Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0429, written 6 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Nov 2023 |
|---|---|
| Reference | 2023-0429 |
| Deceased | Kevin Gale |
| Coroner | Kirsty Gomersal |
| Coroner area | Cumbria |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
KALLY CHEEMA SENIOR CORONER County of Cumbria Fairfield Station Rd Cockermouth, CA13 9PT REGULATION 28 REPORT TO PREVENT FUTURE DEATHS KEVIN CONRAD GALE THIS REPORT IS BEING SENT TO: DEPARTMENT FOR WORK AND PENSIONS (for the attention of the Rt Hon Mel Stride MP, Secretary of State for Work and Pensions) 1 CORONER I am Miss Kirsty Gomersal Area Coroner for County of Cumbria 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: https://www.legislation.gov.uk/ukpga/2009/25/contents http://www.legislation.gov.uk/uksi/2013/1629/contents 3 INVESTIGATION and INQUEST Mr Kevin Conrad GALE died on 4 March 2022 at his home address. An inquest into Mr Gale’s death was opened on 22 March 2022 and his inquest was heard before me on 2 November 2023. The medical cause of Mr Gale’s death was: 1a Hanging The determination was: Mr Kevin Conrad Gale died on 4 March 2022 at his home address, 8 Langton Court, Penrith as the result of deliberate self-suspension . Mr Gale had a long history of low mood and anxiety. He was engaging with mental health services and had been diagnosed with severe depression and anxiety. Mr Gale was taking his medication but was still struggling to manage anxiety. Although Mr Gale denied suicidal intent, on the evidence and on the balance of probabilities, Mr Gale intended to take his life. The conclusion of the inquest was: Suicide 4 CIRCUMSTANCES OF THE DEATH Mr Gale was detained under Section 2 Mental Health Act in November 2021 and was discharged from that section on 4 January 2022. Mr Gale was diagnosed with severe depression and anxiety. Mr Gale was seen regularly by mental health professionals and was in frequent contact with mental health services. Those services were provided by Cumbria, Northumberland Tyne & Wear NHS Foundation Trust (“the Trust”). Mr Gale was compliant with his medication and engaged with services. He was well supported by his family and friends. Mr Gale’s anxiety continued during his engagement with mental health services. Evidence was heard about what caused Mr Gale’s anxiety. One ongoing feature was his application for Universal Credit. On 2 March 2023, 2 days before his death, Mr Gale was seen by an Associate Specialist Psychiatrist, who gave evidence at the inquest. The Psychiatrist considered Mr Gale’s anxiety was exacerbated by his application for Universal Credit. During Mr Gale’s appointment, the Psychiatrist called the benefits office for help but the call was not answered before the end of the consultation. Mr Gale was expecting a call from a DWP representative the next day (3 March). On 3 March 2022 at approximately 11:00 am, Mr Gale spoke to the duty Registered Mental Health Nurse. He remained very anxious and his main concern was the application for Universal Credit. During their evidence, the Associate Specialist Psychiatrist expressed concerns about the experience of mental health service users with DWP. These concerns were not just specific to Mr Gale. Evidence was also given by the Trust’s Group Nurse Director (a Registered Mental Health Nurse) who considered that the issues identified by the Psychiatrist were national. The Director considered it important to address these issues as they were debilitating for service users. The Director advised that the Trust’s Crisis Team had started a food bank 3 years ago to support service users. The Director was also aware that the DWP had been invited to the Cumbria Suicide Prevention Group. I stress that I did not make a causal link between Mr Gale’s death and his anxiety about his Universal Credit application. DWP was not an Interested Person in Mr Gale’s inquest and did not give evidence as the concerns raised did not come to light until the hearing. 5 CORONER’S CONCERNS 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: Current DWP procedures may not be practical for those with mental health illness and can exacerbate symptoms. I heard evidence that: 1. The number of and length of DWP forms required to be completed can be overwhelming for someone with a mental health illness. This is perpetuated if the applicant cannot get help to complete the paperwork. 2. There are long telephone queues to speak to a DWP advisor. 3. Having to travel long distances for appointments can be detrimental for those with a mental health illness. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe the DEPARTMENT FOR WORK AND PENSIONS For the attention of the Rt Hon Mel Stride MP Secretary of State for Work and Pensions Caxton House Tothill Street London SW1H 9NA 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 2 January 2024. 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: Mr Gale’s family. Cumbria, Northumberland Tyne & Wear NHS Foundation Trust I have also sent copies to: Lakes Medical Group (Mr Gale’s GP surgery) 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 Dated this 6 day of November 2023 Miss Kirsty J Gomersal HM Area Coroner County of Cumbria
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.
Miss Kirsty Gomersal Area Coroner for County of Cumbria Fairfield Station Rd Cockermouth CA13 9PT Dear Miss Gomersal, Caxton House Tothill Street London SW1H 9NA 09 January 2024 RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS I write on behalf of the Department for Work and Pensions (“DWP”) in response to your Prevention of Future Deaths Report made under Regulation 28 of The Coroners (Investigations) Regulations 2013 following the inquest into the death of Mr Kevin Conrad Gale. On behalf of DWP, I would like to express my deepest condolences to Mr Gale’s family. He was a well-known figure in the area local to Penrith Jobcentre Plus, where my colleagues were saddened to learn of his death. You raised the following concerns in your report: “Current DWP procedures may not be practical for those with mental health illness and can exacerbate symptoms. I heard evidence that: 1. The number of and length of DWP forms required to be completed can be overwhelming for someone with a mental health illness. This is perpetuated if the applicant cannot get help to complete the paperwork. 2. There are long telephone queues to speak to a DWP advisor. 3. Having to travel long distances for appointments can be detrimental for those with a mental health illness.” As you note in your report, DWP was not an Interested Person to these proceedings. For the avoidance of doubt, I confirm that DWP was not aware that an inquest was taking place in relation to Mr Gale’s death and was not asked to provide evidence to assist within the substantive proceedings or on matters relating to the prevention of future deaths. I note that you “did not make a causal link between Mr Gale’s death and his anxiety about his Universal credit application” within your conclusions. However, I know that a coroner is not limited to such matters when exercising their duty to issue a Prevention of Future Deaths report and I understand that in this case your concerns were raised through witness evidence during the inquest hearing. I further understand that the concerns (in box 5 of the Report) do not necessarily relate specifically to Mr Gale’s individual benefit claim. 1. “The number of and length of DWP forms required to be completed can be overwhelming for someone with a mental health illness. This is perpetuated if the applicant cannot get help to complete the paperwork.” Collecting personal data from claimants is an essential part of any benefit claim, but DWP strives to make the process as straightforward as possible for its customers. Mr Gale claimed Universal Credit (“UC”), a benefit that DWP has developed primarily as an online service. When someone applies for UC online, the IT system will guide them through the questions required to complete their claim and prompt them only to provide necessary information. This enables a far more streamlined data collection process compared with traditional paper-based forms. If a claimant needs support to apply for UC, because of a mental health illness or any other reason, help is available by the following means: • • • • telephone or online video call with a qualified DWP advisor face-to-face support from a partner organisation in the Jobcentre, or through a home visit, where needed, using DWP’s Visiting Service which comprises around 450 Visiting Officers across Great Britain. Where a claimant is unable to claim online, they can claim by phone through the UC helpline. GOV.UK provides details on how to claim, including information about claiming by phone and signposting to additional support available from the Help to Claim Service, about which I provide more detail below. Mr Gale told us that he was unable to use the internet and so was unable to apply for UC online. Instead, he claimed over the phone. The UC telephone claim script for gathering information is designed so claimants are asked only questions relevant to their circumstances, much like the online system. This aims to minimise the length and complexity of the information-gathering process. In Mr Gale’s case, this script would have involved questions about his self-employed work, which would have made it more complicated than for someone with no work at all. The variable level of earnings inherent in self-employment can affect the amount someone is entitled to receive from one month to the next. Because of this DWP asks self-employed claimants to report their earnings monthly. Most claimants can do this quickly and easily online. We ask telephone claimants like Mr Gale to report earnings over the phone, and I note that he did this. DWP recognises the additional complexity of self-employed claims, therefore, every jobcentre has at least one Work Coach with specialist knowledge of how such claims are calculated. Mr Gale expressed confusion over how his payment amounts had been calculated on several occasions. On each occasion either his Work Coach, Case Manager or a UC Telephony Agent were supportive in explaining how his benefit had been calculated. Other help is available for all UC claimants to assist them with their claim. Mr Gale would have been made aware of the wider support available which includes: Help to Claim Since 2019 the government has provided funding for Citizens Advice (“CA”), in partnership with Citizens Advice Scotland (“CAS”), to deliver Help to Claim support for people who need extra help to apply for UC. CA and CAS provide the support through telephony and digital channels. Help to Claim can be accessed until a claimant receives their first full payment of UC. Since 2019, CA and CAS have helped more than 850,000 people with their claim through the Help to Claim service. Citizens Advice will signpost people who are unable to access support through telephony and digital channels to their local Jobcentre Plus for face-to-face help in making or managing their UC claim. Work Coaches already support individuals who approach the jobcentre directly rather than choosing to access independent support such as that provided by CA. UC Work Coaches undergo a comprehensive training programme, including training for working with different vulnerable groups and those with complex needs, to ensure they can support individuals accessing the benefits they are entitled to. Other help Work Coaches can provide to new UC claimants includes: • Setting up an email address. • Working through claimant “to-do’s”. • Accessing the UC Claim by Phone service. • Accessing DWP home visiting support. • Helping to verify identity. • Helping with providing additional evidence. • Helping to access adaptations such as direct payments to landlords and conditionality easements. • Applying for advances and helping to access other financial support. • Helping to prepare for the first monthly payment. • Providing long-term support and signposting out to other organisations via the District Provision Tool, a directory of the support delivered by Jobcentre Plus, local authorities and independent, volunteer and charity organisations. Additional support for customers with complex needs To assist customers who may have a more acute need for support, every Jobcentre is equipped with a “complex needs toolkit” containing links to local organisations who can help and provide appropriate support as required. In Mr Gale’s case, his local Jobcentre (Penrith)’s complex needs toolkit includes links to such support organisations (amongst others) as: • Lancashire County Council Adult Safeguarding Team • NHS Lancashire and South Cumbria wellbeing and mental health teams • Cumbria Law Centre (a community organisation offering free legal advice and representation) • Debt Advice Foundation • Warm Spaces • Eden Housing Association Additionally, DWP has in place a wide range of reasonable adjustments for customers, including: • The production of communications in a range of different (or alternative) formats such as braille, large print and audio. • Email as a reasonable adjustment (for example, to replace any hard copy notifications that would normally be sent to the customer). • A visiting service for vulnerable customers who are unable to use our other contact routes. • Support for our staff including instructions, guides and awareness raising on reasonable adjustments. • Face-to-face British Sign Language (“BSL”) interpretation or Video Relay Service which enables customers to communicate in real time via a BSL interpreter using a video connection. There is no need to be in the same location or for the customer to make an appointment. • A flexible approach to mandatory face-to-face interviews within a jobcentre (and I cover travelling to appointments in more detail below). Improving form design Most types of benefits rely on customers providing information via paper forms at various points during their claim. It may assist you to know how DWP makes this process as accessible as possible for customers, and what support is available if needed. DWP maintains a central team to drive improvements in its printed customer communications, which can include application forms, letters and leaflets – including some forms being available in an “Easy Read” format for people with learning disabilities – and SMS text messages. The team has an on-going programme of work to identify ways in which we can better provide information to customers. DWP continually seeks to improve the content of these communications so that information is clear and accessible for everyone. This includes work to develop products using a quality assurance and sign-off process involving senior communications professionals. The team also tests content with customers and external stakeholders to ensure it is fit for purpose whilst ensuring DWP collects all the information it needs to efficiently process claims. 2. “There are long telephone queues to speak to a DWP advisor.” Times taken to answer calls across benefit lines can vary and are influenced by a number of factors. DWP aims to forecast demand on its inbound enquiry lines and balance resources so that more people are available to answer calls at times of peak demand than during quieter periods. Such forecasting cannot be an exact science, however, and unplanned events such as technical issues or labour market instabilities can increase demand with a knock-on effect on wait times. Despite this, UC enquiry lines have rarely had any problems with high call waiting times. While I accept that waiting times can vary from day to day and even within a single day, most calls to UC enquiry lines are answered within minutes. For example, between January and March 2022 calls were answered on average after 1 minute and 29 seconds. And in the week commencing 28 February 2022 – a week during which Mr Gale called UC with his support worker – the average time taken to answer a call was 2 minutes and 26 seconds. 3. “Having to travel long distances for appointments can be detrimental for those with a mental health illness.” DWP is changing the way that UC claimants are asked to communicate with us such as the introduction of online journal messaging. Most claimants communicate with Work Coaches via an online “journal”, in which they can record work search activity and other related information, and therefore only need visit their Jobcentre for a limited range of reasons such as identity verification interviews. If a claimant is unable to access their claim online, they have the option to complete tasks such as reporting their self-employed earnings by phone. Mr Gale informed the department that he suffered with mental health problems, however, he did not declare any health condition that affected his ability to work and declared that he was self-employed. As a result, he was not asked to attend a Work Capability Assessment, either at an assessment centre or by any other method. Mr Gale attended his local Jobcentre only once, as part of his UC claim identity verification process, which, according to department records, was a journey of less than 200 metres each way. Conclusion DWP is committed to ensuring that it gives claimants the right support at the right time and are constantly reviewing the services we provide in an effort to improve for all our customers, especially the many vulnerable people who rely upon us. Comprehensive guidance is available for colleagues on how to support customers who discuss or imply that they intend to harm themselves. When a threat of self- harm is identified, staff follow a six-point plan that helps them take the appropriate action; this could include alerting the emergency services where appropriate. DWP has a detailed mental health training package which includes modules on appropriate actions to take to support customers with vulnerabilities including mental health issues. This training is delivered to all customer facing staff, to provide colleagues with learning that they can then apply in the different scenarios with which they may be faced. The package is constantly evolving, and work is ongoing to strengthen guidance and training as part of continuous improvement activities, ensuring colleagues have the necessary tools and confidence to respond to these challenging declarations. Upon reviewing the full circumstances of this case, we are satisfied that appropriate support is already available to allow claimants with complex needs to access benefits. I trust that my response helps assure you of the measures DWP has in place, and on which it is committed to building, to meet your concerns. Yours sincerely, Customer Experience Directorate
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