Nazerine Anderson

Miss Fiona Butler 
Assistant Coroner for Rutland and North Leicestershire 
H.M. Coroner’s Office, 
Town Hall, 
Town Hall Square, 
Leicester, 
LE1 9BG. 

Caxton House  
Tothill Street  
London   
SW1H 9NA 

05 April 2024  

Dear Miss Butler,  

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS  

We 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.  

We would like to take this opportunity to express our condolences, both personally and on 
behalf of DWP, to Ms Anderson’s family. 

You raised the following concerns in your report: 

1)  Despite the DWP case workers and call handlers having the availability of an 

additional support tab on a profile of a customer on the DWP computer system; 
there were 6 missed opportunities to use this facility to record vital information 
about Naz’s vulnerability; despite Naz being tearful and distressed on the 
telephone on more than one occasion and advising the DWP of information 
surrounding her mental health and her inability to cope. This meant there was no 
alert to DWP staff of Naz’s vulnerability and consequently no adjustment to how 
communication was made with Naz. The trigger for mental health decline and 
Adjustment Disorder continued. 

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 2)  The failure to act upon a simple request for the DWP to direct communication 
through Naz’s daughter. This was a simple request and had been renewed by 
Naz during telephone calls and journal entries to the DWP. The request which 
had been made in writing by Naz’s daughter sat in another DWP computer 
system for a period of 4 months but even when uploaded to the main DWP 
computer system was not acted upon. In addition to the active requests of Naz 
and her daughter being overlooked, DWP staff did not proactively consider the 
need for communication to be directed to someone else to safeguard Naz, given 
her obvious vulnerability. 

3)  I heard evidence from the DWP of plans to introduce a number of changes. What 
I did not hear was evidence about how DWP operatives were going to be trained, 
upskilled and refreshed in their knowledge (given the toolkit already available to 
them) to ensure the issues identified at 1 and 2 above aren’t repeated with other 
vulnerable individuals.  

Our response to your concerns is as follows: 

The Additional Support tab 

Universal Credit (“UC”) is an online service, meaning a certain amount of written record 
keeping is automatically built in. Customers are encouraged to use an online ‘journal’ to share 
information with their work coach or case manager via online messages, which are free text in 
format. Similarly, case managers and work coaches communicate with customers in the same 
way. Journal messages remain on a customer’s UC record for future reference for the 
duration of the claim, forming a permanent written record of conversations. 

There is a risk that key information could be lost within the detail of what can be lengthy 
conversations with a customer. To guard against this, the UC system enables case managers 
and work coaches to ‘pin’ information shared either via the journal or as the result of a 
conversation with a customer (face-to-face or by telephone) that they deem critical. Pinning a 
note to the claim means it will be flagged to anyone viewing a customer record as soon as 
they open it. DWP guidance states any complex need or vulnerability that is considered an 
urgent risk must be pinned to the customer’s profile. A maximum of three notes can be pinned 
at any one time. 

Colleagues working on UC claims are trained on the effective use of journal messages and 
pinned notes, and also on the standard of messaging and notetaking required. 

Another area where effective notetaking is vital is on the ‘additional support’ tab, a function 
introduced to allow a customer’s complex needs to be recorded. Once the tab is populated an 
alert will display prominently on the customer’s UC account to ensure that colleagues are 
aware of those additional support needs. By making this information easily identifiable, 
colleagues can tailor the support they offer accordingly to address those complex needs 
during interactions with the customer. 

Unlike a pinned note, which flags an urgent issue, the additional support tab is used to record 
long term or temporary complex needs, and how these affect the customer's ability to use the 
Service.  

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 The department acknowledges that there were missed opportunities to record additional 
support information in Ms Anderson’s case, despite the existing guidance on how the tab 
should be utilised. An internal review identified learning for the individuals involved. 

To investigate how to increase UC colleagues’ use of the additional support function, DWP 
conducted user research between July and September 2023. Insight sessions were held with 
UC colleagues to explore what they understood about the concept of additional support and 
how it relates to a customer’s additional support needs. Following these insight sessions, 
workshops were conducted between December 2023 and January 2024 with stakeholders 
from different business areas within DWP (for example colleagues from telephony, Customer 
Experience, Quality Assurance and product managers) to develop an improved and more 
comprehensive approach regarding the purpose of the additional support tab.  

As a result of the insight sessions and the workshops, the UC design team developed a 
prototype of what the improved additional support tab would look like. Plans to finalise and 
launch this improved additional support tab are a priority for the UC design team. User 
research is now being undertaken with UC customers to gather feedback to shape future 
amendments to the additional support tab.  

A campaign to promote awareness and understanding of the additional support tab amongst 
UC colleagues is planned for the second half of 2024. This campaign will include upskilling on 
refreshed guidance and training sessions for colleagues on the additional support tab. It is 
intended that this will translate to an increase in the use of the additional support function. As 
with all colleague training, the package will be followed by an assessment to ensure that the 
training has been effective in improving colleague understanding of the additional support 
function, and when it should be used. Colleagues who worked on Ms Anderson’s case will 
take part in the additional support tab awareness campaign. 

As a learning organisation, the department takes its responsibility to training and upskilling 
seriously and has made improvements in the way it trains colleagues to deal with vulnerable 
customers. One such training package is the detailed mental health training which all 
customer facing colleagues undertake. This provides colleagues with learning that they can 
then apply to the different scenarios with which they may be faced. The training includes 
modules on appropriate actions to take to support customers with vulnerabilities including 
mental health issues. 

DWP has also launched Complex Needs training events which encourage participants to 
reflect on tailored customer service. It consists of two versions: one for customer-facing 
colleagues and another for leaders driving a customer focused experience. These events are 
different to others as delegates are encouraged to view the customer journey through the lens 
of the customer, highlighting the potential consequences of getting this wrong, as well as the 
positive impact of getting it right. 

To date, around 40% of leaders nationwide (2,391) and an initial 2,232 UC colleagues have 
attended. The department plans to deliver the event to the entire service delivery team by the 
end of 2024. 

DWP’s training package is constantly evolving, and work is ongoing to further strengthen 
guidance and training as part of continuous improvement activities. These activities often take 
some time to plan and deliver allowing the department to ensure the learning is accurate and 
effective. The aim of this considered approach is to benefit all our customers, especially the 
many vulnerable people who rely upon us. However, as a direct result of Ms Anderson’s case, 

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 improvements have already been made to UC guidance covering pensions and their impacts 
on a UC claim. 

Quality Assurance 

Aside from large scale upskilling campaigns, the department has robust quality assurance 
processes to ensure colleagues are adhering to DWP’s Quality Framework. The newly 
developed Customer Support Standards were designed specifically to improve the experience 
of customers with complex needs and significantly reduce instances of serious cases by 
providing the right support at the right time. The four Customer Support Standards are; 

•  Advance Customer Support 

•  Accessibility Requirements 

•  Appointees 

•  Six Point Plan (DWP’s response to declarations of suicide or self-harm) 

The standards were trialled and implemented across DWP service lines in the second half of 
2023. 

The Customer Support Standards are incorporated in both tiers of the department’s quality 
assurance process and focuses on customer experience. The first tier sees line managers 
checking their team’s work. This identifies individual errors or non-compliance with guidance 
and allows for immediate feedback and coaching. The second tier sees a dedicated quality 
team checking a sample of customer cases to assure compliance against the Customer 
Support Standards. Where an error is identified at Tier 2, a check is put in place to consider 
how any correction activity might affect a customer’s vulnerability. This is fed back directly to 
the service line to make colleagues aware of the risk to be managed when rectifying the error. 

The improvements to the department’s Quality Assurance processes are intended to reinforce 
training and upskilling campaigns. They enable DWP to identify where additional support 
could have been provided to customers with varying needs or vulnerabilities, reducing the risk 
of a negative customer experience and potential development into serious cases. 

Appointeeships and Explicit Consent on Universal Credit 

In cases where a customer cannot manage their own affairs because they are mentally 
incapable or severely disabled, an appointee may be required to manage the customer’s 
benefit claim. An appointee can be an individual or an organisation who will act on behalf of, 
or make enquiries for, a customer. This can be at any stage of a customer’s UC claim. 

Customers who require an appointee are naturally considered to be vulnerable, and whilst 
DWP has taken significant steps since 2018 to improve colleagues’ ability to understand the 
wide range of mental health issues that benefit customers may face, there is more work being 
undertaken.  

In response to learning from serious cases DWP has acknowledged that the appointee 
process requires strengthening and, as a result, an end-to-end review of the appointee 
process is currently in progress. This is a significant piece of work undertaken by a multi-
disciplinary team and impacts customers across every benefit line. This work involves 
exploring development of digital solutions, a number of legislative changes as well as 
improved guidance and supporting products to build colleague capability. The work will also 
consider the appointee review process, including the timescales for reviewing the 
appropriateness of appointees once in place. 

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 Separate to appointeeships is explicit consent. This is used in cases where a customer is 
unable to find information held on their account or understand more complex issues. With 
explicit consent they may ask a representative (which can be an individual or an organisation) 
to contact DWP on their behalf to obtain the information. Under DWP policies, this information 
can usually be provided if the customer gives explicit consent. Explicit consent can be 
provided by the customer as long as they state (no particular form of words is required):  

• 

that they give consent for their personal information to be disclosed  

•  what information they want to be disclosed  

•  why the information is needed  

• 

• 

the relationship between the representative and the customer  

the name of the representative  

In December 2023, the UC computer system was updated to include a banner which displays 
on a customer’s account when explicit consent is recorded. This immediately identifies that 
there is explicit consent given by a customer and allows colleagues to see what consent has 
been given and whether it is current. To support this, an explicit consent information 
campaign was launched on DWP’s intranet and broadcast to all colleagues working in UC. 
The campaign clearly explained what explicit consent is and how to record this consent on the 
UC system and was accompanied by training videos. Training events have been delivered to 
UC colleagues detailing how to record explicit consent actions to alert other colleagues 
dealing with the claim. As with all training, this has involved an assessment component to 
ensure that the training has been effective. 

UC received extremely positive feedback from colleagues for this campaign and so are 
currently planning to run similar campaigns for other areas of the Complex Needs 
programme. 

The consent and disclosure guidance was most recently updated in January 2024 to allow UC 
colleagues to extend the review period on explicit consent up to six months where appropriate 
(for example, where someone is supporting a customer with an appeal which is expected to 
take longer than one month). Guidance previously advised colleagues to review explicit 
consent every month, but the department recognised this was not always the best approach 
and made the amendment. This change was cascaded through DWP communication 
channels. 

The department acknowledges that there were missed opportunities during Ms Anderson’s 
claim to consider the appropriateness of gaining her explicit consent to speak to a third party 
about her UC claim. Colleagues who worked on Ms Anderson’s case have taken part in the 
explicit consent information campaign. 

Your report states there was a delay between information being received by the department 
and it being acted upon. This delay was, in part, due to the information being recorded in 
standalone computer systems where the onus is on the individual to share. Therefore, the 
department acknowledges there were opportunities for colleagues to have shared information 
sooner, and the need to consider an appointee to manage the claim could have been 
considered. Unfortunately, these opportunities were missed. 

An issue that has been identified is that of system access levels. Different DWP colleagues 
have different access levels on departmental systems, and this is done deliberately to ensure 

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 information remains secure. However, as a result of this, some colleagues cannot pin 
information to claims or use the additional support function on the UC system. To counteract 
this, Performance Management team colleagues will be delivering sessions to all 170 
members of the team by the end of June 2024, which will promote awareness and improve 
understanding of dealing with vulnerable customers. This will provide colleagues with learning 
that they can apply to different scenarios. There will be a focus on the importance of 
prioritising sharing information relating to a customer’s vulnerabilities with UC colleagues to 
allow them to complete the additional support tab. Colleagues who worked on Ms Anderson’s 
case will take part in planned upskilling sessions. 

Conclusion 

The full circumstances of this case have been reviewed, and the department acknowledges 
that there is further work to be undertaken in order to satisfy HM Coroner’s concerns. This 
work includes plans to improve colleague awareness of how the additional support tab should 
be used to identify customer vulnerabilities. Plans are also in place to launch an improved 
version of the tab, based on colleague feedback, as a priority. Feedback is currently being 
sought from UC customers to shape future amendments to the additional support tab. 
Training sessions to upskill UC colleagues on how to best use the additional support tab will 
be delivered by the end of 2024.  

The appointeeship process is also being reviewed currently, with a view to making 
improvements to how these vulnerable customers are supported. An upskilling campaign 
dedicated to the use of explicit consent, and a system upgrade to improve visibility, has 
recently concluded. 

We hope that our response addresses your concerns and helps to assure you of DWP’s 
commitment to improving the service it provides to vulnerable customers.  

Yours sincerely, 

Area Director for Central England 

Chief Medical Advisor 

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