Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0201, written 17 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Apr 2025 |
|---|---|
| Reference | 2025-0201 |
| Deceased | Linda Sitch |
| Coroner | Sean Horstead |
| Coroner area | Essex |
| Category | Suicide (from 2015) · 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
, Director Adult Social Care Mid Alliance Safeguarding, MCA
and DoLs, Essex County Council, County Hall, Chelmsford, Essex, CM1
1QH
CORONER
I am Sean Horstead, Area Coroner, for the coroner area of Essex
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.
INVESTIGATION and INQUEST
On 24th November 2023 I commenced an investigation into the death of Linda
Marilyn Sitch, aged 75 years. The investigation concluded at the end of a three
day inquest on the 3rd April 2025. Mrs Sitch died at Broomfield Hospital, Court
Road, Chelmsford, Essex. The medical cause of death was confirmed as: 1a
overdose.
My Narrative Conclusion confirmed that Mrs Sitch (hereafter ‘Linda’) had taken
her own life on a background of the impact upon her emotional and mental
health well-being of looking after her elderly husband (with whom she had
shared a long and happy marriage) and who, himself, suffered from significant
on-going mental and physical health problems. The Narrative Conclusion
included a summary chronology of the involvement of Adult Social Care with
Linda over the last six weeks or so of life.
During my summing-up, when providing my findings and determinations, I made
it clear that the failings identified in the course of the inquest, although very
possibly contributed to the death, I did not find, in the specific circumstances,
that they were probably more than minimally causative of the death.
CIRCUMSTANCES OF THE DEATH
Linda’s husband had been suffering from significant physical and mental health
challenges for more than a year or so prior to her death; the impact of aspects of
his initial presentation deeply affected Linda, to the extent that she attempted to
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take her own life on three occasions in October 2022. This led to her admission
as a voluntary in-patient at a Mental Health facility under the care of Essex
Partnership University NHS Foundation Trust (EPUT). She received a diagnosis
of an ‘Adjustment Disorder’. She was discharged to the care of the Community
Mental Health Team in February 2023 and remained largely stable in her
presentation through until the late summer of 2023. Her husband, having
himself been detained under the provisions of the Mental Health Act 1983, was
discharged back to the family home in June 2023.
On 29th September 2023 Linda’s husband’s EPUT Care Coordinator raised an
Adult Safeguarding (ASG) concern with Essex County Council’s Adult Social
Care (ASC) regarding Linda’s potential (unintentional) maladministration of her
husband’s medication. The referral contained details of Linda’s own history of
overdosing and the concerns of family members relating to Linda’s presentation
and her ability to care for her husband. By the time of her death on 11th
November, no action had been taken by ASC regarding this Safeguarding
referral.
On the 2nd October 2023 a further referral was received from the same CPN
requesting a Care Act (2014) Carer’s Assessment for Linda. The referral again
informed ASC that Linda was struggling with caring for John. Without apparently
considering the ASG referral, this further referral was subsequently erroneously
downgraded by the Community Team Manager from Priority 1 (requiring an
immediate response) to Priority 2 (response within 28 days). The rationale for
so doing was not recorded, as it should have been. By the time of her death no
further action had been taken by ASC regarding the referral for a carer’s
assessment.
On 16th October further contact was made by Linda’s daughter chasing-up the
2nd October referral, re-emphasising the escalating and serious family concerns
regarding Linda’s presentation, reiterating that Linda had attempted suicide the
previous year and expressing concerns that Linda was exceptionally stressed
and needed a break. As a consequence of (admitted) human error this
information was not acted upon. Had it been reviewed the priority level would
have been changed back to Priority 1 and there would have been immediate
action, within 24 to 48 hours. Options would likely have included, inter alia,
interim carers or residential respite. This would also have been an opportunity
to establish if Linda had need in her own right. By the time of her death no
further action had been taken by ASC regarding this additional contact.
On 7th November Linda’s husband was admitted to Hospital for a medical issue;
he was due to be discharged the following week. Prior to his discharge home,
Linda took her own life.
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CORONER’S CONCERNS
During the inquest the evidence revealed matters giving rise to concern and 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. –
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a. Although not determined to be probably causative of the death, by the
date of Linda’s death ASC had failed to respond substantively or at all to
the Adult Safeguarding Referral dated 29th September 2023; the referral
for a Carer’s Assessment for Linda herself, received by ASC on 2nd
October 2023; the concerns reiterated by Linda’s family when chasing
the 2nd October referral on 16th October 2023. These failures were
explained as ‘human error’.
b. The oral evidence of the ASC Service Manager at the inquest (though
not mentioned in her statement prepared for the purposes of the
inquest), confirmed that the Team Manager responsible for downgrading
the Priority 1 status of the carer’s assessment referral on 2nd October to
Priority 2, without recording a rationale, had likely done so without
undertaking the required consideration of either the readily available
ASG referral of the 29th September, or the Mental Health Act assessment
of Linda herself from the previous year. She agreed that, had an
estimated “ten minute” review of the “slim files” for both Linda and her
husband been undertaken, as should have happened, the Priority level
could not and would not have been reasonably downgraded. She
accordingly accepted that, in fact, (and contrary to her witness
statement) the decision to downgrade to Priority 2 was capable of being
determined, by her as an ASC Service Manager, to be ‘inappropriate’.
c. Nonetheless, the ASC Service Manager remained personally “reassured”
that a change in Team Manager - along with reminders to personnel of
best practice - had sufficiently addressed issues identified by the inquest
proceedings.
d. In contrast to this view, I remain concerned that ASC continues to lack a
robust system to ensure sufficiently rigorous oversight, including active
auditing, capable of identifying the kind of sub-optimal managerial level
performance as has been brought to the fore in this case. A change in
personnel and moves towards “embedding best practice” do not, in my
opinion, sufficiently address
the
effectiveness of such changes will still rely very substantially upon the
performance of any Team Manager and/or a Deputy Team Manager.
There appears to me to be a continuing lack of robust Service level
oversight of those managers themselves, (including the appropriateness
of their decision making), absent which any sub-optimal performance by
said managers may well not be identified.
this systemic
lacuna given
that
e. Absent a sufficiently robust system for providing oversight and identifying
and significantly mitigating (if not entirely removing) such individual
human error, alongside, for example, the inclusion of simple auditable
check lists of matters to be accessed, reviewed and documented
whenever a referral is received, then there is a continuing risk of urgent
future referrals being inappropriately graded as Priority 2 (and/or being
downgraded
thorough and
from Priority 1) without
the requisite
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professional review, adequately documented, being undertaken. This
gives rise to a concomitant risk of future deaths.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
and your organisation 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 Wednesday 12th June 2025. I, the coroner, may extend the
period.
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 the following
Interested Persons and others:
The Family of Linda Sitch
Essex Partnership NHS Foundation Trust
Essex Safeguarding Adult Board and ESAB SAR Panel Independent Chair
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.
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HM Area Coroner for Essex Sean Horstead
17.04.2025
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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.
The Central Safeguarding Triage Team has undergone transformative change, which has
included increasing the resource of the team, implementing an initial screening check of all
safeguarding alerts raised and those which are deemed to meet the criteria for safeguarding
are then progressed to a safeguarding concern for further enquiries. As a result of these
changes, 96% are triaged for a decision as to whether to proceed to safeguarding section 42
enquiry within 72 hours, with outcomes shared back with referrers and next actions agreed.
The remaining 4% take a little longer with continuous oversight, whilst waiting for
information at the triage stage to enable decision making. Therefore, there are no longer
significant delays in progressing safeguarding referrals received.
Adult Social Care has reviewed our essential training offer, which follows the National
Competency Framework for Safeguarding, which includes:
• 1-day basic awareness training for all operational and non-operational workers
• 2-day enquiry officer training for enquiry officers for all operational workers
• 2-day safeguarding adult manager training for all team managers and deputy team
managers
• 1-day Mental Capacity Act (MCA) in Practice for all operational workers
• New Carers practice guidance for Adult Social Care operational workers to support
better and more timely outcomes for carers.
• New Core Practice Guidance in March 2024, which includes guidance on Care Act
assessments, carers assessments, reviews, support planning and safeguarding
• A new Risk Priority Matrix for carers assessments and reviews was implemented in
2023, which was being embedded throughout the year.
This training ensures that all operational workers including team managers, service managers
and directors are clear on their responsibilities.
b) The oral evidence of the ASC Service Manager at the inquest (though not mentioned
in her statement prepared for the purposes of the inquest), confirmed that the Team
Manager responsible for downgrading the Priority 1 status of the carer’s assessment
referral on 2nd October to Priority 2, without recording a rationale, had likely done so
without undertaking the required consideration of either the readily available ASG
referral of the 29th September, or the Mental Health Act assessment of Linda herself
from the previous year. She agreed that, had an estimated “ten minute” review of the
“slim files” for both Linda and her husband been undertaken, as should have
happened, the Priority level could not and would not have been reasonably
downgraded. She accordingly accepted that, in fact, (and contrary to her witness
statement) the decision to downgrade to Priority 2 was capable of being determined,
by her as an ASC Service Manager, to be ‘inappropriate’.
c) Nonetheless, the ASC Service Manager remained personally “reassured” that a
change in Team Manager - along with reminders to personnel of best practice - had
sufficiently addressed issues identified by the inquest proceedings.
We recognise an error occurred and that we should have taken actions to allocate a social
worker sooner. We also recognise that there was human error by the specific team manager
and deputy team manager involved as highlighted above. We can confirm that the Team
Manager no longer works for Essex County Council and the deputy team manager has
undergone reflective supervision and additional training.
Adult Social Care is satisfied that the current Team Manager who returned to the team in
November 2023, is very experienced, has reviewed the process within the team and has
oversight of decisions.
Adult Social Care has an audit schedule where individual casework is reviewed and alongside
this there is a more focused scheduled of Appreciative Reviews, which focuses on how
individual teams operate. This team had an Appreciative Review in May 2024, which
highlighted strengths in multi-agency practice, with further focus on embedding this; coupled
with good oversight of work from both the team manager and service manager.
Adult Social Care have scheduled an audit cycle within the next three months, specifically
focused on how referrals are progressed when an initial referral is received, through to point
of allocation. Following analysis and outcomes of this, we will consider issuing further
practice guidance to confirm expectations about making good, defensible decisions around
priority levels, including expected timescale for the allocation of work.
In Spring 2024, Adult Social Care commissioned an external review of the end-to-end
safeguarding process. There were several recommendations, that we are implementing to
improve the customer journey and safeguarding practice.
There is a priority matrix in place to support determination of level of risk for carers. There is
also a risk priority matrix for safeguarding, issued in September 2023, which was in the
process of being embedded across Adult Social Care at the time of Linda Sitch’s suicide.
By introducing the measures highlighted in this response we have enhanced the tools
required to support better practice decisions. Our practice audits demonstrate our
workforce are clear on recording expectations.
d) In contrast to this view, I remain concerned that ASC continues to lack a robust
system to ensure sufficiently rigorous oversight, including active auditing, capable of
identifying the kind of sub-optimal managerial level performance as has been brought
to the fore in this case. A change in personnel and moves towards “embedding best
practice” do not, in my opinion, sufficiently address this systemic lacuna given that the
effectiveness of such changes will still rely very substantially upon the performance of
any Team Manager and/or a Deputy Team Manager. There appears to me to be a
continuing lack of robust Service level oversight of those managers themselves,
(including the appropriateness of their decision making), absent which any sub-optimal
performance by said managers may well not be identified.
We are satisfied that Adult Social Care has robust oversight in place. We created a data and
insights team in August 2024, who provide detailed reports on performance. Directors /
service managers / team managers receive a weekly report in relation to safeguarding
activity across all teams. There is also a weekly report which details people waiting alongside
a dashboard, these have team manager /service manager and director oversight.
Furthermore, there is a monthly quality, performance and accountability meeting (QPAM)
within each locality area, where data information reports are scrutinised by service managers
and directors, which ensures greater accountability and oversight of all work and what stage
it is at.
Adult Social Care have also implemented an improved supervision framework in 2024. There
are four main elements to supervision which are to:
(i) reflect upon our practice and our emotional response to the situations we encounter.
(ii) clarify our work priorities.
(iii) support our general wellbeing.
(iv) consider our development and learning needs.
This also enables greater oversight and scrutiny of work held at all levels of the operational
workforce.
Time to Reflect sessions are held on a quarterly basis for operational teams and focus on key
themes and areas of practice for learning for example, in June 2024, the session was
dedicated to practice in relation to Valuing Carers.
Adult Social Care has a Practice Governance Board, which is chaired by our Principal Social
Worker. There are several subgroups have a specific focus lens and report into the six weekly
Practice Governance Board. These are:
SAR/DARDR/Inquests Subgroup to ensure robust actions and learning is taken from
•
recommendations
• Compliments, Complaints and Local Government Ombudsmen Reports Subgroup
•
•
Learning and Development Steering Group
Practice, Policy and Guidance Subgroup
• Research Governance Panel
All groups have a focus on learning and best practice to support our wider workforce.
e) Absent a sufficiently robust system for providing oversight and identifying and
significantly mitigating (if not entirely removing) such individual human error,
alongside, for example, the inclusion of simple auditable check lists of matters to be
accessed, reviewed and documented whenever a referral is received, then there is a
continuing risk of urgent future referrals being inappropriately graded as Priority 2
(and/or being downgraded from Priority 1) without the requisite thorough and 4
professional review, adequately documented, being undertaken. This gives rise to a
concomitant risk of future deaths
Adult Social Care’s approach to quality assurance has been reviewed and enhanced since
2023 and is twofold.
There is a Quality Control focus on the accuracy of the information that we capture, with an
expectation on all levels of our operational workforce to ensure Data Quality:
This data feeds into performance data and reporting as per the Quality Assurance
Individuals, managers, or supervisors are responsible for ensuring data entry is
•
completed correctly and on time.
•
framework.
•
•
Emphasizes the importance of getting things right the first time.
Provides Adult Social Care (ASC) with quantitative intelligence.
Team managers, deputy team managers and supervisors undertake quality control checks as
part of their responsibilities for oversight of work in their teams daily.
Alongside the Quality Control measures in place, Adult Social Care refreshed its Quality
Assurance Framework in 2024 and there are now eight audit cycles in place throughout every
year. These focus on care act assessments/reviews, carers assessments, mental capacity
assessments and safeguarding. Audits are analysed and reports are presented to the
Practice Governance Board.
Deep Dive thematic audits are also undertaken as and when requested/required to ensure
continuous learning in specific areas of practice.
Adult Social Care’s Principal Social Worker and Principal Occupational Therapist, along with
The Essex Social Care Academy (training department) and Adult Social Care’s dedicated
Practice Quality Team recognise there is a critical role between learning from assurance,
development and practice quality activity. Therefore, they work closely together to ensure
learning and intelligence from assurance activity and continued professional development
programmes, informs the approach of both, to ensure a rounded overview of practice quality
in Adult Social Care.
If you have any further queries, please do not hesitate to contact me directly.
Yours sincerely,
Director, ASC Alliance (Mid), Safeguarding, MCA and DoLs
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