Thomas Godderidge

Cumbria House 
117 Botchergate 
Carlisle 
CA1 1RD 

22 March 2024  

HM Assistant Coroner for Cumbria 
Fairfield  
Station Road 
Cockermouth 
Cumbria 
CA13 9PT 

Dear Mr Cohen 

RE: Regulation 28 report to prevent future deaths (

) 

Further to your Regulation 28 Report of 8th February 2024, I am writing to you to confirm the 
actions either taken or planned by Cumberland Council, Adult Social Care.   
There  were  two  interrelated  actions  concerning mental  capacity,  one  focusing  on  how  Adult 
Social  Care  responds to  escalations  from  care  providers, and  the second  focusing on Adult 
Social  Cares  response  where  an  adult  with  care  and  support  needs  might  be  experience 
fluctuating capacity.  
I have set out the two matters of concern below and have followed this with the actions Adult 
Social Care are taking, or will take, to address these concerns: 

1.   During the inquest I heard from the carers who worked with Mr Godderidge. They 
reported  to  me  that  when  concerns  are  raised  about  a  service  users’  capacity 
there is not reliable and routine liaison between Adult Social Care and the care 
providers.  I  am  concerned  that  this  gives  rise  to  a  risk  of  future  deaths.  Care 
workers are very likely to see a service user more often than others. They have 
a particularly valuable perspective as to a person's capacity. If their observations 
are not being considered, then opportunities to provide care to vulnerable people 
may well be missed. 

2.  Mr Godderidge's carers also reported to me that in their experience consideration 
of  capacity  by  Adult  Social  Care  does  not  always  reflect  the  possibility  that  a 
person's capacity may be variable and fluctuating. I am concerned that this gives 
rise to a risk of future deaths if a person is considered on a 'good day' without 
understanding that their presentation fluctuates substantially over time. 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 The Council has reflected on the Coroner’s concerns and has considered how we can improve 
practice  in  the  context  of  direct  responses  to  an  adult  who  may  be  experiencing  fluctuating 
capacity, as well as ensuring all information sources shared with Adult Social Care are given 
due regard in order to respond appropriately, and reduce risk in regards their care and support 
needs. 

Actions taken or planned by Adult Social Care:  

1.  A  guidance  and  briefing note  is  being  developed  for  care providers  on  how to 
raise concerns around potential changes in a person’s mental capacity, or any 
other  issues  where  Adult  Social  Care  are  the  responding agency. This  will  be 
shared with all providers via the councils Adult Social Care Commissioning team. 
The note will also be circulated across all Adult Social Care teams for practitioner 
and manager awareness. The target date for completion and circulation is 29th 
March 2024. 

2.  The council have a Mental Capacity Act forum in place which is open to social 
care and health practitioners across Adults and Childrens services. The last two 
forums  have  explored  the  topic  of  fluctuating  capacity.  On  the  13th  December 
2023 the forum focused on Executive Dysfunction and was delivered by Dr Paul 
Russell (Consultant Clinical Psychologist), who spoke on practice experience of 
working with fluctuating capacity. A further forum took place on the 25th January 
2024  and  was  a  Community  of  Practice  reflective  practitioner  session,  with  a 
focus  on  fluctuating  capacity.  The  forum  is  a  recurring  event,  providing  a 
reflective  workspace  where  key  learning  is  shared,  and  practice  is  continually 
developed  and  improved.  The  sessions  to  date  have  focused  on  the  area  of 
fluctuating capacity specifically to raise and maintain awareness, and to reduce 
the risk to our customers where this is a factor in regards their care and support 
needs. 

3.  The Adult Social Care Advanced Practice Lead team are producing a 7-minute 
briefing  on  fluctuating  capacity  for  managers  to  deliver  in  team  meetings  and 
for  continuous 
individual  staff  supervisions.  This  will  remain  available 
professional  development  for  existing  and  any  newly  appointed  staff  in  Adult 
Social Care. The target date for completion and circulation is 29th March 2024. 
The aim of this briefing is to raise and maintain awareness across all Adult Social 
Care  teams,  to  improve  practice  and  reduce  the  risk  to  our  customer’s  where 
fluctuating capacity is a factor in regards their care and support needs. 

4.  A rolling programme of mandatory training regards the Mental Capacity Act is on 
the Training Plan and marked as ‘High Priority’. This will incorporate a specific 
focus  around  carers  noting  changes  in  presentation  and  how  these  are  to  be 
responded to. The program will also cover the main nuances such as executive 
capacity,  fluctuating  capacity  and  interpersonal  influence  on  capacity.  The 
Advanced Practice Lead team will utilise this training as the grounding from which 
Mental Capacity Act forums, Community of Practice forums, practice workshops 

 
 
 
 
 
 
 
 and briefings will build upon. Having the Mental Capacity Act on a rolling training 
program ensures the matter of mental capacity is maintained at the forefront of 
practice  and  all  staff  –  new  and  experienced  –  are  continuously  developing 
through a refresher and reflective approach.  

5. Adult  Social  Care  have  planned  legal  briefings  every  6  weeks,  with  the  last 

briefing on the 20th March covering the matter of fluctuating capacity. 

I trust the information provided and actions the Council has taken, or will be taking, give you 
assurance that suitable action has taken place to address your concerns and that any risk of a 
future death occurring is minimised. 

Yours sincerely 

  Assistant Director – Adult Social Care Operations