Sydney Piper

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 
Fax: 

www.cqc.org.uk 

Car 

H.M.Senior Coroner 
Mr Graeme Irvine 
East London Coroner’s Court 
Queens Road 
Walthamstow 
E17 8QP 

By email: 

31 May 2024 

Care Quality Commission 
Our Reference: 

Dear H.M. Senior Coroner Graeme Irvine, 

CQC response to prevention of future deaths report in respect of Mr Sydney Piper 

Thank you for naming the Care Quality Commission (CQC) as a respondent to the 
above report. I apologise again for the delay responding, caused by reorganisation 
within CQC, and I’m grateful to you for allowing an extension to the deadline for 
response. 

At CQC, we make sure that health and care services in England provide people with 
safe, effective and high-quality care. 

I note from section 5 of the report that your concerns are as follows: 

1.  The support worker who accompanied Mr Piper on the day of his 

disappearance claimed that she did not constantly supervise Mr Piper 
as alternatively; she did not wish to crowd him, she was allergic to 
cigarette smoke, and finally that she needed to rest her legs. The 
witness accepted that she had neither read Mr Piper’s support plan, nor 
the relevant policies and procedures relevant to her duties that day. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I am concerned that there is no clear evidence before me that the risk of 
a similar incident of inadequate supervision of a vulnerable person has 
been effectively mitigated. 

2.  Mr Piper’s death was the latest in a series of deaths investigated by this 
court in which homeless persons have died in tents and encampments 
in wooded areas along the A406 and the periphery of Epping Forest due 
to high risk behaviours including, but not limited to, crush injuries, fire, 
third party assaults and drug misuse. The monitoring and policing of 
such encampments is, in the view of the court, lacking which increases 
the risk of fatal harm. 

Regarding the first concern, Mr Piper was resident at Waterside Lodge Recovery 
Centre, a care home run by Outlook Care. Outlook Care are registered with CQC to 
provide the regulated activity of ‘Accommodation for persons who require nursing or 
personal care’. We last inspected Waterside Lodge Recovery Centre in December 
2019, rating it as Good under our five domains of Safe, Effective, Caring, Responsive 
and Well-led. Outlook Care closed Waterside Lodge Recovery Centre on 31 March 
2023. 

We have reviewed whether there has been a failure by Outlook Care or the Registered 
Manager for Waterside Lodge (Registered Persons), to provide Mr Piper with safe care 
and treatment causing Mr Piper avoidable harm. CQC does not have the power to take 
enforcement action against individuals who are not Registered Persons, except in 
circumstances where individual directors or members may be held individually liable for 
the commission of the offence by a registered provider that is a body corporate or 
unincorporated association, under sections 91 or 92 of the Health and Social Care Act 
2008. Those circumstances do not arise in this case. On reviewing the available 
evidence, we do not find that there are grounds to proceed with a criminal investigation 
against a Registered Person. 

We have reviewed the information we hold regarding Waterside Lodge Recovery Centre 
and asked Outlook Care to provide us with a copy of their response to H.M Senior 
Coroner. We note that although Outlook Care are not able to take action at Waterside 
Lodge due to its closure, they have committed to changes across their remaining nine 
locations to prevent such a sad event as this happening again. The changes include 
review of missing person policy, training for staff, additional risk assessments for 
supporting people using the service in the community and spot checks on one to one 
community visit support. We further note that the majority of these changes are due to 
be completed by the end of June 2024. Working with the CQC team covering the area 
where Outlook Care’s head office is located, we will request and review evidence of 
completion of these actions to ensure this has taken place. As part of CQC’s ongoing 
monitoring of registered providers, we will seek further evidence from Outlook Care to 
assure ourselves that all the changes made have been embedded into their ways of 
working. 

With reference to the report’s second area of concern, while CQC shares this concern, I 
note that the Metropolitan Police Service are also a named respondent and trust that 
they will be best placed to address this. 

 
 
 
 
 
 
 I hope the above assures H.M. Senior Coroner that CQC are monitoring Outlook Care 
to ensure that appropriate action has been taken to prevent future deaths. 

Yours sincerely, 

Deputy Director, London and East of England

This  is  the  London  Borough  of  Waltham  Forest’s  (the  “Local  Authority”) 

response to the Regulation 28 Report Reference 22449640 in respect of Sydney 

Piper.   

The Concerns raised were: 

1. The support worker who accompanied Mr Piper on the day of his disappearance 
claimed  that  she  did  not  constantly  supervise  Mr Piper as  alternatively;  she did not 
wish to crowd him, she was allergic to cigarette smoke, and finally that she needed to 
rest her legs. The witness accepted that she had neither read Mr Piper’s support plan, 
nor the relevant policies and procedures relevant to her duties that day.  

I  am  concerned  that  there  is  no  clear  evidence  before  me  that  the  risk  of  a  similar 
incident  of  inadequate  supervision  of  a  vulnerable  person  has  been  effectively 
mitigated.  

2. Mr Piper’s death was the latest in a series of deaths investigated by this court in 
which homeless persons have died in tents and encampments in wooded areas along 
the A406 and the periphery of Epping Forest due to high risk behaviours including, but 
not limited to, crush injuries, fire, third party assaults and drug misuse. The monitoring 
and policing of such encampments is, in the view of the court, lacking which increases 
the risk of fatal harm.  

The Local Authority did not employ the support worker or commission the service that 

employed them in this case.  We set out below the processes by which such services 

are monitored when commissioned by the Local Authority. 

The Local Authority does not own or manage the relevant part of Epping Forest or the 

surrounding land in this case.  It is understood that the relevant land is owned and 

managed by the Corporation of London.  However, we set out below how parks and 

open spaces within Local Authority remit are managed, as well as the safeguards in 

place for land owned and managed by third parties. 

1.  SPECIALIST RESIDENTIAL/SUPPORTED LIVING 
1.1.  In this case the Supported Living for Mr Piper was commissioned by the NHS 
Trust.  The Local Authority had no involvement in commissioning that service in 

this case and Mr Piper was not cared for by the Local Authority under the Care 

Act 2014. 

 
 
 
 
 1.2.  Where  an  individual’s  care  needs  are  assessed  as  needing  to  be  met  by 
provision of residential care by a Local Authority, then the Local Authority would 

have duties to that individual under the Care Act 2014.  The nature and extent of 

those  duties  would  depend  on  the  particular  circumstances,  but  would  be 

governed by the applicable law, statutory guidance and Local Authority policy. 

1.3.  Where  a  placement  was  to  be  commissioned  by  the  Local  Authority,  its 
Brokerage  team  would  source  a  placement  that  could  effectively  meet  the 

individual’s needs.  That team has a number of safeguards  in place to ensure 

that placements are suitable and appropriate: 

a)  Where a provider is registered with the Care Quality Commission, the Local 
Authority will only be brokered if the latest rating with the CQC is “Good” or 

“Outstanding” 

b)  There  will  be  consultation  with  the  Quality  Assurance  team,  who  monitor 

providers within the Borough, for their feedback. 

c)  For providers outside of the Borough, contact will be made with the host local 

authority for their feedback. 

d)  Once a provider is deemed provisionally suitable, the Quality Assurance team 
undertake a further review that assesses the financial standing, a review of 
the  provider’s  key  policies  and  procedures  including  but  not  limited  to, 

Safeguarding, Support Planning, and Incident reporting, Health and Safety, 
insurance, and the provider’s Quality Assurance framework. 

1.4.  In  terms  of  ongoing  monitoring,  the  Quality  Assurance  monitoring  team 
undertake  at  least  one  visit  annually  to  all  provisions  in  the  Borough.    Where 

concerns are identified and a service improvement plan has been implemented, 

the team will visit with greater frequency to support the improvement process.  

The provisions are monitored on a number of key areas: Staffing, Support/Care, 

Health  and  Safety,  Policy  and  Procedure,  Governance,  Quality  Assurance, 

Resident feedback, staff feedback, Medication Safeguarding and MCA/DoLs.  A 

report is sent to the provider detailing actions required within a given timeframe.  
1.5.  An individual in such a placement would also have the benefit of a review of their 
Care and Support plan on at least an annual basis that would include considering 

the appropriateness of the particular placement. 

 
 
 2.  SAFEGUARDING 
2.1.  Duties 
2.1.1.  The Local Authority has a duty to make a Safeguarding Enquiry under section 

42 of the Care Act 2014 where it: 

has  reasonable  cause  to  suspect  that  an  adult  in  its  area  (whether  or  not 
ordinarily resident there)— 

(a) 

(b) 

(c) 

has needs for care and support (whether or not the authority is meeting 
any of those needs), 

is experiencing, or is at risk of, abuse or neglect, and 

as a result of those needs is unable to protect himself or herself against 
the abuse or neglect or the risk of it. 

2.2.  Making a referral 
2.2.1.  The  majority  of  Safeguarding  concerns  are  raised  via  the  Multi  Agency 
Safeguarding Hub (“MASH”) or the Adult Front Door service and generally come 

from direct concerns of professionals from various disciplines. 

2.2.2.  Contact details for MASH are widely available and, for example, come up as 

the first result in a Google search for “safeguarding Waltham Forest”.   

2.2.3.  The  first  result  in  that  search  is  a  page  from  the  Local Authority’s 
website  about  MASH, explaining  what  it  is and  providing  an  email 

address, telephone  numbers  for the  working  day  and  out  of hours 

and a MASH referral form for professionals’ use.   

That page also indicates that urgent concerns should be raised by 

contacting  the  safeguarding  team  directly  by  telephone,  and 

provides the telephone number. 

2.2.4.  The second result is another Local Authority webpage headed, “How 
to  report  adult  safeguarding  concerns”.    It  contains  the  telephone 

number  for  the  Safeguarding  Adults  Team  and  a  link  to  a 

Safeguarding Alert form that can be completed online. 

 
 
 
 
 
 
 
 2.3.  Process 
2.3.1.  Where a concern relates to an individual that is open to a Local Authority team, 
the concern will be recorded and progressed to that team for them to establish 

whether the section 42 criteria are met.  That is on the basis that they are likely 

to have some direct knowledge of the person concerned. 

2.3.2.  Where the individual is not known to the Local Authority, or not open to a team 
(and in this case, Mr Piper was not known to the Local Authority other than as a 

DOLS  supervisory  body),  the  adult  MASH  team  will  be  responsible  for 

establishing if the section 42 criteria are met. 

2.3.3.  In either case, if the criteria are met, the individual will be allocated to the most 
relevant team that most closely matches their presenting care and support team.  

For example, if the primary support needs relate to mental health, then this would 

be the Community Recovery Team in Northeast London NHS Foundation Trust 

(“NEFLT”), which is part of a prescribed arrangement between the Local Authority 

and NHS under section 75 of the National Health Service Act 2006.   

2.4.  Policy 
2.4.1.  The Local Authority is bound by the London Multi-Agency Safeguarding Policy 

& Procedures as agreed by the London Safeguarding Adults Board.   

2.4.2.  The policy provides Indicative Timescales: 

INDICATIVE TIMESCALES 

Stage one: Concerns 

Immediate action in cases of emergency  

Within one working day in other cases  

Stage two: Enquiries  

• 

Initial conversation  

Same day concern received if not already taken 
place  

•  Planning meetings 

Within 5 working days 

 
 
 
 
 
 
 
 
 
 
 
 
 •  Enquiry actions  

Target time within 20 working days 

•  Agreeing outcomes 

Within 5 working days of enquiry report 

2.4.3.  All enquiries are triaged the same day. 

2.5.  In this case 
2.5.1.  It is very likely that a vulnerable person such as Mr Piper going missing would 
meet the section 42 criteria.  In this case, the Local Authority did not receive the 

referral because it was sent to a wrong email address. 

2.5.2.  All  emails  correctly  sent  to  the  Adult  Front  Door  and  MASH  receive  an 

immediate automated response to acknowledge receipt.   

2.5.3.  Had the referral been received, it is likely that the first step would have been to 

make contact with the police to share information. 

2.5.4.  The enquiry would also have been allocated to NELFT because of the mental 

health needs here. 

3.  ROUGH SLEEPING 
3.1.  All  parks and  open  spaces  within the Local Authority’s  remit  are monitored as 

follows: 

a)  Through  a  weekly regime  of  litter picking  by an  appointed  contractor.   The 
contractor will report any rough-sleepers, tents or evidence of rough-sleeping 

that is identified to the Local Authority rough-sleeper team. 

b)  Through Park Officers and officers in the Sports and Leisure team carrying 

out regular inspections and making referrals. 

3.2.  The  Council’s  Rough  Sleeper  team  makes  three  attempts  to  engage  with 
individuals identified during the inspections. They offer support and assistance 

to  connect  them  with  appropriate  services.    They  also  make  a  referral  to 

 
 
 
 
 
 
 
 
 
 
 
 
 StreetLink, a platform that connects people sleeping rough to other agencies and 

charities, including St Mungo’s. 

3.3.  Where  appropriate,  Neighbourhood  Officers  can  issue  Community  Protection 

Notices  instructing  individuals  to  move  on.  If  necessary,  they  collaborate  with 

local police to enforce these notices. 

3.4.  The Local Authority has a contract in place to cut back overgrown vegetation, 

particularly that which may attract rough sleepers.   

3.5.  Where land is owned by other parties, Neighbourhood Officers liaise with those 

landowners to ensure that appropriate action is taken. 

London Borough Waltham Forest

METROPOLITAN
POLICE

Our Ref: IX/2341/23 FY

Mr Graeme Irvine Deputy Assistant Commissioner
HM Senior Coroner Metropolitan Police Service
East London Coroner’s Court New Scotland Yard
Queens Road Victoria Embankment
Walthamstow London
London E17 8QP SWI1A 2JL

30" April 2024
Dear Mr Irvine

Iam the Deputy Assistant Commissioner for Frontline Policing in the Metropolitan Police Service
(“MPS”). On behalf of the Commissioner of Police of the Metropolis, I write to provide the response
to the matter of concern addressed to the MPS in your Report to Prevent Future Deaths dated 15" March
2024.

On behalf of the MPS, may I first of all express my sincere condolences to the family and friends of Mr
Sydney Piper, our thoughts and sympathies are very much with them.

The Coroner’s “Matter of Concern”

The Prevention of Future Deaths’ report dated 15 March 2024 records:-

“2. Mr Piper’s death was the latest in a series of deaths investigated by this court in which homeless
persons have died in tents and encampments in wooded areas along the A406 and the periphery
of Epping Forest due to high risk behaviours including, but not limited to, crush injuries, fire,
third party assaults and drug misuse. The monitoring and policing of such encampmenits is, in

the view of the court, lacking which increases the risk of fatal harm”.

MPS Response

The MPS have liaised with the Coroner and have been unable to identify any other deaths in this area

which would suggest any specific or ongoing risk to public safety, or significant criminal activity.

In accordance with statutory guidance, any unauthorised encampment which poses a risk of safety to
occupants and others will be addressed as a public safety/public health issue through a multi-agency
approach led by the local authority. Further, where individual crimes are reported there will be a duty

for police to investigate.

METROPOLITAN
POLICE

I can confirm that ongoing work is being undertaken with the respective local authorities and there is
strategic police/partnership joint working to focus on rough sleeping. The police neighbourhood teams
are supporting the local authority strategy for rough sleeping, which includes community safety, housing

and enforcement.

We have increased engagement with local residents who use the forest and surrounding environs to
encourage reporting of rough sleeping they become aware of directly to the Local Authority. The MPS
is working closely with the Local Authorities and the Epping Forest Park Rangers to ensure any early

identification of rough sleeping is addressed as a partnership.

Yours sincerely,

eputy Assistant Commissioner
Local Policing and Met VAWG Lead

Outlook Care response to: Sydney Piper; Prevention of future deaths report 10 
May 2023 

Background 

•  Date of report: 15/03/2024 
•  Ref: 2024-0145 
•  Deceased name: Sydney Piper 
•  Coroner name: Graeme Irvine 
•  Coroner Area: East London 
•  Category: Alcohol, drug and medication related deaths 

Full report Sydney Piper: Prevention of future deaths report - Courts and Tribunals 
Judiciary 

The MATTERS OF CONCERN are as follows. 
1. The support worker who accompanied Mr Piper on the day of his disappearance 
claimed that she did not constantly supervise Mr Piper as alternatively; she did not 
wish to crowd him, she was allergic to cigarette smoke, and finally that she needed 
to rest her legs. The witness accepted that she had neither read Mr Piper’s support 
plan, nor the relevant policies and procedures relevant to her duties that day. 

I am concerned that there is no clear evidence before me that the risk of a similar 
incident of inadequate supervision of a vulnerable person has been effectively 
mitigated. 

Response: 

1.  Following the initial safeguarding alert being raised and the issuing of notice for a 
Section 42 Enquiry, in partnership with key stakeholders on notification of death 
of Mr Piper, we implemented an action plan, appendix 1, which in summary 
consisted of: 
•  External feedback continuing to contribute to our reviews and improvement 

plans for services. 

•  Continued inclusion of feedback from stakeholders, London Borough of 
Waltham Forest (LBWF), in management reviews and how it meets the 
support and oversight of service delivery in local areas, ensuring feedback is 
evident in management decisions taken. 

•  Collaborative working with LBWF to ensure management decisions will 
benefit from the feedback and experience of LBWF/North-East London 
Foundation Trust (NELFT) partners. 

 
 
 
 
 
  
 •  Continued close working with LBWF to share opportunities and their wider 

experience/resources that can enhance the quality of the support provided by 
services.   

•  Raising awareness of LBWF Safeguarding Team and their role in ensuring 

customer safety from Abuse or Neglect.  Local Safeguarding Information to be 
recirculated to raise awareness. All noticeboards reviewed and local 
Safeguarding information clearly displayed. 
Induction and Probation management reviewed to see what areas can be 
more effective. 

• 

•  Supporting staff learning regarding their ‘Duty of Care’ including review of 
policy on Care and Support with a view to strengthen the focus on 1:1 
support. 

•  Shared learning in teams to review how we evidence engagement and 

• 

learning for customers using 1:1 support in the community and safeguarding 
best practice. 
Increase emphasis on Positive Behaviour Support principles evident in 
delivery and review of staff training and development to strengthen duty of 
care for customers using individual support. 

•  Share learning across the whole of the organisation at a learning event from 

this lived experience following conclusion of Organisational Safeguarding and 
MISPER Incident for the Management Team. 

•  Safeguarding Training for Managers with all Managers refreshing their Level 3 
Safeguarding Training for Managers. Managers to supplement by attending 
their Local Authority Safeguarding for Managers training when it becomes 
available. 

•  Application of Missing Person’s Policy to strengthen how it is reflected 
individual’s risk assessments, support guidelines and Missing Person 
Information. Any recommendations to be made to Director of Care and 
Support with Chief Executive. 

•  Review potential risk for individual support and MISPER for all customers by 
identifying Risk Profiles for current customers and ensuring future customers 
are identified when they start to use our services. This will be subject to 
ongoing monitoring of customer’s changing needs.   

•  Staff awareness of Duty of Care when providing support to people at risk of 

MISPER is increased. 

•  GDPR Policy implementation is monitored at all stages of service closure to 
ensure there is secure storage available during decommissioning of service 
and transport of archiving to secure archive. 

•  Feedback from Customers on consultation during service closures will be 

more detailed. 

2 

 
 
 2.  A full briefing was issued to our Board of Trustees who continue to provide 

scrutiny and oversight of our progress. The action plan implementation is led by 
the Chief Executive and real time reporting to the Board of Trustees continues 
alongside regular briefings issued to all of the workforce. 

3.  We participated in the Safeguarding Adults Board review led by the London 

Borough of Waltham Forest, appendix 2. We revised our action plan accordingly 
based on learning from this process. 

4.  In response to the Regulation 28 Notice issued by the Coroner and the matters of 

concern noted, the following actions have also been implemented: 
•  Staff briefings held with all staff led by Chief Executive, Director of Care and 

Support and Managers. 

•  Discussions with all staff during staff meetings. 
•  Further review and relaunch of Missing Persons Policy, appendix 3. 
•  Workforce review of understanding of the Missing Persons Policy, see 
appendix 4. To date we have a >90% response rate evidencing good 
understanding. 

•  Further review of updated risk assessments for all service users supported in 
relation to Herbert Protocol, missing persons process and delivery of 1:1 
support in the community. 

•  Training for all staff in mitigation service user risk of going missing and 
managing the process should a service user go missing, emphasising: 
o 

the role of day-to-day risk assessment as a preventative measure for 
service users at risk of going missing. 
the critical nature of the golden hour should a missing person incident 
occur. 

o 

•  The use of a day to day, app based, risk assessment completed every time a 
service user is supported in the community, appendix 5. This process was 
implemented on 22 March 2024 and to date 1098 risk assessments have 
been completed and records stored securely, reviewed monthly by the 
Director of Care and Support to identify trends or areas of concern. To date 
the risk assessments have been completed by 458 staff. 

•  Spot checks on 1:1 support being delivered to service users in the community 
to check for both safety and quality as well as validating that our action plan is 
being implemented in practice, appendix 6. To date 21 spot checks have been 
completed and reported on to the Executive Management Team. Where 
performance of staff has fallen below our standards, staff are undergoing 
further training/performance management and cease to deliver community-
based support until they reach the required competency level. 

3 

 
 
 •  Guidance on the delivery of 1:1 support and the importance of maintaining a 
‘line of sight’ has been issued, in form of video briefing, written guidance, 
posters, key facts cards issued to staff name badges, see appendix 7. 

5.  Further actions scheduled for completion by end of June 2024 include: 

•  Completion of an unannounced Business Continuity Management test in 

• 

relation to a Missing Person incident, to be repeated annually. 
Including audits of risk management process in relation to Missing Person and 
delivery of community support to mitigate risk of service users going missing 
into our annual audit schedule, to be completed twice per year on an ongoing 
basis. Outcomes will be reported to Board of Trustees for scrutiny and 
oversight. 

•  Revised induction and handover formats that include specific reference to 

Missing Person risk and mitigation of such risk, see appendix 8. 

Finally, in October 2024, we will be hosting a learning event for all stakeholders, 
partners and other providers, to share our learning and revised procedures, 
stemming from this tragic incident. 

Please do not hesitate to contact me if you have any questions. 

Yours sincerely 

Chief Executive and Trustee 

Supporting documents*: 
•  Appendix 1: Section 42 Enquiry Action Plan 
•  Appendix 2: Safeguarding Adult Board Review Final Report 
•  Appendix 3: Missing Persons Policy 
•  Appendix 4: Missing Person Policy Survey Sample 
•  Appendix 5: Sample Risk Assessment Form 
•  Appendix 6: 1:1 Support Delivery Audit Sample 
•  Appendix 7: Sample Guidance Documents/Video 
*The above listed documents can be provided at the Coroners request. 

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