Derrick Tully

1 

PROVIDER RESPONSE TO REPORT MADE UNDER PARAGRAPH 7, SCHEDULE 5 OF THE CORONERS AND JUSTICE 
ACT 2009 

IN THE MATTER OF AN INVESTIGATION INTO THE DEATH OF DERRICK FREDERICK TULLY (DECEASED) 

29 April 2025 

SERVICE USER: Derrick Frederick Tully (Deceased) 
NHS Number: 
Date service Ended: 22 February 2024 

1.  Overview  

This report constitutes the formal response of Daryel Care pursuant to its duty under Paragraph 7(1) of Schedule 
5 to the Coroners and Justice Act 2009 and Regulation 28 of the coroners (Investigations) Regulations 2013. It 
addresses the matters of concern raised in the Prevention of Future Deaths (PFD) report issued by HM Assistant 
Coroner Melanie Sarah Lee dated 28 March 2025, following the conclusion of the inquest into the death of Mr 
Derrick Frederick Tully. 

Daryel Care provided time-limited home support to Mr Tully from 2 February 2024 to 22 February 2024 under the 
framework of the Islington Local Authority’s ‘Take Home and Settle’ (THS) pilot project. This project aimed to 
facilitate timely hospital discharge through short-term, flexible care packages delivered by community providers, 
operating within a multi-agency framework involving Islington Council, Whittington Health NHS Trust (including 
Rapid Response and Reablement services), and the Integrated Discharge Service. Decision-making regarding care 
pathways and clinical oversight involved multiple stakeholders, as fundamental in the pilot's design. 

Daryel  care  approaches  its  duty  to  respond  with  the  utmost  seriousness  and  is  committed  to  learning, 
transparency, and the continuous improvement of its services to ensure the safety and well-being of all service 
users. 

2.  Coroner’s Concern 

Daryel Care & Islington Adult Social Services: On 20 February Derrick suffered a fall. Severe bruising and swelling 
developed on his face over the following days but this was not recorded in his care notes by his care workers and not 
escalated until his daughter raised concerns on 24 February.  “No Concerns” was written in Derrick’s care record and 
no consideration given to whether he needed to be reviewed by a doctor. 

Daryel Care has undertaken a thorough internal review, examining all contemporary electronic care records (held 
on the CM2000 system), communication logs, incident reports, and relevant email correspondence pertaining to 
Mr Tully's care during the period 2 February 2024 to 22 February 2024. Our response addresses each element of 
the concern based on this evidence. 

3.  Response to Specific Elements of the Concern 
a.  Recording of the Fall Incident (20 February 2024) 

The  assertion  that  the  fall  incident  was  "not  recorded"  is  factually  incorrect  based  on  Daryel  Care's  existing 
records. The electronic care note entry for the visit commencing at 19:00 hrs on 20 February 2024, logged at 19:04 
hours, explicitly documents the following: “The carer observed Mr Tully upon arrival with a fresh plaster wrap 
and wound dressing on his scalp. Mr Tully informed the carer he had sustained an injury from a fall. The carer 

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immediately contacted Mr Tully’s daughter via telephone for clarification. The daughter confirmed Mr Tully had 
fallen near a local shop, had been transported to hospital via ambulance, received treatment for his wound, and 
had subsequently been discharged home shortly before the carer's visit.” This record confirms the incident was 
documented promptly by the attending care worker and the office team. 

b.  Escalation of the Fall Incident (20 February 2024) 

The assertion that the incident was "not escalated until his daughter raised concerns on 24 February" is factually 
incorrect. At 22:33 hrs on 20 February 2024, approximately three hours after the incident was recorded by the 
carer, a Daryel Care Care-coordinator sent an escalation email detailing the head injury incident. This email was 
addressed  to  key  professionals  within  the  multi-disciplinary  team  (MDT),  including  the  Specialist  Domiciliary 
Pharmacy Technician (Islington Reablement Service, Whittington Health/Islington Council), the Single Point of 
Access  (SPOA),  and  the  Rapid  Response  team  contact.  This  documented  email  demonstrates  timely  and 
appropriate escalation to the relevant health and social care professionals responsible for Mr Tully’s wider care 
coordination and clinical oversight, in line with multi-agency working practices of the THS pilot. 

c.  Recording of Developing Injury Presentation (21 – 22 February 2024) 

The PFD report states that "Severe bruising and swelling developed on his face over the following days but this 
was not recorded". On 21 February 2024 (11:18 hrs), the care worker noted Mr Tully was "having some pains due 
to the injury on his head." On 22 February 2024 (11:16 hrs), the care worker observed and recorded that the "injury 
on the head has made his eye to be swollen." These entries demonstrate that Daryel Care staff did continue to 
observe and document the presentation of the injury, including pain and the subsequent development of facial 
swelling, during their visits on the days following the initial incident. Daryel Care acknowledges the importance 
of  detailed  descriptions  of  injury  progression,  particularly  evolving  bruising  and  swelling.  While  observations 
were recorded, we recognise that greater specificity regarding the extent and nature of the swelling could have 
enhanced the record. This is addressed further under Section 5 (Actions Taken). 

d.  Reference to "No Concerns" Entry  

The PFD report states, "“No concerns” was written in Derrick’s care record". Daryel Care utilises the CM2000 
electronic care monitoring and recording system for all care worker visit notes. A review of all CM2000 electronic 
care notes logged by Daryel Care staff for Mr Tully between 20 February 2024 and the final visit on 22 February 
2024  has  been conducted.  This comprehensive review has  not  located  any  entry  made  by  a  Daryel Care staff 
member within the CM2000 system during this period that contains the phrase "No concerns" or substantively 
similar wording used in an inappropriate context (i.e., as an overall assessment negating the known head injury). 
All located notes contain specific details pertinent to the care provided and observations made, including the 
entries regarding the head injury referenced above. Daryel Care acknowledges the information presented by HM 
Assistant Coroner regarding this entry. However, as we can find no record of such an entry within our official 
electronic  care  recording  system  attributable  to  our  staff  during  the  relevant  timeframe,  we  are  unable  to 
comment definitively on its origin or intended context. It is possible the reference pertains to records held in a 
different recording format outside of Daryel Care’s CM2000 system. 

e.  Consideration of Medical Review  

The PFD report raises concern that "no consideration given to whether he needed to be reviewed by a doctor." 
Daryel Care staff were operating within a complex multi-agency framework where clinical oversight, particularly 
post-discharge and concerning medication, was understood to be led by the Whittington Health Rapid Response 
team.  The  decision-making  process  regarding  further  medical  review  by  Daryel  Care  staff  considered  the 
following factors: Firstly, Mr Tully had been assessed and treated at the hospital A&E department immediately 
following his fall on 20 February and was discharged home. Additionally, Daryel Care had formally escalated the 
head injury to the MDT (including Rapid Response) on the evening of 20 February. Observations during visits on 
21 and 22 February recorded pain (on the 21st) and a swollen eye (on the 22nd). The existing records do not note 
the presence of additional 'red flag' indicators that would typically trigger an immediate, separate medical re-
escalation,  such  as  reported  loss  of  consciousness,  significant  confusion  beyond  baseline,  vomiting,  seizure 
activity,  or  sudden  deterioration  in  mobility  or  responsiveness.  Furthermore,  on  22  February,  Mr  Tully  was 
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recorded as being alert and engaging with his daughter. It is also worth noting that on 21 February, following an 
MDT discussion during which Mr Tully’s case was presented, confirmation was received that the Daryel Care THS 
package would end after the evening visit on 22 February, with care transferring to the Reablement service. Staff 
were aware that the handover was imminent. Therefore, based on these factors, the prior A&E review, existing 
escalation to MDT, absence of acute red flags during Daryel Care visits, and the imminent planned handover of 
care, Daryel Care staff continued observational monitoring as documented, anticipating review by the ongoing 
clinical  teams.  Daryel  Care  acknowledges  that  the  basis  for  not  seeking  a  further,  immediate  medical  review 
beyond the initial escalation could have been more explicitly documented within the care notes. This aspect of 
reflective practice and documentation is addressed under Section 5 (Actions Taken). 

4.  Summary of Findings (Daryel Care Perspective) 
▪  The fall incident and head injury on 20 February was promptly recorded in the electronic care notes and 

escalated appropriately via email to the multi-agency team within approximately three hours. 

▪  Subsequent  care  notes  demonstrate  ongoing  observation  and  recording  of  the  injury's  presentation, 

including pain and developing facial swelling, during visits on 21 and 22 February. 

▪  A review of Daryel Care's electronic records (CM2000) did not locate the "No concerns" entry referenced 

by the coroner as having been made by Daryel Care staff during the relevant period. 

▪  Consideration regarding further medical review was informed by Mr Tully's recent A&E assessment, the 
existing escalation to the MDT (Rapid Response), the absence of acute red flags during Daryel Care visits, 
and the imminent planned cessation of the Daryel Care package. 

▪  Daryel  Care’s  involvement  ceased  as  planned  on  the  evening  of  22  February  2024,  following  the 

commissioner-led decision communicated on 21 February 2024. 

5.  Actions Taken and Proposed Further Action 

Daryel Care  is  committed  to  learning  from  this  incident  and has  taken  and  proposes  the  following  actions  to 
mitigate the risk of future similar occurrences: 

Action 
Mandatory  refresher  training  delivered  to  all 
care  staff  on  Falls,  Head  Injury  Recognition, 
Recording, and Escalation Protocols. 
injury  upload 
Enhance  digital  photographic 
capability (with explicit client consent obtained 
according  to  policy)  to  supplement  written 
descriptions in care notes. 

to 

include 

(e.g.,  bruising, 

Update  care  documentation  guidelines  and 
training 
structured  prompts 
reinforcing the need for detailed descriptions of 
injury  evolution 
swelling 
extent/colour)  across  visits,  and  explicit 
recording  of  the  rationale  when  a  decision  is 
initial 
made  not  to  escalate  further  after 
reporting. 
Reinforce 
roles, 
responsibilities, and escalation pathways within 
multi-agency frameworks like THS during staff 
supervisions, staff and stakeholder meetings. 

understanding 

of 

Responsibility 
Training 
Registered Manager 

Coordinator, 

Registered  Manager, 
Deputy  Care  Manager, 
Care  Coordinator,  Field 
Care  Supervisors,  All 
Care Workers 
Registered  Manager, 
Training Coordinator 

Target Date 
March 2024 

Status 
Completed 

June 

Scheduled  

30 
2025 

31 May 2025 

Scheduled 

Registered  Manager, 
Deputy  Care  Manager, 
Care Coordinators, Field 
Care Supervisors 

Ongoing 

Ongoing 

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6.  Lessons Learned 
▪  The importance of detailed, objective descriptions of injury development (particularly bruising/swelling) 
over  subsequent  visits,  beyond  initial  recording,  is  vital.  Training  and  documentation  prompts  must 
reinforce this. 

▪  Care staff must be supported and trained to clearly document not only their observations but also the 
rationale behind their decisions regarding escalation or non-escalation, particularly following an initial 
incident report. 

▪  While inherent in pilot schemes, this case underscores the critical need for absolute clarity regarding the 
designated clinical lead and specific communication procedures for ongoing condition monitoring versus 
acute escalation, especially during short-term transitional care packages. This must be clearly understood 
by all providers, service users, and families from the outset. 

7.  Conclusion 

Daryel Care extends its sincere condolences to the family of Mr Tully. We acknowledge the concerns raised by HM 
Assistant Coroner Lee and have sought to address them fully and transparently based on the evidence available 
within our records. We submit that the evidence demonstrates Daryel Care staff acted promptly to record and 
escalate  the  initial  incident  on  20  February  2024  and  continued  to  monitor  Mr  Tully’s  condition  during  the 
subsequent two days of the short-term package. We have addressed the specific points regarding record-keeping 
and  the  "No  Concerns"  entry  based  on  the  documented  evidence.  Daryel  Care  is  committed  to  robust 
safeguarding  practices  and  continuous  improvement.  We  believe  the  actions  already  taken,  along  with  those 
proposed as a result of lessons learned from this case, will strengthen our service delivery and documentation 
practices, thereby mitigating the risks identified within our sphere of operation. Daryel Care remains committed 
to working collaboratively with Islington Council, Healthcare providers, and other partners to ensure the safe and 
effective delivery of care. We are available to provide any further information required. 

Safeguarding Officer, acting for Daryel Care 

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HM Coroner Melanie Lee 
St Pancras Coroner’s Court  
Camley Street 
London N1C 4PP 

Adult Social Care  
4th Floor  
222 Upper Street 
London N1 1XR 

Telephone: 

By email only 

www.islington.gov.uk 

Dear Assistant Coroner Lee, 

London  Borough  of  Islington  response  to  the  Regulation  28  Prevention  of  future  death 
report into the death of Derrick Frederick Tully (died 20 March 2024) 

In response to the concerns raised in the Prevention of Future Death report, that states there was 
a failure by Islington Council Adult Social Care (ASC) and Housing Departments to consider a 
number of issues relating to Mr Tully’s support and housing requirements. Islington’s Council ASC 
and Housing Department have considered the report and have addressed the following elements 
under the headings provided in the report.  

Islington Housing Options: 
Award of Medical Points 

Islington Council acknowledge that no medical points were awarded to Mr Tully. An email was 
received  by  the  Housing  Needs  Team  on  5  March  2024  from  an  NHS  email  address.  The 
attachment  to  the  email  could  not  be  opened.  On  24  April  2024  a  letter  was  sent  to  Mr  Tully 
explaining that the attachment could not be opened and that no medical points had been awarded. 
A request was made for the information to be re-sent in another format. The information was not 
re-sent and there was no social care letter of support on the file. Upon subsequent investigation 
following receipt of the PFD report, it transpires that the attachment to the email dated 5 March 
2024 included a ‘Supporting letter for rehousing’ dated 29 February 2024 from an OT who the 
letter  head  refers  to  as  being  within  the  Social  Care  and  Rehabilitation  Team  (Incorporating 
Islington REACH), which is a part of Whittington NHS Heatlh Trust not the London Borough of 
Islington’s Adult Care Services.  

Islington  council  has  a  corporate  deadline  of  10  working  days  in  which  to  respond  to  general 
correspondence. If this is not possible, officers should contact the sender to explain that there will 
be a delay in responding and inform them when they will provide a substantive response. That 
deadline was not adhered to in this case and as such the following action has been taken.  

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 On 16 May 2025, Housing Needs Managers were asked to remind all officers, no later than by 27 
June 2025, of the following:  

1/  All  staff  should  aim  to  respond  to  written  correspondence  within  the  council’s  corporate 
deadline of 10 working days. If this is not possible, officers should alert the sender of a delay in 
responding and inform them when they will respond to their correspondence.  
2/ All communication in writing must be indexed to the resident’s records/file. 
3/  Any  correspondence  with  attachments  that  cannot  be  read  due  to  formatting  issues  should 
evidence attempts to contact the sender of the issue. The sender should be asked to resend any 
attachments in a readable format.  
4/ If written correspondence is received by a Housing Needs Council officer that is relevant to 
another team in the service or Council, this must be passed on to the relevant team within 2 to 5 
working days (maximum) or sooner. If an email is incorrectly received by a team and passed to 
the relevant team, the original email sender must be copied in to ensure they are able to follow 
the audit trail.  

In addition to the guidance above, all Housing Needs Managers were also reminded on 16 May 
2025 of the following: 
1/  Housing  Needs  managers  must  carry  out  monthly  file  checks  on  a  sample  of  cases  that 
includes noting whether correspondence is responded to within the Council’s corporate targets 
and if not, whether a holding response has been sent to the sender.  
2/ All file checks should be recorded via the case audit logs appropriate for their team. 

Once new medical information is provided regarding a resident, the Housing Needs Team aim to 
process the information within 6 weeks.  

If the letter received on 5th March 2024 had been opened/read on time and a medical assessment 
had been conducted, it would sadly not have led to Mr Tully having been housed any sooner as 
he passed away within 15 days of receipt of the OT report. Regrettably, this is due to the severe 
shortage of social housing available in Islington. 

Provision of a Key safe 

The Housing Needs Team have been unable to evidence any requests made to the team for a 
key safe, by Mr Tully, his family or anyone involved in his care. If a resident, or anyone on their 
behalf, ask the Housing Needs Team about a key safe, they would be signposted or referred to 
a service that would be able to advise and assist further, such as ASC, Telecare or Age UK. As 
no  such  requests  were  made  to  the  Housing  Needs  Team  on  behalf  of  Mr  Tully,  no  such 
signposting or referral was undertaken. 

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 Islington Adult Social Care: 
Provision of a keysafe: 

ASC acknowledge that there was no keysafe in place, when Reablement support commenced. 
Mr Tully was assessed as being able to provide access to the property. This assessment would 
have been made in the context of Islington Council’s ASC practice model for promoting strengths-
based  practice  and  that  Mr  Tully  had  the  mental  capacity  to  make  a  decision  about  how  he 
supported access to his property.  

ASC have been unable to evidence repeated requests from Mr Tully’s family for a keysafe as 
stated. Our records do highlight that on the 27 February 2024 the Reablement Team noted the 
potential need for a key safe. There is no documentation detailing the follow up to the 27 February 
2024 record. 
A key safe was also mentioned on the 20 March 2024 in a conversation between the Emergency 
Duty Team and Mr Tully’s family when access to the property could not be gained, when he was 
later found deceased on this day.  
ASC had, as part of Mr Tully’s telecare arrangement, ensured that in the event of an incident, two 
family  members  were  listed  as  emergency  contacts  to  support  access.  These  emergency 
contacts were contacted on a number of occasions when Mr Tully did not reply to the care workers 
at the door and had gone out. 

Islington Council recognise the important role key safes can play in managing risk to individuals, 
as well the importance of resident consent, risk management and promoting independence and 
strength. In response to the PFD Notice Islington Council will inform the workforce through the 
Principal Social Worker the importance of considering access to people’s property in the event of 
risk,  as  well  as  the  importance  of  contingency  planning.  In  addition,  Islington  Council  will 
undertake a review of its Key safe Policy which will include the factors to be considered when 
deciding to install.  

Islington Adult Social Services: 

The PFD Notice states that the Coroners Court has determined that Derrick was not suitable for 
reablement because of his declining cognition and progressive dementia.  

The decision  to  support  Mr  Tully move  to  Reablement  was made by  a  Take  Home and Settle 
case manager, on the basis that Mr Tully had no formal care previously and his family advised he 
was largely independent prior to hospital admission. Mr Tully’s case records summarise a meeting 
held  on  the  12  February  2024,  where  the  decision  to  refer  to  Reablement  was  made  with  his 
daughter present. The notes under a section headed ‘Cognition’ states that Mr Tully was able to 
communicate his views and wishes, this is also reflected in the referral to Reablement.   Islington 
Council maintain that this was an appropriate decision and in line with practice and legal 

3 

 
 
 
 
 
 
 
 requirements,  which  also  include  not  excluding  people  with  cognitive  challenges  from  the 
opportunity to be supported by Reablement. 

Reablement  provides  support,  on  a  daily  basis,  with  activities  of  daily  living.  Intervention  can 
range from direct care delivery to confidence building and guidance with activity.  

Adult Social Care records state that the Community Health OT from REACH (Whittington Health 
NHS Trust) who advised the ASC Single Point of Access Physio on the 28 Feb 2024 that the 
resident ‘is likely an unsuitable candidate for rehabilitation due to his cognition’. Rehabilitation is 
a different service offer to Reablement, with Rehabilitation considered a health service focussed 
on  periodic  clinical  intervention  to  restore  function,  opposed  to  Reablement  which  is  care  led 
focussing on improving skills in activities of daily living. Section 22 of the Care Act 2014 prevents 
local authorities providing health services and to that end Rehabilitation.  

Care was provided throughout the period from Mr Tully’s discharge to his death, which included 
support  with  meal  preparation.  Mr  Tully  was  considered  to  have  the  mental  capacity  to  make 
decisions around his care and support needs.  

In response to the coroner’s findings, Islington does support its workforce through training, audit 
and the support of the principal social worker with the skills to identify issues relating to residents’ 
cognitive abilities, their capability to identify risk and the management of that risk in line with the 
Mental Capacity Act 2005 and its principles. Islington Council will revisit this training in the light 
of the coroner’s findings. 

Daryel Care & Islington Adult Social Services:  

Daryel Care were commissioned to provide support as part of the Take Home and Settle provision 
prior to Reablement. This support was provided to Mr Tully between the 2 – 22 February 2024. 
The  Coroner’s  Report  raises  concern  about  the  lack  of  reporting  by  Daryel  Care  of  a  fall 
experienced on the 20 February 2024.  

It is ASC’s understanding that Daryel Care was not requested to provide evidence to the coroner's 
court  of  their  recording  and  reporting  of  the  fall  on  the  20  February  2024.  As  part  of  ASC’s 
response to the the PFD Notice, we have engaged Daryel Care who have provided their records. 
These evidence that on the 20 February 2024 at 19:12 ‘Derek sustained an injury on his face. He 
said he had an accident when he went out. The injury was plastered. I prompted his medication 
from the medication box, and he asked me to leave’.  

The Assistant Coroner states in the PFD that the fall and subsequent bruising and swelling... ‘was 
not recorded in his care notes by his carers and not escalated by Daryel Care...’ however 

4 

 
 
 
 
 
 
 
 
 
 the Coroners Statement and case notes shared by ASC with the Coroner do highlight that Daryel 
Care did report the occurrence of the fall to Adult Social Care on the 21 February 2024. 

Reviewing the London Care Record, it is evident that London Ambulance Service attended Mr 
Tully’s address on the 20 February 2024 at 9:47am and conveyed him to Whittington Hospital for 
treatment at Accident and Emergency.  Health Professionals had already responded to Mr Tully 
falling  on  the  20  February  2024  and  facilitated  treatment,  this  is  reflected  in  Daryel  Care’s 
reporting of the same day and will have determined their level of response.  

Islington Council has a robust process in place to monitor the quality of care of our providers. We 
work  closely  with  CQC  and  across  the  system  to  ensure  a  system  wide  approach.  This  is 
overseen by the Islington Provider Quality Oversight Board (IPQOB), which reports to the Senior 
Leadership Team within Adult Social Care and the Independent Adults Safeguarding Board. 

The council undertakes an annual audit of home care providers. The audit is based on CQC Key 
Lines of Enquiry, which provides robust assurance around the suitability of providers who work 
with  Islington  residents.  This  includes  reviewing  the  care  plans,  staff  files  and  reviewing  key 
policies to ensure that people are receiving a safe service in line with the standards.   

The  council  leads  quarterly  provider  forums  with  the  aims  of  fostering  a  supportive  learning 
environment to share, reflect and shape best practice across the sector. It’s also an opportunity 
to  hear  from  commissioning  colleagues  about  any  key  trends,  important  information  to  share, 
including presentations from other areas to share learning.  It is in this forum that commissioners 
share  important  information  and  key  trends. The  forum  is  supplemented  by  a  regular  provider 
bulletin, which provides updates and news stories that may be of interest to providers, as well as 
reminders of changes in regulation. 

Contracts and commissioning colleagues work closely with safeguarding and operational social 
work teams to share intelligence about providers, to ensure a coordinated approach to decision 
making and agreeing the proportionate approach to address concerns.  Operations colleagues 
submit “service issues” to providers where they have identified issues with an individual’s package 
of care. The provider is expected to investigate and report back to the Council within 10 days. 
Service issues are a useful source of intelligence to identify if there are wider quality concerns 
about  a  provider.  This  process  also  enables  general  trends  to  be  identified,  which  feed  into 
provider forums to share learning that may be useful for all home care providers. 

Where providers are found not to be performing well, the Council can enact its Provider Concerns 
Process.  This  process  is  supported  by  CQC  who  attend  meetings.  The  process  supports  the 
provider to identify areas of improvement. 

5 

 
 
 
 
 
 
 
 
 Further, it seeks assurances that these changes are embedded to ensure that Islington residents 
are receiving safe care. Where a provider is not assessed to be making the necessary changes 
to ensure a safe service, the Council may then seek to move individuals to another provider. This 
board reports to the Islington Safeguarding Adults Partnership Board so that the whole system 
can  review  and  consider  concerns,  this  has  also  helped  refine  the  process  to  ensure  we  are 
effectively capturing and addressing concerns.  

Integrated Community Aging Team, Whittington Health 

Islington  Council  note  that  the  Prevention  of  Future  Death  Notice  requests  that  the  Integrated 
Community  Aging  Team, Whittington  Health NHS  Trust,  respond  to  the  Coroners'  concerns  in 
that  Mr  Tully  did  not  want  to  engage  with  their  home  assessment  of  him  and  that  this  was 
compounded by problems he’d experienced with neighbours and cuckooing concerns meaning 
that at times, he didn’t feel safe at home. It does not appear that these were factored into his 
inability to engage with the team.  

Islington Council feel it would be helpful to note that Safeguarding Concerns were raised on the 
following dates and by the following professionals: 

05/02/2025 - District Nursing – Whittington Health 

-  The  referral  considers  concerns  about  the  noise  from  neighbours  and  the  neighbour's 

property being a drugs den, impacting on Mr Tully’s ability to sleep.  

08/02/2025 - Whittington Hospital Staff 

-  The referral considers concerns about Mr Tully’s ability to care for himself and the risk of 
falls.  It  does  note  the  same  concerns  about  his  neighbours  as  highlighted  on  the 
05/02/2025. 

26/02/2025 - Whittington Hospital Staff 

-  The referral considers concerns about Mr Tully’s ability to care for himself and the risks 
this  poses  to  his  well-being.  The  referral  notes  that  Mr  Tully  is  scared  around  other 
residents in the hostel, but no incidents had occurred. The Hospital at this time offered to 
admit Mr Tully however the referral suggests the family declined. 

The concerns were considered in line with Islington Council’s Safeguarding Policy, with none of 
the concerns being taking forward to a Safeguarding Enquiry. These decisions were made on the 
basis that Mr Tully was considered to have mental capacity to make decisions around his care, 
support and accommodation. Mr Tully clearly did not like living in the accommodation at that time 
due to the noise and the behaviour of other residents, however, he reported that there had been 
no direct incident and on two occasions reported that the alleged perpetrators had moved out. 
The  concerns  in  relation  to  his  care  needs  were  being  actively  considered  through  ASC  case 
management and he was being supported to consider alternate independent accommodation. I 

6 

 
 
 
 
 
 
 hope this clarification is supportive in considering Whittington Health’s response to the Prevention 
of Future Death Notice.  

Adult Social  Care  recognise  the  importance  of  interagency  working  and  sharing  information  in 
relation to people being supported in the community. ASC work closely with Whittington Health 
and  will  explore  opportunities  to  improve  these  working  relationships  and  information  sharing 
through its integrated front door and integrated neighbourhood strategy. These programmes of 
work seek to consider people’s referrals and needs more holistically, with health and social care 
staff working more collaboratively.  

Islington Adult Social Care and Housing Department have considered the Section Regulation 28: 
Prevention  of  Future  Deaths  report  and  have  identified  several  areas  of  learning  that  will  be 
shared across the organisation.  Should the Coroners Court wish to discuss any element of the 
response, then please contact Islington Council at the address above.  
Yours sincerely, 

Corporate Director of Health and Social Care 
Islington Council 

7

Acting Medical Director 
Medical Directorate 
Jenner Building 
Magdala Avenue 
London N19 5NF 

Email: 

Tel 

www.whittington.nhs.uk 

Private and Confidential 
HM Coroner Melanie Lee 
Assistant Coroner 
Inner North London 
St. Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 
By email to 

02 May 2025 

Dear Coroner Lee, 

Regulation 28 Prevention of Future Deaths (PFD) 

I am writing to respond to the Regulation 28 Prevention of Future Deaths (PFD) report for Derrick 
Tully, received on 28 March 2025. This response is written on behalf of Whittington Health NHS 
Trust. 

I would like to take this opportunity at the outset to offer our sincere condolences to Mr Tully’s family. 

The Trust did not receive notification that the inquest had been re-listed and were only 
aware that it had been held on receipt of the PFD. There was no opportunity to provide 
details of the care provisions for Derrick at the time to the court and his family. 

In the PFD you raised the following matters for concern and the actions we have taken 
in response to these concerns are as follows: 

Integrated Community Aging Team, Whittington Health 

Following Multidisciplinary (MDT) meetings due to concerns over Derrick’s increasing deterioration 
and  inability  to  cope  with  his  own  care  needs  at  home,  the  Integrated  Community  Aging  Team 
(ICAT)  reviewed  him  on  06  March  2025  following  a  referral  from  GP  via  Integrated  Care 
Coordination (INC). The ICAT discharged him from the service on 12 March 2025 following a home 
assessment, because he did not want to engage further with the service. In addition, the problems 

Chair:  

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 identified  at  this  assessment  were  already  being  managed  under  the  care  of  other  community 
services. Derrick was suffering from cognitive impairment as a result of previous strokes and newly 
diagnosed dementia. He also had a mental health history and was paranoid. This was compounded 
by problems he’d experienced with neighbours and cuckooing concerns meaning that at times, he 
didn’t feel safe at home. It does not appear that these were factored into his inability to engage with 
the  team.  A  review  of  the  care  records  has  identified  that  his  mental  capacity  was  not  clearly 
documented. 

 Matter of concern 1 

Following  MDT meetings  due to concerns over Derrick’s  increasing  deterioration  and inability  to 
cope with his own care needs, the Integrated Community Aging Team reviewed him on 6 March. 
They discharged him from the service on 12 March because he did not want to engage with their 
home assessment of him. Derrick was suffering from cognitive impairment as a result of previous 
strokes and newly diagnosed dementia. 

The Lead Consultant for the Integrated Community Aging team (ICAT) has confirmed that families 
are  usually  involved  as  much  as  possible  in  assessments  with  the  consent  of  patients  in  ICAT 
service. Where a patient does not have capacity to decline speaking with their next of kin, attempts 
are made to do so in their best interests. It is unclear why this did not happen in this case, and this 
will be explored in detail following an independent structured judgement review  at the next ICAT 
governance  meeting  on  May  21st,  2025.  The  minutes  for  those  unable  to  attend  will  be 
disseminated  by  email  and  one  to  one  discussions.  This  case  will  also  be  discussed  at  weekly 
Safeguarding drop ins on 6th May 2025. 

In terms of how such incidents will be addressed in future, the learning from this case will be taken 
to the governance, Clinical and Quality Lead and team meetings. In addition, details will be added 
to the assessment proforma around engagement with the next of kin to get collateral history and 
discuss  concerns,  if  the  patient  consents  to  this.  If  the  patient  does  not  give  consent,  a  mental 
capacity  assessment  will  be  conducted  and  documented  around  this  decision  and  discussed  at 
MDT with the lead clinician. 

In  terms  of  the  decision  making  around  discharge,  although  Derrick’s  refusal  for  ongoing 
assessment was a factor, the primary reason for discharge was that all the identified problems were 
being addressed by existing teams and ICAT could not add anything further to Derrick’s care. In 
addition,  as  he  remained  under  Integrated  Networks  Coordinators  (INC)  and  several  other 
community services there was a safety net in place in terms of ongoing follow up. 

Matter of concern 2 

DT also had a mental health history and was paranoid. This was compounded by problems he’d 
experienced with neighbours and cuckooing concerns meaning that at times, he didn’t feel safe at 
home. It does not appear that these were factored into his inability to engage with the team. 

The team were in receipt of the knowledge regarding the concerns the coroner has raised and duly 
considered.    A  community  matron  raised  a  safeguarding  adult  concern  on  6th  February  2024  in 
relation to Derrick’s living conditions and his neighbours. Another safeguarding adult concern was 

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 raised on 25th February by Whittington Hospital Accident and Emergency which explicitly highlights 
concerns  the  coroner  raised  around  family  concerns  involving  Mr  Tully’s  living  conditions, 
neighbours and ability to care for himself at home.  

The Trust will use the learning from the concerns raised from this incident and have identified the 
following actions: 

•  The  case  will  be  discussed  at  the  next  ICAT  governance  meeting  on  May  21st,  2025, 
following  a  structured  judgement  review  by  an  independent  consultant  to  share  learning.  
The  minutes  for  those  unable  to  attend  will  be  disseminated  by  email  and  one  to  one 
discussions. This case will also be discussed at weekly Safeguarding drop ins on 6th May 
2025. 

•  Further  learning  from  this  case  and  response  will  be  shared  at  senior  Trust  governance 
meetings; Quality Governance committee  on 10th June and Quality assurance committee 
on 9th July 2025.  

•  Details will be added to the assessment proforma clearly showing the requirement to consult 

with the patients’ family where applicable. 

•  Compliance with the additional information completion will be audited monthly and reported 

back to the governance meeting. 

•  Mental capacity assessment will be conducted for all patients when they are not engaging 

with services as well as family involvement where appropriate. 

Yours sincerely, 

Acting Medical Director 

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    Chief Executive: