Alison Binyon

Miss Sophie Lomas 
His Majesty’s Assistant Coroner for Derby and 

Derbyshire  
St Katherine’s House  
St Mary’s Wharf  
Mansfield Road 
Derbyshire 
DE1 3TQ 

PRIVATE AND CONFIDENTIAL 

Dear Miss Lomas,  

06 January 2025 

Date: 
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Regulation 28: Report to Prevent Future Deaths  

Inquest into the death of Alison Binyon – concluded on 31 October 2024 

I  am  writing  in  response  to  the  Regulation  28  Report  to  Prevent  Future  Deaths  (RPFD) 
made under paragraph 7, schedule 5 of the Coroners and Justice Act 2009 and regulations 
28 and 29 of the Coroners (Investigations) Regulations 2013 on the 11th November 2024, 
following the inquest into the sad death of Alison Binyon.  

I  take  the  matters  of  concern  identified  in section  5  of  the  RPFD  in turn  and  respond  to 
these as follows:  

1.  Communication  

“Whilst consideration had been given to conversations with the service user in this situation, 
the court heard evidence from those supporting Alison (including community mental health 
nurses) that they were unclear on the stage the process had reached, the specific steps of 
the process and the likely timescales involved. This affected the type of support they could 
provide. There was a lack of evidence of a specific approach or policy addressing how the 
process can be clearly communicated to those supporting service users in the community 
of a specific approach or policy addressing how the process can be clearly communicated 
to those supporting service users in the community.” 

Adults and Communities 

Leicestershire County Council, County Hall, Glenfield, Leicestershire LE3 8RL 

www.leics.gov.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 It is acknowledged that a change in accommodation can result in period of uncertainty in 
any individual’s life and this can be particularly unsettling where that individual has a history 
of  significant  mental  health  difficulties  and  has  spent  a  period  residing  in  a  specialist 
residential setting, as was the case here. In such circumstances any proposed or actual 
changes in accommodation require very careful management and consideration alongside 
clear and effective communication with both the individual and the professionals or multi-
disciplinary team (MDT) supporting that individual. A lack of clear communication between 
professionals  supporting  an  individual  can  impact  on  the  type  and  effectiveness  of 
professional support provided to them.  

The  Adult  Social  Care  Team  have  carefully  considered  this  matter  and  reviewed  my 
department’s  current  processes  and  policies  around  communication  with  individuals  and 
other  agencies  supporting  accommodation  moves  proposed  and  actual.  As  a result,  the 
team  are  improving  our  current  processes  by  creating  a  visual  flowchart  of  the 
accommodation process from beginning to end so that all those involved can clearly see 
what the next steps are and how close the individual is to any proposed move. Within the 
flow  chart,  Adult  Social  Care  workers  will  be  reminded  that  they  must  include  the  MDT 
working  with  the  individual  concerned  (including  care  providers  and  Community  Mental 
Health  Teams)  so  that  accurate  information  can  be  shared  regarding  future  plans,  and 
appropriate actions taken. To improve communication with those supporting or close to an 
individual, this flowchart will be shared with an individual, their current care provider, family 
or friends’ representatives so that uncertainty around the process is minimised. This flow 
chart is in the planning stages; it will be introduced in February 2025. 

It  should  be  noted  that  timeframes  for  any  change  of  accommodation  can  often  be 
unpredictable  due  to  a  range  of  factors  including  availability  of  a  particular  property, 
procurement  processes to identify  support  providers  and legal  or  administrative steps to 
begin a tenancy. Communication at each step of the process needs to be clear, and where 
uncertainty arises there is a plan in place with all involved to provide reassurance to the 
individual at the centre and those supporting the individual.  

The Adult Social Care Workers will be provided with communication from the  department 
within our weekly internal newsletter, which directs them to our key goal: that staff are aware 
of the need to reassure individuals at each stage of the process, check for clarification of 
understanding, and ensure that providers and other professionals are made aware of any 
raised  anxiety  levels.  The  newsletter  will  also  direct  staff  to  be  person-centred  when 
considering the date or timescales of a move and to avoid any periods of time where an 
individual may already be experiencing stress or anxiety. This information will be included 
in the newsletter circulated week commencing 13th January 2025. 

2.  Internal Review  

“Further,  no  internal  review  was  carried  out  at  Leicestershire  County  Council  following 
Alison's  death.  If  such  reviews  are  not  conducted this  could  lead  to  inadequate  learning 
from deaths which creates a risk of further deaths.” 

My understanding is that on the fourth day of the inquest, clarification was sought from, and 
provided  by  Counsel  representing  Leicestershire  County  Council  on  the  fact  that 

 
  
 
 
 
 
 Leicestershire County Council had not carried out an internal review in this case and the 
reasons  for  the  same,  but  that  during  the  course  of  the  inquest  witness  evidence  and 
submissions  were  not  sought  on  Leicestershire  County  Council’s  internal  investigation 
processes.  

Nevertheless,  in  light  of  this  concern  being  raised  in  the  RPRD,  I  have  considered  this 
matter  and  consultation  has  occurred  within  the  department  around  the  internal  review 
process for when an unexpected death occurs. 

There are existing policies and procedures already in place in line with the statutory duties 
on local authorities to make safeguarding adults enquiries under s42 of the Care Act 2014 
including responding to Safeguarding Alerts and undertaking Safeguarding Enquiries. As 
explained  during  the  inquest,  in  Alison’s  case,  Derbyshire  County  Council’s  adult  social 
care  department  were the lead authority for  the s42  enquiry.  However, we acknowledge 
that  there  is  a  need  to  communicate  clarity  around  roles  and  responsibilities  for 
Leicestershire County Council as the commissioning authority where an individual is living 
outside of this authority’s geographical area, as was the case here. Furthermore, staff have 
been reminded that strategy discussions and meetings should clearly detail any elements 
of  a  Safeguarding  Enquiry  that  are  being  delegated  by  the  host  authority  to  any  other 
parties.  

The  RPRD  has  identified  the  need  for  an  internal  review  process  also.  Accordingly,  a 
procedure  has  been  developed  for  all  Adult  Social  Care  managers  which  will  go  live  in 
January 2025 to ensure that where an unexpected death occurs, an internal review takes 
place to consider the departments involvement, the views of those involved, and whether 
there are any specific learning points or amendments to policies or processes required.   

Yours sincerely 

Director of Adults & Communities • S0001 Adults & Communities