Adrian Green

Response to Regulation 28 Request 

Title 

Author/Role 

Accountable Executive Director 

Coroner Regulation 28 – Prevention of 
Future Deaths Report into the death of 
Adrian Stuart Green 

, Associate Director of 

Patient Safety and Quality 

, Interim Chief Nurse 

Concerns raised by the coroner leading to the Regulation 28 – Prevention of Future 
Deaths Report: 

Adrian Green died on 1st November 2021 following admission to Torbay and South 
Devon NHS trust via ambulance on 26th October 2021. Adrian Green was admitted 
acutely unwell, in organ failure and in a state of neglect. Prior to his death Adrian 
Green had been assessed as requiring a 3 x per day care package and support with 
shopping, no concerns were raised regarding Adrian Green’s welfare by his carers 
(care support-based at Whitley court).  Neighbours raised concerns that they had not 
seen Adrian Green and they raised the alarm to being visited by the carers. 

A safeguarding alert was raised by Adrian Green’s sister following his death. The 
safeguarding enquiry made recommendations directed at care support (the agency 
responsible for the care package). The safeguarding referral referenced a number of 
findings including: 

  Adrian Green had been seen by other residents with bruising to the face, in 

previous months/weeks indicating an altercation, yet there was no welfare 
concerns or safeguarding’s raised by the care provider.   

  Adrian Green was reportedly declining medication which will have been prescribed 

to assist in his health and well-being and could have been important in any 
subsequent deterioration in his health and presentation. 

  Adrian Green was reportedly receiving intercom calls as opposed to face to face 
visits.  The Trust considers that face to face visits from the care provider, which 
would have furnished carers with additional risk assessment information as to the 
living conditions, and his general health and well-being. 

  The Record of log sheets is inadequate dating back to 2020 as there are few visits 
recorded.  It is also not clear in the record what is a telephone call or a face to face 
visit .  Several entries worryingly report “no MARS (medication administration 
record) sheet “.  It is a requirement for the administration of medications that they 
are recorded safely and appropriately. 

  There is inadequate record keeping in many areas of Adrian Green’s care planning 

 

 

 

and delivery of care. 
It is reported by head office and 
, Care Support, that records have 
been deleted and are not available to the investigating officer.  It is reported that 
outgoing management deleted records from their own IT equipment. As a Trust we 
suggest this is not appropriate, safe, confidential or good record keeping practices. 
It was reported by a whistle blower that efforts were made to clean up the flat prior 
to SWAST(South West Ambulance Service Trust) attendance,  

 (Adrian Green’s sister) states that if Adrian Green had been 
admitted to hospital or received medical attention earlier, he would have had a 
greater chance of survival.  

Following Adrian’s death, the subsequent HM Coroner’s Inquest delivered a regulation 28 
report detailing actions to prevent future deaths. The matters of concern raised by the 
coroner are detailed below: 

1 

 
 
 
 (1)  Despite there being a safeguarding meeting following Mr. Green’s death on 22nd January 
2022 there appeared to be no review of whether the local authority ought to be have had 
policies in place to ensure that independent providers were adequately carrying out their 
contractual duties towards vulnerable individuals especially if the CQC duties towards 
vulnerable individuals especially if the CQC were correct and there was no role for them 
in this case 

(2) 

 gave evidence to the inquest that she believed that there was a role for the 
CQC here as she believed that Mr Green had been in receipt of a personal care package  

(3) 

 made a referral to the Disclosure and Barring service in respect of the 

former manager’s actions and received no response as to what action if any the service 
were taking or an acknowledgement of her concerns 

The Trust sought further clarification from the Coroner and she advised: 

An issue arose during the inquest surrounding the attached Safeguarding report and not 
treatment within the hospital and for that reason I did not consider it necessary to adjourn 
the inquest ( the death was in 2021 ) and invite representation on the issue as the area I 
was concerned about was the apparent lack of investigation at that safeguarding meeting 
into how a similar situation could be improved upon and or prevented .  

The meeting minutes appeared to simply ask the provider Care Support to revise their 
systems and report back to the meeting. My worry as expressed in the Regulation 28 
report was that there should there be a way of the Trust overseeing any systems put in 
place by independent contract providers to avoid something like this happening again. 

I was left in a difficult situation at inquest because the CQC had told my officers there was 
no role for them as the client was not in receipt of personal care and the contract provider 
manager had simply left her employment and destroyed records along the way.  

I believed that action could be taken by the Trust to ensure that this type of death could be 
prevented from happening again by some Trust oversight of independent providers, whilst 
understanding that it was an independent contractor who held the contract for these 
services.  

Background: 

Adrian Green died on 1st November 2021 following admission to Torbay and South 
Devon NHS trust via ambulance on 26th October 2021. The care team, at Adrian 
Green’s accommodation, were alerted to check on him by a neighbour who raised 
concerns about not hearing Adrian Green’s music or seeing lights on in his flat for some 
time.  Upon entering the flat the care and housing staff members found him to be 
‘unwell’ and an ambulance was called. Safeguarding records show that Adrian Green 
was acutely unwell on admission to hospital ‘with a 10% chance of survival with 
complete organ failure and nutritionally deprived.’ Adrian Green was observed by 
hospital staff to present as neglected and ‘dirty’.  

Adrian Green’s brother and sister report that the staff who entered the flat found him 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 lying in blood and faecal matter. His family shared they had been told that if he had 
received medical attention sooner he would have had a 50 % chance of survival.  
 raised a safeguarding alert to the Police and the Trust and made a 

referral to the Disclosure and Barring service.  

Prior to his death Adrian was residing in Whitley court (which was under the management 
of Care Support), and his assessed package of care was for 3 x per day support with 
medication and 3 x per week support with shopping. Adrian Green was not in receipt of 
any domiciliary care. 

It should be noted that Adrian Green’s death occurred during the Covid 19 pandemic, from 
the 14th October 2021 (the weeks leading up to his death) there had been a relaxation in 
coronavirus restriction to allow greater mixing. 

Safeguarding referral and alert 3rd November 2021 

Following Adrian Green’s death two safeguarding alerts were raised on 3rd November 
2021. The first referral was made on behalf of his sister, regarding Adrian Green’s 
condition on admission to hospital, his subsequent death and the fact that the care 
provider had not raised any alarm. This was referred by Torbay and South Devon NHS 
Foundation Trust. On 3rd November the care provider, Care Support, also raised a 
safeguarding referral via 

. 

The referrals stated his sister and other family had visited the property on the 2nd 
November and it was in a poor state with evidence that Adrian Green had been lying in 
pools of blood and faecal matter. The alert advises Adrian Green’s package of care ‘was 
for medication three times per day and for 3 shopping trips per week’. 

The referrals also advised of an issue that 3 members of the senior team in Whitley Court 
all left on the 15/10/2021, and on that day those 3 members of staff deleted all the 
company data that they had on their systems and devices, such as laptops, desktop, and 
mobile phones. This data included service user information, safeguarding concerns, 
complaints, investigations etc. 

 The referral advised that deleting data, which belonged to Care Support, is against 
company policy, procedure and legislation that governs how we should protect, store and 
dispose of any data.    

The provider’s referral states checks have taken place for all service users, and reviews 
were underway with all services users to identify they are happy with the service they are 
being provided and ensure it is safe and meeting their needs. 

The Torbay Safeguarding Adult Single Point of Contact (SPOC) received further 
information as part of their review advising that a neighbour had raised welfare concerns 
to Care Support on the 26th October. There were also concerns that the new manager 
and agency staff had cleaned Adrian Green’s property before paramedics attended 
allegedly to cover up any evidence of neglect.   

A section 42 safeguarding adults meeting was held on 3rd February 2022 which 
identified the following ongoing risks: 

  Adrian Green is deceased and the risks going forward will be related to those of 
the wider community and those being cared for by the provider (care support) 

 

 (Adrian’s sister) outlined her concerns at her brother’s passing 

and that it may have been preventable. She was particularly struck by the 

3 

 
 comment that he would have had a 50% chance of survival if he had received 
medical treatment earlier. It was the shared view of the family and social care that 
there are wider implications and lessons to be learned for the wider public 
following the death of Adrian Green. 

The section 42 enquiry made the following recommendations: 

  Care support to detail what protocols are in place for the recording of safeguarding 

incidents and concerns and how this is relayed to carers. 

  Care support to outline their own internal enquiries into the death of Adrian Green 

and their own internal findings. 

  Care support to outline how they report and record daily carer logs and the advice 

and guidance given to carers as to what should be recorded. 

  Care support to ensure that all MARS sheets are available and consistently used 

in the administration and recoding of medication. 

  The communication handbook which provides handover information should be 

more detailed and use appropriate and compassionate language when referring to 
the cared for person. 

 

Information should be secured as to the name of the whistleblower in order that 
their views should be obtained in relation to the enquiry.  

TSDFT response to HM coroners Matter of Concern 1 

Despite there being a safeguarding meeting following Mr. Green’s death on 22nd January 
2022 there appeared to be no review of whether the local authority ought to be have had 
policies in place to ensure that independent providers were adequately carrying out their 
contractual duties towards vulnerable individuals especially if the CQC duties towards 
vulnerable individuals especially if the CQC were correct and there was no role for them in this 
case . 

Mr. Green died on 1st November 2021 and the safeguarding meeting took place on 3rd 
February 2022. The Trust can confirm that a Provider of Concern Protocol (PCP) 2020 
was in in place at the time of Adrian Green’s death to support action to be taken in 
response to concerns raised relating to residential, nursing home, day and 
domiciliary care services in the unitary authority of Torbay and for which Torbay 
and South Devon NHS Foundation Trust commission services.  

This PCP (which is now obsolete and has been replaced by a more rigorous 
process-see below reference to Provider Quality Support Protocol ) detailed the 
process in place to manage concerns with respect to a number of adults at risk in 
one establishment, or where there are serious concerns about poor quality of 
care from a provider, but for which the threshold for safeguarding whole home / 
large scale intervention is not met.  

The PCP is clear that any action taken does not replace individual adult 
safeguarding investigations. The protocol is intended to supplement the guidance 
provided in the Torbay Safeguarding Adult Whole Home / Large Scale 

4 

 
 
 
 
 
 
 
 Safeguarding Adult Policy and Safeguarding Adults, Commissioning and Quality 
Assurance, Guidance for staff. 

The PCP detailed a number of possible triggers for the provider of concern 
process which include external concerns such as a poor CQC inspection, 
safeguarding referrals, incidents reports etc.  

Adrian Green had his own tenancy for a flat within Whitley Court. Mr Green was in 
receipt of a 3 x per day medication support package and 3 x per week support with 
shopping. No concerns had been raised by health or care professionals, or by any 
other mechanism to trigger the PCP to be enacted. Whitley Court had been rated 
as good by the CQC in Jan 2020. As Adrian Green had his own tenancy there was 
no legal right of access for the trust or tiggers of concern.  

It is the view of the Torbay and South Devon NHS Foundation Trust that Care 
support was in a position of Trust in providing care for Adrian Green and that they 
failed to provide the agreed level of care for Mr Green per the contract 
arrangement, this lack of care contributed to his state of neglect and ill health. In 
addition records were deliberately deleted which is a significant concern. 

Since this tragic case the Torbay and South Devon NHS Foundation Trust and 
local authority have taken a number of steps to improve oversight via robust 
contract management, including contract review meetings and quality assurance 
oversight of providers commissioned by Torbay adult social care. The frequency of 
review meetings is adjusted based on the type of service, the value and risk of the 
service with some being quarterly and others 6 monthly. 

Actions taken to improve oversight and assurance (all documents referred to 
in this section are included at appendix TSDFT1) 

1)  The Market Management Lead was brought into post in October 2022 to 

oversee the Independent Sector Market and Contracts and line manage the 
four Contract Managers. 

2)  Creation of a Contract Management procedure and toolkit, and set-up of a 
contracts register were delivered between October 2022 and October 2023 
(Doc 1).  

3)  The team are currently in the process of reviewing and re-issuing all 
contracts to include updated quality standards and key performance 
indicators within our service specifications (Doc 2) 

4)  In January 2024, the Market Management Lead took over line management 

of the Quality Assurance and Improvement Team (QAIT), merging the 
quality function with the contract management function (Docs 3 and 4). 

5)  In  February  2024  ,  the  Provider  Quality  Support  Protocol  (PQSP)  (Doc  5) 
was  ratified  through  Care  and  Clinical  Governance,  replacing  the  previous 
policy, the Provider of Concern protocol.  The Provider Quality Support Policy 
(PQSP) has been developed to establish a formal and coordinated response 

5 

 
 
 
 
 
 
 
 
 
 
 
 to concerns about standards of care within regulated and other care provider 
services in Torbay.   

The  Provider  Quality  Support  policy  covers  all  adult  social  services  and 
encompasses:  

  Regulated residential and nursing care homes 
  Regulated domiciliary care services 
  Outreach services (including unregulated domiciliary care) 
  Regulated and unregulated Supported Living services  
  Day care services 
  Extra care services 
  Live-in care services 

The PQSP establishes a formal means of responding to concerns about 
these services where there is reason to believe that there are a number of 
individuals whose well-being needs as defined within Chapter 1 of Care Act 
2014 Statutory Guidance are not being met.   This applies to all persons 
living with the care provider service regardless of whether the host authority 
or other placing authorities are carrying out a care and support function.   

6)  The QAIT Officers gather intelligence from a variety of sources to determine 
which providers require additional support or actions plans to be put in 
place, for example CQC, Safeguarding (Doc 6), Incidents reported within 
DATIX, our Incident Reporting System, KPI Data (Doc 7), and soft 
intelligence from front line operational staff gathered at weekly Quality 
Assurance Huddle meetings (Docs 8 and 9). 

7)  Contract Managers complete Contract Review Meetings on a regular basis 

with all providers (Doc 10). 

8)  QAIT Officers monitor trends and themes and put in place Action Plans 
(Service Improvement Plans) for any providers which do not meet the 
required standards (Doc 11). 

9)  Providers who have been rated as Requires Improvement by CQC and 

those who are falling below the Trust’s required standards and are subject 
to ongoing monitoring are reported through the governance cycles within 
both Torbay and South Devon NHS Foundation Trust and Torbay Council 
(Doc 12). 

10) Please note, not all providers are subject to all parts of the Quality 

Assurance and Contracts Management process so therefore the assurance 
evidence below refers to a number of different providers and has been 
anonymised. 

6 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Further actions taken following Mr Green’s Death 

Immediate Actions taken to ensure safeguarding of residents 

  3rd November 2021 Safeguarding referral/ alert submitted following contact from 

Adrian Green’s sister and a referral the same day from 
Manager for Care and Support relating to the same incident 

, Registered 

  4th November 2021 Safeguarding alert forwarded to CQC. Initial contact made 

with Devon and Cornall police. 

  4 November 2021; a mul(cid:415)-agency, large-scale safeguarding adults meeting was 
conveyed. This resulted a full large scale enquiry being convened that included; 
-  Full engagement with CQC in response to concerns linked to a regulated care 

provider. 

-  Ongoing engagement with Devon and Cornwall Police. 
-  Assessment of risk and engagement with all residents within Whitley Court and 

Dunboyne Court in which the regulated provider operated within Torbay. 
-  Ongoing monitoring and support to the provider in response to the staffing 

issues, destruction of care plan documentation and need for continuity of care 
for people impacted by the safeguarding incident. 

-  Full participation with commissioners of care to consider their contractual 

position with the regulated provider.  Care and Support subsequently were 
unsuccessful with the tender for the new contract. 

  5th November 2021 referral was made to Devon and Cornwall Police to consider 
what if any action they wished to consider in response to alleged gross neglect. 

  On the 5th November, the referral passed ownership from Single Point of Contact 
(SPOC) to the Adult Social Care (ASC) Community Team to pursue the enquiry 
response. 

  18 November 2021 meeting to review the initial safeguarding plan made for the 
residents at Whitley Court; this was a multi-agency meeting; which included 
Commissioners from Torbay Council and CQC. Agreed that the contract notice 
would be issued, with an expected completion date of 2 December 2021. 
Geraldine Hodge from CQC advised that CQC would be undertaking a monitoring 
activity call with the provider 

  2nd December 2021 safeguarding meeting with the provider. The action plan needs 
to focus on understanding the specific needs of individuals to prioritize who should 
get priority care. CQC not in attendance however kept updated. 

  6 December 2021 focused meeting to agree the terms of reference for the 

safeguarding enquiry 

 

findings of Section 42 safeguarding meeting 

7 

 
 
 
 
 
 Actions to ensure shared learning and wider system improvement to reduce the 
likelihood of future similar incidents. 

  Thematic review commissioned into individuals who had died in Devon of self -

neglect. The review was published in February 2023. The recommendations from 
this review are being monitored via TDSAP and the learning has been widely 
disseminated. 

  6th July 2022 and as part of the safeguarding adult review ( SAR), the Torbay and 

Devon Safeguarding Adults Partnership (TDSAP) organised a partnership 
practitioner and manager fishbowl event which enabled practitioners and 
managers to engage in the review and provider their narrative of the challenges 
and opportunities in practice to support people who self-neglect.   

  The TDSAP Learning and Improvement Sub-Group has also published and widely 
distributed a SAR practice briefing in response.  This has been widely distributed 
across the Partnerships boundaries including to front line practitioners 

 

 Torbay and South Devon NHS Foundation Trust has distributed the briefing to all 
commissioned adult social care services including its commissioned out of area 
authorities, care home sector, homecare sector, supported living services, daytime 
activity and enabling services, voluntary and community sector and all other 
commissioned services. 
a)  In response to the thematic self-neglect review, TDSAP has also created and 
approved Multi-Agency Risk Management Meetings (MARMM): Guidance and 
Over-Arching Principles.  The purpose of this guidance is: 

  To provide a multi-agency forum to coordinate joined up support for individuals 
displaying  high  risk  behaviours  or  who  are  at  risk  of  harm  due  to  the 
circumstances they find themselves in.  

  To  provide  an  environment  enabling  a  proactive  approach,  focusing  on 
prevention and early intervention, with professionals responding to chronic or 
entrenched behaviours as part of their day-to-day work. 

  To identify and escalate cases for multi-agency collaboration and actions. 
  To  have  senior  level  representation  to  support  practitioners  and  offer  a  fresh 
approach with creative solutions, access to specialist support and legal advice 
where appropriate. 

  To  enhance  local  partnership  connections  and  relationships  and  develop  a 
database of useful contacts. It is hoped this will result in dynamic safeguarding 
and information sharing taking place outside of the MARMM process. 

Currently TDSAP Operational Delivery Group is undertaking task and finish group 
activity to implement this guidance into practice. 

In 2023 Torbay’s MCN (multiple and complex needs) Alliance was formed. This is 
an  innovative  form  of  commissioning  and  delivering  a  range  of  services  under  a 
shared  contract,  whereby  member  organisations  take  collective  ownership  of  and 
responsibility for all the services being provided. The services within the Alliance are 
drug  and  alcohol  services,  domestic  abuse  services  and  the  homeless  hostel 
(Leonard Stocks Centre).  

Actions taken to improve oversight and assurance 

8 

 
 
 
 
 
 Following Adrian Green’s death a full review and restructure of how contracts are 
managed and continually reviewed has been completed by Torbay and South Devon 
NHS Foundation Trust.  
The Trust now has a more robust system of contract management, quality control 
and audit in place which, we suggest, would mitigate the chances of another incident 
like this occurring.  
Regular contract review meetings take place with all care providers, all service level 
agreements  are  monitored  including  key  performance  indicators. A  review  of  the 
interactions with service users and how many missed appointments a service user 
has had in this period is also assessed.  
By undertaking this review, when a service user misses a number of appointments, 
or assessment is not carried out by a face to face appointment, a welfare check can 
be arranged which would seek to ensure that the circumstances such as Adrian’s of 
self  neglect  would  be  highlighted  at  an  earlier  stage  to  enable  intervention  to  be 
undertaken. 

 Matters of concern No 2 raised by HM coroner 

a) 

 gave evidence to the inquest that she believed that there was a role for 

the CQC here as she believed that Mr Green had been in receipt of a personal care 
package - Torbay and South Devon NHS Foundation Trust are not able to answer this 
point. Adrian was not in receipt of personal or domiciliary care package. Adrian was 
provided with 3 times daily medication reminders and 3 times weekly assistance with 
shopping. As no personal or domiciliary care package was provided Torbay and South 
Devon NHS Foundation Trust aver there was no CQC role 

Matters of concern no 3 raised by HM coroner 

b) 

 made a referral to the Disclosure and Barring service in respect of the 

former manager’s actions and received no response as to what action if any the service 
were taking or an acknowledgement of her concerns. Torbay and South Devon NHS 
Foundation Trust are unable to answer this concern and this should be raised directly 
with the Disclosure and Barring Service. 

9 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 TSDFT Appendix 1 

Document 1 – Contract Management Procedure: 

Document 2 – An example of a recently issued Service Specifica(cid:415)on (part of contract): 

Contract 

Management Procedure v1.6.docx

Document 3 – Current Markets, Contracts and Quality Team Structure: 

Document 4 – QAIT Officer Job Descrip(cid:415)on 

Document 5 – Provider Quality Support Protocol: 

Document 6 – Safeguarding Dashboard 

Document 7 – Example of KPI Dashboard for a provider 

Document 8 – Care Provider Quality Assurance Huddle Terms of Reference 

Document 9 – Care Provider Quality Assurance Agenda and Minutes Template 

Document 10 – Example of a Contract Review Mee(cid:415)ng minutes 

Document 11 – Example of a Full Ac(cid:415)on Plan (ongoing case) 

Document 12 – Sample of Quality Assurance Monthly Repor(cid:415)ng 

Service Secification 
Final.docx

Team Structure.docx

QAIT Job 
Description.docx

PQSP.docx

Safeguarding 
Dashboard.png

Provider%20KPI%20
Dashboard%20Example.png

Care Provider Quality 
Assurance Huddle TOR.docx

Care Provider Quality 
Assurance Huddle Agenda & Minutes.docx

Contract Review 
Meeting Example.docx 

Full Action Plan 
Example.docx

Sample of Monthly 
Reporting.pptx

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