Janet Brown Townend

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 03000 616161 
Fax: 03000 616171 

HM Senior Coroner: Professor Paul Marks BA LLM MD FRCS 

The Coroners Courts & Office 
The Guildhall 
Alfred Gelder Street 
Kingston upon Hull 
HU1 2AA 

By Email 

11 December 2024  

Care Quality Commission 
Our Reference: 

Dear HM Coroner Professor Paul Marks, 

CQC response to prevention of future death report [Name of Deceased]  

Thank you for naming the Care Quality Commission (CQC) as a respondent in the 
prevention of future death report issued on 5 November 2024 following the death 
of Janet Brown.  

Background  

On 1 April 2015 the CQC assumed enforcement responsibility for health and safety 
related  serious  incidents  concerning  people  using  services  in  health  and  social 
care  settings  in  England.  This  is  where  people  using  services  have  sustained 
avoidable  harm  including  death,  have  been  exposed  to  a  significant  risk  of 
avoidable harm, or have suffered a loss of money or property as a result of a failure 
by  the  Registered  Person.  The  ‘Registered  Person’  is  the  Registered  Provider 
and/or  Registered  Manager.  Where  Registered  Providers  are  corporate  bodies 
(such  as 
(such  as 
limited  companies)  or  unincorporated  associations 
partnerships), individual office holders or members may in certain circumstances 
be criminally liable under sections 91 and 92 Health and Social Care Act 2008. 

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 Criminal enforcement can arise from single specific incidents where the incident 
and  resulting  harm  provides  evidence  of  a  serious  breach  of  a  prosecutable 
regulation by the Registered Provider. 

We  have  reviewed  all  our  records  and  cannot  find  that  we  received  a  statutory 
notification  in  relation  to  Janet  Brown’s  death.    Failure  to  provide  statutory 
notifications  in  accordance  with  Regulation  16  of  the  Care  Quality  Commission 
(Registration) Regulations 2009 is a criminal offence and we have contacted the 
service  to  about  this.  The  provider  has  advised  us  that  the  death  did  not  occur 
while services were being provided in the carrying on of a regulated activity and 
no further regulated activity was completed following the admission to hospital. We 
have requested Janet Brown’s care records so this can be reviewed, and so that 
we can consider whether any other regulatory action needs to be taken. 

Regulatory History  

Bridlington  was  registered  with  CQC  on  7  February  2019  under  the  current 
provider, A & B Healthcare Limited. In that time, the location has been inspected 
twice; once in January 2020 (Appendix 1) and once April 2023 (Appendix 2). On 
both occasions, the location was rated Good in all the domains assessed. In the 
time since CQC last inspected Bridlington, ongoing monitoring of the service had 
not identified any emerging risk.  

We note that the concerns are as follows: 

1.  Carers at times spent no more than 15 minutes, on one occasion 8 
minutes, with Ms Townend. Bearing in times the tasks, document 
keeping and care to administer and considering Early Warning Signs 
have there was no attention to detail; Their duties when there 
included to prepare meals, conduct personal care if required and talk 
to the service user. 8 to 15 minutes is not an adequate time to 
conduct these tasks; 

Both inspections of Bridlington found no concerns regarding the 
deployment of staff and the published reports include positive feedback 
from people about the support they received. In response to the concerns 
raised by the coroner concerning the death of Janet Brown, the CQC has 
received an action plan from the provider addressing the duration of staff 
visits. We intend to undertake an unannounced assessment of the service 
which will include staff having adequate time to meet people’s needs. 
CQC only regulates the carrying out of personal care, however, adequate 

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 time must be afforded to staff to support people in a safe, person-centred 
way (Appendix 1, Appendix 2). 

2.  Carers did not escalate any concerns when Ms Townend was not 
eating. As Ms Townend had comorbidities and was at risk of 
infection nutrition was very important; 

The inspection of Bridlington in January 2020 found no concerns regarding 
the support people received to eat and drink and/or the ongoing 
assessment and monitoring of people’s needs and support to access other 
healthcare services. The inspection of Bridlington in April 2023 did not 
include these areas. In response to the concerns raised by the coroner 
concerning the death of Janet Brown, the CQC has received an action 
plan from the provider addressing nutrition and hydration. We intend to 
undertake an unannounced assessment of the service which will include 
nutrition and hydration and how staff identify people’s changing needs and 
escalate concerns. (Appendix 1, Appendix 2). 

3.  Carers did not escalate any concerns when Ms Townend was unwell 
with sickness. There were a number of times Ms Townend presented 
with having been sick and this was not considered as a concern; 

Neither inspection of Bridlington raised concerns about staff not escalating 
concerns about people. The inspection of Bridlington in January 2020 
found staff supported people to access health care professionals and 
referrals were made when required. (Appendix 1). In response to the 
concerns raised by the coroner concerning the death of Janet Brown, the 
CQC has received an action plan from the provider addressing how staff 
will monitor people’s health and well-being. We intend to undertake an 
unannounced assessment of the service which will include how people are 
supported to live healthier lives and how the provider will monitor peoples 
care (Appendix 1, Appendix 2). 

4.  Carers did not accurately record concerns regarding Early Warning 
Signs (EWS) or escalate when they were present. The EWS were 
always recorded as no concerns. This was not correct as there were 
occasions where Ms Townend was displaying signs that were Early 
Warning Signs which should have been escalated; 

Neither inspection of Bridlington raised concerns about the accuracy of 
record keeping. In both cases, our inspections found checks and audits 
were in place to ensure good governance of the service. (Appendix 1, 
Appendix 2). In response to the concerns raised by the coroner 
concerning the death of Janet Brown, the CQC has received an action 
plan from the provider addressing staff training, oversight of records and 
processes for escalating concerns. We intend to undertake an 

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 unannounced assessment of the service which will include recording 
keeping, governance processes and oversight of people’s care.  

5.  Carers did not follow up with Ms Townend when she had indicated 
she was seeking GP support as she was feeling unwell. This was 
recorded in the Observation Log that Ms Townend said she would 
contact her GP however the proceeding carers did not enquire 
whether this had been done; 

The inspection of Bridlington in January 2020 found no concerns regarding 
how staff supported people to access healthcare services and support 
(Appendix 1). In response to the concerns raised by the coroner 
concerning the death of Janet Brown, the CQC has received an action 
plan from the provider addressing their systems for monitoring people’s 
health effectively within the staff team. We intend to undertake an 
unannounced assessment of the service which will include governance 
processes and oversight of people’s care. 

6.  Although  Ms  Townend  was  deemed  to  have  capacity  carers  did  not 
escalate  any  concerns  when  Ms  Townend  was  making  unwise 
decisions  to  refuse personal care,  decline  food  and  decline medical 
intervention. This meant that she was sitting at times in her own faeces 
and becoming weak and it was not considered whether she needed to 
be reassessed regarding her capacity. 

Neither inspection of Bridlington identified concerns regarding staffs ability 
to recognise and escalate safeguarding concerns. The inspection of 
Bridlington in January 2020 found staff had a good understanding of 
safeguarding processes (Appendix 1). In response to the concerns raised 
by the coroner concerning the death of Janet Brown, the CQC has 
received an action plan from the provider addressing staff understanding 
of the mental capacity act. We intend to undertake an unannounced 
assessment of the service which will include safeguarding and decision 
making. We have also requested immediate assurances from the provider 
regarding their safeguarding processes.  

Yours sincerely 

Deputy Director,  

4

County Hall   Beverley   East Riding of Yorkshire   HU17 9BA   Telephone (01482) 393939
www.eastriding.gov.uk

Jessica Cross   Director of Locality Wellbeing and Safeguarding

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

FOLLOWING THE INQUEST TOUCHING THE DEATH OF JANET BROWN TOWNEND

PROVIDED BY HANNAH FEENEY – HEAD OF SERVICE, SAFEGUARDING AND QUALITY
ASSURANCE, ADULT SOCIAL CARE AND HEALTH, EAST RIDING OF YORKSHIRE
COUNCIL

Matters of concern

There was a referral to Adults Safeguarding from
both Yorkshire Ambulance Service and Hull
Royal Infirmary regarding concerns as to the
care Ms Townend had received.

As a result of the referrals there was a review
that was deemed necessary. However, the
quality of that review was lacking.

The Safeguarding Adult Review that took place
did not probe the responses received
appropriately from the care company and the
Community Nurses in any way.

Response
It is usual practice that the local authority may
receive multiple safeguarding concerns about the
same person and in relation to the same
circumstances. It is good practice that both
Yorkshire Ambulance Service and Hull University
Teaching Hospital Trust recognised the potential
signs of abuse and neglect and acted in line with
local East Riding Safeguarding Adults Board
Multi-agency Safeguarding Procedures.

Both safeguarding concerns received were
triaged by East Riding Adult Social Care and
Health Safeguarding Adults Team and progressed
under section 42 of The Care Act 2014 on the
grounds that there was reasonable cause to
suspect that Janet Brown Townend:

(a) had needs for care and support

(b) was experiencing, or is at risk of, abuse

or neglect, and

(c) as a result of those needs was unable to
protect herself against the abuse or
neglect or the risk of it

The safeguarding adults enquiry process seeks to
understand the likelihood of whether abuse or
neglect occurred and takes appropriate action
based on the findings. A response as to the
quality of the section 42 work undertaken will be
provided below.

The Safeguarding Adult Review referred to here
is a Section 42 enquiry that was undertaken by a
qualified and registered social worker from East
Riding Adult Social Care and Health.

Interim Executive Director of Adult Social Care and Health (DASS)

Brickchand Ramruttun

 In evidence it was heard that the procedure
adopted did not record how the responses had
been obtained.

The family's input was not recorded. The
process happened hastily and the review not to
the appropriate standards that would have been
of any benefit.

In evidence it was heard that there was a lack of
professional curiosity and the full review process
not followed or documented properly.

When a safeguarding adult concern is received
by the local authority and is related to potential
neglect by the professionals caring for the
person, the social worker would make enquiries
with the services subject to the allegations made
as happened in this case.

A social worker undertaking a S42 enquiry may
seek the information they require through a
range of different methods and in a way that they
believe is proportionate to key lines of enquiry.
This can range from gathering information by
email or over the telephone to attending a
service or a property to speak to a person
directly or view records. They must also strike
the balance between responding in a timely way
and taking enough time to review all the
information available to them.

As the professional accountable for the enquiry
and any recommendations or actions required in
response to their analysis of the information
received, the social worker will use the method
they believe gives them what they need to
complete the enquiry. It is good practice that a
social worker will make their methodology clear
in the S42 report and that they will present their
rationale for the approach they take and how
this has assisted them to achieve the outcome
they reach. The local authority accepts that this
did not fully happen in this case.

The record of the enquiry also lacked analysis of
the information that was received from both
services approached for information and it was
not fully triangulated with other information
gathered from both Janet Brown Townend
herself and members of her family within the
record of the section 42 enquiry. It is difficult to
say whether the outcome of the enquiry would
have been different had these issues been
addressed, however, it is acknowledged that the
recorded evidence for decision making and
subsequent actions in this case could have been
improved. The practice issues identified in this
enquiry have been addressed with the individual
practitioner and lessons learned disseminated
within the team.

The adult safeguarding service has also been
under a programme of transformation and
continuous improvement since early 2023 that
has resulted in changes that support good
practice in this area. At the time of this enquiry
taking place, ERYC ASCH had undertaken a full
review and remodel of the safeguarding adults

 service with the aim of ensuring that the
processes, paperwork and practice achieves the
best possible outcomes for all people subject to
intervention under section 42 of the care act
2014.

In November 2023 (after this enquiry took
place), as part of the implementation of a new
service and practice model for safeguarding
adults, the service launched a new set of forms
to record safeguarding adult concerns and
section 42 enquiries. These forms lead the
practitioner through a much more succinct
process for undertaking and recording their
intervention with the voice of the person and
their family/representative at the heart of the
enquiry record.

The roll out of the forms was accompanied by
training and learning for those who are
completing them, refreshing practitioners
understanding about the expectations for their
completion, what good looks like and
encouraging professional curiosity. There is also
accompanying guidance for practitioners within
and external to the form to support them to
undertake and record a thorough section 42
enquiry.

It is good practice that at the end of a section 42
enquiry, the outcome and recommendations are
shared with all parties subject to the review.
The local authority accepts that in this case, this
did not happen as expected. This has been
addressed with the individual practitioner and
lessons learned have been disseminated with the
team.

Since this section 42 enquiry was concluded, as
described above, the service has implemented
new paperwork that supports the worker to
ensure that they share the outcome and
recommendations with relevant parties. The
form requires the worker to state who they
have consulted as part of the enquiry and who
they have shared the outcomes and
recommendations with. As well as taking steps
to ensure this important process is followed by
practitioners, embedding this in the forms gives
the service the opportunity to monitor and audit
practice and raise quality in relation to this
expectation.

The outcomes of the review and recommendations
were not provided to the subjects of the review.

The importance of Safeguarding reviews must
not be underestimated. They are in place to

Since this section 42 enquiry was undertaken,
East Riding of Yorkshire Council have
implemented a new service model for

 identify concerns and prevent any such issues
occurring in the future. The procedure
conducted needs to be looked at to avoid any
impact on anyone else.

Safeguarding Adults inclusive of the new
paperwork mentioned above.

The new service model sees a dedicated
safeguarding adults hub focussing on managing
incoming concerns and mitigating the immediate
risks to people, enabling robust decision making
around actions to be taken under Section 42 of
the care act.

Where a case is progressed to a section 42
enquiry, the work is allocated to the most
appropriate practitioner, usually within a locality
based assessment team or the review team who
are likely to have an established relationship with
the person and those providing care, enabling a
more person centred approach and alignment
with other social care processes such as annual
review and contract monitoring and compliance
with providers.

To support high quality safeguarding adults
enquiry practice, the services practice
development team has implemented a training
programme of practice workshops accompanied
by a weekly practice forum with the safeguarding
adults hub where cases can be discussed and
practitioners can receive guidance from the
safeguarding adults leadership team. The service
also leads a safeguarding champions programme
bringing professionals from within and external
to the local authority together to share good
practice and develop consistent responses to
safeguarding across the sector.

The service has also launched a safeguarding
audit to enable us to measure quality and identify
themes and trends for improving and developing
safeguarding adults practice further. This is
overseen by the principal social worker and
presented as part of the quarterly audit report
to the practice development board where
recommendations can be made to the Executive
Director and their leadership team and to
ensure collective oversight of actions taken and
any required mitigations.

Further actions to be taken:

Safeguarding Adults Reviews (SARs) are a statutory requirement for Safeguarding Adults Boards (SABs) under
section 44  of The Care Act 2014.  Safeguarding  adult  practice can  be  improved  by identifying  what  is  helping
and  what  is  hindering  safeguarding  work  across  the  system  partnership,  in  order  to  highlight  good practice,
learn lessons, continually improve, and pertinently protect adults from harm.

As a partner of the East Riding Safeguarding Adults Board the Council will make an application to the Board

 for a Safeguarding Adults Review to be considered for Janet Brown Townend.

All applications are considered by a multi-disciplinary team of senior leaders from across various agencies such
as Humberside Police, Integrated Care Board, Humber Teaching Foundation Trust (mental health) City Health
Care Partnership and the Council.

The meeting  is called the  Safeguarding  Adults Review Group  (SARG)  and in order  to ensure  equity  to  each
case the group follow a decision-making framework which also ensures proportionality.

The  Pretention  of  Future  Deaths  report  will  be  included  in  the  application  which  will  be  considered  by  all
parties and recorded in the official Minutes of the meeting.

Following  the  decision being  made it  is common practice  for  the Boards Independent Chair to  write  to  the
family members and alert them to the outcome and advise them of next steps, whilst offering assurance and
being sensitive to the complexities of the case. If the family do not wish to participate that is their right, but
the Board will continue with the piece of work in an anonymised manner without participation from the family
to ensure lessons learnt and continuous improvement.

If the SARG  agree  to  progress  a  SAR  an Independent Reviewer (IR) will  be  commissioned who  will  lead  the
review,  following  this  the  IR  will  host  a  formal  feedback  and  recommendations  session  with  all  agencies
involved. All agencies will then be required to evidence the actions they have taken to improve practice and
mechanisms implemented to safeguard against future concerns reoccurring, activity is overseen by the Boards
Actions and Assurance sub-group, where overall feedback is then given the Independent Board Chair within a
full  Board  meeting,  along  with  the  Annual  Assurance  Conversation,  which  is  also  reported  to  the  Councils
Cabinet Members.

Any specific recommendations for the Adult Social Care & Health Directorate in the Council will be escalated
to  the  Practice  Development  Board  where  the  Principal  Social  Worker  and  Executive  Director  and  their
leadership team will have collective oversight of actions taken and ongoing mitigations.