Neville Abbott

Chief Executive’s Office  
BCP Council Civic Centre  
Bourne Avenue 
Bournemouth  
BH2 6DY 

FAO   Mr Allen 

Sent via email: Dorset Coroners 

Date         19 June 2024 
Your ref    2309778 
Our ref     GF/ER 
Contact   

Dear Mr Allen, 

Re Regulation 28 Report following the inquest touching on the death of Neville Abbott 

We acknowledge receipt of the Regulation 28 Report issued to BCP Council following the inquest 
touching on the death of Mr Neville Abbott. The report, dated 3 May 2024, was received by BCP Council 
on the same day. Our thoughts are with Mr Abbott’s family following their loss.  

After Mr Abbott died, we undertook a review of the care and support offered and we have made changes 
to the way in which we support people who find it difficult to engage with support services. These 
changes were shared with the Inquest parties in our Action Plan. 

Following the Inquest, we undertook a series of debrief discussions with the witnesses and the further 
learning and actions are included in our response to your concerns below. 

In respect of the specific Regulation 28 matters of concern notified to the Council, I will respond to each 
of these in turn: 

1. 

The lack of use of the Professionals Checklist by the Adult Social Care (ASC) Practitioners 
who had contact with Mr Abbott. 

We linked with the practitioner and manager, who still works for ASC, as part of a debrief after the 
Inquest. During these discussions, they shared that several actions to prevent future deaths had already 
been undertaken and they made several reflections on how the Inquest has impacted on their practice: 

The reflections of the practitioner, in relation to their own practice and actions, are listed below: 

a)  Gained a deeper understanding of her responsibilities as a registered practitioner to provide 

direction to non-registered practitioners. 

b)  Reflection that undertaking a Care Act assessment of Mr. Abbot’s needs could have prompted 
consideration of other interventions or prompted convening a Multi-Agency Risk Management 
meeting (MARM). 

c)  Reflection that had she or her colleague sought management oversight, the above may have 

been prompted. 

‘BCP Council’ is the operational name for Bournemouth, Christchurch and Poole Council. 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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d)  Reflection that had she completed a Self-Neglect Checklist, she would have considered 

convening a MARM and will do so in the future. 

e)  The above reflections have prompted her to now require practitioners who she oversees to 

undertake regular contact with people living in similar circumstances to Mr. Abbott, i.e. a weekly 
welfare check. 

f)  Reflection that a MARM can be effective in sharing information and a method to escalate 

unmitigated risks; she was supportive of Option 2.1.f below re: Complex Case Panel as a method 
of escalating issues within ASC and with partner agencies, such as contact with Community 
Mental health Team. 

The reflections of the manager, in relation to their own practice and actions, are listed below: 

g)  Prompted discussion with the practitioner above, to facilitate reflection during and after the 

Inquest.  

h)  Prompted discussion with peer managers, which has led to an approach of undertaking regular 

face to face welfare checks with people who find it difficult to engage and where risks are not fully 
mitigated.  This included managers considering enabling joint working of such cases. 

i)  Prompted review of all people where ASC manages their finances, to ensure any concerns for 

welfare are addressed and monitored as detailed above. 

j)  Reiterated need for management oversight of all cases and closures, i.e. managers must ensure 
a case note is added to the person’s record and include any actions/options that have been 
discussed as required. Regular monitoring should be undertaken and recorded by the manager 
to ensure actions are completed. 

k)  Prompted discussion within Locality and Acute Hospital Services to raise awareness of the Self-
Neglect checklist, MARM framework and to encourage their use were discussed at the service 
managers planning meeting. This has led to service managers discussing in their team managers 
meeting and further cascading to front line staff.  This included raising awareness of available 
self-neglect/hoarding training and MARM Training.  

l)  Checked that safeguarding training is up to date for all practitioners and instructed uptake if not. 

m)  Reminded managers that all cases should be risk screened using the Risk and Demand 

Guidance (so high-risk cases allocated quickly).  

n)  Reminded managers to check that assessment of risk in assessments is robust and that a full risk 
assessment is completed where unmitigated risk is identified. Ensure risk assessment is shared 
where necessary and communicate with partner agencies over mitigation of risk, possibly through 
use of a MARM. Ensure practitioners give evidence-based rationale for both actions and 
inactions. 

o)  Reminded managers of need to raise awareness with practitioners of the need to consider 

executive functioning alongside capacity; specifically, to explore why a person is making what 
appear to be unwise decisions and whether they have the skills to carry out tasks to improve the 
quality of their lives and are perhaps choosing not to because they can’t achieve it without 
support.  This relates to professional curiosity and not assuming capacity if there may be reasons 
to doubt it.  

p)  Reminded managers to encourage practitioners to use professional curiously and not accept the 

status quo without thorough assessment of needs and risk.  

q)  Reminded managers to discuss cases where consent to contact family/those with an interest in 

the person to be revisited if refused and ensure contact details for Next of Kin are recorded when 
consent given.  

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r) 

In relation to the General Practitioner Multi-Disciplinary Team meetings, which are held weekly in 
most surgeries, when actions are identified the person will remain on Virtual Ward to ensure any 
actions have been completed satisfactorily. 

s)  Reminded managers to ensure they and practitioners have good legal literacy and seek advice, 

to ensure all statutory interventions and frameworks are considered.  

In respect of your concern that little has changed regarding the awareness and use of the Professionals 
Checklist more widely in ASC, we will respond to this below - however, we also hope that the actions 
detailed above provide reassurance too. 

2. 

The lack of knowledge of and use of the Professionals Checklist by ASC practitioners.  
Consequently, missing the requirement to consider calling a MARM. 

The changes we have made are detailed below:  

a.  On 6 June, we instructed all operational staff in ASC via email to complete the Self-Neglect 
Checklist when they are allocated a person who appears to find engaging with services 
challenging.  We will update our own ‘Managing Risk and Engagement Guidance’, to include this 
information. 

b.  The Self-Neglect Checklist is now much more prominent on our updated Adult Social Care 

intranet site, to help raise awareness in the future. 

c.  Based on the above instruction, we will also be holding a mandatory webinar for all staff on 26 
June 2024. The purpose of this webinar is to further highlight what constitutes self-neglect, to 
highlight the guidance that is available in the Safeguarding Adults Board (SAB) Procedures and 
our own guidance, including the requirement to use the Self-Neglect Checklist. We will remind 
practitioners that they are required to undertake a Risk Assessment if a person ‘declines an 
assessment, services or support’ and to discuss this issue with their line manager. We will 
promote the use of the MARM framework in supporting the formulation of a multi-agency risk 
assessment and management plan. 

d.  We will continue to direct all case holding ASC staff to watch the SAB MARM training videos at 

the above webinar. 

e.  We will be undertaking a deep dive audit during June and July into cases where self-neglect is 

mentioned in case records. We will be looking for assurance that practitioners have been curious, 
assertive and have sought to manage risks appropriately, including consideration of holding a 
MARM. We will seek to redress any circumstances where risks are not managed appropriately 
through robust practice and management oversight, escalating matters to Section 42 Enquiries if 
necessary. 

f.  We are undertaking a review of our existing Self-Neglect & Hoarding Panel function to explore 
whether a Complex Case Panel is more likely to prompt practitioners to escalate cases where 
risks are not fully mitigated. We anticipate that this will allow a formal route for practitioners to 
escalate issues to both their own senior managers, but also other partner agencies. We aim to 
have completed this review by August. 

g.  As part of our ongoing improvement journey, we will be publishing Mental Capacity Act practice 

guidance in August. This guidance includes reference to self-neglect and links it with the need to 
consider assessment of executive functioning when people are self-neglecting. We are 
developing a plan on how to promote the practice guidance; we intend on its publication being 
high profile within services. 

h.  We will continue to operate monthly peer group drop-ins for practitioners to discuss complex 

cases with advanced practitioners. 

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 I hope this detailed information is useful to you and reassures you about the depth of our response to the 
issues raised in this case, but please let me know if you need any more information. 

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Yours sincerely, 

Chief Executive   
BCP Council  

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