Omar Ahmed

From Minister Stephen Kinnock MP   
Minister of State for Care   

39 Victoria Street   
London   
SW1H 0EU  

13 September 2024 

Our ref: 

HM Coroner Graeme Irvine  
East London Coroner's Court 
Queens Road 
Walthamstow 
E17 8QP 

By email: 

Dear Graeme,  

Thank you for the Regulation 28 report of 7 July, sent to the Department of Health and Social 
Care (DHSC), about the death of Mr Omar Abdi Ahmed. I am replying as the Minister with 
responsibility for adult social care.  

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Ahmed’s 
death; I offer my sincere condolences to his family and loved ones. The circumstances your 
report describes are very concerning and I am grateful to you for bringing these matters to 
my attention.  

The report raises concerns over: 

1.  Poor  standards  of  communication  between  the  domiciliary  care  company,  Local 
Authority  (LA)  and  NHS  trust  resulted  in  a  failure  to  identify  the  deterioration  in  Mr 
Ahmed's living conditions and health. 

2.  An  under-resourced  and  demoralised  district  nursing  team  that  lacked  the  clinical 
curiosity  to  predict  the  harm  that  would  befall  Mr  Ahmed  should  he  be  allowed  to 
disengage from treatment. 

3.  An unwillingness by domiciliary carers to challenge Mr Ahmed's poor decision-making in 
how  he  budgeted,  leading  to  a  lack  of  nutritious  food  and  cleaning  materials,  and  a 
reluctance to switch on his central heating, the latter being a contributary factor in  his 
death from hypothermia. 

In preparing this response, departmental officials have made enquiries with NHS England 
(NHSE) and the independent chair of Newham Safeguarding Adults Board (SAB). 

In  response  to  your first  concern,  section  6(7)  of the  Care  Act  2014  states  LAs  must  co-
operate  with  relevant  partners,  such  as  domiciliary  care  companies  and  NHS  trusts,  and 
those partners must co-operate with the LA in the exercise of their functions to protect adults.  

The Care Act 2014 requires each LA to set up a SAB in its area. SABs are required to carry 
out a Safeguarding Adult Review (SAR) where an adult has died, and the SAB knows or  

   
 
 
 
 
 
 
 
 
 
 
 
     
  
 
  
  
 
 suspects the death resulted from abuse or neglect (whether or not they knew this at the time 
of death). The SAR should identify the lessons to be learnt from the adult’s case and apply 
those lessons to future cases. To understand the communication failures related to your first 
concern, DHSC contacted the independent chair of Newham SAB asking whether they are 
considering  doing  a  SAR.  The  chair  shared  they  are  collecting  information  on  the  case 
before deciding what to do next.  

In response to your second concern, NHSE shared details of their Community Nursing Safer 
Staffing Tool to support organisations to triangulate their nursing staffing numbers. This will 
create availability for more nursing staff to meet increasing patient demand. NHSE are also 
looking to scope and commission future educational support for district nursing, and within 
the Long-Term Workforce Plan there is an ambition to increase training places for district 
nurses by 41%. 

NHSE also reached out to the East London Foundations NHS Trust directly – my officials 
await their response and will consider how to learn from any information that is relayed. To 
note the Trust, Council, and private care provider are also recipients of this PFD and will be 
developing their own responses, which officials expect to be sighted on in due course. 

Your third concern was regarding Mr Ahmed’s carers’ failure to challenge his poor decision-
making.  I  infer  from  this  that  you  feel  Mr  Ahmed  may  have  lacked  the  relevant  mental 
capacity and that you feel professionals responsible for his care should have assessed his 
mental  capacity.  I  note  professionals  should  start  by  presuming  capacity  and  that  poor 
decision-making  does not necessarily  equate  to  a  lack  of  mental  capacity to make  those 
decisions. These are two of the five principles under the Mental Capacity Act (MCA) which 
is strongly supported by experts by experience. However, I am aware these principles have 
been used to justify a lack of clinical curiosity from health and social care workers in several 
cases. I can say that using the presumption of capacity and the freedom to make unwise 
decisions to avoid challenging poor decision-making is not in line with the MCA guidance or 
case law. Government is clear that professionals applying the MCA are expected to keep 
up to date with the guidance and not misuse the principles within the Act. 

While  employers  in  the  health  and  care  sector  have  ultimate  responsibility  to  satisfy 
themselves regarding the skills and competence of their staff, DHSC also provides support. 
On January 10th, 2024, the DHSC published the first part of the Care Workforce Pathway, a 
new  national  career  framework  for  the  adult  social  care  sector.  This  pathway  defines 
knowledge, skills, values, and behaviours of those working in, or wanting to work in adult 
social care, should have. Although not mandatory, it is designed to improve how providers 
can  support  and  develop  their  workforce.  The  Pathway  is  being  developed  to  work  in 
conjunction  with  existing  standards  and  competency  frameworks.  The  Care  Quality 
Commission (CQC) will look at a provider's approach to staff induction, support and training 
using CQC's key lines of enquiry.   

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,   

 
 
 
 
 
 
 
 
 
 
 
 
  
 STEPHEN KINNOCK MP

Private & Confidential  

His Majesty’s Senior Coroner Mr Graeme Irvine 
Walthamstow Coroner’s Court 
Queens Road 
Walthamstow 
London  
E17 8QP 

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

Telephone: 
Email:  

Website: http://www.elft.nhs.uk

Dear Sir, 

RE: Regulation 28 Response for the late Mr Omar Abdi Ahmed 

16 September 2024 

1.  This is a formal response to your Regulation 28 Report (the ‘Report’) issued on 22 July 

2024  where  you  set  out  concerns  relating  to  the  care  of  late  Omar  Abdi  Ahmed  whilst 

under East London NHS Foundation Trust’s (the ‘Trust’s’) care. 

2.  I  understand  that  at  Mr  Ahmed’s  inquest,  you  heard  evidence  from  the  72  hour  report 

author outlining the learning that has taken place since his death. I understand that you 

remained concerned about the risk of future deaths in relation to the following areas: 

2.1. Poor standards of communication between the domiciliary care company, the 

local authority and NHS trust resulted in a failure to identify the deterioration in 

Mr Ahmed's living conditions and health. 

2.2. Evidence heard in the inquest suggested an under-resourced and demoralised 

district nursing team lacked the clinical curiosity to predict the harm that would 

befall Mr Ahmed should he be allowed to disengage from treatment. 

Chief Executive: 

Chair: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.3. Mr Ahmed's poor decision-making in how he budgeted was never challenged, this led 

to a lack of nutritious food and cleaning materials in his home. Similarly, Mr Ahmed's 

unwillingness to turn on his central heating, a contributory factor in the development 

of  his fatal  condition  hypothermia, remained  unchallenged  at  the  time  of  his  death. 

Domiciliary  carers  capitulated  to  Mr  Ahmed's  express  wishes  that  they  ought  not 

assist  him  with  cleaning,  personal  care  or  meals  instead,  state-funded  care  hours 

were utilised to assist Mr Ahmed in attending his local pub and café. 

3.  I  wish  to  assure  you  and  the  family  of  Mr  Ahmed  that  the  Trust  reviewed  the  issues 

highlighted in the Report and has taken the following action.  

RESPONSE 

Standards of communication  

4.  The Trust is unable to comment on behalf of London Borough of Newham (‘LBN’) or the 

domiciliary care company. However, it can confirm that LBN and the Trust have systems 

in place which facilitate joint working to improve care for service users under both services. 

5.  The Trust raised a Safeguarding Adult concern to LBN in relation to Mr Ahmed, however 

it  was  not  followed  up  until  after  his  death  by  LBN.  LBN  have  conveyed  that  they  are 

struggling with capacity at the moment. 

6.  In  light  of  this,  all  Trust  staff  have  been  reminded  (during  individual  supervision)  of  the 

Trust’s internal escalation pathway. They are expected to follow this pathway when there 

are concerns about the safeguarding process between public bodies. It is a tool to support 

staff  in  recognising  their  responsibilities  and  ensuring  they  follow  up  all  safeguarding 

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 Trust staff 

that they should not wait for the monthly safeguarding forum to escalate any barriers or 

problems related to safeguarding process initiated by them. 

Chief Executive: 

Chair: 

 
 
 
 
 
 
 
 
 
 
 
 7.  Since  the  receipt  of  the  Report,  two  meetings  have  taken  place  between  the  Trust’s 

Director  of  Nursing,  Community  Health  Service’s  Medical  Director  and  LBN’s  Senior 

Safeguarding Adviser and Interim Service Manager for Access to Adult Social Care and 

hospital discharge. It was explored how to further improve escalation and communication 

between the services in relation to high risk service groups. The outcome of both of these 

meetings is that both the Trust and LBN’s teams will meet in October 2024 to review the 

current pathways and organisational interface to ensure better communication relating to 

patient care. 

8.  Communication between domically care providers and Community Health Newham (the 

Trust)  is  done  on  an  individual  service  user  basis.  The  system  is  designed  so  that  a 

General  Practitioner  is  the  gate  keeper  of  care  and  manages  and  coordinates 

communication between the public bodies. That said, if a high risk service user presents 

as a concern to Trust staff members, they are proactive and will arrange a professionals 

meeting for all agencies involved. We plan to review this process with all staff over the 

next two months to ensure that they are aware of their responsibilities and understand the 

importance of acting on concerns. 

District  nursing  team  lacked  clinical  curiosity  as  a  consequence  of  resourcing  and 

demoralisation 

9.  It was concerning to hear that clinical staff members in charge of wound dressing were 

under-resourced  and  demoralised  resulting  in  a  lack  of  clinical  curiosity  towards  Mr 

Ahmed.  

10. Further  context  may  assist  in  how  that  impression  was  reached.  Traditionally,  simple 

wound care services were provided by multiple providers across Newham. However, over 

time the wound dressing clinic at East Ham Care Centre (the ‘dressing clinic’) became the 

default provider for all wound dressing services. This created significant pressures on staff. 

11. In order to reduce these demands, in September 2023, the Integrated Care Board led an 

improvement  program  to  transfer  the  management  of  simple  wounds  to  General 

Practitioners. This process commenced in April 

Chief Executive: 

Chair: 

 
 
 
 
 
 
 
 
 
 2024. Now, only complex wounds are managed by the dressing clinic.  Consequently, only 

secondary and primary care professionals such as General Practitioners, practice nurses, 

and acute care clinicians (doctors and nurses) can refer complex wounds to the dressing 

clinic. Simple wounds are managed in GP practices. It is anticipated that this reallocation 

of care will improve the working conditions for the wound care team. 

12. Since the sad death of Mr Ahmed, some further changes were introduced to the dressing 

clinic. It is now staffed by a substantive band 6 nurse (as opposed to temporary staff) 

whose clinical and professional line management is provided by senior nursing within the 

Trust’s Community District Nursing Team. I expect this will improve the accountability of 

clinical staff on the team as well as allow them to receive more consistent supervision 

and improve clinical skills and enhance curiosity.  

13. On 24 July, a new standard operating procedure was put into place for dressing clinic 

staff. The key change is that the time slots allocated to attend to service users has 

increased from 10 minutes to 30 minutes. It is anticipated that the provision of additional 

time to complete work should improve care planning and allow more meaningful 

communications with other services as well as improve staff morale. 

Poor decision making 

The local authority, not the Trust commissioned the domiciliary care providers. 

Consequently, it is expected that the commissioner and the General Practitioner would 

manage concerns. However, as outlined in paragraph 8, Trust staff should be proactive 

when they witness concerns and arrange professionals’ meetings between agencies. 

This will be reviewed with staff over the next two months.  

Conclusion  

14. I hope this response provides sufficient reassurances to you and to the family of Mr 

Ahmed about the additional learning that has taken place at the Trust because of his sad 

death.  

Chief Executive: 

Chair: 

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

time.   

Yours sincerely 

Chief Medical Officer 

Cc:   

Chief Executive: 

Chair:

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

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

12 September 2024
Our ref:

Dear Mr Irvine

Re: Regulation 28 Report concerning Omar Ahmed

Response from the London Borough of Newham

Thank you for sharing the conclusion of your Inquest into Mr Ahmed’s death, and the subsequent
Regulation 28 Report. May I start by expressing my sincere regret and disappointment to learn of
the  circumstances  surrounding Mr Ahmed’s passing.  On  behalf of the Council  I  wish  to place  on
record  our  deepest  condolences  to  his  family  and  friends  and  all  those  that  knew  him.  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 Ahmed’s case  in
detail and have developed a series of direct actions in response. The following actions have been
agreed

1 

Action:
Immediate Safeguarding Adults Review (SAR)
Referral for presentation at the next SAR
subcommittee

2  A meeting with the Sunlight Care to ensure that
any risks to residents they provide care and
support to is mitigated. This will be achieved by
the following actions

Page 1 of 4

By who:

(Director of Quality
Assurance,
Safeguarding and
Workforce
Development) and
(
 North
West
Neighbourhood
Team)
Strategic
Safeguarding and
the Quality
Assurance and

By when:
Completed
on 09/08/24

Mr Ahmed is
on the
agenda for
the SAR
subcommittee
on 24/09/24

Meeting held
on 17/07/24
although the
QIP is
ongoing

 Commissioning
Team

  A quality improvement plan (QIP) is in

place

  Enhanced monitoring of all residents

Sunlight Care provide care and support
to is in place

  Welfare checks of all residents Sunlight
Care provide care and support to who
live alone has taken place

3  Enhanced monitoring of the provider will take

4

place at the 6 weekly provider risk
management board (PRAMB). The board is a
multi-agency partnership which includes social
care, health and the CQC
Adult Social Care will lead on the development
of an escalation procedure which will enable
partners to flag cases where there is concern
about a high level of unmitigated risk or
differences of opinion about the level of risk.
This procedure will involve reviews of the
following protocols:
1) The no reply protocol
2) The refusal of care protocol

PRAMB
Partnership

Ongoing

March 2025

Strategic
Safeguarding/
Workforce
Development/Quality
Assurance and
Commissioning
Team

5  The issues regarding the safeguarding activity
in this case will be addressed by reflective
sessions which cover the following areas
  The London Borough of Newham’s

Workforce
Development and
Strategic
Safeguarding

30/11/24

decision making/actions in relation to
safeguarding concerns

  Multi-agency working
  The application of Making Safeguarding

Personal

These sessions will be available for all
operational staff in Adult Social Care. Content
will also be available to selected staff from
Sunlight Care and staff from ELFT

6  The issues regarding risk assessment and risk
management will be addressed by a reflective
session which covers the following areas:

 
Information sharing
  Joint decision making
  Co-ordinated intervention
  Thresholds for home visits/joint home

visits

  Thresholds for urgent reviews

Page 2 of 4

30/12/24

Workforce
Development and
Strategic
Safeguarding

   Executive capacity and decision making
  Risks associated with social isolation
  Non adherence with care plans

These sessions will be available for all
operational staff in Adult Social Care. Content
will also be available to selected staff from
Sunlight Care and staff from ELFT
7  Produce a ‘7 minute briefing on the

development of risk management plans. This
will be distributed  across all Adults and Health
staff groups and presented at the provider
forum

8  Produce a ‘7 minute briefing with a focus on
the issue of non-adherence with care plans.
This will be distributed  across all Adults and
Health staff groups and presented at the
provider forum

9  Adult Social Care will lead on a joint learning
event involving staff from ASC, staff from
Sunlight Care and staff from ELFT. The
learning event will focus on the following
issues:

  Professional and clinical curiosity
  Working with resistance and non-

adherence

  Executive capacity and decision making

30/12/2024

30/01/24

20/12/2024

Workforce
Development and
Strategic
Safeguarding

Workforce
Development and
Strategic
Safeguarding

Workforce
Development and
Strategic
Safeguarding

10 Review of the Safeguarding Adults Operational

Procedure

11 Training on how to implement lessons  of

inquest hearings to improve  service delivery to
vulnerable persons within our community

Strategic
Safeguarding
Legal
Department

30/11/24

06/09/24

Governance and Oversight

The following people have been sighted on the action plan:

 
 
 
 

-Corporate
-Director of Quality Assurance, Safeguarding and Workforce Development

-Head of Service - Older People & Disability, Operations

-Head of Service - Older People & Disability, Operations

Page 3 of 4

 All elements of the plan are linked to specific teams with accountability for their delivery. Oversight
of the action plan is being held by the Strategic Safeguarding team who will monitor progress against
the stated timescales and then report back to our Directorate Management Team. We also recognise
that the overall plan will need to remain agile and be adapted if further information comes to light,
particularly if Mr Ahmed’s case is the subject of a 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,

PP

Corporate Director of Adults, Health & Communities, Director of Public Health & Director of Adult
Social Services (acting)

CC:

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

Page 4 of 4

Mr Graeme Irvine  
Senior Coroner for East London  
East London Coroner’s Court  
Queen's Road Walthamstow, E17 8QP 

Dear Sir  

Inquest into the death of Omar Ahmed – 15 July 2024 
Prevention of Future Deaths Report 
Ref: 

We write in response to the Prevention of Future Death Report (‘the PFD Report’) issued at 
the  conclusion  of  the  inquest  hearing  in  accordance  with  Regulation  28  of  the  Coroners 
(Investigations) Regulations 2013.  

We are committed to providing the highest standards of safety and care and wish to ensure 
that any lessons to be learnt from the circumstances of Mr Ahmed’s tragic death are identified 
and  implemented  as  necessary  within  our  agency.  Alongside  our  engagement  with  the 
coroner’s  investigation,  we  have  conducted  our  own  internal  review  process,  updated  our 
policies,  commenced  the  implementation  of  a  full  programme  of  updated  communication, 
consultation and training, and proactively liaised with the East London Foundation NHS Trust 
(‘the Trust’) and the London Borough of Newham (‘the Local Authority’). 

We have provided further details concerning this process below, including the time frames for 
elements of this process which are in progress.  

Our review process 

After being informed of Mr Ahmed’s death by the Local Authority on 22 December 2023, we 
conducted a thorough Serious Incident Review (‘SI Review Report’), with a focus on the care 
provided in cases  involving  a history  or risk  of  self-neglect. This  involved  a comprehensive 
review  of  our  policies  and  procedures  and  preparation  of  a  detailed  report  focussing  upon 
protecting and supporting our service users. The SI Review Report sets out the steps we are 
taking  to  enhance  our  safeguarding  practices  and  provides  a  framework  for  continuous 
improvement.  

In addition to updating and, where necessary amending our policies, we commenced an eight-
week implementation programme on 5 August 2024. A summary of this programme setting out 
the topics of training, appears in Appendix A.   

Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. 
Registered Office: 3-9 Balaam Street, London, E13 8EB 

A: 3-9 Balaam Street, London E13 8EB 
T: 02086 112 771 
E: info@sunlightgroup.co.uk 
W: www.sunlightgroup.co.uk  

A Brighter Tomorrow… 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 At  the  conclusion  of  the  programme,  we  will  hold  review  meetings  to  discuss  the 
implementation  programme,  including  challenges  and  successes,  as  well  as  developing 
further areas of continuous improvement.  

The implementation programme of our revised policies and training is being led and overseen 
by a new internal Governance Team led by our Director of Nursing (Advanced Practitioner / 
Registered  Mental  Health  Nurse)  and  including  our  Director  for  Quality,  Trusted Assessor, 
Care  Champion,  Nominated  Individual  and  Registered  Manager.  We  have  engaged  an 
independent  Registered  Mental  Health  Nurse 
to  provide  external  governance  and 
accountability. This programme is being properly resourced and supported by the most senior 
managers and leaders within our service.   

Response to the coroner’s ‘matters of concern’ 

Our Internal Governance Team has carefully considered the ‘matters of concerns’ set out in 
the  PFD  report  relevant  to  the  service  provided.  With  this  in  mind,  we  have  set  out  our 
response  with  respect  to  the  first  and  third  matters  highlighted  by  the  coroner  which  are 
relevant to the care we provided.  

1.  Poor standards of communication  

The coroner highlighted the following concern in the PFD Report:  

“Poor  standards  of  communication  between the domiciliary  care  company,  the  local 
authority and NHS trust resulted in a failure to identify the deterioration in Mr Ahmed’s 
living conditions and health.” 

Mr Ahmed  was  under  the  care  of  our  agency  from  31  October  2023  and  was  admitted  to 
hospital  on  15  November  2023  before  he  sadly  passed  away  on  21  November  2023.  We 
submitted  a  detailed  chronology  of  our  care  notes  and  communications  with  the  Local 
Authority and GP for the purposes of the inquest hearing. Our Duty Manager contacted the 
Local Authority on 10 November and again on 12 November 2023 regarding concerns about 
the lack of basic supplies and issues with financial decision-making. On 13 November 2023, 
the Local Authority responded, confirming that the duty social worker had made enquiries with 
Mr Ahmed’s next of kin. They also invited follow-up communication in the coming days and 
weeks.  

Our own review  

We have  scrutinised  how  we would  approach circumstances  in the future where  a client  is 
making poor decisions with respect to their nutrition, cleaning and personal care, as well as 
their finances. In circumstances where clients have capacity, to enable appropriate action to  

Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. 
Registered Office: 3-9 Balaam Street, London, E13 8EB 

A: 3-9 Balaam Street, London E13 8EB 
T: 02086 112 771 
E: info@sunlightgroup.co.uk 
W: www.sunlightgroup.co.uk  

A Brighter Tomorrow… 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 be taken in conjunction with social work and health services, the key issues to be addressed 
are early notification internally, escalation to the Local Authority and NHS Trust as necessary, 
and proactive follow up.  

This issue was identified and addressed in our SI Review Report in which we have confirmed 
our revised standard notification and response protocols with the Admissions Policy as follows:  

1.  Continuing to provide detailed and factual reports of safeguarding concerns to local 

authorities within 24 hours; 

2.  Expect a response and action from local authorities within 48 working hours; 
3.  Actively  monitor  the  situation  and  follow  up  to  ensure  concerns  are  addressed 

effectively. 

This is supplemented by updated notification and monitoring procedures within our suite of 
relevant policies:  

Infection Control Policy  

•  Self-Neglect Policy  
•  Home Environment Safety Policy  
•  Nutrition and Hydration Policy  
• 
•  Admissions Policy  
•  Handover Policy  
•  Environmental Safety Policy 
•  Care Plan Adherence Policy  
•  Risk Management Policy  
•  Decision Making and Consent Policy  
•  Engagement and Participation Policy  
•  Multi-Disciplinary Team Collaboration Policy 
•  Medication Management Policy 
•  Safeguarding Policy  
•  Admissions Policy  
•  Handover Policy  

Multi-agency liaison and plan  

In addition, we attended a multi-agency discussion with the Local Authority and NHS Trust to 
discuss lessons learnt on 23 July 2024 and arranged a follow up on 4 September 2024. At the 
second  meeting,  the  following  actions  were  agreed  to  be  undertaken  within  a twelve  week 
time frame:  

•  Communication and Escalation Strategies: The team will implement new strategies to 
improve communication and timely escalation of safeguarding issues across teams.  

Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. 
Registered Office: 3-9 Balaam Street, London, E13 8EB 

A: 3-9 Balaam Street, London E13 8EB 
T: 02086 112 771 
E: info@sunlightgroup.co.uk 
W: www.sunlightgroup.co.uk  

A Brighter Tomorrow… 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Development  of  Risk  Assessment  Tool:  Newham  Council  and  Sunlight  Care  will 
collaborate  on  the  development  of  a  risk  assessment  tool  to  identify  and  protect 
vulnerable individuals. 

•  Training and Process Improvements: Sunlight Care staff will receive additional training 
on safeguarding protocols, communication, and the new risk assessment processes. 

A Serious Adults Review Board Meeting has been arranged to take place on 24 September 
2024.  

In view of the above, we are confident that our revised policies and procedures are robust and 
staff  will  proactively  escalate  similar  concerns  internally  and  our  managers  will  proactively 
monitor concerns raised with the Local Authority.  

2.  Lack of challenge to poor decision-making  

The coroner highlighted the following concern in the PFD Report:  

“Mr Ahmed’s poor decision-making in how he budgeted was never challenged, this led 
to a lack of nutritious food and cleaning materials in his home.  

Similarly, Mr Ahmed’s unwillingness to turn on his central heating, a contributory factor 
in the development of his fatal condition -hypothermia, remained unchallenged  at the 
time of his death. 

Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist 
him  with  cleaning,  personal  care  or  meals  instead,  state-funded care  hours  were 
utilised to assist Mr Ahmed in attending his local pub and café.” 

An element of Mr Ahmed’s Care and Support Plan was to facilitate community engagement 
and  social  interaction,  which  was  important  to  Mr Ahmed.  In  circumstances  where  there  is 
evidence  of  self-neglect  and  a  client  may  not  be  making  appropriate  decisions  concerning 
eating, cleaning, hearing and personal care, it is clear that this must be addressed by those 
involved  in  the  client’s  care.  As  the  coroner  is  aware,  Mr  Ahmed  had  capacity  and  was 
therefore  able  to  make  his  own  decisions.  This  creates  significant  challenges  for  care 
providers, which are reliant upon working alongside the statutory agencies to make any formal 
interventions necessary.  

Within the existing framework, we have considered what additional steps could be taken in 
the  future.  We  have reviewed  and  updated  our protocols to ensure that care  providers  are 
well-supported in addressing situations where clients with capacity may be making decisions 
that appear to be against their best interests, such as in cases of self-neglect. Specifically: 

Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. 
Registered Office: 3-9 Balaam Street, London, E13 8EB 

A: 3-9 Balaam Street, London E13 8EB 
T: 02086 112 771 
E: info@sunlightgroup.co.uk 
W: www.sunlightgroup.co.uk  

A Brighter Tomorrow… 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1.  As  set  out  above,  we  have  revised  our  own  policies  and  training  to  reinforce  the 
importance of clearly and swiftly communicating issues of concern internally to enable 
the concerns to be properly assessed and escalated to the Local Authority and NHS 
as appropriate;   

2.  As  set  out  above,  we  are  implementing  more  robust  inter-agency  collaboration  and 
clearer guidelines for escalation pathways. This will involve enhanced communication 
with social workers, GPs, and mental health teams to provide timely and appropriate 
interventions while respecting the client's autonomy; 

3.  We are introducing regular multidisciplinary reviews for cases involving self-neglect, 
allowing  for  a  more  holistic  approach  to  care  that  includes  input  from  a  range  of 
professionals. This will help ensure that all aspects of the client's well-being—physical, 
mental, and social—are considered in decision-making processes; 

4.  The  training  programme  referred  to  above  includes  additional  training  focused  on 
identifying  early  signs  of  self-neglect,  understanding  legal  frameworks  such  as  the 
Mental Capacity Act, and how to engage effectively with clients who may resist care or 
intervention.  This  proactive  approach  aims  to  minimize  risks  while  upholding  the 
individual's rights and dignity. 

We also highlight the relevance and importance of the ‘Liberty Protection Safeguards’ (‘LPS’) 
framework  which  was  to  have  been  introduced  to  replace  the  ‘Deprivation  of  Liberty 
Safeguards’ (‘DoLs’) framework. One relevant difference would have been the availability of 
the LPS framework to those living in their own home, as DoLs orders are only available to 
those in care homes and hospitals. We understand that the LPS framework provides a simpler 
and clearer framework to seek authorisation for an order to facilitate care and health treatment 
where needed, including those in their own home.      

The Local Authority has informed us that the LPS framework will no longer be implemented. 
As a result, they will continue to rely on the existing DoLs framework, which does not apply to 
individuals living at home. We understand that the new LPS framework would have provided 
those involved in Mr Ahmed’s care with the opportunity for assessment of his ability to make 
appropriate decisions in his own best interests. This is a challenge we trust will be remedied 
within new legislation.  

Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. 
Registered Office: 3-9 Balaam Street, London, E13 8EB 

A: 3-9 Balaam Street, London E13 8EB 
T: 02086 112 771 
E: info@sunlightgroup.co.uk 
W: www.sunlightgroup.co.uk  

A Brighter Tomorrow… 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Finally, we wish to reiterate our deepest sympathies for Mr Ahmed’s family. We emphasise our 
desire to ensure that any changes to our service are identified and implemented to ensure that 
similar issues with clients in future are dealt with as quickly and effectively as possible.  

Yours faithfully  

 (Director) 

Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. 
Registered Office: 3-9 Balaam Street, London, E13 8EB 

A: 3-9 Balaam Street, London E13 8EB 
T: 02086 112 771 
E: info@sunlightgroup.co.uk 
W: www.sunlightgroup.co.uk  

A Brighter Tomorrow… 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 meetings. 

procedure. 

self-neglect. 

APPENDIX A: Summary of 8-week implementation programme following SI Review  

Week 1: Planning and Communication 

•  Conduct  a  meeting  with  key  stakeholders  (management,  supervisors, 

training 

coordinators) to discuss the implementation plan. 

•  Review and finalize all new policies with input from relevant staff and legal advisors. 
•  Develop a communication plan to inform all staff about the upcoming changes. 
(training  materials,  budget,  personnel) 
•  Allocate  necessary 
implementation. 

resources 

for 

the 

Week 2: Staff Communication and Initial Training Preparation 

•  Communicate the new policies and training schedule to all staff via emails, posters, and 

•  Develop a detailed training schedule, including dates, times, and venues. 
•  Prepare  training  materials  (manuals,  presentations,  handouts)  for  each  policy  and 

Week 3: Training Sessions - Week 1 

•  Self-Neglect Policy Training: Conduct training sessions on recognizing and managing 

•  Home Environment Safety Policy Training: Conduct training sessions on assessing and 

maintaining home safety and cleanliness. 

Week 4: Training Sessions - Week 2 

•  Nutrition  and  Hydration  Policy  Training:  Conduct  training  sessions  on  nutritional 

assessments, meal planning, and support services. 
Infection  Control  Policy  Training:  Conduct  training  sessions  on  maintaining  high 
standards of infection control. 

• 

Week 5: Training Sessions - Week 3 

•  Environmental  Safety  Policy  Training:  Conduct  training  sessions  on  assessing  and 

•  Care  Plan  Adherence  Policy  Training:  Conduct  training  sessions  on  reviewing, 

maintaining heating and cooking facilities. 

documenting, and adjusting care plans. 

Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. 
Registered Office: 3-9 Balaam Street, London, E13 8EB 

A: 3-9 Balaam Street, London E13 8EB 
T: 02086 112 771 
E: info@sunlightgroup.co.uk 
W: www.sunlightgroup.co.uk  

A Brighter Tomorrow… 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Week 6: Training Sessions - Week 4 

•  Risk  Management  Policy  Training:  Conduct  training  sessions  on  risk  assessments, 

management plans, and monitoring. 

•  Decision Making and Consent Policy Training: Conduct training sessions on capacity 

assessments and supporting informed decision-making. 

Week 7: Training Sessions - Week 5 

•  Engagement and Participation Policy Training: Conduct training sessions on strategies 

to promote active engagement and participation. 

•  Multi-Disciplinary Team Collaboration Policy Training:  Conduct training sessions on 

effective multi-disciplinary team collaboration. 

Week 8: Training Sessions - Week 6 and Monitoring 

•  Medication  Management  Policy  Training:  Conduct  training  sessions  on  safe  and 

•  Monitoring  and  Evaluation:  Begin  monitoring  and  evaluating  the  effectiveness  of  the 

effective medication management. 

training and implementation. 

Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. 
Registered Office: 3-9 Balaam Street, London, E13 8EB 

A: 3-9 Balaam Street, London E13 8EB 
T: 02086 112 771 
E: info@sunlightgroup.co.uk 
W: www.sunlightgroup.co.uk  

A Brighter Tomorrow…