Christopher Vickers

Ms Leila Benyounes 
Assistant Coroner for Gateshead and South Tyneside 
Coroner Office 
Town Hall and Civic Offices 
Westoe Road 
South Shields 
Tyne and Wear 
NE33 2RL 

Dear Maam  

Inquest touching the death of Christopher Vickers 

We write to formally respond to your Preven�on of Future Deaths (PFD) Report, dated 29 February 
2024, following the sad death of Mr Vickers. We note that the Regula�on 28 Report is directed to 
both Cumbria, Northumberland Tyne and Wear NHS Founda�on Trust (Trust) and South Tyneside 
Council. This response is provided on behalf of the Trust.  

We note that your concerns in this mater relate to mul�ple missed opportuni�es to not follow clear 
processes and policies in rela�on to safeguarding referrals and the conven�on of a mul�-
disciplinary/mul� agency mee�ng.  

As a Trust we have given Mr Vickers' death and the learning associated with it significant 
considera�on, and have implemented a number of changes to ensure that, where appropriate, 
relevant safeguarding referrals and mul�-agency mee�ngs are convened.  We have made changes to 
our prac�ces, mul� agency working and monitoring, details of which are described below.   

As explained at the inquest, since Mr Vickers' death, there has been a lot of work within the Trust to 
improve awareness and skills, through bespoke training, email communica�on and team mee�ngs.  
This has emphasised the importance of when referrals to safeguarding should be made, and what 
process should be followed.  

Process and Systems Change 

Within the Crisis and ADHD team, MDT (Mul�-Disciplinary Team) processes have changed, and 
safeguarding and considera�on of a mul�-agency mee�ng is now a standing agenda item.  It serves 
to act as a reminder to clinicians to review and ensure all areas of iden�fied risk have been 
addressed, and responded to where appropriate.  

Similarly in the Community Treatment Team (CTT), Safeguarding and mul�-agency mee�ngs are also 
now a standard item on the agenda for the mee�ngs.  MDT mee�ngs take place a�er each 
assessment, replacing previous prac�ce which could be a conversa�on between the people carrying 
out the assessment (as was the case with Mr Vickers). 

In addi�on, staff also have the opportunity to refer to a complex case panel with a prac�ce guidance 
note to assist with that process.   

 
 
 
 
 
 
 
 
 
 Within Crisis services a new process of a weekly telephone triage review has been implemented. This 
looks at calls to the Crisis Team, which have not required a face-to-face assessment, as was 
some�mes the case in the past and in rela�on to Mr Vickers.  

This new process looks at 5 records where there have been mul�ple triage contacts within the last 5 
months, in addi�on to 5 random telephone triages. As part of this review, the quality and safety of 
the contact is considered and this includes checking to see if any safeguarding issues have been 
ac�oned and if appropriate, and whether a mul�-agency mee�ng should have been convened.  

Safeguarding issues are reported through an incident repor�ng system, which is reviewed by a 
dedicated Safeguarding Prac��oner who will offer any relevant safeguarding advice to the repor�ng 
service and its manager. This advice will, where appropriate, advise on local authority referral and 
mul�agency communica�on, with any recommended ac�ons monitored by managers. A template 
has now been implemented for the Safeguarding Prac��oner to assist with ensuring that the advice 
is provided in a consistent way.   

In Mr Vickers' case, the concerns highlighted around referrals to safeguarding related to issues of 
domes�c abuse to others. Since Mr Vickers' death the Trust's Mul�-Agency Risk Assessment 
Conference (MARAC) policy (now the domes�c abuse policy) has been updated and circulated to 
staff via the Trustwide policy bulle�n. As part of this policy, there is guidance for staff around 
iden�fying if someone is at risk of abuse and when a referral for a MARAC should be requested 
(which is a police coordinated mul� agency mee�ng including health representa�ves, police and 
children and adult social care).  However, following the inquest, a decision was made to review the 
domes�c violence policy, and this is due to be completed by July 2024, to ensure that the Trust 
incorporates all the learning from this inquest, and other incidents, and provides clarity on staff roles 
and responsibili�es in rela�on to safeguarding referrals.  

Monitoring Arrangements 

Within all teams, clinician supervision takes place every 4 weeks, which includes a random sample of 
cases being checked, and safeguarding and the need for convening a mul�-agency mee�ng is now 
embedded as part of this review process.  

With regard to the Crisis Teams, along with the telephone triage review, a monthly audit of 20 
random triage calls also takes place, to ensure all ac�ons have been iden�fied and implemented. 

A compliance audit against the domes�c abuse policy will look to ensure that MARAC referrals are 
being ac�oned in line with Safeguarding advice. 

Family and Carers  

In addi�on to the above, a significant amount of work has been carried out to improve engagement 
with families and carers, which in turn will improve the iden�fica�on of any concerns of domes�c 
abuse so that relevant ac�ons can be taken in response.  This is incorporated into our new risk 
assessment framework which went live on 7th April 2024 and in the Triangle of Care Improvement 
area which is a quality priority for the Trust. 

We hope that the ac�ons elaborated above addresses your concerns, but please contact us if you 
have any ques�ons or comments to ensure that we as a Trust learn from this sad event and make our 
care safer for those who require it. 

 
 Your sincerely 

Medical Director / Deputy Chief Execu�ve

Inquest touching the death of Christopher Paul Vickers 

Prevention of Future Deaths Report  
(Regulation 28): South Tyneside Council’s response  

Date: 23 April 2024 

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response 

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 INTRODUCTION FROM SOUTH TYNESIDE COUNCIL  

South Tyneside Council would like to express its deepest condolences to Christopher’s 
family and friends.   

Changes had already been made at the time of Christopher’s inquest, however we have 
further re-evaluated our internal policies and procedures in light of the evidence heard 
and the concerns of the Coroner.   

Below we respond to each of the Coroner’s concerns setting out what we have already 
done,  what  we  are  doing  now  and  what  we  intend  to  do  in  the  future  (including  our 
timetable for action where applicable).  

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response 

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 CORONER’S CONCERNS IN RELATION TO SOUTH TYNESIDE COUNCIL 

1. There were multiple missed opportunities to co-ordinate the Deceased’s care with 
the  convention  of  multi-disciplinary  and  multi-agency  meetings  despite  known 
escalating risks. 

2. There were multiple repeated missed opportunities to make safeguarding referrals 
for  formal  safeguarding  supervision  from  the  safeguarding  adult  public  protection 
team despite known escalating risk to self and to others.  

Further, ‘…the missed opportunities were significant and multiple and relate to clear 
processes and policies that were not followed’.  

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response 

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 SOUTH TYNESIDE COUNCIL’S RESPONSE 

1.  Action taken prior to inquest: 

1.1.  Multi-agency working 

Multi-agency  working  is  key  to  effective  safeguarding  and  work  has  been 
undertaken to develop and improve multi-agency working with partner agencies 
that support adults with complex mental health needs.  There is a commitment 
from  South  Tyneside  Council  and  partner  agencies  to  ensure  that  vulnerable 
individuals  receive  the  appropriate  care  and  support.  Through  improved  multi-
agency  working  agencies  provide  a  more  seamless  response  to  those  with 
multiple  and  complex  needs.  This  collaborative  working  has  ensured  that 
individuals receive the support they need, in a timely manner. 

To ensure effective collaborative, multi-agency working, a number of new multi-
agency meetings and groups have been established.  These include: 

•  South Tyneside Interface Meeting – a monthly meeting that is attended 
by the Service Manager for South Tyneside Adult Mental Health Service and 
leads from the Community Treatment Team (CTT), the Assertive Outreach 
Team  (AOT),  Psychiatric  Liaison  Team  (PLT)  and  the  Crisis  Team.    The 
purpose  of  the  meeting  is  to  provide  a  forum  for  open  communication 
across  the  agencies  to  address  issues,  concerns,  decision  making  and 
planning. 

•  High  Intensity  User  Group  –  a  monthly  meeting  that  is  attended  by  the 
Service  Manager  for  South  Tyneside  Adult  Mental  Health  Service  and 
operational leads from the relevant agencies.  The purpose of this group is 
to have oversight for individuals who have repeat and frequent interactions 
with the agencies.  The purpose of this group is to ensure that the individual 
is  receiving  the  right  support  from  the  right  agency  to  achieve  the  best 
possible outcome for them.   

•  Near  Miss  Project  Group  –  a  monthly  meeting  that  is  attended  by  the 
Service  Manager  for  South  Tyneside  Adult  Mental  Health  Service  and 
operational leads from the relevant agencies.  The purpose of the meeting 
is to have oversight for individuals with complex mental health needs who 
are at high risk of death from misadventure.  The group provides assurance 
that these individuals are receiving the right support from the right agency 
to reduce risk and achieve the best possible outcome for the individual. 
•  Suicide  Prevention  Group  –  a  meeting  that  is  attended  by  the  Service 
Manager for South Tyneside Adult Mental Health Service and operational 

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response 

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 leads  from  the  relevant  agencies  when  required.    The  purpose  of  the 
meeting is to bring together the relevant agencies when it is identified that 
an individual or individuals are at high risk of suicide.  The group provides 
assurance that these individuals are receiving the right support from the 
right agency to reduce risk and achieve the best possible outcome for the 
individual. 

•  Weekly MDTs – these are weekly multi-disciplinary team meetings that are 
attended by practitioners from mental health and social care services to 
discuss high risk individuals.  The purpose of the meeting is to discuss risks 
and  concerns,  agree  roles  and  responsibilities,  agree  actions  to  reduce 
risk, and agree co-ordinated support to achieve the best possible outcome 
for the individual. 

•  Corporate Risk Register – all high risk cases that are identified by South 
Tyneside  Council  Mental  Health  Team  are  placed  on  the  Corporate  Risk 
Register, which provides oversight and assurance to Senior Management.   

1.2.  Police Triage 

The Police have a duty to recognise the signs and symptoms of abuse and to act 
on  any  concerns.  This  includes  notifying  the  Local  Authority  of  safeguarding 
concerns  relating  to  vulnerable  adults.    The  process  for  the  Police  to  refer 
safeguarding  concerns  to  South  Tyneside  Council  is  via  a  Police  Concern 
Notification  (ACN)  form.    Adult  Social  Care  receives  ACNs  from  Northumbria 
Police daily and the number of ACNs has significantly increased year-on-year.   

To ensure that people referred to Adult Social Care via the Police ACN receive the 
right  response,  a  Police  Triage  Process  was  established  in  January  2023.  This 
involves  a  multi-agency  meeting  that  takes  place  every  morning  between 
representatives  from  Northumbria  Police,  South  Tyneside  Adult  Safeguarding 
Team, South Tyneside Homes, and Adult Social Care Let’s Talk Team (first point of 
contact service).  The MDT discuss ACNs received, share information, and agree 
the  most  appropriate  action,  including  whether  to  progress  to  safeguarding 
procedures.    Where  it  is  agreed  that  safeguarding  procedures  are  needed,  the 
Safeguarding Team Social Worker ensures that the individual is transferred to the 
Safeguarding Team or allocated Social Worker on the same day, so that actions 
can  be  progressed  to  safeguard  the  individual.  Individuals  that  receive  repeat 
ACNs  are  identified  as  part  of  the  Police  Triage  and  are  considered  in  a  wider 
context  so  that  a  holistic  assessment  of  risk  can  be  made,  and  appropriate 
referrals, and escalations made to safeguard the individual.    

1.3.  Decision Making Forum 

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response 

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 Adult Social Care in South Tyneside has a number of teams that support adults 
with care and support needs. These include: 

•  Neighbourhood  Teams  x  3  –  that  support  adults  with  care  and  support 

needs. 

•  Mental Health Team – that supports adults with diagnosed mental health 

conditions that mean they have care and support needs. 

•  Learning  Disabilities  Team  –  that  supports  adults  with  a  diagnosed 

learning disability and have care and support needs. 

•  Let’s Talk Team – first point of contact for adults who present with care and 
support needs and are not involved with another Adult Social Care team. 
•  Hospital  Discharge  Team  –  that  supports  adults  with  care  and  support 

needs that are in hospital and need support at discharge. 

Adult Social Care recognised that it is not always clear which team is the most 
appropriate  team  to  support  an  individual  and  therefore  there  were  occasions 
when individuals were passed around different social care teams.  This results in 
individuals  not  receiving  the  most  appropriate  support  and  increases  the  time 
they wait for social care interventions.   

To address this issue, in January 2023 Adult Social Care set up a weekly Decision 
Making Forum. The purpose of the Forum is to bring together representatives from 
adult social care teams to agree which team is best placed to provide support and 
interventions  that  produce  the  best  possible  outcomes  for  individuals  with 
complex care and support needs when this is not clear. 

The aims of the Decision-Making Forum are:  

•  To ensure the individual receives the right support, in a timely manner, 
from appropriately trained, experienced and qualified practitioners.  
•  To reduce the number of contacts, ensuring the individual remains the 

focus of our conversations, interventions, and responses.  

•  To provide flexible responses to individual needs and circumstances.  
•  To  empower  participants  to  make  consistent  decisions  and  to  be 

confident in the rationale for those decisions.  

•  To ensure we work within legal frameworks and statutory guidance.  
•  To  ensure  practice  and  outcomes  for  people  are  fair,  lawful,  and 

reasonable. 

•  To evidence management oversight of decisions.  

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response 

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 1.4.  Risk Management Forum 

Adult Social Care has seen a significant increase in the number of safeguarding 
concerns it receives and an increase in the number of people that are referred 
who have multiple and complex needs, resulting in a high risk to the individual 
and/or  others.    To  support  staff  with  the  risk  management  of  these  high  risk 
individuals,  in  March  2023,  Adult  Social  Care  set  up  a  weekly  Risk 
Management  Forum  that  has  oversight  from  Service  and  Senior  Managers 
from  across  the  service.   The  purpose of the  Forum  is  to assist  Adult Social 
Care workers in the interventions they provide to people who have social care 
needs and whose planned outcomes are not being achieved despite the best 
efforts of Adult Social Care and other professionals, and for whom risks remain 
or are increasing.  This ensures the service has oversight of people who may 
be at risk of suffering from severe harm or death. 

Guidance for the Risk Management Forum describes risk as:  

•  Risk is the probability that an event will occur with harmful outcomes for 

a particular person or others with whom they come into contact.  

•  Risk  is  a  product  of  the  likelihood  that  an  event  will  happen  and  the 

impact that the thing happening will have if it does happen.  

High risk individuals are described as: 

• 

• 

• 

Individuals  living  in  the  community,  whether  by  themselves,  with  their 
families  or  in  supported  accommodation  or  residential  care,  who  are 
exhibiting behaviours which create a risk of significant harm, whether to 
self  or  others,  through  violence,  offending,  self-harm,  or  serious 
substance misuse.  
Individuals  with  multiple  complex  needs  at  risk  of  poor  outcomes  - 
individuals that have both mental health problems and substance misuse 
issues;  mental  health  problems  and  learning  disability  or  unresolving 
severe mental illness.  
Individuals  that  may  have  suffered  previous  trauma  which  impacts  on 
their decision making are harder to reach or difficult to engage.  

1.5.  Quality Assurance - Audit 

South Tyneside Council Adult Social Care is committed to delivering the highest 
standards  of  quality  in  social  care  for  adults.  To  ensure  the  delivery  of  high 
quality  social  care,  Adult  Social  Care  developed  and  implemented  a  new 
Quality Assurance Framework in April 2023, which includes a range of activities 
to  monitor  compliance  with  policies  and  procedures;  evidence  strengths  and 

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response 

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 good practice; identify gaps and areas for development; and drive learning and 
service improvement. The Quality Assurance Framework provides assurance 
that the Adult Social Care effectively delivers its statutory duties. This means 
keeping  adults  safe,  promoting  positive  outcomes,  and  ensuring  agreed 
standards are being met.  

Auditing  makes  up  a  substantial  part  of  our  Quality  Assurance  programme, 
offering insight into the strengths and areas for development of our practice and 
the  impact  on  adults.  New  Practice  Quality  Audits  and  Safeguarding  Audits 
have  been  developed  and  were  implemented  in  April  2023.    These  are 
undertaken  by  supervisors  at  all  levels  as  part  of  a  shared  commitment  to 
understanding the quality of practice. Auditing provides an opportunity to pause 
and reflect on the quality of case work, and on the impact our assessments and 
interventions make towards positive outcomes for adults and their family. The 
Practice  Quality  Audits  and  Safeguarding  Audits  are  designed  to  provide  a 
broad focus on standards and compliance, as well as the quality of social care 
practice. The audits are used to take stock of performance across all areas of 
social  work  intervention  at  regular  intervals.  They  focus  on  the  journey  and 
experience of the adult through services, as well as the rationale for decisions 
being  made  on  their  behalf.  They  allow  Adult  Social  Care  to  identify  if  the 
support that has been offered is planned, purposeful and undertaken in a timely 
manner. Crucially, these audits go beyond the marking of compliance, and seek 
to generate qualitative data about our practice, its impact on the adult, and how 
the  system  and  organisation  supports  good  practice,  as  well  as  identifying 
areas of development. 

The Practice Quality Audits are based on our Practice Standards, of which there 
are six. Standard Five relates to safeguarding: 

Standard Five: Safety  
We talk to people openly about risk and to help them to manage risks.  We help people to think 
about ways of staying safe and we listen to what is important to them. Making sure their 
experience is personal.  
Evidence that:  
Any risks identified have been done so in partnership with the person and / or 
their carer and are evidenced based.  
Approaches to risk demonstrate positive risk taking and informed decision 
making.  
Any risks identified are reflected in the person’s conversation record, clearly 
stating how they have been agreed to be managed or maintained.  
Any risk intervention is proportionate to the individual’s circumstances but leaves 
no doubt they have been fully considered.  

Yes/No/NA  

Yes/No/NA  

Yes/No/NA  

Yes/No/NA  

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response 

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 People with significant risks e.g., risk to life or others, which requires ongoing 
monitoring and review have been considered within a multi-agency meeting 
involving the person where applicable with clearly defined actions and 
responsibilities.  
People with significant risks e.g., risk to life or others, which requires ongoing 
monitoring and review have been considered within the LA Risk Management 
Panel where applicable and have been identified in LA recording system via a Risk 
Indicator.  
Any appropriate multi-agency pathways e.g., MARAC/ MAPPA have been explored 
and involved where applicable.    
Any safeguarding concerns have been identified and addressed effectively, with 
reference to LA guidance and Multi Agency Safeguarding Procedures.  
Where safeguarding concerns are identified, key principles of Adults Safeguarding 
are demonstrated, and Making Safeguarding Personnel (MSP) is evident.  
Comments - 
Auditor  
Comments - 
Practitioner  
Quality 
Rating  

Requires 
improvement  

Outstanding  

Adequate  

Good  

Yes/No/NA  

Yes/No/NA  

Yes/No/NA  

Yes/No/NA  

Yes/No/NA  

Each practitioner has one Practice Quality Audit per quarter, so a total of four 
Practice Quality Audits per year. 

The focus of the Safeguarding Audits relates to the quality of the Safeguarding 
practice and the decisions made.  There are two Safeguarding Audit tools that 
consider  practice  in  relation  to  Section  42(1)  and  Section  42(2)  procedures.  
Safeguarding  Team  practitioners  have  two  Sec  42(1)  and  Sec  42(2)  audits 
completed each quarter, so four Sec 42(1) and four Sec 42(2) audits per year.  
Practitioners in all other social work teams have one Sec 42(1) audit and one 
Sec 42(2) audit per year. 

1.6. 

Tools and Guidance 

1.6.1.  South Tyneside Safeguarding Adults Threshold Guidance Tool  

A new Safeguarding Adults Threshold Guidance Tool has been produced by the 
Safeguarding  Adults  Board,  which  was  launched  in  July  2023.    The  threshold 
guidance supports professionals across the partnership to understand when it is 

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response 

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 necessary  to  refer  an  individual  to  the  local  authority  under  the  safeguarding 
adults’ procedures. The aim of the guidance is: 

• 

to ensure a consistent approach to identifying what concerns may require 
a response under the safeguarding process, and  

•  support decision making when alternative processes should be used.  

Within the Guidance there is a clear matrix that gives examples of when a situation 
must be taken into adult safeguarding procedures. This includes ‘self-neglect’ as 
a category of abuse and examples of high risk self-neglect include: 

• 
• 

‘Behaviour poses risk to self and others’, and 
 life is in danger without intervention. 

The  Threshold  Guidance  has  been  launched  across  all  adult  social  care  teams 
and  training  has  been  provided  on  how  the  tool  should  be  used.    There  is  an 
expectation  that  all  staff  use  the  guidance  when  making  decisions  about 
safeguarding,  and  the  rationale  for  their  decision  must  be  recorded  in  case 
records.  Adherence to this process, and quality of decision making is assured via 
the Adult Social Care Practice Quality Audits.  Each social care worker has one of 
their cases audited per quarter, so four audits per year.   

South Tyneside Safeguarding Adults Thresholds Guidance Tool – South Tyneside 
Safeguarding Adults Board APPP (southtynesidesafeguardingappp.co.uk) 

1.6.2.  South Tyneside Safeguarding Adults Self-Neglect Guidance 

The  Self-Neglect  Guidance  was  developed  by  the  Safeguarding  Partnership  in 
collaboration with practitioners from across the partnership in November 2023. 
The  purpose  of  the  toolkit  is  to  support  professionals  that  are  working  with 
individuals  who  are  at  risk  due  to  self-neglect.      It  emphasises  that  the  Local 
Authority has a duty to make safeguarding enquiries where a person may be at risk 
of harm due to self-neglect and includes ‘inability to avoid self-harm’ as a type of 
self-neglect. 

The  Self-Neglect  Guidance  was  launched  across  all  adult  social  care  teams. 
There  is  an  expectation  that  all  staff  use  the  guidance  when  making  decisions 
about safeguarding, and the rationale for their decision must be recorded in case 
records.  Adherence to this process, and quality of decision making is monitored 
via the Adult Social Care Practice Quality Audits.  Each social care worker has one 
of their cases audited per quarter, so four audits per year.   

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response 

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 Self-Neglect-Guidance-for-Multi-Agency-Partners.pdf 
(southtynesidesafeguardingappp.co.uk) 

2.  What we are doing now: 

2.1.  Multi-Agency Safeguarding Hub (MASH) 

A new Multi-Agency Safeguarding Hub (MASH) will be effective from summer 
2024.    This  will  bring  together  safeguarding  professionals  from  services  that 
have  contact  with  adults,  making  the  best  possible  use  of  their  combined 
knowledge  to  keep  adults  safe  and  offer  prevention,  protection,  and 
proportionate  responses.    To  ensure  consistency  in  the  decision-making 
process, all safeguarding contacts and referrals will be screened in the MASH.   

The aims of the MASH are:   

•  Established pathways for information gathering and access to services from 

all partners. 

•  Maximised effectiveness of multi-agency information gathering and decision 

making. 
It supports decision making by providing an earlier richer picture. 

• 
•  Optimised decision making for vulnerable adults through a multi-agency 

• 

integrated approach. 
It provides a faster, more co-ordinated response through improved 
information sharing between partners. 

•  Assists in the early identification of safeguarding concerns as a result of 

improved inter-agency working arrangements. 
Improves recognition of risk. 

• 
•  Enables closer partnership working and clearer accountability. 
• 

Identifies and targets resources effectively, to ensure individuals are 
accessing the most appropriate service or intervention to meet their needs 
and improve overall outcomes. 

The South Tyneside Adult Multi-Agency Safeguarding Hub (MASH) will include:  

•  Police  
•  CNTW Mental Health 
•  Adult Social Care including Let’s Talk staffing. 
•  STARS - Drug and Alcohol Service  
•  South Tyneside Homes  
•  South Tyneside Foundation Trust – Safeguarding or Clinical Lead 
•  Probation 
• 

ICB Health Navigator 

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 •  Domestic Abuse 
•  Tyne and Wear Fire and Rescue Service  

2.2.  Complex Adult Risk Management (CARM) 

South  Tyneside  Council  has  worked  with  partners  in  the  South  Tyneside 
Safeguarding Adults Board to develop a new, collaborative approach to managing 
complex risk when the adult safeguarding duty does not apply. The Complex Risk 
Management  (CARM)  approach  can  be  used  in  specific  circumstances;  when 
working with adults deemed to have capacity to make decisions for themselves, 
but who are at risk of serious harm or death through:  

•  Self-neglect (Care Act 2014); 
•  Behaviours that place them at risk/chaotic lifestyles; or  
•  Lack of engagement with services.  

The aim of CARM is to provide professionals with a framework to facilitate effective 
multi-agency working with adults who are at significant risk.  

The CARM is a multi-agency adult assessment risk management process to:  

•  Identify the relevant risks for the individual; 
•  Discuss and agree agency responsibilities/actions;  
•  Record, monitor and review progress with an agreed action plan; 
•  Agree when the risks have been managed and evaluate the outcome.  

One or more of the following conditions must apply for a CARM to be called:  

a.  The  Adult  has  the  mental  capacity  to  make  decisions  and  choices  about 

their life; 

b.  There is a risk of serious harm which is life-threatening and/or traumatic, 
and which is viewed to be imminent or very likely to occur, or death due to 
non-engagement  with  services,  and  they  do  not  meet  the  criteria  for  a 
safeguarding referral; 

Or 

c.  There is the potential of death and or life changing injuries and/or a potential 

risk to the health and safety of others in the community;   

d.  There is a high level of concern from partner agencies.  

A CARM meeting is held when the above criteria are met.  The meeting involves 
all  relevant  agencies,  and  there  is  agreement  from  members  of  the  partnership 
that an appropriate member of staff, with the required seniority to make decisions 

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response 

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 on  behalf  of  their  organisation,  attends.    The  meetings  are  chaired  by  an 
appropriate senior member of the appropriate partner agency. 

The purpose of the meeting is to hear about the concerns people have and share 
views  about  the  risks  identified.  A  risk  management  plan  is  developed  that 
identifies the agreed risk and who is going to do what to reduce the risk.  The plan 
may  also  include  any  additional  help,  support  or  information  needed  to  help 
manage  risks.  Members  of  the  meeting  may  also  need  to  think  about  ways  in 
which they could work with the person differently to help manage risk and/or the 
risk of harm. The aim of the risk management meeting is not to remove all risks, 
but to ensure everyone has an agreed understanding of the risks and what needs 
to happen. 

3.  Considerations for the future: 

3.1.  Workforce development 

3.1.1.  Mental Health Act 

that  practitioners 

It  has  been  acknowledged 
in 
neighbourhood  teams  (see  above)  have  a  gap  in  their  knowledge  of  the  Mental 
Health Act 1983.  This includes their understanding of the rights of the Nearest 
Relative,  who  have  specific  legal  powers  in  relation  to  a  person’s  care  and 
treatment.  These powers include: 

(including  managers) 

• 

• 

the right to ask for the person to be detained or put on guardianship; 
the right to ask for an Approved Mental Health Professional (AMHP) to see the 
person. 

And, in addition, the AMHP must inform the Nearest Relative if they choose not to 
undertake a Mental Health Act assessment, and the person ‘MUST’ be informed in 
writing  of  the  reason  why  they  are  not  undertaking  a  Mental  Health  Act 
assessment.  

In  recognition  of  this  gap,  Mental  Health  Act  training  will  be  provided  to  all 
practitioners across adult social care so that they are able to advocate on behalf 
of  individuals  to  ensure  their  rights  are  upheld,  and  provide  appropriate  and 
accurate information to families and carers who are concerned about a relative. 

3.1.2.  Adult Social Care Learning and Development Programme for 2024 

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 The  newly  developed  Adult  Social  Care  Learning  and  Development  Programme 
includes  a  mandatory  safeguarding  module  that  must  be  undertaken  by  all 
frontline practitioners in Adult Social Care.  The module, ‘Safe and Effective Core 
Module’  has  been  developed  in  response  to  feedback  from  the  workforce  to 
develop  competencies  and  confidence  in  the  South  Tyneside  system  and 
approach to a safe and effective safeguarding response at all points across Adult 
Social  Care.  The  content  of  this  module  will  be  peer  reviewed  through  the 
Safeguarding Adults Board to ensure that it captures learning from Safeguarding 
Adult Reviews and Coroner’s Inquests. 

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South Tyneside Council, Town Hall & Civic Offices, Westoe Road, South Shields, Tyne & 
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© 2024 – South Tyneside Council  

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