Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0542, written 18 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Dec 2023 |
|---|---|
| Reference | 2023-0542 |
| Deceased | Carl Owston |
| Coroner | Gareth Jones |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Rt Honourable Victoria Atkins Secretary of State for Health & Social Care 1 CORONER I am Gareth JONES, Assistant Coroner for the coroner area of West Sussex, Brighton and Hove 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 19 January 2023 I commenced an investigation into the death of Carl Anthony OWSTON aged 34. The investigation concluded at the end of the inquest on 18 December 2023. The conclusion of the inquest was that: Carl Owston died on the 10th of January 2023 at his home from sudden unexplained death in alcohol misuse with steatosis and steatohepatitis. 4 CIRCUMSTANCES OF THE DEATH Carl Owston died on the 10th of January 2023 at his home from sudden unexplained death in alcohol misuse with steatosis and steatohepatitis. 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) Mr. Owston had a Care Package commissioned for him by Brighton and Hove City Council. They were unable to find a Care provider willing to provide the service due to a shortage of care providers and carers nationwide. The lack of carers and care providers could well lead to people in future not receiving the care they need with fatal results. 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 You are under a duty to respond to this report within 56 days of the date of this report, namely by February 12, 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 – Arch Healthcare - Mother - Father - Sussex Partnership NHS Foundation Trust - St Mungo’s - Brighton & Hove City Council 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. 9 Dated: 18/12/2023 Gareth JONES Assistant Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Helen Whately MP 39 Victoria Street London SW1H 0EU 020 7210 4850 Gareth Jones of Assistant Coroner for the coroner area of West Sussex, Brighton and Hove 04/03/2024 Dear Gareth, Thank you for your letter of 18th December 2023 about the death of Carl Anthony Owston. I am replying as the Minister with responsibility for social care. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Owston’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for raising the matter of capacity in the care market and its impact on this case. Under the Care Act (2014), local authorities have the duty to promote the efficient and effective operation of their care market and deliver a range of care and support services to meet diverse local needs. They must have regard to current and future demand for care and support services and consider how providers will meet that demand, including through fostering a workforce with the appropriate skills. I understand that Brighton and Hove Council have plans to address the lack of care provision in their market, including the necessary accommodation, and accompanying care & support services for those with mental health needs. However, the government recognises that shaping a care market and ensuring local provision meets local needs is challenging, which is why we are supporting local authorities in a number of ways. Firstly, the government has made available up to £8.6 billion in additional funding over this financial year and next to support adult social care and discharge. This includes the Market Sustainability and Improvement Fund (MSIF) and the MSIF Workforce Fund, which are worth almost £2 billion over two years and are designed to support local authorities to increase adult social care capacity by targeting improvements in workforce recruitment and retention, reduce waiting times and increase fee rates paid to providers in their local areas. The MSIF Workforce Fund includes a particular focus on workforce pay. The government is also committed to supporting the construction of new specialist and supported housing. This includes through our Care and Support Specialised Housing Fund (CASSH), which provides capital subsidies to providers and, alongside this, the £11.5bn Affordable Homes programme (2021-26) (for England) which includes the delivery of new supported housing. Furthermore, to ensure local authorities are always aware of local demand for specialist and supported housing (and the accompanying care & support serices), the government has recently introduced a new duty on local authorities, through the Supported Housing Act 2023, to complete strategic plans for this part of the market. These plans will include forecasting the future supported housing need for all groups in the area, including for people with mental ill-health and those experiencing homelessness, and will set out a delivery plan on how they will meet this need. The government is consulting on this duty soon. We are also committed to supporting local authorities with shaping their care markets and commissioning for all diverse local needs,. While local authorities are best placed to understand and plan for the needs of their populations, there are elements of good market shaping practice that can be universally applied, such as using population and market data to inform commissioning decisions and working effectively with providers to plan for meeting future demand. That is why, in Next steps to put people at the heart of care (2023), we committed to setting national standards for commissioners: to set clear expectations of what good commissioning looks like and to drive greater consistency across the country. We are also investing in a pilot training programme for senior local authority commissioners to help local areas with developing their strategic planning skills and to ensure they have the data they need to shape their markets well. I hope this response is helpful and thank you again for raising these concerns. Yours sincerely, Helen Whately MP 2
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