Christopher Vickers

Dear Maam

Inquest touching the death of Christopher Vickers

We write to formally respond to your PrevenƟon of Future Deaths (PFD) Report, dated 29 February 2024, following the sad death of Mr Vickers. We note that the RegulaƟon 28 Report is directed to both Cumbria, Northumberland Tyne and Wear NHS FoundaƟon Trust (Trust) and South Tyneside Council. This response is provided on behalf of the Trust. We note that your concerns in this mater relate to mulƟple missed opportuniƟes to not follow clear processes and policies in relaƟon to safeguarding referrals and the convenƟon of a mulƟ- disciplinary/mulƟ agency meeƟng. As a Trust we have given Mr Vickers' death and the learning associated with it significant consideraƟon, and have implemented a number of changes to ensure that, where appropriate, relevant safeguarding referrals and mulƟ-agency meeƟngs are convened. We have made changes to our pracƟces, mulƟ agency working and monitoring, details of which are described below. As explained at the inquest, since Mr Vickers' death, there has been a lot of work within the Trust to improve awareness and skills, through bespoke training, email communicaƟon and team meeƟngs. This has emphasised the importance of when referrals to safeguarding should be made, and what process should be followed. Process and Systems Change Within the Crisis and ADHD team, MDT (MulƟ-Disciplinary Team) processes have changed, and safeguarding and consideraƟon of a mulƟ-agency meeƟng is now a standing agenda item. It serves to act as a reminder to clinicians to review and ensure all areas of idenƟfied risk have been addressed, and responded to where appropriate. Similarly in the Community Treatment Team (CTT), Safeguarding and mulƟ-agency meeƟngs are also now a standard item on the agenda for the meeƟngs. MDT meeƟngs take place aŌer each assessment, replacing previous pracƟce which could be a conversaƟon between the people carrying out the assessment (as was the case with Mr Vickers). In addiƟon, staff also have the opportunity to refer to a complex case panel with a pracƟce guidance note to assist with that process.

Within Crisis services a new process of a weekly telephone triage review has been implemented. This looks at calls to the Crisis Team, which have not required a face-to-face assessment, as was someƟmes the case in the past and in relaƟon to Mr Vickers. This new process looks at 5 records where there have been mulƟple triage contacts within the last 5 months, in addiƟon to 5 random telephone triages. As part of this review, the quality and safety of the contact is considered and this includes checking to see if any safeguarding issues have been acƟoned and if appropriate, and whether a mulƟ-agency meeƟng should have been convened. Safeguarding issues are reported through an incident reporƟng system, which is reviewed by a dedicated Safeguarding PracƟƟoner who will offer any relevant safeguarding advice to the reporƟng service and its manager. This advice will, where appropriate, advise on local authority referral and mulƟagency communicaƟon, with any recommended acƟons monitored by managers. A template has now been implemented for the Safeguarding PracƟƟoner to assist with ensuring that the advice is provided in a consistent way. In Mr Vickers' case, the concerns highlighted around referrals to safeguarding related to issues of domesƟc abuse to others. Since Mr Vickers' death the Trust's MulƟ-Agency Risk Assessment Conference (MARAC) policy (now the domesƟc abuse policy) has been updated and circulated to staff via the Trustwide policy bulleƟn. As part of this policy, there is guidance for staff around idenƟfying if someone is at risk of abuse and when a referral for a MARAC should be requested (which is a police coordinated mulƟ agency meeƟng including health representaƟves, police and children and adult social care). However, following the inquest, a decision was made to review the domesƟc violence policy, and this is due to be completed by July 2024, to ensure that the Trust incorporates all the learning from this inquest, and other incidents, and provides clarity on staff roles and responsibiliƟes in relaƟon to safeguarding referrals. Monitoring Arrangements Within all teams, clinician supervision takes place every 4 weeks, which includes a random sample of cases being checked, and safeguarding and the need for convening a mulƟ-agency meeƟng is now embedded as part of this review process. With regard to the Crisis Teams, along with the telephone triage review, a monthly audit of 20 random triage calls also takes place, to ensure all acƟons have been idenƟfied and implemented. A compliance audit against the domesƟc abuse policy will look to ensure that MARAC referrals are being acƟoned in line with Safeguarding advice. Family and Carers In addiƟon to the above, a significant amount of work has been carried out to improve engagement with families and carers, which in turn will improve the idenƟficaƟon of any concerns of domesƟc abuse so that relevant acƟons can be taken in response. This is incorporated into our new risk assessment framework which went live on 7th April 2024 and in the Triangle of Care Improvement area which is a quality priority for the Trust. We hope that the acƟons elaborated above addresses your concerns, but please contact us if you have any quesƟons or comments to ensure that we as a Trust learn from this sad event and make our care safer for those who require it.

Your sincerely

Medical Director / Deputy Chief ExecuƟve

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

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Inquest touching the death of Christopher Paul Vickers

Prevention of Future Deaths Report (Regulation 28): South Tyneside Council’s response

Date: 23 April 2024

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

2 INTRODUCTION FROM SOUTH TYNESIDE COUNCIL

South Tyneside Council would like to express its deepest condolences to Christopher’s family and friends.

Changes had already been made at the time of Christopher’s inquest, however we have further re-evaluated our internal policies and procedures in light of the evidence heard and the concerns of the Coroner.

Below we respond to each of the Coroner’s concerns setting out what we have already done, what we are doing now and what we intend to do in the future (including our timetable for action where applicable).

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

3 CORONER’S CONCERNS IN RELATION TO SOUTH TYNESIDE COUNCIL

1. There were multiple missed opportunities to co-ordinate the Deceased’s care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risks.

2. There were multiple repeated missed opportunities to make safeguarding referrals for formal safeguarding supervision from the safeguarding adult public protection team despite known escalating risk to self and to others.

Further, ‘…the missed opportunities were significant and multiple and relate to clear processes and policies that were not followed’.

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

4 SOUTH TYNESIDE COUNCIL’S RESPONSE

1. Action taken prior to inquest:

1.1. Multi-agency working

Multi-agency working is key to effective safeguarding and work has been undertaken to develop and improve multi-agency working with partner agencies that support adults with complex mental health needs. There is a commitment from South Tyneside Council and partner agencies to ensure that vulnerable individuals receive the appropriate care and support. Through improved multi- agency working agencies provide a more seamless response to those with multiple and complex needs. This collaborative working has ensured that individuals receive the support they need, in a timely manner.

To ensure effective collaborative, multi-agency working, a number of new multi- agency meetings and groups have been established. These include:

• South Tyneside Interface Meeting – a monthly meeting that is attended by the Service Manager for South Tyneside Adult Mental Health Service and leads from the Community Treatment Team (CTT), the Assertive Outreach Team (AOT), Psychiatric Liaison Team (PLT) and the Crisis Team. The purpose of the meeting is to provide a forum for open communication across the agencies to address issues, concerns, decision making and planning.
• High Intensity User Group – a monthly meeting that is attended by the Service Manager for South Tyneside Adult Mental Health Service and operational leads from the relevant agencies. The purpose of this group is to have oversight for individuals who have repeat and frequent interactions with the agencies. The purpose of this group is to ensure that the individual is receiving the right support from the right agency to achieve the best possible outcome for them.
• Near Miss Project Group – a monthly meeting that is attended by the Service Manager for South Tyneside Adult Mental Health Service and operational leads from the relevant agencies. The purpose of the meeting is to have oversight for individuals with complex mental health needs who are at high risk of death from misadventure. The group provides assurance that these individuals are receiving the right support from the right agency to reduce risk and achieve the best possible outcome for the individual.
• Suicide Prevention Group – a meeting that is attended by the Service Manager for South Tyneside Adult Mental Health Service and operational

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

5 leads from the relevant agencies when required. The purpose of the meeting is to bring together the relevant agencies when it is identified that an individual or individuals are at high risk of suicide. The group provides assurance that these individuals are receiving the right support from the right agency to reduce risk and achieve the best possible outcome for the individual.
• Weekly MDTs – these are weekly multi-disciplinary team meetings that are attended by practitioners from mental health and social care services to discuss high risk individuals. The purpose of the meeting is to discuss risks and concerns, agree roles and responsibilities, agree actions to reduce risk, and agree co-ordinated support to achieve the best possible outcome for the individual.
• Corporate Risk Register – all high risk cases that are identified by South Tyneside Council Mental Health Team are placed on the Corporate Risk Register, which provides oversight and assurance to Senior Management.

1.2. Police Triage

The Police have a duty to recognise the signs and symptoms of abuse and to act on any concerns. This includes notifying the Local Authority of safeguarding concerns relating to vulnerable adults. The process for the Police to refer safeguarding concerns to South Tyneside Council is via a Police Concern Notification (ACN) form. Adult Social Care receives ACNs from Northumbria Police daily and the number of ACNs has significantly increased year-on-year.

To ensure that people referred to Adult Social Care via the Police ACN receive the right response, a Police Triage Process was established in January 2023. This involves a multi-agency meeting that takes place every morning between representatives from Northumbria Police, South Tyneside Adult Safeguarding Team, South Tyneside Homes, and Adult Social Care Let’s Talk Team (first point of contact service). The MDT discuss ACNs received, share information, and agree the most appropriate action, including whether to progress to safeguarding procedures. Where it is agreed that safeguarding procedures are needed, the Safeguarding Team Social Worker ensures that the individual is transferred to the Safeguarding Team or allocated Social Worker on the same day, so that actions can be progressed to safeguard the individual. Individuals that receive repeat ACNs are identified as part of the Police Triage and are considered in a wider context so that a holistic assessment of risk can be made, and appropriate referrals, and escalations made to safeguard the individual.

1.3. Decision Making Forum

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Adult Social Care in South Tyneside has a number of teams that support adults with care and support needs. These include:

• Neighbourhood Teams x 3 – that support adults with care and support needs.
• Mental Health Team – that supports adults with diagnosed mental health conditions that mean they have care and support needs.
• Learning Disabilities Team – that supports adults with a diagnosed learning disability and have care and support needs.
• Let’s Talk Team – first point of contact for adults who present with care and support needs and are not involved with another Adult Social Care team.
• Hospital Discharge Team – that supports adults with care and support needs that are in hospital and need support at discharge.

Adult Social Care recognised that it is not always clear which team is the most appropriate team to support an individual and therefore there were occasions when individuals were passed around different social care teams. This results in individuals not receiving the most appropriate support and increases the time they wait for social care interventions.

To address this issue, in January 2023 Adult Social Care set up a weekly Decision Making Forum. The purpose of the Forum is to bring together representatives from adult social care teams to agree which team is best placed to provide support and interventions that produce the best possible outcomes for individuals with complex care and support needs when this is not clear.

The aims of the Decision-Making Forum are:

• To ensure the individual receives the right support, in a timely manner, from appropriately trained, experienced and qualified practitioners.
• To reduce the number of contacts, ensuring the individual remains the focus of our conversations, interventions, and responses.
• To provide flexible responses to individual needs and circumstances.
• To empower participants to make consistent decisions and to be confident in the rationale for those decisions.
• To ensure we work within legal frameworks and statutory guidance.
• To ensure practice and outcomes for people are fair, lawful, and reasonable.
• To evidence management oversight of decisions.

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1.4. Risk Management Forum

Adult Social Care has seen a significant increase in the number of safeguarding concerns it receives and an increase in the number of people that are referred who have multiple and complex needs, resulting in a high risk to the individual and/or others. To support staff with the risk management of these high risk individuals, in March 2023, Adult Social Care set up a weekly Risk Management Forum that has oversight from Service and Senior Managers from across the service. The purpose of the Forum is to assist Adult Social Care workers in the interventions they provide to people who have social care needs and whose planned outcomes are not being achieved despite the best efforts of Adult Social Care and other professionals, and for whom risks remain or are increasing. This ensures the service has oversight of people who may be at risk of suffering from severe harm or death.

Guidance for the Risk Management Forum describes risk as:

• Risk is the probability that an event will occur with harmful outcomes for a particular person or others with whom they come into contact.
• Risk is a product of the likelihood that an event will happen and the impact that the thing happening will have if it does happen.

High risk individuals are described as:

• Individuals living in the community, whether by themselves, with their families or in supported accommodation or residential care, who are exhibiting behaviours which create a risk of significant harm, whether to self or others, through violence, offending, self-harm, or serious substance misuse.
• Individuals with multiple complex needs at risk of poor outcomes - individuals that have both mental health problems and substance misuse issues; mental health problems and learning disability or unresolving severe mental illness.
• Individuals that may have suffered previous trauma which impacts on their decision making are harder to reach or difficult to engage.

1.5. Quality Assurance - Audit

South Tyneside Council Adult Social Care is committed to delivering the highest standards of quality in social care for adults. To ensure the delivery of high quality social care, Adult Social Care developed and implemented a new Quality Assurance Framework in April 2023, which includes a range of activities to monitor compliance with policies and procedures; evidence strengths and

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

8 good practice; identify gaps and areas for development; and drive learning and service improvement. The Quality Assurance Framework provides assurance that the Adult Social Care effectively delivers its statutory duties. This means keeping adults safe, promoting positive outcomes, and ensuring agreed standards are being met.

Auditing makes up a substantial part of our Quality Assurance programme, offering insight into the strengths and areas for development of our practice and the impact on adults. New Practice Quality Audits and Safeguarding Audits have been developed and were implemented in April 2023. These are undertaken by supervisors at all levels as part of a shared commitment to understanding the quality of practice. Auditing provides an opportunity to pause and reflect on the quality of case work, and on the impact our assessments and interventions make towards positive outcomes for adults and their family. The Practice Quality Audits and Safeguarding Audits are designed to provide a broad focus on standards and compliance, as well as the quality of social care practice. The audits are used to take stock of performance across all areas of social work intervention at regular intervals. They focus on the journey and experience of the adult through services, as well as the rationale for decisions being made on their behalf. They allow Adult Social Care to identify if the support that has been offered is planned, purposeful and undertaken in a timely manner. Crucially, these audits go beyond the marking of compliance, and seek to generate qualitative data about our practice, its impact on the adult, and how the system and organisation supports good practice, as well as identifying areas of development.

The Practice Quality Audits are based on our Practice Standards, of which there are six. Standard Five relates to safeguarding:

Standard Five: Safety We talk to people openly about risk and to help them to manage risks. We help people to think about ways of staying safe and we listen to what is important to them. Making sure their experience is personal. Evidence that:

Any risks identified have been done so in partnership with the person and / or their carer and are evidenced based. Yes/No/NA Approaches to risk demonstrate positive risk taking and informed decision making. Yes/No/NA Any risks identified are reflected in the person’s conversation record, clearly stating how they have been agreed to be managed or maintained. Yes/No/NA Any risk intervention is proportionate to the individual’s circumstances but leaves no doubt they have been fully considered. Yes/No/NA

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

9 People with significant risks e.g., risk to life or others, which requires ongoing monitoring and review have been considered within a multi-agency meeting involving the person where applicable with clearly defined actions and responsibilities. Yes/No/NA People with significant risks e.g., risk to life or others, which requires ongoing monitoring and review have been considered within the LA Risk Management Panel where applicable and have been identified in LA recording system via a Risk Indicator. Yes/No/NA Any appropriate multi-agency pathways e.g., MARAC/ MAPPA have been explored and involved where applicable. Yes/No/NA Any safeguarding concerns have been identified and addressed effectively, with reference to LA guidance and Multi Agency Safeguarding Procedures. Yes/No/NA Where safeguarding concerns are identified, key principles of Adults Safeguarding are demonstrated, and Making Safeguarding Personnel (MSP) is evident. Yes/No/NA Comments - Auditor

Comments - Practitioner

Quality Rating Outstanding

Good

Adequate

Requires improvement

Each practitioner has one Practice Quality Audit per quarter, so a total of four Practice Quality Audits per year.

The focus of the Safeguarding Audits relates to the quality of the Safeguarding practice and the decisions made. There are two Safeguarding Audit tools that consider practice in relation to Section 42(1) and Section 42(2) procedures. Safeguarding Team practitioners have two Sec 42(1) and Sec 42(2) audits completed each quarter, so four Sec 42(1) and four Sec 42(2) audits per year. Practitioners in all other social work teams have one Sec 42(1) audit and one Sec 42(2) audit per year.

1.6. Tools and Guidance

1.6.1. South Tyneside Safeguarding Adults Threshold Guidance Tool

A new Safeguarding Adults Threshold Guidance Tool has been produced by the Safeguarding Adults Board, which was launched in July 2023. The threshold guidance supports professionals across the partnership to understand when it is

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

10 necessary to refer an individual to the local authority under the safeguarding adults’ procedures. The aim of the guidance is:

• to ensure a consistent approach to identifying what concerns may require a response under the safeguarding process, and
• support decision making when alternative processes should be used.

Within the Guidance there is a clear matrix that gives examples of when a situation must be taken into adult safeguarding procedures. This includes ‘self-neglect’ as a category of abuse and examples of high risk self-neglect include:

• ‘Behaviour poses risk to self and others’, and
• life is in danger without intervention.

The Threshold Guidance has been launched across all adult social care teams and training has been provided on how the tool should be used. There is an expectation that all staff use the guidance when making decisions about safeguarding, and the rationale for their decision must be recorded in case records. Adherence to this process, and quality of decision making is assured via the Adult Social Care Practice Quality Audits. Each social care worker has one of their cases audited per quarter, so four audits per year.

South Tyneside Safeguarding Adults Thresholds Guidance Tool – South Tyneside Safeguarding Adults Board APPP (southtynesidesafeguardingappp.co.uk)

1.6.2. South Tyneside Safeguarding Adults Self-Neglect Guidance

The Self-Neglect Guidance was developed by the Safeguarding Partnership in collaboration with practitioners from across the partnership in November 2023. The purpose of the toolkit is to support professionals that are working with individuals who are at risk due to self-neglect. It emphasises that the Local Authority has a duty to make safeguarding enquiries where a person may be at risk of harm due to self-neglect and includes ‘inability to avoid self-harm’ as a type of self-neglect.

The Self-Neglect Guidance was launched across all adult social care teams. There is an expectation that all staff use the guidance when making decisions about safeguarding, and the rationale for their decision must be recorded in case records. Adherence to this process, and quality of decision making is monitored via the Adult Social Care Practice Quality Audits. Each social care worker has one of their cases audited per quarter, so four audits per year.

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

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Self-Neglect-Guidance-for-Multi-Agency-Partners.pdf (southtynesidesafeguardingappp.co.uk)

2. What we are doing now:

2.1. Multi-Agency Safeguarding Hub (MASH)

A new Multi-Agency Safeguarding Hub (MASH) will be effective from summer
2024. This will bring together safeguarding professionals from services that have contact with adults, making the best possible use of their combined knowledge to keep adults safe and offer prevention, protection, and proportionate responses. To ensure consistency in the decision-making process, all safeguarding contacts and referrals will be screened in the MASH.

The aims of the MASH are:

• Established pathways for information gathering and access to services from all partners.
• Maximised effectiveness of multi-agency information gathering and decision making.
• It supports decision making by providing an earlier richer picture.
• Optimised decision making for vulnerable adults through a multi-agency integrated approach.
• It provides a faster, more co-ordinated response through improved information sharing between partners.
• Assists in the early identification of safeguarding concerns as a result of improved inter-agency working arrangements.
• Improves recognition of risk.
• Enables closer partnership working and clearer accountability.
• Identifies and targets resources effectively, to ensure individuals are accessing the most appropriate service or intervention to meet their needs and improve overall outcomes.

The South Tyneside Adult Multi-Agency Safeguarding Hub (MASH) will include:
• Police
• CNTW Mental Health
• Adult Social Care including Let’s Talk staffing.
• STARS - Drug and Alcohol Service
• South Tyneside Homes
• South Tyneside Foundation Trust – Safeguarding or Clinical Lead
• Probation
• ICB Health Navigator

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

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• Domestic Abuse
• Tyne and Wear Fire and Rescue Service

2.2. Complex Adult Risk Management (CARM)

South Tyneside Council has worked with partners in the South Tyneside Safeguarding Adults Board to develop a new, collaborative approach to managing complex risk when the adult safeguarding duty does not apply. The Complex Risk Management (CARM) approach can be used in specific circumstances; when working with adults deemed to have capacity to make decisions for themselves, but who are at risk of serious harm or death through:

• Self-neglect (Care Act 2014);
• Behaviours that place them at risk/chaotic lifestyles; or
• Lack of engagement with services.

The aim of CARM is to provide professionals with a framework to facilitate effective multi-agency working with adults who are at significant risk.

The CARM is a multi-agency adult assessment risk management process to:

• Identify the relevant risks for the individual;
• Discuss and agree agency responsibilities/actions;
• Record, monitor and review progress with an agreed action plan;
• Agree when the risks have been managed and evaluate the outcome.

One or more of the following conditions must apply for a CARM to be called:

a. The Adult has the mental capacity to make decisions and choices about their life;
b. There is a risk of serious harm which is life-threatening and/or traumatic, and which is viewed to be imminent or very likely to occur, or death due to non-engagement with services, and they do not meet the criteria for a safeguarding referral; Or

c. There is the potential of death and or life changing injuries and/or a potential risk to the health and safety of others in the community;
d. There is a high level of concern from partner agencies.

A CARM meeting is held when the above criteria are met. The meeting involves all relevant agencies, and there is agreement from members of the partnership that an appropriate member of staff, with the required seniority to make decisions

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

13 on behalf of their organisation, attends. The meetings are chaired by an appropriate senior member of the appropriate partner agency.

The purpose of the meeting is to hear about the concerns people have and share views about the risks identified. A risk management plan is developed that identifies the agreed risk and who is going to do what to reduce the risk. The plan may also include any additional help, support or information needed to help manage risks. Members of the meeting may also need to think about ways in which they could work with the person differently to help manage risk and/or the risk of harm. The aim of the risk management meeting is not to remove all risks, but to ensure everyone has an agreed understanding of the risks and what needs to happen.

3. Considerations for the future:

3.1. Workforce development

3.1.1. Mental Health Act

It has been acknowledged that practitioners (including managers) in neighbourhood teams (see above) have a gap in their knowledge of the Mental Health Act 1983. This includes their understanding of the rights of the Nearest Relative, who have specific legal powers in relation to a person’s care and treatment. These powers include:

• the right to ask for the person to be detained or put on guardianship;
• the right to ask for an Approved Mental Health Professional (AMHP) to see the person.

And, in addition, the AMHP must inform the Nearest Relative if they choose not to undertake a Mental Health Act assessment, and the person ‘MUST’ be informed in writing of the reason why they are not undertaking a Mental Health Act assessment. In recognition of this gap, Mental Health Act training will be provided to all practitioners across adult social care so that they are able to advocate on behalf of individuals to ensure their rights are upheld, and provide appropriate and accurate information to families and carers who are concerned about a relative.
3.1.2. Adult Social Care Learning and Development Programme for 2024

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

14 The newly developed Adult Social Care Learning and Development Programme includes a mandatory safeguarding module that must be undertaken by all frontline practitioners in Adult Social Care. The module, ‘Safe and Effective Core Module’ has been developed in response to feedback from the workforce to develop competencies and confidence in the South Tyneside system and approach to a safe and effective safeguarding response at all points across Adult Social Care. The content of this module will be peer reviewed through the Safeguarding Adults Board to ensure that it captures learning from Safeguarding Adult Reviews and Coroner’s Inquests.

Prevention of Future Deaths (Regulation 28): South Tyneside Council’s response

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