Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0108, written 20 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Feb 2025 |
|---|---|
| Reference | 2025-0108 |
| Deceased | Janet Scott |
| Coroner | Robert Cohen |
| Coroner area | Cumbria |
| Category | Community health care and emergency services related deaths · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Miss K J Gomersal LLB | Acting Senior Coroner | Cumbria
Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT
Tel:
| Email:
Case Ref:
20 February 2025
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
1
2
3
THIS REPORT IS BEING SENT TO: Northumberland Childrens and Adults
Safeguarding Partnership
CORONER
I am Mr Robert Cohen, HM Assistant Coroner for Cumbria
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 3 April 2023 an investigation was commenced into the death of Janet Scott. The
investigation concluded at the end of the inquest. The conclusion of the inquest was
Janet Scott was 60 years old. She lived in Haltwhistle, Northumbria. Ms Scott had a
complex medical history. She had been diagnosed with schizophrenia. She was diabetic.
As result of her conditions Ms Scott struggled to care for herself in later life. She was very
vulnerable.
Ms Scott lived in social housing. She required regular support with her mental and
physical health needs. She struggled to maintain her home and ensure that it remained
clean and safe. Ms Scott was at serious risk of self-neglect.
In 2022 attempts began to rehouse Ms Scott. Unfortunately, it was not easy to identify a
suitable alternative address in the small area in which she was willing to live. As a result,
she remained at the same address until a scheduled move in March 2023.
On 7th March 2023 Ms Scott's Community Psychiatric Nurse ('CPN') contacted Adult
Social Care. She had been allowed entry into Ms Scott's home and was very concerned.
She described 'squalor': a property full of rubbish bags, with a build-up of food parcels
that Ms Scott was not using. On that day, Ms Scott had been kneeling when she
answered the door. On the next day, Ms Scott was visited by her support worker. She
was observed to be dishevelled, exhibiting poor personal hygiene and struggling to walk.
Following these encounters, there was a failure to activate multi-agency safeguarding
procedures. Multiple attempts were made to contact ASC over the coming days, but these
were not responded to with sufficient speed or rigour. Ms Scott was visited on 20th March
2023 but no immediate risk to her was recognised.
Ms Scott was found at home, unresponsive, on 28th March 2023. She had developed
sepsis. Ms Scott was transported to the Cumberland Infirmary, Carlisle, by ambulance.
She died there on 30th March 2023. Ms Scott's death was confirmed at 17:50.
It is more likely than not that Ms Scott's self-neglect, her living conditions in the last weeks
of her life, and the very limited medical assistance provided to her in those weeks caused
or contributed to Ms Scott's death.
Ms Scott's death was contributed to by neglect, being the failure to procure basic medical
care for her after concerns were raised on 7th March 2023.
1a Sepsis
1b
1c
II Diabetes Mellitus and Schizophrenia
CIRCUMSTANCES OF THE DEATH
Ms Scott had a serious tendency toward self-neglect. She was a 'hoarder' and her living
conditions were seriously unsanitary. She was also without a functioning boiler for 18
months after her gas supply was capped.
Prior to Ms Scott's death there were numerous occasions on which her self-neglect was
apparent to different agencies. Although it is true that Ms Scott was often unwilling to
accept help, I heard evidence of several occasions on which there had been missed
opportunities to provide assistance.
4
To their substantial credit, many of the agencies involved in Ms Scott's situation provided
evidence to me of the steps they have taken to avoid a repeat. There was a consensus
that more could and should have been done to adopt a multi-agency approach to
safeguarding.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
5
(1) Although individual agencies referred me to training they had provided to staff since
Ms Scott's death, I also received evidence that, for instance, the GP surgery might not
raise a safeguarding referral if the same circumstances were repeated because social
services had already been informed. This leads me to be concerned that the message
that 'safeguarding is everyone's responsibility' has not been taken on board. I am
concerned that future cases will occur in which a multiagency approach is not adopted or
that individuals will not make safeguarding referrals because they assume that other
agencies are already aware of the issue.
(2)
(3)
ACTION SHOULD BE TAKEN
6
In my opinion action should be taken to prevent future deaths and I believe you
Northumberland Childrens and Adults Safeguarding Partnership have the power to
take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 18th April 2025. I, the coroner, may extend the period.
7
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to each of the Interested
Persons.
8
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
20 February 2025
9
Signature
Robert Cohen HM Assistant Coroner for Cumbria
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Northumberland Children and Adults Safeguarding Partnership
County Hall
Morpeth
NE61 2EF
Email:
Robert Cohen
HM Assistant Coroner for Cumbria
Fairfield, Station Road,
Cockermouth,
Cumbria
CA13 9PT
Dear Mr Cohen,
Date: 17th April 2025
RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
I write on behalf of Northumberland Children and Adults Safeguarding Partnership (NCASP) in response to
your Prevention of Future Deaths Report made under paragraph 7, Schedule 5, of the Coroners and Justice
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
I would like to take this opportunity to express my condolences, both personally and on behalf of NCASP, to
Ms Scott’s family.
The MATTERS OF CONCERN you raised with the partnership were. –
(1) Although individual agencies referred me to training they had provided to staff since Ms Scott’s death, I
also received evidence that, for instance, the GP surgery might not raise a safeguarding referral if the
same circumstances were repeated because social services had already been informed. This leads me to
be concerned that the message that ‘safeguarding is everyone’s responsibility’ has not been taken on
board. I am concerned that future cases will occur in which a multiagency approach is not adopted or
that individuals will not make safeguarding referrals because they assume that other agencies are already
aware of the issue.
As a partnership we have given Ms Scott’s death, and the learning identified as a result, significant
consideration; through the decision to progress to a Safeguarding Adult Review (SAR) and the involvement
of several NCASP partners in the inquest. We have previously shared with you the initial findings of the SAR
which is a Thematic Review of self-neglect and includes the death of Ms Scott. We would like to take this
opportunity to provide a more detailed picture of how practice and multi-agency working has and we expect
will change because of this and detail how this will be monitored going forward.
Actions undertaken by NCASP since Ms Scott’s death notwithstanding the SAR include:
Updated Self-neglect Policy in 20241
This revised guidance was launched across the partnership during Safeguarding Adults Week in November
2024 and provides guidance for skilled practice in the context of self-neglect. This includes a clutter rating
1
tool for use by practitioners and outlines suggested responses depending upon the level of risk and harm
identified. The policy emphasises the importance of a person-centred approach as well as the need to
balance autonomy with protection and a duty of care, which was highlighted in the review of Ms Scott’s
death. Multi-agency training has been delivered across the partnership to increase awareness of the policy,
and training will continue throughout 2025 including with Ms Scott’s GP practice in July 2025.
Principles of Engagement across the Partnership2
Nine clear and concise principles have been adopted for professionals to consider when working with
complex clients including recognition that vulnerability can impact on a person’s ability to engage and the
potential consequences if we fail to engage the client. These principles were published in November 2024
and are being reiterated within self-neglect training sessions throughout 2025.
Neglect (including Self-neglect) as a Strategic Priority
NCASP have identified neglect as a priority area of work (as from 2023-2026) which we hope will improve
outcomes for adults and children. The impact will be measured via assurance work and performance
frameworks. A multi-agency task and finish group has been in place since March 2024 and has been looking
at the following areas:
• Raising awareness of self-neglect and its impact
• Hoarding
• Substance Misuse
• Informed decision making
• Consider pathways for those that don't meet threshold.
• Engagement
• The impact of and the response to complex chronic neglect
• Learning from neglect summit and SARs
• Training for all partner agencies in relation to neglect.
• Neglect and the impact on the whole family.
Audits of clients at risk of self-neglect have evidenced a range of referral sources including (but not limited
to) family, friends and neighbours; community health staff; probation workers; fire service personnel and
GPs. Close examination of records includes historic cases as well as recent referrals and consideration of
whether appropriate and timely action was taken (including escalation to safeguarding procedures) and if
there has been sufficient management oversight. Findings from these audits will be shared with partners
across NCASP via the task and finish group work once completed and implications for practice considered
and kept under review.
NCASP commissioned
as an independent reviewer to conduct the SAR as a
nationally recognised expert and one of the authors of the second national analysis of SARs, hence he has
extensive knowledge of effective practice in learning reviews, in particular self-neglect which currently
accounts for 60% of SARs nationally3.
’s initial findings highlighted that ‘there was a good understanding of “safeguarding
is everyone’s business”, this being demonstrated by the range of services making adult safeguarding
referrals, including Citizens Advice, North East Ambulance Service, care providers, hospital staff and a gas
engineer. However…. there had been a lack of escalation of concerns and missed opportunities to refer adult
safeguarding concerns.’ This finding echoed your concerns that there may be an assumption that
safeguarding referrals are not necessary because someone else is aware of the abuse or neglect.
NCASP have now considered
’s final report and have committed to accepting and
implementing his recommendations in full. Future changes to practice that will be promptly implemented,
these include (not exhaustive):
http://nland.uk/ncasp
Multi-agency Risk Management (MARM) Framework
NCASP will introduce a multi-agency risk management framework within 6 months, which will set out a
shared commitment across agencies who work with risk in Northumberland and will provide practice
guidance to practitioners who are working with adults who have multiple and complex needs and are at risk
of serious harm or abuse. This framework will support professionals to provide earlier multi-agency
intervention than traditional safeguarding procedures and encourage referrals for low level concerns before
they become significant and critical.
Policy and Procedure implementation feedback
NCASP will adopt an approach that requires teams across the partnership to feedback when newly
introduced policies and guidance, including those on self-neglect have been discussed and the changes to
practice that will follow. Agencies will be required to report into the Practice Learning Group which meets
quarterly, within 3 months of new policies and practice guidance being published.
Impact assessment of learning from reviews
NCASP’s SAR Framework and Practice Guidance has been updated to reflect improvements to processes for
identifying cases that may warrant review including the introduction of a Rapid Review process which allows
earlier identification of areas of learning and good practice. Prior to publication a further requirement will
be added that the partnership must review the impact of the learning one-year post completion of a SAR.
In addition, as a Statutory Partner, the Integrated Care Board are taking the lead in relation to ensuring
escalation processes and safeguarding responsibilities are widely known and understood across Primary Care
services and will ensure evidence of this is shared with NCASP.
I hope this provides you with assurance in response to the concerns you have raised.
Yours Sincerely,
On behalf of Northumberland Children and Adults Safeguarding Partnership
(Partnership Chair)
1 north-of-tyne-self-neglect-policy-2024-northumberland-final-version.pdf
2 ncasp-principles-of-engagement-adults.pdf
3 Second national analysis of Safeguarding Adult Reviews: April 2019 - March 2023 (executive summary) | Local
Government Association
http://nland.uk/ncasp
See every Prevention of Future Deaths report matching Community health care and emergency services related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.