Regina Ademiluyi

Office of the Chief Medical Officer 
Trust Headquarters 
Robert Dolan House 
5th Floor 
9 Alie Street 
London E1 8DE 

Private & Confidential 

Date 17 May 2025 

Dear Sir  

RE: REGULATION 28 REPORT  

1.  This is a formal response to your Regulation 28 report issued on 23 March 2024 where you set out 

concerns  relating  to  the  care  of  late  Ms  Regina  Olufunmilola  Ademiluyi  at  East  London  NHS 

Foundation Trust’s (the ‘Trust’s’) care. 

2. 

I understand that at the inquest into Ms Ademiluyi’s death, you heard evidence from the Trust’s 

Serious Incident (the ‘SI’) review author outlining the learning that has taken place because of 

her death. I understand that you remained concerned about the risk of future deaths in relation 

to the following areas: 

2.1.  From October 2023 until her death in March 2024, Ms Regina Ademiluyi was deprived of the 

state-funded domiciliary care to which she was entitled. The NHS Trust and Local Authority 

responsible for her care during this period failed to ensure effective care was provided in 

the following ways: 

2.1.1. A safeguarding report submitted by NHS district nurses was insufficiently detailed to 

reflect the concerns that had developed regarding the deceased. The content of the 

safeguarding report did not trigger the threshold to investigate the matter further. 

2.1.2. When  faced  with  the  limited  information  within  the  safeguarding  report  the  Local 

Authority did not seek further information or clarification from the Trust on the basis 

of the report. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 2.1.3. The Trust failed to formally assess Ms Ademiluyi's mental capacity, had they done so it 

is  possible  that  an  Independent  Mental  Capacity  Advocate  (IMCA)  would  have  been 

appointed to act as her voice, over-ruling her daughter's views which may have resulted 

in effective care being put in place. 

2.1.4. Despite  the  concerns  raised  regarding  the  behaviour  of  Ms  Ademiluyi's  daughter  no 

effort was made to offer a carer assessment to address whether she was overwhelmed 

by the task in hand. 

3. 

I  wish  to  assure  you  and  the  family  of  Ms  Ademiluyi  that  the  Trust  has  reviewed  the  issues 

highlighted within the Regulation 28 Report and has planned the actions outlined below. 

RESPONSE 

The safeguarding report 

4. 

I was concerned to hear evidence that the safeguarding report filled out by the Trust’s district 

nurse was insufficiently detailed to reflect concerns and therefore did not trigger the threshold 

to investigate it further.  

5. 

I  asked  that  this  matter  be  reviewed  by  the  Named  Professional  for  Safeguarding  Adults  for 

Newham (the ‘Named Professional’), and Lead Borough Nurse for Newham Community Health 

Services  (the  ‘Lead  Nurse’).  They  liaised  with  London  Borough  of  Newham  Adult  Social  Care 

(LBN) to understand more fully what occurred and how this situation can be prevented in the 

future.  

6.  According to LBN, the referral was screened according to their own internal safeguarding policy 

and the Trust was advised that it met threshold for the Section 42 safeguarding enquiry. However, 

LBN  is  managing  a  backlog  of  such  referrals.  Therefore,  it  was  not  addressed  before  Ms 

Ademiluyi’s sad death. Please refer to LBN’s response to this Regulation 28 report. 

7.  The Trust recognises that all public bodies are currently under pressure. Therefore, it is more 

important than ever that they (the public bodies) work together to ensure that vulnerable adults 

do not slip through the net.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 8.  The Named Professional, the Lead Nurse and LBN have implemented arrangements to improve 

collaborative working and developed processes to escalate any drifting delays and/or cases with 

significant level of risk. These are as follows:  

8.1.  A  strategic  safeguarding  meeting,  which  aims  to  identify  and  address  any  barriers  to  the 

safeguarding process, will take place monthly between LBN and Newham Community Health 

services. 

8.2.  A  safeguarding  forum  attended  by  the  Named  Professional,  the  Lead  Nurse,  Newham 

Community Health Services’ Operational Leads and LBN’s Adult Social Care’s Neighbourhood 

Teams  will  take  place  monthly  to  discuss  current  safeguarding  concerns  and  create 

escalation plans where necessary.  

9.  Whilst the detail in the safeguarding referral was not the reason the safeguarding concern was 

not investigated further; the Named Professional agrees that it provided insufficient information. 

To ensure this does not occur again, the following training and supervision has been arranged for 

Community Health Services staff in Newham area: 

9.1.  Safeguarding  Adults  Training  will  be  delivered  quarterly  to  Newham  Community  Health 

Services. The first module was delivered in May 2024 and will focus on how to complete good 

quality safeguarding referrals. 

9.2.  Each of the Trust’s Named Safeguarding Professionals meets with every single team within 

the  Trust  for  quarterly  supervision.  This  case  has  been  considered  in  the  most  recent 

supervision. 

Further information and joint working 

10.  The Trust is unable to comment on behalf of LBN. However, it can confirm that the two public 

organisations have systems in place which help them to work together closely and collaboratively 

to improve care for service users under both services. 

11.  Additionally,  Newham  Community  Health  Services  staff  have  been  reminded  of  the  Trust’s 

internal escalation pathway which they are expected to follow when there are concerns about 

the safeguarding process between public bodies during supervision. The escalation pathway is a 

tool  to  support  staff  with  recognising  their 

 
 
 
 
 
 
 
 
 
 
 
 
 responsibilities in ensuring they follow up referrals made, and escalate any barriers identified 

without delay. It also ensures that the relevant senior management is aware of concerns.  It has 

been made clear to Newham Community Health Services staff that they should not wait for the 

monthly safeguarding forum to escalate any barriers or problems related to safeguarding process 

initiated by them. 

Mental Capacity  

12.  I  asked  the  Trust’s  Mental  Capacity  Act  Lead  to  explore  issues  surrounding  Ms  Ademiluyi’s 

capacity. They confirmed that in-line with the provisions of the Mental Capacity Act 2005 (the 

“MCA”) the Trust is only the decision-maker in relation to decisions pertaining to her health care. 

The social care provider (LBN) is responsible for assessing capacity in relation to care and support 

needs. 

13.  The Trust does recognise that this area of law can be confusing. Therefore, it has agreed with 

LBN that the forums for collaborative working as described above, will also be used as space for 

any practitioners to discuss concerns related to service user’s capacity.  

14.  Furthermore,  Newham  Community  Health  Services  staff  have  been  reminded,  during  their 

quarterly  safeguarding  supervisions,  about  the  support  offered  by  the  Trust’s  Mental  Capacity 

Act Lead (the “MCA Lead”).  The MCA Lead also supports practitioners with necessary escalations 

across public bodies.   

15.  It is unlikely that an IMCA would be appointed in this situation. According to sections 37-39 of 

the MCA, the statutory requirement for the IMCA to be involved relates to situations when the 

matter pertains to the serious medical treatment or the care plan involves a new, permanent 

place of residence.  

Carer’s Assessment 

16.  The  Named  Professional  for  Safeguarding  Adults  and  Lead  Borough  Nurse  for  Community 

confirmed that staff did not make a separate carer’s assessment. Staff believed that LBN would 

undertake it as part of the safeguarding adult’s response. 

17.  However, anyone can make a carer’s assessment referral and should do so if there are concerns. 

Therefore,  all  staff  were  reminded  during  their 

 
 
 
 
 
 
 
 
 
 
 
 
 most recent safeguarding supervision to either; 1) discuss with carers about self-referring for the 

carer’s assessment; or 2) to support the carer by making referral on their behalf. 

18.  I hope this response provides sufficient reassurances to you and to the family of Ms Ademiluyi 

about the additional learning that has taken place at the Trust because of her sad death.  

19.  I would like to offer my sincere and heart-felt condolences to the family at this difficult time.   

Yours sincerely 

Chief Medical Officer 

Cc:

Mr G Irvine 
Senior Coroner  
Walthamstow Coroner’s Court 
Queens Road 
Walthamstow  
E17 8QP  

Dear Mr Irvine  

Adults and Health (DASS) 
London Borough of Newham 
1000 Dockside Road 
London 
E16 2QU 

10th May 2024 

Re: Regulation 28 Report concerning Regina Olufunmilola Ademiluyi (Ref: 22689174) 

Response from the London Borough of Newham  

Thank you for sharing the conclusion of your Inquest into Mrs Ademiluyi’s death, and the subsequent 
Regulation 28 Report. May I start by expressing my sincere regret and disappointment to learn of 
the circumstances surrounding Mrs Ademiluyi’s passing. On behalf of the Council I wish to place on 
record  our  deepest  condolences  to  her  family  and  friends  and  all  those  that  knew  her.  We  fully 
acknowledge the findings from the Inquest and are firmly committed to putting actions in place to 
address  the  concerns  raised  in  the  Prevention  of  Future  Deaths  report  to  ensure  that  a  similar 
situation is not repeated. 

A core group of Senior Officers from within the department have reviewed Mrs Ademiluyi’s case in 
detail  and  have  developed  a  series  of  direct  actions  in  response.  I  have  summarised  the  key 
elements below with associated timescales, and grouped this against the thematic areas from the 
Regulation 28 Report. I hope this addresses any unanswered questions, the areas for improvement 
and gives assurance on the actions we are taking.  

1.  Reflection and Learning     

1.1 

Action: 
Immediate s.44 Safeguarding Adult Review (SAR) 
Referral completed and submitted for presentation at 
the next SAR subcommittee of Newham’s 
Safeguarding Adults Board on 7th May 2024 

By who: 
Team Manager 
Neighbourhood 
Team  

By when: 
27.03.24 

1.2  Review and improve training and awareness of 
pressure care and risks for ASC staff. This will 
include: 
 

Incorporating mandatory pressure care 
refresher training for all Operational ASC staff 
into 2024/25 training plan.   

Strategic 
Safeguarding, 
Practice and 
Workforce 
Development 
Team 

July 2024 

Page 1 of 5 

       
 
 
 
 
 
 
 
 
 
 
 
 
   Session content to include overview of 
pressure sore reporting and notification 
processes, and its interface with Safeguarding 
Adults.  

1.3  Convene focussed reflective practice sessions for 

frontline operational staff based around 
circumstances highlighted in Mrs Ademiluyi’s care, 
thematically orientated around “professional curiosity” 
and “cultural needs vs. risks” (reinforcing the 
message that risk management comes first). 

1.4  Creation of an anonymised ‘7 minute briefing’ note 
concerning the lessons learned from this case for 
circulation across all Adults and Health staff groups 
at LBN.  

December 
2024 

June 2024 

Strategic 
Safeguarding, 
Practice and 
Workforce 
Development 
Team   

Strategic 
Safeguarding, 
Practice and 
Workforce 
Development 
Team 

2.  Continuity of Care Funded via Direct Payments 

Action: 

2.1  Desktop reviews of all current DP users with double-

handed packages for indicators of under-utilisation of 
care.  

By who: 
Direct 
Payments 
Team  

By when: 
End of 
May 2024 

Through 2022/23 work took place to review and 
improve DP monitoring processes with a series of 
changes coming into effect from August 2023. This 
included an increase to the number of established 
posts for DP Monitoring Officers. This has allowed for 
faster feedback to operational teams on any future 
monitoring issues/irregularities  

In addition to this, the new DP set up process 
provides additional 'hand holding' support for the first 
6 weeks to ensure that DP recipients and their 
representative(s) fully understand how to utilise their 
DP. 

2.2  Undertake a review of the Council’s Direct Payment 

Policy, and develop associated practice guidance 
(including a practitioner checklist). This will 
encompass:   

  Non-transfer of DP cases for annual reviews 
where PAs are not engaged and a mental 
capacity assessment / best interest decision 
has not been completed.  

December 
2024 

Direct 
Payments 
Project 
Group 

Page 2 of 5 

       
 
 
 
 
  
  
 
 
 
 
   The recording of mental capacity / best 
interest decisions pre-agreement of DP 
(explicitly in relation to managing/coordinating 
care and not solely payment administration). 

  Triggers for further mental capacity 

assessment / best interest decisions if the 
person’s DP circumstances have changed (for 
existing DP users).  

  Explicit processes for DPs for individuals with 
double-handed care needs, including assisting 
and moving assessment and training 
requirements for PAs.  

  Processes for hospital discharge to existing 
DP packages without full PA coverage. An 
interim process has been implemented by the 
Discharge and Assessment Team to ensure 
evidence is seen that PAs are in place before 
DP packages are increased from hospital. 
  The interface of quality in care concerns and 

Safeguarding Adults thresholds.  

2.3 

Implement a defined process for 3rd Party Fund 
Managers to escalate issues relating to PA sourcing 
to LBN, within specified time bands.  

Direct 
Payments 
Team  

July 2024 

2.4  Enhancements to be made to the AzeusCare case 
management system to make double-handed care 
packages more prominent for system users and 
reportable. The longer-term solution will require 
development from the software supplier; in the short 
term other local options are being considered 
including flags and additional question(s) in core 
forms.  

December 
2024 

Head of 
Brokerage 
and 
Transaction 
Management  

3.  Mental Capacity and Decision Making 

3.1 

Action: 
Improve consistency of MCA practice and decision 
making in the context of best interest decisions which 
override family where appropriate (including the use 
of Independent Mental Capacity Advocacy). This will 
encompass:  

  Themes from Mrs Ademiluyi’s case being 
shared with the borough’s MCA Oversight 
Group.  

  Reviewing MCA training and refresher offers 

for staff to ensure it encompasses all 
Page 3 of 5 

By when: 
July 2024 

By who: 
Strategic 
Safeguarding, 
Practice and 
Workforce 
Development 
Team 

       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 professional groups in ASC (including non-
qualified frontline staff, Social Workers and 
Occupational Therapists). 

  Developing specific training interventions for 
Occupational Therapy staff regarding the 
application of the Mental Capacity Act in 
practice – this has been planned as a topic for 
the borough’s cross-organisational OT Peer 
Learning session in May 2024. A separate 
formal training date is being planned.  

Principal 
Occupational 
Therapist 

4.  Support for Informal/Family Carers  

Action: 

4.1  An all-age Carers Strategy is in place for the borough 
and overseen by a multi-agency delivery board. 
Further work has taken place through 2023/24 to 
update carer definitions, improve recording 
processes and enhance documentation used by 
frontline staff with carers.  

By who: 
Carers 
Strategy 
Delivery 
Board  

By when: 
End of 
May 2024  

In addition, a suite of new public-facing videos and 
improved carer information resources have been 
created. These will go live in May 2024. 

An updated round of refresher training on carer 
awareness for all frontline ASC staff is being rolled 
out in May 2024.  

4.2  Develop specific guidance for frontline ASC staff on 

informal/family carers and Safeguarding Adults.   

End of 
June 2024 

Strategic 
Safeguarding, 
Practice and 
Workforce 
Development 
Team 

In addition to this summary of internal action, we also recognise that further activities need to be 
considered  with  our  system  partners  at  East  London  NHS  Foundation  Trust  (ELFT).  Regular 
Safeguarding meetings have now been established between ELFT Community Health Newham and 
the  Council’s  Neighbourhood  Teams  for  Older  People  and  Disabilities  (mirroring  the  same 
processes which are in place in Mental Health services and have been shown to be successful in 
improving communication between professional groups). This space will be used to address issues 
such  as  the  quality  of  referrals,  thresholds  and  reoccurring  safeguarding  themes.  Attendance  at 
these  meetings  will  also  be  reviewed  to  consider  involvement  from  the  Council’s  Safeguarding 
Adults Team who are responsible for screening referrals. 

We also intend to work with ELFT to jointly review the information provided to families and informal 
carers about pressure care, the associated risks and exacerbating factors (for example, friction and 

Page 4 of 5 

       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 double incontinence). Alongside this we are eager to convene a shared learning event with multi-
disciplinary staff from across both organisations to explore the themes identified in Mrs Ademiluyi’s 
case from a clinician/practitioner perspective. These discussions are being progressed separately 
with our counterparts at the Trust.   

Governance and Oversight    

The Directorate Management Team (DMT) for Adults and Health and the departmental Quality and 
Governance Board have been sighted on the action points identified here. All elements of the full 
plan are now linked to named senior officers with accountability for their delivery. Oversight of the 
action  plan  is  being  held  by  the  Practice  and  Workforce  Development  Team  who  will  monitor 
progress against the stated timescales and then report back to the Quality and Governance Board. 
We also recognise that the overall plan will need to remain agile and be adapted if further information 
comes to light, particularly if Mrs Ademiluyi’s case is the subject of an independent Safeguarding 
Adults Review (SAR).    

Thank you again for raising this matter with us. I hope this response gives adequate assurance on 
the actions we have taken on the improvements required.    

Please do not hesitate to come back to me if you require further information or updates.   

Yours sincerely, 

Head of Older People and Disabilities 

CC: 

Chief Executive 
Corporate Director of Adults and Health  
Director of Operations (Adults) 
Director of Change, Improvement and Control  
Director of Quality Assurance, Safeguarding and Workforce Development 
Head of Law (Community)     

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