Source · Prevention of Future Deaths

Geoffrey Cheney

Ref: 2024-0561 Date: 18 Oct 2024 Coroner: Ian Pears Area: West Yorkshire Western Responses identified: 2 / 1 View PDF

An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, which could have been crucial.

Date 18 Oct 2024
56-day deadline 13 Dec 2024 est.
Responses identified 2 of 1
Community health care and emergency services related deaths Suicide (from 2015)

Coroner's concerns

AI summary
An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, which could have been crucial.
View full coroner's concerns
From the evidence it was clear that there was an assumption that could not be removed and as a result no attempt was made to see if it was actually possible to have removed

Responses

2 respondents
Kirklees Council Local Authority / Fire Service
PDF
Action Taken

Kirklees Council amended its Housing Assistance Policy to reflect that they may remove adaptations should they pose any risk to any persons in the household. The council will raise a Safeguarding Adults Review (SAR) referral to help identify any learning for future purposes. (AI summary)

View full response
Dear Mr Ian Pears.

RE: Coroners instruction regarding future removal of adaptations.

Kirklees Council write in support of Radis Community Care’s response to the instruction you have issued to them in connection with the removal of future adaptations if they present a safeguarding issue.

To give you some additional background with regards to the operational structure, Radis Community Care is the company who are the care providers to our customers, Pinnacle Group Ltd and Kirklees Council hold responsibility for all policy aspects of the property management, including adaptations.

Kirklees Council have a Housing Assistance Policy which lays out how we deliver adaptations. Previously there was nothing in the policy with regard to removing adaptations should they present a risk to a person.

Following your report, I can confirm that amendments have been made with immediate effect to reflect that we may remove adaptations should they pose any risk to any persons in the household. The Policy is currently undergoing a formal sign-off process following several amends, but our process for this has already been updated. For information, the section in the draft Policy reads as follows:

Removing and re-using aids and adaptations.
• It is standard practice that generally we do not remove minor aids and adaptations once fitted. If the adaptations are no longer needed it is the responsibility of the homeowner, landlord or tenant to remove them.
• There are exceptions to this, however, as some aids and adaptations, such as hoists and stairlifts can be re-used in other properties needing aids and adaptations. Also, we would consider removing certain adaptations if there are risks to persons or safeguarding concerns.
• We may re-use some specialist equipment if we have suitable items in stock.
• For Council properties we will endeavour to match an adapted property to the needs of a person following appropriate assessments from the Accessible Homes Team.

For additional information, on internal review of this case we are not entirely satisfied that a multi-agency approach was taken, and Kirklees Council will raise a Safeguarding Adults Review (SAR) referral as soon as possible.

Although we are not sure it will meet the criteria, we believe that a discretionary SAR will help us identify any learning for future purposes. We believe there are improvements that can be made in terms of joined up working and improvements on aligning policies, the SAR process will assist us with this. Specific actions and timescales will be determined by this process and an update can be shared with the Coroner’s Office as required.

Should a SAR not be undertaken, Kirklees Council will ensure learning is shared across all relevant departments and agencies regarding the change to our Policy of assessing adaptations for risks to persons or safeguarding concerns and the removal of them where needed.

We are keen to offer support to all agencies involved in this case and if anyone would like any further discussions, please do not hesitate to contact me.
Radis Community Care Other
PDF
Noted

Radis Community Care states that they generally do not remove minor aids and adaptations once fitted, as it is the responsibility of the homeowner, landlord or tenant to remove them. Exceptions are made for re-usable items or safeguarding concerns. (AI summary)

View full response
It is standard practice that generally we do not remove minor aids and adaptations once fitted. If the adaptations are no longer needed it is the responsibility of the homeowner, landlord or tenant to remove them. There are exceptions to this, however, as some aids and adaptations, such as hoists and stairlifts can be re-used in other properties needing aids and adaptations. Also, we would consider removing certain adaptations if there are risks to persons or safeguarding concerns.

Report sections

Investigation and inquest
On 22 January 2024 I commenced an investigation into the death of Geoffrey Stuart CHENEY aged 71. The investigation concluded at the end of the inquest on 11 October 2024. The conclusion of the inquest was that: Geoffrey Stuart Cheney hung himself and a short form conclusion of suicide was recorded.
Circumstances of the death
On 8th November 2023 an initial assessment for home treatment was undertaken on Geoffrey Stuart Cheney by the Kirklees Outreach Team. In that assessment Geoffrey indicated that he regularly had suicidal thoughts, including in his flat to hang himself. His family asked that be removed. Geoffrey was admitted as a voluntary patient and after some time was deemed to be fit enough to have unescorted leave. He undertook that successfully on a number of occasions. On 16th January 2024 he went to his home at on unescorted leave. He put the chain on the door and hung himself that was still in place.

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Report details

Reference
2024-0561
Date of report
18 October 2024
Coroner
Ian Pears
Coroner area
West Yorkshire Western

Responses identified

Responses identified 2 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Dec 2024 (estimated).

Sent to

Radis Community Care

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