Caroline Harris

Prevention of Future Deaths Report (Regulation 28):
Oxfordshire County Council’s response

Contents

Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response

 Coroners matters of concern
Executive Summary
Social and Health Care Response

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Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response

 The Coroner’s matters of concern as detailed in
the Regulation 28 report are as follows:

Background:
In March 2023, Thames Valley Police passed on a report about Caroline (Miss
Caroline HARRIS) to the Mult-Agency Safeguarding Hub (MASH) which raised
concerns about her behaviour and mental state and dishevelled appearance. The
report stated that it was, ‘Shared in the interests of safeguarding as may be having
relapse’.

MASH undertook a review of the report and concluded that Caroline was not at risk
but may have needs for care and support from the local authority. The information
was passed to the Council’s Adult Social Care Team (ASCT) who in turn passed the
information onto Caroline’s GP. At the Coroner’s inquest evidence was given that the
ASCT were unable to directly refer to Adults Mental Health Team (AMHT), even if
they had considered it necessary. As the GP was not made aware that Caroline had
declined to attend the clinic to receive her medication, she saw no need to refer the
Police report to AMHT.

Evidence was given that AMHT took a different view regarding the Police report and
would have viewed the report as evidence of Caroline relapsing. AMHT’s view was
the criteria for being shared with them, and with their
that such a report met
knowledge of Caroline’s past history of self-neglect and non-compliance with taking
medication, it ought to have been shared with them; and had it been done so it would
have been followed up assertively and urgently including undertaking home visits
and the possible use of compulsory powers under the Mental Health Act.

Reg 28 extract of concerns raised:
My concern is that important information regarding a deterioration in mental health
was not shared with the appropriate Team who may have been able make
appropriate interventions and to have taken steps to avoid a fatal outcome.

You should consider a review of how such information is assessed and shared
between the respective agencies.

Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response

 Executive Summary

This document is in response to the Regulation 28 report from the Coronors, relating
to Caroline Harris (died on or before 27/07/2023), for the purpose of Prevention of
Future Deaths.

The document describes the steps already taken prior to the hearing by The Social
and Health Care Team, who are the initial point of contact for Adult Social Care into
Oxfordshire County Council,
regarding potential safeguarding concerns for
Oxfordshire residents.

The Social and Health Care Team act as the ‘Front Door’ to Adult Social Care within
Oxfordshire. The team, as that initial point of contact, support Oxfordshire residents
through strength based conversations to ascertain their needs and either signpost
them to the voluntary care sector or begin their journey within Oxfordshire County
Council’s (OCC) Adult Care Service. The team can also order basic equipment for
residents, reducing unnecessary waiting times for simple but meaningful tools to
improve their lives. The Social and Health Care Team also screen out of hour
contacts predominantly from Thames Valley Police and South Central Ambulance
Service, which highlight potential safeguarding concerns of vulnerable adults
residing in Oxfordshire. As it stands, the team deals with approx. 20,000 out of hours
contacts each year.

The Social and Health Care Team acknowledges that action should have been taken
to share the Police report with Adult Mental Health Teams (AMHT), as Caroline
Harris had been open to that team previously.

Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response

 Coroner’s concern:
My concern is that important information regarding a deterioration in mental health
was not shared with the appropriate Team who may have been able make
appropriate interventions and to have taken steps to avoid a fatal outcome.

Action taken prior to the inquest:

1. Oxfordshire Safeguarding Adults Board Safeguarding matrix states for
situations where self-neglect is reported: "All standard interventions must be
used first to manage risk e.g. Care Management/Care Plan Approach/Multi-
Disciplinary Team”; The Social and Health Care Team will primarily complete
referrals to Adult Social Care, Mental Health Care (via GP) or other
appropriate services, such as housing or voluntary sector agencies. The team
will raise a safeguarding referral if a person does not consistently engage with
offered services or where there are concerns about their mental capacity to
make decisions about their care and support. 

2. Where the person is presenting primarily with a mental health concern and
additional concerns about self-neglect,
lack of access to food and/ or
medication or difficulties with finances or tenancy, the report is shared with the
person’s GP for mental health assessments and referrals; in addition, Social
and Health Care Team will make direct contact with the person in order to
signpost them to other appropriate agencies Oxfordshire County Council has
worked with healthcare partners and was able to reinstate access to mental
incident where
health records on the 16 August 2023, following a critical
access was removed by the NHS.

3. A critical incident took place in August 2022, and had an impact on how the
Social and Health Care Team processed reports from the Police and
Ambulance Service. To mitigate the loss of mental health systems, where
mental health involvement needed verification, the Social and Health Care
Team would contact AMHT. This was achieved by telephone or email.
Through the screening process, each report is discussed and the necessary
action agreed with a Social Worker before action was taken.

4. Once access to mental health records was reestablished, process
improvements and changes to all
incoming safeguarding reports were
implemented from August 2023, guidance/training material on this task was
updated and shared to all members of the team.

5. As a learning from the critical incident in August 2022, where online systems
failed, we have worked with partners to ensure that there are robust business
continuity plans in place. These include the use of manual processes to
instances where there are
ensure that checks are still being made on all
potential safeguarding concerns.

6.

7. Training was undertaken by the Specialist Customer Service Advisors and
Professional Support Team in August 2023. At this time the reintroduction that
all reports are checked against health databases (EMIS, HIE, RIO) to confirm

Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response

 GP details and NHS numbers, and to establish active or recent involvement
with mental health services/and or other health professionals. As these
systems give a broader view of the person referred across Health records.

8. This is in addition to checks made to the Council’s own Adult Social Care
systems, which will provide records of any previous interactions or
involvements. The collective data gathering cross checking across multiple
systems plus verification from the Professional Support Team (Social workers
and Occupational Therapists), who sit within the Social and Health Care
Team, gives us robust decision making and corroboration.

9. For quality assurance, decisions made by Specialist Customer Service
Advisors are checked by Social Workers, Occupational Therapists, Team
Leaders and the Training Officer. This forms part of the quality assurance
undertaken monthly to upskill the Customer Service Advisors and ensure that
the correct decisions are being made. This is done across all of their work and
various contact channels.

10. The guidance issued to the Social and Health Care Team in August 2023,
is shared with the person’s GP in the following

states that a report
circumstances.

a. Where the main concern expressed is of mental health difficulties, and;
b. Where the person is not recorded under any health database to be

already supported by a secondary mental health team.

The team will send an accompanying email to the GP making clear the
reasons why the report has been shared and request that the GP informs
the Social and Health Care Team of any follow-up. The email will also
request that the GP informs the team of any needs that may fall under the
social care remit requiring further contact from the Social and Health Care
Team.

11. Where the situation appears to be urgent the team will either:

Immediately contact the GP via telephone and discuss concerns, or;

a.
b. Escalate the case to the Professional Support Team for

further

evaluation and decision.

Action Taken immediately following the inquest:

1. A full review of the process and decision making in regard to decision making

was made in July 2024 to ensure that this situation does not arise again.

2. All staff involved in decision making were reminded in the daily team huddle of
the process changes implemented in August 2023 and to be ‘professionally
curious’ when looking at persons records and using all tools available to paint
a picture of that person’s circumstances. As this has been standard practice
since August 2023, we are now confident that this is fully embedded into the

Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response

 Social and Health Care Team.

3. Where access to online records like RIO for mental health, is not possible the
team must immediately email AMHT to check for mental health involvement
before action is taken. The Social and Health Care Team will continue to
follow up with AMHT until a response and decision is reached. In the unlikely
event that contact cannot be made with AMHT, this is escalated to Team
Leaders who will contact their counterparts in AMHT.

Summary
Since the Regulation 28 Order was received in July 2024, and the Social and Health
Care Team have reviewed and improved processes, to make sure that appropriate
checks, sharing of reports and decisions are made in conjunction with their updated
guidance when screening safeguarding reports. This has been done to avoid any
future issues and to ensure that important information is shared with the appropriate
internal teams and external partners.

The additional layers of checking online systems and liaising with the Professional
Support Team, gives added assurance that there is consistency in decision making
and ongoing learning for the Specialist Customer Service Advisors within the Social
and Health Care Team

Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response