Gerard Goodwin

Response to Report to Prevent Future Deaths 

I am writing in response to your Regulation 28 report following the investigation and inquest into the 
circumstances of the death of Gerald Goodwin on 11th November 2022. 

I hope to answer the concerns you have raised as follows: 

1.  The  Liaison  and  Diversion  team  of Lancashire  and South  Cumbria  NHS  Foundation  Trust  had 
contact  with  Mr.    Goodwin  in  September  and  October  2022.    Liaison  and  Diversion  Team 
members visited Mr.  Goodwin at home and concluded he was at risk of self-neglect.  They noted 
his appearance, his living conditions and the fact that he was not taking prescribed medication.  
On any view Mr.  Goodwin was vulnerable: he suffered from Alzheimer’s dementia and was 
thought  o  misuse  alcohol.    The  Liaison  and  Diversion  Team  considered  that  there  were 
safeguarding concerns in respect of Mr.  Goodwin and referred hm to the Adult Social Care Team 
of Cumbria Council.  I understand that the team in question now forms part of Westmorland 
and Furness Council.  Despite this  referral from practitioners who had personally visited Mr.  
Goodwin, it was rejected at triage on 5th October 2022.  I am concerned that this indicates that 
an  approach  to  triage  is  being  taken  which  pays  insufficient  regard  to  the  concerns  of 
practitioners who had personally witnessed apparent safeguarding concerns. 

The referral in question was received by Adult Social Care on 5th October 2022.  The referral identified 
potential  safeguarding  concerns  and  was  therefore  considered  initially  by  the  Safeguarding  Team 
which sits within Adult Social Care.  It was decided at that stage that the threshold for a statutory 
safeguarding enquiry was not met   and the provision of social work support was considered to be 
more  appropriate.      The  fact  that  the  initial  triage  concluded  that  the  threshold  for  a  statutory 
safeguarding  enquiry  was  not  met  does  not  mean  that  any  safeguarding  issues  would  not  be 
addressed.  The approach would generally be that the individual should be given the opportunity to 
engage with a Care Act assessment and potentially reablement but that any safeguarding issues would 
also be addressed if they emerged during the process. One of the options available to the social work 
team is to make a referral to the reablement service.  This service helps individuals to learn or re-learn 
skills to engage in activities or tasks that are important to them.   

Whilst  the  referral  relating  to  Mr.  Goodwin  was  never  rejected  by  Adult  Social  Care,  the  need  to 
improve the management of referrals from three key perspectives is accepted and the following areas 
of improvement have been identified: 

a.  Where self-neglect is a possible factor in the individuals’ circumstances. 
b.  The approach taken to triaging a referral. 
c.  The timescale between reablement intervention being requested and contact being made. 

These three issues have been addressed below. 

Where self-neglect is a possible factor in the individuals’ circumstances 

A Self-Neglect Strategy was put in place under the direction of the Westmorland and Furness Council  
Principal Social Worker and this was implemented on 1st July 2023.  This strategy aims to strengthen 
Adult Social Care’s practice and response to people who are or may be self-neglecting.   

 
 
 
 
 
 
 The strategy ensures that if a referral such as the one relating to Mr. Goodwin should come into Adult 
Social Care now, a face-to-face visit would take place which would take into account factors relating 
to capacity and risk. 

The key messages of the strategy are as follows: 

•  ALL circumstances where self-neglect is or may be a factor MUST have a face to face 
in-person visit from a practitioner to determine risk, need and appropriate support. 
•  Assessments  of  the  person’s  capacity  for  decision-making  must  be  completed 
regularly.  Practice  should  reflect  our  common  law  duty  of  care  and  professional 
accountability. The appearance of capacity and/or non-engagement do not equate to 
risk reduction. 

•  Risk  assessment  must  be  thorough,  dynamic  and 

involve  other  relevant 

parties/professionals as appropriate. 

•  Practitioners must employ concerned curiosity and respectful challenge. This means 
not taking information on face value, but being alert to differing perspectives, our own 
professional accountability and the issues around executive functioning. 

•  Managers and supervisors must provide support around the nature and timeframes 
for working with self-neglect, reflection in supervision and consider escalation either 
internally or externally if required. 

The approach taken to triaging a referral 

In  respect  of  making  improvements  to  the  triaging  process  new  guidance  on ‘Decision  Making  for 
Single Point of Access and Practitioner Teams’ has also been introduced under the direction of the 
Principal Social Worker. This guidance was introduced in September 2023. 

The guidance aims to strengthen practice in response to people referring themselves or being referred 
into Adult Social Care through our Single Point of Access (SPA).  

It reflects the learning from our SPA and Multi-Disciplinary Team (MDT) pilot in the summer of 2023. 
This pilot sought to ensure that decisions about individuals referred for our services are made in a 
timely way and supported by a thorough multi-disciplinary process so that the right professionals are 
involved  from  the  earliest  opportunity.    Through  actively  seeking  to  improve  the  timeliness  and 
streamlining of decision making, and reducing the number of professional ‘hand-offs’, the learning 
and recommendations from that pilot seek to strengthen and embed the following principles: 

•  Decision-making to be collaborative, respectful and supportive. 
•  Decisions to be made on the basis of the best outcome for the person. 
•  All decisions to be made by the end of each working day. 
•  Decisions made will result in a referral’s one way journey from SPA to the agreed team  or 
practitioner. Any further change in allocation of the work will be the responsibility of the team 
manager. 

•  All duty officers for the day must prioritise participation in the twice daily SPA Multidisciplinary 

calls unless they are out on a duty visit. 

•  The  practice  guidance  should  be  followed  but  does  not  replace  professional  judgement  in 

circumstances of significant concern, need or risk.  

 
 
 
 I am confident that following the implementation of the guidance summarised above, should a similar 
referral to that of Mr.  Goodwin’s be received in the future, a more robust triage discussion would be 
in place and that would include consideration of mental capacity. 

The timescale between reablement intervention being requested and contact being made 

Adult Social Care and Cumbria Care Services (who operate the reablement service) have set up a task 
and finish group to undertake a quality assurance review and to identify required process changes.   

The  remit  of  the  task  and finish  group  is  to  bring together  the  relevant  individuals  to  undertake  a 
process mapping review to determine which parts of the current process work well, and which parts 
require improvement or change.  One of the lessons learned from this investigation is the need to 
review  how  cases  are  triaged  in  the  first  instance  to  determine  priority  and  to  avoid  unnecessary 
delays for those most in need.   

The triage guidance referred to above and the self-neglect policy, also now ensures where there are 
concerns of self-neglect, we would carry out a visit by a social worker which includes a robust risk 
assessment, prior to making any onward referrals for reablement.    

2.  The witness statement on behalf of the Adult Social Care Team explains that after the refusal to 
conduct a safeguarding enquiry, Mr.  Goodwin was nevertheless referred for the Social Work 
Team to ‘engage’ with him.  A Social Worker took steps to engage with Mr.  Goodwin and his 
family and concluded that a care assessment was appropriate.  Despite this the ‘Reablement 
Team’ referred the case for closure indicating that they did not consider that such an assessment 
was not required.  I am concerned that this indicates further circumstances in which the needs 
of  a  vulnerable  person  might  be  overlooked.    After  a  Social  Worker  considered  that  a  care 
assessment was needed the Reablement team appear to be able to come to an alternative view 
and close the case without further discussion or rationale.  In another case this might lead to a 
vulnerable person being disregarded. 

In some situations the threshold for a statutory safeguarding enquiry is not met and this can also apply 
in circumstances where self-neglect is a factor.  In this case the practitioner recognised that although 
a formal safeguarding enquiry was not necessary, there needed to be further involvement via Adult 
Social Care in order to engage with Mr. Goodwin regarding the concerns that had been raised.    As 
stated earlier reablement was identified as appropriate but it was an error not to refer the case back 
to  the  social  work  team  when  Mr  Goodwin  declined  reablement  input.    It  is  recognised  that  the 
reablement team and the social work team should have worked together more closely in relation to 
Mr.  Goodwin in order to promote engagement. We now have weekly meetings between reablement 
and adult social care which provides an opportunity for similar situations to be discussed. In addition 
to this  risk  assessments  are  carried  out  by  social  workers  for  those  customers  who  are  awaiting  a 
reablement service.  

Both the Self-Neglect Strategy and the guidance on Decision Making for Single Point of Access and 
Practitioner Teams referred to in section 1  address some of the issues that have been raised in respect 
of the above.  Examples of how this is achieved include office-based duty workers who have face to 
face timely discussions regarding the appropriate action in respect of inkling referrals.  It also includes 
twice daily multi-disciplinary meetings (including safeguarding staff where appropriate) to resolve any 
concerns relating to incoming referrals and weekly meetings between Social Work and reablement 

 
 
 
 
 
 
 teams  so  that  any  concerns  regarding  particular  individuals  can  be  highlighted  and  actions  agreed 
quickly. 

3.  Fortunately, the Closure Team noticed that the Reablement Team were seeking to close a case 
in which another social worker had recommended a Care Assessment.  They sent the case to the 
‘Short Term Allocation Tray’.  This should have resulted in a referral but that did not happen.  I 
am  concerned  that  in  a  future  case  a  referral  might  not  be  generated  and  a  person’s  needs 
overlooked.  The witness statement prepared by the Service Manager indicated ‘we are looking 
at a way of ensuring that notifications requiring an action are only acknowledged once the task 
is complete’.  This indicates that such work has not yet borne fruit and the risk still exists. 

Following completion of the witness statement a process was put in place in place and a directive was 
shared with Adult Social Care staff on 10th October 2023.  This instructs staff that when they receive a 
case note asking for an action to be completed, the case note is only acknowledged once the task has 
been carried out.  This will ensure that when there are competing demands for practitioners the case 
note notification will serve as a prompt and a task is not overlooked.   

4.  Thereafter  Mr.  Goodwin’s  case was  allocated  and  de-allocated  to  a  social worker within the 
space of one day, without anything being done.  It is said that there is no note or explanation 
for this.  I am concerned that, once again, the ability of a case to be allocated and deallocated 
within a short period and without anything having been done may enable a case to ‘fall through 
the cracks’.  Indeed, the referral for the care assessment was not ultimately actioned until 25th 
November 2022, 2 weeks after Mr.  Goodwin died. 

Following completion of the witness statement a process was put in place in place and a directive was 
shared with Adult Social Care staff on 10th October 2023.  This instructs staff that if a case is picked up 
to be allocated and is subsequently de-allocated this must be recorded as a case note on the electronic 
case recording system with a clear explanation of why the case is being closed, thus ensuring a clear 
audit trail is in place. We have also implemented a system where there is management oversight of 
all case closures to provide increased governance in this area.  

Regular  case  file  audits  are  already  in  place  which  do  look  at  the  case  chronology  to  ensure  that 
appropriate actions have been taken. 

5.  More  generally,  it  is  striking  how  many  different  teams  and  systems  appear  to  co-exist  and 
require mutual communication and cross referencing.  I am concerned that the above narrative 
demonstrates that those systems do not function effectively.  I am concerned that this exposes 
other vulnerable adults to risk. 

This has been recognised and new guidance on decision making for Single Point of Access (based on 
the  pilot  work  undertaken  to  improve  the  Multi-Disciplinary  Discussions  relating  to  new  referrals) 
together with the new strategy relating to Self-Neglect have been introduced under the direction of 
the Principal Social Worker.  As stated previously, this guidance introduces a structured approach to 
improve communication both between professionals and between different teams.  Examples of how 
this is achieved include office-based duty workers, twice daily multi-disciplinary meetings to resolve 
any concerns relating to incoming referrals and weekly meetings between social work and reablement 
teams  so  that  any  concerns  regarding  particular  individuals  can  be  highlighted  and  actions  agreed 
quickly. 

 
 
 
 
 
 
 
 I hope this helps to answer the points that you have raised.  However, if we can assist with anything 
further, please let me know.