Source · Prevention of Future Deaths

Regina Ademiluyi

Ref: 2024-0161 Date: 22 Mar 2024 Coroner: Graeme Irvine Area: East London Responses identified: 2 / 2 View PDF

Deficiencies in safeguarding reporting, failure to assess mental capacity, and lack of a carer assessment led to Regina being deprived of entitled domiciliary care. Little meaningful reflection or remediation followed her death.

Date 22 Mar 2024

56-day deadline 17 May 2024 est.

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

ln the circumstances it is my statutory duty to report to you. 1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information withing the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi's mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter's views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi's daughter no effort was made to offer a carer assessment to address whether she was overwhelmed by the task in hand.
2. Despite the death of Mrs Ademiluyi's occurring in the spring of 2023 no meaningful reflection or remediation had been undertaken by the LocalAuthority into the failings in care by the time of the inquest almost a Vear later. lt was suggested by the legal representative of local authority that the inquest hearing itself was the extent of the significant event analysis undertaken by their professional client.

Responses

2 respondents

Newham Council Local Authority / Fire Service

10 May 2024 PDF

Action Planned

The council has planned a series of actions including: a Safeguarding Adult Review, mandatory pressure care refresher training for ASC staff, mandatory safeguarding training refreshers, improving staff awareness of making safeguarding referrals, working with a partner to improve communication about risks of pressure sores, and working with ELFT to review information for families about pressure care. (AI summary)

View full response

Dear Mr Irvine

Re: Regulation 28 Report concerning Regina Olufunmilola Ademiluyi (Ref: 22689174)

Response from the London Borough of Newham

Thank you for sharing the conclusion of your Inquest into Mrs Ademiluyi’s death, and the subsequent Regulation 28 Report. May I start by expressing my sincere regret and disappointment to learn of the circumstances surrounding Mrs Ademiluyi’s passing. On behalf of the Council I wish to place on record our deepest condolences to her family and friends and all those that knew her. We fully acknowledge the findings from the Inquest and are firmly committed to putting actions in place to address the concerns raised in the Prevention of Future Deaths report to ensure that a similar situation is not repeated.

A core group of Senior Officers from within the department have reviewed Mrs Ademiluyi’s case in detail and have developed a series of direct actions in response. I have summarised the key elements below with associated timescales, and grouped this against the thematic areas from the Regulation 28 Report. I hope this addresses any unanswered questions, the areas for improvement and gives assurance on the actions we are taking.

1. Reflection and Learning

Action: By who: By when:
1.1 Immediate s.44 Safeguarding Adult Review (SAR) Referral completed and submitted for presentation at the next SAR subcommittee of Newham’s Safeguarding Adults Board on 7th May 2024

Team Manager Neighbourhood Team
27.03.24
1.2 Review and improve training and awareness of pressure care and risks for ASC staff. This will include:  Incorporating mandatory pressure care refresher training for all Operational ASC staff into 2024/25 training plan. Strategic Safeguarding, Practice and Workforce Development Team July 2024

 Session content to include overview of pressure sore reporting and notification processes, and its interface with Safeguarding Adults.

1.3 Convene focussed reflective practice sessions for frontline operational staff based around circumstances highlighted in Mrs Ademiluyi’s care, thematically orientated around “professional curiosity” and “cultural needs vs. risks” (reinforcing the message that risk management comes first).

Strategic Safeguarding, Practice and Workforce Development Team December 2024
1.4 Creation of an anonymised ‘7 minute briefing’ note concerning the lessons learned from this case for circulation across all Adults and Health staff groups at LBN.

Strategic Safeguarding, Practice and Workforce Development Team June 2024

2. Continuity of Care Funded via Direct Payments

Action: By who: By when:
2.1 Desktop reviews of all current DP users with double- handed packages for indicators of under-utilisation of care.

Through 2022/23 work took place to review and improve DP monitoring processes with a series of changes coming into effect from August 2023. This included an increase to the number of established posts for DP Monitoring Officers. This has allowed for faster feedback to operational teams on any future monitoring issues/irregularities

In addition to this, the new DP set up process provides additional 'hand holding' support for the first 6 weeks to ensure that DP recipients and their representative(s) fully understand how to utilise their DP.

Direct Payments Team End of May 2024
2.2 Undertake a review of the Council’s Direct Payment Policy, and develop associated practice guidance (including a practitioner checklist). This will encompass:  Non-transfer of DP cases for annual reviews where PAs are not engaged and a mental capacity assessment / best interest decision has not been completed. Direct Payments Project Group December 2024

 The recording of mental capacity / best interest decisions pre-agreement of DP (explicitly in relation to managing/coordinating care and not solely payment administration).  Triggers for further mental capacity assessment / best interest decisions if the person’s DP circumstances have changed (for existing DP users).  Explicit processes for DPs for individuals with double-handed care needs, including assisting and moving assessment and training requirements for PAs.  Processes for hospital discharge to existing DP packages without full PA coverage. An interim process has been implemented by the Discharge and Assessment Team to ensure evidence is seen that PAs are in place before DP packages are increased from hospital.  The interface of quality in care concerns and Safeguarding Adults thresholds.

2.3 Implement a defined process for 3rd Party Fund Managers to escalate issues relating to PA sourcing to LBN, within specified time bands.

Direct Payments Team July 2024
2.4 Enhancements to be made to the AzeusCare case management system to make double-handed care packages more prominent for system users and reportable. The longer-term solution will require development from the software supplier; in the short term other local options are being considered including flags and additional question(s) in core forms.

Head of Brokerage and Transaction Management December 2024

3. Mental Capacity and Decision Making

Action: By who: By when:
3.1 Improve consistency of MCA practice and decision making in the context of best interest decisions which override family where appropriate (including the use of Independent Mental Capacity Advocacy). This will encompass:  Themes from Mrs Ademiluyi’s case being shared with the borough’s MCA Oversight Group.  Reviewing MCA training and refresher offers for staff to ensure it encompasses all Strategic Safeguarding, Practice and Workforce Development Team

July 2024

professional groups in ASC (including non- qualified frontline staff, Social Workers and Occupational Therapists).  Developing specific training interventions for Occupational Therapy staff regarding the application of the Mental Capacity Act in practice – this has been planned as a topic for the borough’s cross-organisational OT Peer Learning session in May 2024. A separate formal training date is being planned.

Principal Occupational Therapist

4. Support for Informal/Family Carers

Action: By who: By when:
4.1 An all-age Carers Strategy is in place for the borough and overseen by a multi-agency delivery board. Further work has taken place through 2023/24 to update carer definitions, improve recording processes and enhance documentation used by frontline staff with carers.

In addition, a suite of new public-facing videos and improved carer information resources have been created. These will go live in May 2024.

An updated round of refresher training on carer awareness for all frontline ASC staff is being rolled out in May 2024.

Carers Strategy Delivery Board End of May 2024
4.2 Develop specific guidance for frontline ASC staff on informal/family carers and Safeguarding Adults. Strategic Safeguarding, Practice and Workforce Development Team End of June 2024

In addition to this summary of internal action, we also recognise that further activities need to be considered with our system partners at East London NHS Foundation Trust (ELFT). Regular Safeguarding meetings have now been established between ELFT Community Health Newham and the Council’s Neighbourhood Teams for Older People and Disabilities (mirroring the same processes which are in place in Mental Health services and have been shown to be successful in improving communication between professional groups). This space will be used to address issues such as the quality of referrals, thresholds and reoccurring safeguarding themes. Attendance at these meetings will also be reviewed to consider involvement from the Council’s Safeguarding Adults Team who are responsible for screening referrals.

We also intend to work with ELFT to jointly review the information provided to families and informal carers about pressure care, the associated risks and exacerbating factors (for example, friction and

double incontinence). Alongside this we are eager to convene a shared learning event with multi- disciplinary staff from across both organisations to explore the themes identified in Mrs Ademiluyi’s case from a clinician/practitioner perspective. These discussions are being progressed separately with our counterparts at the Trust.

Governance and Oversight

The Directorate Management Team (DMT) for Adults and Health and the departmental Quality and Governance Board have been sighted on the action points identified here. All elements of the full plan are now linked to named senior officers with accountability for their delivery. Oversight of the action plan is being held by the Practice and Workforce Development Team who will monitor progress against the stated timescales and then report back to the Quality and Governance Board. We also recognise that the overall plan will need to remain agile and be adapted if further information comes to light, particularly if Mrs Ademiluyi’s case is the subject of an independent Safeguarding Adults Review (SAR).

Thank you again for raising this matter with us. I hope this response gives adequate assurance on the actions we have taken on the improvements required.

Please do not hesitate to come back to me if you require further information or updates.

East London NHS Foundation Trust NHS / Health Body

17 May 2025 PDF

Action Taken

The Trust has taken several actions including: reminding staff about detailed safeguarding reports, agreeing with the local authority to use collaborative forums for discussing capacity concerns, reminding staff about support from the Trust's Mental Capacity Act Lead, and reminding staff to offer or make referrals for carer's assessments. (AI summary)

View full response

Dear Sir

RE: REGULATION 28 REPORT

1. This is a formal response to your Regulation 28 report issued on 23 March 2024 where you set out concerns relating to the care of late Ms Regina Olufunmilola Ademiluyi at East London NHS Foundation Trust’s (the ‘Trust’s’) care.

2. I understand that at the inquest into Ms Ademiluyi’s death, you heard evidence from the Trust’s Serious Incident (the ‘SI’) review author outlining the learning that has taken place because of her death. I understand that you remained concerned about the risk of future deaths in relation to the following areas:

2.1. From October 2023 until her death in March 2024, Ms Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and Local Authority responsible for her care during this period failed to ensure effective care was provided in the following ways:

2.1.1. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.

2.1.2. When faced with the limited information within the safeguarding report the Local Authority did not seek further information or clarification from the Trust on the basis of the report.

2.1.3. The Trust failed to formally assess Ms Ademiluyi's mental capacity, had they done so it is possible that an Independent Mental Capacity Advocate (IMCA) would have been appointed to act as her voice, over-ruling her daughter's views which may have resulted in effective care being put in place.

2.1.4. Despite the concerns raised regarding the behaviour of Ms Ademiluyi's daughter no effort was made to offer a carer assessment to address whether she was overwhelmed by the task in hand.

3. I wish to assure you and the family of Ms Ademiluyi that the Trust has reviewed the issues highlighted within the Regulation 28 Report and has planned the actions outlined below.

RESPONSE

The safeguarding report

4. I was concerned to hear evidence that the safeguarding report filled out by the Trust’s district nurse was insufficiently detailed to reflect concerns and therefore did not trigger the threshold to investigate it further.

5. I asked that this matter be reviewed by the Named Professional for Safeguarding Adults for Newham (the ‘Named Professional’), and Lead Borough Nurse for Newham Community Health Services (the ‘Lead Nurse’). They liaised with London Borough of Newham Adult Social Care (LBN) to understand more fully what occurred and how this situation can be prevented in the future.

6. According to LBN, the referral was screened according to their own internal safeguarding policy and the Trust was advised that it met threshold for the Section 42 safeguarding enquiry. However, LBN is managing a backlog of such referrals. Therefore, it was not addressed before Ms Ademiluyi’s sad death. Please refer to LBN’s response to this Regulation 28 report.

7. The Trust recognises that all public bodies are currently under pressure. Therefore, it is more important than ever that they (the public bodies) work together to ensure that vulnerable adults do not slip through the net.

8. The Named Professional, the Lead Nurse and LBN have implemented arrangements to improve collaborative working and developed processes to escalate any drifting delays and/or cases with significant level of risk. These are as follows:

8.1. A strategic safeguarding meeting, which aims to identify and address any barriers to the safeguarding process, will take place monthly between LBN and Newham Community Health services.

8.2. A safeguarding forum attended by the Named Professional, the Lead Nurse, Newham Community Health Services’ Operational Leads and LBN’s Adult Social Care’s Neighbourhood Teams will take place monthly to discuss current safeguarding concerns and create escalation plans where necessary.

9. Whilst the detail in the safeguarding referral was not the reason the safeguarding concern was not investigated further; the Named Professional agrees that it provided insufficient information. To ensure this does not occur again, the following training and supervision has been arranged for Community Health Services staff in Newham area:

9.1. Safeguarding Adults Training will be delivered quarterly to Newham Community Health Services. The first module was delivered in May 2024 and will focus on how to complete good quality safeguarding referrals.

9.2. Each of the Trust’s Named Safeguarding Professionals meets with every single team within the Trust for quarterly supervision. This case has been considered in the most recent supervision.

Further information and joint working

10. The Trust is unable to comment on behalf of LBN. However, it can confirm that the two public organisations have systems in place which help them to work together closely and collaboratively to improve care for service users under both services.

11. Additionally, Newham Community Health Services staff have been reminded of the Trust’s internal escalation pathway which they are expected to follow when there are concerns about the safeguarding process between public bodies during supervision. The escalation pathway is a tool to support staff with recognising their

responsibilities in ensuring they follow up referrals made, and escalate any barriers identified without delay. It also ensures that the relevant senior management is aware of concerns. It has been made clear to Newham Community Health Services staff that they should not wait for the monthly safeguarding forum to escalate any barriers or problems related to safeguarding process initiated by them.

Mental Capacity

12. I asked the Trust’s Mental Capacity Act Lead to explore issues surrounding Ms Ademiluyi’s capacity. They confirmed that in-line with the provisions of the Mental Capacity Act 2005 (the “MCA”) the Trust is only the decision-maker in relation to decisions pertaining to her health care. The social care provider (LBN) is responsible for assessing capacity in relation to care and support needs.

13. The Trust does recognise that this area of law can be confusing. Therefore, it has agreed with LBN that the forums for collaborative working as described above, will also be used as space for any practitioners to discuss concerns related to service user’s capacity.

14. Furthermore, Newham Community Health Services staff have been reminded, during their quarterly safeguarding supervisions, about the support offered by the Trust’s Mental Capacity Act Lead (the “MCA Lead”). The MCA Lead also supports practitioners with necessary escalations across public bodies.

15. It is unlikely that an IMCA would be appointed in this situation. According to sections 37-39 of the MCA, the statutory requirement for the IMCA to be involved relates to situations when the matter pertains to the serious medical treatment or the care plan involves a new, permanent place of residence.

Carer’s Assessment

16. The Named Professional for Safeguarding Adults and Lead Borough Nurse for Community confirmed that staff did not make a separate carer’s assessment. Staff believed that LBN would undertake it as part of the safeguarding adult’s response.

17. However, anyone can make a carer’s assessment referral and should do so if there are concerns. Therefore, all staff were reminded during their

most recent safeguarding supervision to either; 1) discuss with carers about self-referring for the carer’s assessment; or 2) to support the carer by making referral on their behalf.

18. I hope this response provides sufficient reassurances to you and to the family of Ms Ademiluyi about the additional learning that has taken place at the Trust because of her sad death.

19. I would like to offer my sincere and heart-felt condolences to the family at this difficult time.

Report sections

Circumstances of the death

Regina Olufunmilola Ademiluyi was a frail 83 yr old woman who had a number of co-morbidities including; osteoarthritis, vascular dementia, hypertension and a previous post-surgical CVA. ln the months leading to Mrs Ademiluyi's death she was bed-bound due to complications arising from the surgical repair of a broken hip. From the time of that surgery the local authority had assessed Regina as requiring double-handed domiciliary care 4 times per day. From October 2023 state-funded domiciliary care was not provided to Regina as her daughter (Regina's primary carer) was dissatisfied with the quality of care being provided and asked for it to cease. Regina's daughter was thereafter given control of the state-allocated care budget to deploy as she saw fit. At the time of Regina's death in March 2024, no carers had been engaged by the family using the state-allocated care budget. To be clear, Regina's daughter did not take any state funding for herself, she simply did not deploy it to instruct domiciliary carers. From October 2023 until her death Regina's cognition and physical health declined. Regina's dysphagia and loss of appetite led to malnutrition and a corresponding decrease in physical reserve evidenced at autopsy by atrophy of the liver and virtually no abdominal fat. Regina developed a grade 4 pressure ulcer on her sacrum and suffered an aspiration incident that led to her fatal illness.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2024-0161
Date of report: 22 March 2024
Coroner: Graeme Irvine
Coroner area: East London

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 May 2024 (estimated).

Sent to

East London Foundation NHS Trust

Newham Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.