Stella James

28th August 2023 

Ms R Knight, 
Assistant Coroner for South Wales Central Coroner Area  

Dear Ms Knight, 

Re: Cardiff Council response regarding Regulation 28 Report - Stella Ann 
James  (deceased) 

I am writing on behalf of 
correspondence from the Coroner’s Office dated 4th July 2023. I was greatly 
concerned to read about Ms James’s tragic and untimely death. 

 to formally acknowledge receipt of the 

A thorough review has been undertaken in respect of Cardiff Adult Service’s 
involvement with Ms James to gain a comprehensive overview of how her case was 
managed. We recognise the importance of identifying any lessons that can be 
learned from the Coroner’s report, understanding the important contribution this 
makes to preventing future deaths.  

I am now in the position to respond appropriately to the two points of concern 
outlined in your Regulation 28 Report and address them below. 

1.  Stella appeared to meet the criteria as an ‘adult at risk of neglect’ due to 
her food avoidance and very low body weight, yet there was no apparent 
mechanism for Social Services to be aware of Stella’s status.  Stella was 
very secretive and formally had capacity when assessed months before 
her death, although it is noted that this can fluctuate. 

Cardiff Council staff were not directly involved in Ms James’s care whilst she was living in 
Cardiff, however, we do have officers working in the Pendine Centre as part of the Multi-
disciplinary Community Mental Health Team (CMHT).  

Having received your correspondence, we have now had the opportunity to access 
Stella’s medical notes on PARIS (Cardiff and Vale University Health Board 

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 Database) and we have also had access to the Draft Internal Review conducted by 
Cardiff and Vale UHB’s Mental Health Directorate. In addition, we have also had the 
opportunity to discuss the case with the Deputy Directorate Manager for Specialist 
Services within Cardiff and Vale UHB who has overall responsibility for the Serious High 
Risk Eating Disorder Service (SHED). 

As you are aware, Ms James received input from a number of professionals employed by 
Cardiff  and  Vale  UHB  which  included  Consultant  Psychiatrists,  Clinical  Psychologist, 
Dieticians and Nurses from various teams including SHED, Liaison Psychiatry, Dietetics, 
and the District Nurse Service. 

When  Ms  James  returned  to  live  in  Cardiff  she  was  referred  to  SHED.  To  access  this 
service  a  patient  needs  to  be  open  to  a  Community  Mental  Health  Team  which  in  Ms 
James’s case was the team based at the Pendine Centre. This team is a multi-disciplinary 
team made up of local authority and health professionals.  

As Ms James’s needs were identified as being health and not social care related, she had 
no direct involvement from local authority staff when under this team.  Her case, however, 
would have been discussed at the multi-disciplinary team meetings, in which local authority 
staff would have been present. If any issues had been raised during these meetings that 
indicated  that  input  from  local  authority  social  work  staff  was  required,  this  would  have 
been acted upon, however this was not the case.  

When Ms James was closed to the Serious High Risk Eating Disorder Service (SHED) in 
December 2020, a plan was put in place should the situation change.  It was agreed that 
if Ms James’ parents had concerns and Ms James had not been able or willing to get help, 
they could contact services directly as they had done previously.   

At point of closure to secondary mental health services Ms James continued to have other 
health professionals, namely her GP and District Nurses involved in her care who could 
have  raised  concerns  or  made  a  referral  to  social  services  at  any  time  if  they  felt  it 
appropriate. 

Therefore, we are confident that although the local authority staff had no direct involvement 
with Ms James’s care, the professionals involved from Cardiff and Vale UHB could have 
made a referral for social work assistance if that was required.  

The process and procedures around this are well established and we have no doubt that 
if the professionals involved felt it appropriate a referral would have been made.   

2.  Could  there  be  a  register  to  include  a  person  in  Stella’s  position,  whereby 
unannounced house visits from a social worker can be an option?  Perhaps 
involving a mechanism for anonymous referral? 

At the time of the closure of her case to secondary mental health services, Ms James was 
deemed to have capacity to make decisions  about her care and during her involvement 
with  services  had  declined  to  see  anyone  face  to  face,  choosing  to  see  professionals 
‘virtually.’ 

 One of the points of learning from the internal review carried out by Cardiff and Vale UHB 
Mental  Health  Clinical  Board  was  that,  with  one  exception  (in  June  2019),  none  of  the 
health  professionals  involved  saw  her  in  person.  This  made  physical  health  monitoring 
difficult.  

It was acknowledged during the internal review that although Ms James had declined face 
to  face  meetings,  there  was  nothing  to  stop  this  from  happening,  and  the  health 
professionals  involved  could  have  taken  a  more  assertive  approach  and  insisted  on  a 
home visit. As Ms James was living with her parents, there would have been no issue with 
gaining  access,  and  I  understand  that  Ms  James’s  parents  would  very  much  have 
welcomed a home visit from the health professionals involved in their daughter’s care.  

Other findings from the internal review included the need for better case co-ordination and 
a more formal multi-disciplinary approach to the closure of cases.  I understand that the 
learning from this review was shared appropriately, including with senior clinical staff.  

While the findings in this case applied to the Cardiff and Vale UHB rather than the local 
authority, we have reviewed these to ensure that we are also learning from the outcome 
of this very tragic case.  

In  terms  of  holding  a  register  of  adults  with  similar  needs  to  Ms  James,  as  her  needs 
required  clinical  expertise,  it  would  be  more  appropriate  that  any  ongoing  review 
arrangements were carried out by Cardiff and Vale UHB.  

In cases such as Ms James, involving complex medical and health issues, it requires the 
input  of  health  professionals  with  the  appropriate  knowledge  and  training  to  make  any 
determinations, this would include whether  an unannounced visit should take place and 
also to undertake that visit.  

In terms of holding a register of vulnerable adults more generally, we think that this could 
potentially negatively impact on the existing arrangements in place for appropriate multi 
agency involvement in future complex cases.   

In this case the decision not to refer for social worker involvement was the correct one and, 
having  reviewed  current  arrangements,  all  partners  are  confident  that  should  such  a 
referral  be  assessed  as  needed  in  a  future  case  then  the  process  is  clear  and 
unambiguous.  There  is  also  the  potential  that  the  creation  of  a  much  wider  vulnerable 
adults list would give the misguided impression to someone referring an individual onto the 
register, that the individual would be safeguarded.  

Currently,  all  professionals  involved  with  each  vulnerable  individual  must  ensure  that 
appropriate  monitoring  and  oversight  is  in  place  and,  the  internal  review  carried  out  by 
Cardiff  and  Vale  UHB  brought  invaluable  learning  into  this  aspect  of  current  working 
practice.   

Therefore, after full consideration, we suggest that the creation of a separate list would not 
answer the key issues arising from this tragic case and would not reduce the risk that future 
deaths might occur. Further, potentially we would be concerned that such a step would 
potentially  negatively  impact  on  effective  multi-agency  referral  arrangements  and  make 
professional accountabilities less clear.  

 I would like to assure you that the Council has fully considered the concerns set out in the 
Regulation 28 report and whilst we have concluded that it would not be appropriate for the 
Council  to  operate  a  separate  register  for  vulnerable  adults  in  similar  circumstances, 
please be assured that we have reviewed the learning from the internal review carried out 
by Cardiff and Vale UHB and have appropriately reflected on the points raised. We are 
committed to ensure that the learning from this case informs practice going forward.  

Yours sincerely, 

Corporate Director People and Communities