Derrick Tully

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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

2 SGA Providers Report | Care Services | Kaamil Education Ltd T/A Daryel Care- 108 Regent Studios, 1 Thane Villas, London, N7 7PH | Tel: 0207 272 4914|

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 Responsibility Target Date Status Mandatory refresher training delivered to all care staff on Falls, Head Injury Recognition, Recording, and Escalation Protocols. Training Coordinator, Registered Manager March 2024 Completed Enhance digital photographic injury upload capability (with explicit client consent obtained according to policy) to supplement written descriptions in care notes. Registered Manager, Deputy Care Manager, Care Coordinator, Field Care Supervisors, All Care Workers 30 June 2025 Scheduled Update care documentation guidelines and training to include structured prompts reinforcing the need for detailed descriptions of injury evolution (e.g., bruising, swelling extent/colour) across visits, and explicit recording of the rationale when a decision is made not to escalate further after initial reporting. Registered Manager, Training Coordinator 31 May 2025 Scheduled Reinforce understanding of roles, responsibilities, and escalation pathways within multi-agency frameworks like THS during staff supervisions, staff and stakeholder meetings. Registered Manager, Deputy Care Manager, Care Coordinators, Field Care Supervisors Ongoing Ongoing

4 SGA Providers Report | Care Services | Kaamil Education Ltd T/A Daryel Care- 108 Regent Studios, 1 Thane Villas, London, N7 7PH | Tel: 0207 272 4914|

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

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

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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.

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.

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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

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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

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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.

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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

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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.