the
OT dept. The AMT did not share the report with the OT department. I was
informed that although the Lifting Operations and Lifting Equipment
Regulations 1988 (LOLER) did not apply, nonetheless six-monthly
inspections were performed on a voluntary basis.
• The last Bureau Veritas inspection was done without access to reports from
Higher Elevation and email reports from Shirley to the OT department.
Veritas reported there were no problems on its last inspection of 30/6/23 over
2 weeks before the death. That report was made without sight of the Shirley’s
report to the OT department, on 9/4/21, and the Higher Elevation report to the
AMT on the same day.
•
I was also told by Shirley’s husband that the same model of hoist in the
bathroom had also failed to lower on occasions.
• At present the bedroom hoist, and hoists in the bathroom and living room
remain in situ at Shirley’s home and are available for inspection. Shirley was
a local authority tenant when she died and due to pressure on its housing
stock the local authority is anxious to re-let the property to new tenants.
Therefore, it is desirable that the hoists are inspected in situ as soon as
possible. Otherwise, they will have to be inspected whilst in local authority
storage.
•
I was reassured that the London Borough of Southwark is seeking to
introduce guidance to its OT service to ensure the risk of recurrence in future
is reduced in relation to service users operating hoist equipment unassisted in
their homes. However, given my concern that recurrence should be avoided
elsewhere in England and Wales I am reporting this to the MHRA to
investigate and if necessary, alert and give guidance to other local authorities
regarding the evidence which emerged during my investigation.
The MATTERS OF CONCERN are as follows. –
Awareness of Asphyxia Risk – Service Providers
1) The risk of fatal positional asphyxia associated with the use of
harnesses/slings when hoisting was not appreciated by the OT services and
AMT concerned with the provision, use and maintenance of the hoist. This
indicates that training may be required to raise awareness of the risk of
positional asphyxia in order to reduce the risk of future deaths. I consider it
important to highlight to service providers the dangers associated with
unassisted use of ceiling hoists and sling harnesses.
4
Awareness of Asphyxia Risk – Users and Carers
2) Users and carers did not appear to have been made aware of the asphyxia
risk associated with hoisting. It was not clear whether Shirley was trained in
the use of the red cord safety feature on the hoist as there was no
documentation to confirm this. Her husband and carer had never received
training in the use of the red cord for emergency lowering. He was also
unaware of the risks of positional asphyxia when Shirley was operating the
hoist on her own. My concern is that there may be a general a lack of training
of users and carers in the operation of this type of hoist and the risk of
positional asphyxia.
Information Sharing – Service Providers
3)
I am concerned that two departments in the local authority, the OT
department and AMT, did not share information concerning the condition of
the hoist, namely, Shirley’s reports to OT were not shared with AMT and visit
reports from contractors to AMT were not shared with the OT. Likewise, the
Bureau Veritas inspection on 30/6/21 appears to have occurred in an
information vacuum regarding recent problems with the hoist. Whilst the
Veritas inspection report was shared with the AMT it was not shared with the
OT department.
Possible Hoist Design Problem
4) There was some evidence that another hoist of the same model in the
bathroom had a problem with the lowering function and the possibility of a
fault in the design of the lowering function. I raise this concern to alert the
MHRA and Prism Medical UK Ltd in order to conduct appropriate safety
investigations. The hoists are available in situ for a limited period or otherwise
will be kept in storage by the Local Authority for inspection purposes.
Inspection of Hoist without background information
5)
I am concerned that the Bureau Veritas inspection report of 30/6/21 made no
reference the report of Higher Elevation and Shirley’s complaint on 9/4/21
indicating that the inspector was unaware of recent problems. Had they been
aware they might have been able to detect the problem which caused the
failure of the hoist to lower on the 20/7/21.
Enclosures accompanying the Regulation 28 report:
positional asphyxia.
Post-Mortem report 2/5/23, exhibiting 3 academic articles on
Diagram prepared by
(Shirley’s husband).
Manufacturer’s guidance on the use of Transactive-Xtra hoists.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisations has 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 the day month 2023. I, the coroner, may extend the period.
5
Your responses 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 who may find it useful or of interest:
1. Solicitors representing the London Borough of Southwark.
2. Higher Elevation Ltd.
3.
next-of-kin.
4.
5.
pathologist.
pathologist.
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.
Dated:
Signed:
9
17th August 2023
Christopher Williams
6
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.
Inquest into the Death of Shirley Ashelford Response by London Borough of Southwark to the Regulation 28 Report to Prevent Future Deaths dated 17.08.23 1. LBS was surprised to receive a Regulation 28 Report to Prevent Future Deaths (PFD) (the Report/the Regulation 28 Report). The evidence that was heard at the inquest and, the indication at its conclusion, was that any PFD would be made to the Medicine Healthcare Products Regulatory Agency (MHRA) and not to (London Borough of Southwark) (LBS, the Council) in recognition of the fact that the risks of positional asphyxia were not well or widely known at the time of Ms Ashelford’s death. 2. LBS understands that it was noted by HM Coroner in open Court in this case that “the CQC penalise organisations when PFD’s are made. That would do an injustice in this case, this is not a failure but an opportunity to learn and to make the use of hoists safer”. It is further noted that HM Coroner had general concerns that individuals who are “independently minded need to be supported but they need to be aware of that risk and use of hoist as safe as possible”. 3. As a result of the inquest process as a whole, LBS has given further consideration to the issue of self-hoisting service users and made some changes, which are set out below. 4. For ease, this response adopts the numbering from the Regulation 28 report dated 17 August 2023. Items 1 and 2 - Awareness of Asphyxia Risk – Service Providers and Users and Carers 5. The risk of death or injury would be most likely to occur in the very rare situation where a service user has the skills combined with both the independence and motivation to use a hoist independently. The additional risk of fatal positional asphyxia may specifically be more likely if somebody has a diagnosis that can be associated with problems with swallowing effectively, such as Parkinson’s. At the time of her death Ms Shirley Ashelford was the only service user in the whole Borough who independently self-hoisted. Ms Ashelford became a self – hoister in 2008 and at that time, she was the only self – hoister. This has been the case for the last 15 years. 6. As was explored in the inquest and acknowledged by HM Coroner, the risk of positional asphyxia is not a well-known about risk. 7. Part of the rarity of the risk is that it is unusual to have someone ‘self-hoist’. In the vast majority of cases, individuals are supported to use hoisting equipment with a carer and so there is always the safety mechanism by which the equipment is used when there is someone else present and able to help or call for help, if required. 8. Whilst it was accepted during the inquest that LBS had taken steps to protect Ms Ashelford by offering a care package, a pendant alarm and a micro environment in a room downstairs when she started reporting concerns with her hoist, LBS has reflected upon matters that arose in the inquest. As part of this LBS has now developed a policy and checklist, titled “Self Hoisting Policy London Borough of Southwark”, which is to be followed in the event LBS is working with a service user who expresses the motivation and demonstrates both the mental and physical capacity to use a hoist independently. As set out above, there are no current service users who fit this categorisation. However, the policy is now in place in the event that such occurs in the future. 9. In such an eventuality, the service user will be advised that there are risks present in the event of using a hoist. This could include asphyxiation (choking) or other sudden onset of illness which could result in serious injury or death. The new policy and checklist will support the Occupational Therapist and resident to agree the mitigating factors to reduce/remove this risk. A copy of the policy with checklist is attached to this response. 10. This new policy (which contains a checklist) will be placed on Adult Social Care’s internal case management system and the information will shared by the Occupational Therapy Team Manager and Principal Occupational Therapist with all relevant staff It will also be included in the new starter induction to advise new starters within the service. LBS also proposes to have a training session on the new policy. This training will be provided to the approximately 23 OTs who are currently employed by LBS’ Social Care. It will also include OT apprentices and students, team managers and health colleagues (that is, OTs, sitting within Health e.g. the reablement team that will be invited). 11. The outline of the new policy/checklist is structured on the Risks to Service users known to self-hoist and transfer using ceiling track hoists Health and Safety Executive Safety Alert Bulletin FOD WSW2-2010 and includes: a) A reminder of the checks necessary before the equipment is used; b) Recording of the demonstration of how any lowering equipment should be used; c) Information on how to report any adaptation faults; d) A recorded plan of how a service user can seek help in an emergency i.e. use of a telecare pendant or mobile phone within reach. 12. The checklist will need to be signed by the service user and any relevant person, even if informally involved in the service user’s care. The service user will be reminded to contact Adult Social Care if their needs change, and if they reconsider accepting care for hoisting. 13. In the event LBS works with clients who are known to self-hoist in the future they will not be ‘discharged’ from Occupational Therapy’ and instead will be invited for a reassessment yearly, or sooner if their needs are known to have changed. 14. For the avoidance of doubt, this new process will be used very specifically when working with service users known to self-hoist and transfer. The policy and checklist will be used as an additional precaution to supplement the moving and handling plans that LBS issues where there is particular/individual moving and handling advice which needs to be confirmed. The Occupational Therapist will provide demonstrations to the service user and any relevant person even if informally involved in the service user’s care, as required and until competency of moving and handling techniques is confirmed. 15. When a contractor installs mobility equipment, which includes hoists, the contractor demonstrates the use of the equipment, and the service user signs to say they have been shown how to use the equipment. The housing adaptations team save this on its case management system against the clients file. Item 3 Information Sharing – Service Providers 16. The Asset Management/ Engineering Services team (AMT/ES) is responsible for the service, repair, maintenance & inspection of mobility equipment (AMT/ES). Asset Management Home Adaptions Team (AMT/HAT) has responsibility for the survey and installation of Mobility equipment. The Occupational Therapy (OT) team is responsible for recommending the appropriate type of equipment based on their assessment of the person’s need. 17. In relation to sharing information between the Occupational Therapy team and the Asset Management Team: this was a deliberate decision. There were, and remain concerns, that the O.T. team will be overburdened by information if they are sent every email or piece of paperwork. The purpose behind having a division of departments is so they can focus their resources on matters where their expertise is. That said: if there are issues with a piece of equipment, of course the Occupational Therapist needs to know. 18. The usual procedure for reporting faults/raising repairs is that a resident would contact the call centre to report a fault and the call centre would raise the order for the contractor to attend. If the matter is escalated, as it appears to have been in this case, the report can be sent by any interested person directly to AMT/ES. 19. When Higher Elevation (contracted by AMT/ES at the time) referred the bedroom ceiling hoist for replacement, it is believed that liaison/communication between OT and AMT/ES and AMT/HAT, in relation to assessing/procuring the new hoist, took place in a reasonable manner. Please refer to paragraphs 38 – 44 of Mr Kitchener’s witness statement dated 05.06.23. Bureau Veritas, or indeed any contractor, would normally, at that time only report back to AMT/ES. 20. Under normal circumstances, OT’s usual line of communication with AMT is via AMT/HAT, to whom AMT/ES would have fed any relevant information. It is only in exceptional circumstances that OT will communicate directly with ES or vice versa. In this particular case and due to the specific nature of the hoist the contractor was unable to supply a suitable replacement hoist and a re- assessment request was sent directly by AMT/ES to OT. OT sent the re- assessment to AMT/HAT, who then sent an order for installation shortly after. The whole process from the recommendation for replacement to a new proposed installation date took around two months. During this period, the bedroom-ceiling hoist was considered operable and useable and continued to be covered by the AMT/ES repairs contract. 21. It was also established that OT or AMT/HAT did not have direct access to the fault repair records. Steps have now been put in place to remedy this such that both OT and /or AMT/HAT can access relevant fault repair records, as required – this is explained further below. 22. In order to address the issue of sharing information, Engineering Services team (AMT/ES) has set up a Fault Repair Reporting System; this is contained in a folder that will log all call outs for repairs to mobility equipment each month. The information will be kept up to date and located in a shared folder, with access available to both AMT/HAT and AMT/ES. The OT team also has access to this folder however they will not be expected to check the folder on a regular basis. Instead, they will obtain information regarding faults as detailed in paragraph 24 below. AMT/ES currently sends this information to the insurance contractor (formally Bureau Veritas, now replaced by HSB) on a monthly basis until such a time as access can be provided to them. This folder will enable the insurance contractor to see faults reported to equipment, including re-occurring issues. 23. The detailing of repairs on the excel sheet will enable information to be collated with regards to reoccurring repairs over a period of time and whether the repair is economically viable. 24. Currently, there is a regular quarterly meeting between AMT/HAT and the OT team. Following the inquest, self – hoisting cases and the issues arising therefrom, has become a rolling item on the agenda. AMT/ES will also now be attending these meetings. As part of this, AMT will make OT aware of any engineering concerns regarding equipment in situ, being used by self – hoisters and action that is being taken to resolve such concerns. Item 5 Inspection of Hoist without background information 25. As the Coroner heard from the evidence called at the inquest, the Bureau Veritas inspector would not have been told of the report of Higher Elevation and Ms Ashelford’s’ complaint on 9/4/21, because a ‘fresh eyes’ approach was the preferred industry standard. 26. The recommendation (by the AMT/ES’ contractor) for the replacement of the bedroom-ceiling hoist was based on the fact that a number of callouts had been made in previous months; that recommendation was not based on any evidence to suggest the equipment was unsafe or potentially unsafe to use. Job sheets and service sheets from Higher Elevation produced as evidence at the inquest portrayed the condition of the equipment as serviceable, of good working order and that many key parts had been replaced. The last call recorded by Higher Elevation on 09/04/21 recorded the equipment as “working”. 27. In a period of 16 months between 22/01/20 to the 09/04/21 there had been five callouts for repairs; three of these occurred in the months March to April 2021. The last independent inspection report from Bureau Veritas was on 30/06/21, reporting the equipment safe to operate. The evidence the local authority had did not show that any fault was evident or present during the last visits made by both the service provider and the independent inspector. The equipment was confirmed in the last two separate independent visits as working and safe. Under these circumstances, other than the recommendation to replace the unit, there was nothing from the engineer’s report that would have influenced the response from the inspector so as to change the outcome of his report. 28. AMT/ES team has met with the local authority’s current inspection provider, HSB Engineering Insurance Limited (HSB), to discuss the concerns raised by HM Coroner as to the sharing of background information/previous inspection reports. In response to the question about supplying them with service records and operational information, HSB has stated that the provision of additional information other than whether the asset was at the location or is in use would not be of particular relevance for their independent inspection. The reason for this being that these are statutory inspections which are governed by the provisions of the Lifting Operations and Lifting Equipment Regulations 1998 (LOLER), safe working practices laid out by industry standard and company method statements. The provision of any additional information would not have not influenced or altered the outcome given that the inspections had to be undertaken to specific requirements. 29. In addition, LBS has asked staff to ensure that they make it clear to third party contractors who supply and install equipment, that they should: a) Provide the user and any other member of the household or carer responsible for operating the equipment, a thorough demonstration of the day to day operating process; b) Ensure that this process shall include a demonstration by the user(s) to the installer, that they are competent in using the installation; c) Provide written confirmation to the Council that the demonstration has been carried out – the written confirmation is to be signed and dated by the user or others responsible for its operation. d) Collect evidence of resident satisfaction (including any comments) on completion of works and document it on Case Manager. 30. HAT will review all collected and uploaded documentation referred to at paragraph 29 above. Conclusion 31. The council recognises that steps must be put in place to ensure that in future, any such death can be prevented and that everything must be done to ensure the highest standard of safety and wellbeing of all residents. As set out above, there is no current self – hoister in the borough. The council has reviewed its practices/policies in light of the inquest and the Regulation 28 Report and it has taken, and is continuing to take, steps to ensure that the concerns raised by HM Coroner are addressed. Some of these steps include the following: i. A number of interdepartmental meetings has occurred with representation from all parties ii. A new policy, the “Self Hoisting Policy London Borough of Southwark”, has been developed iii. Adding the issue of self hoisters as a standing item to the OT/AMT Quarterly meetings iv. A monthly Fault Repair Report (in spreadsheet format) containing information on repairs is now made available for the inspection provider and AMT/HAT and OT to view, as required. v. The lift contract is in transition currently to a new contractor. Once in place the new mobility equipment provider will be requested to supply a regular updated risk register to highlight areas of concern. This will include those sites subject to multiple visits. vi. The AMT department has procured the services of “True compliance” to deliver an IT compliance solution. This will enable the council to store multiple data information sources against a property file and provide access to a range of users. The intention is that the service reports and inspection reports will be stored and that access can be provided to all stakeholders to include OT and the inspection provider. The system allows access to be via an app, which can be downloaded to handheld devices and used whilst on site. It is expected that it will take at least a year to put this in place. It should be noted that to prevent OT being provided with excessive information they will not access these reports regularly and will instead, be provided with information at the quarterly meetings. London Borough of Southwark Date: 31st January 2024
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