Source · Prevention of Future Deaths

Nazerine Anderson

Ref: 2024-0080 Date: 13 Feb 2024 Coroner: Fiona Butler Area: Rutland and North Leicestershire Responses identified: 1 / 1 View PDF

DWP staff failed to record and act upon a customer's known vulnerability and requests for communication through her daughter, indicating inadequate training and use of existing support tools.

Date 13 Feb 2024
56-day deadline 9 Apr 2024 est.
Responses identified 1 of 1
Alcohol, drug and medication related deaths Mental Health related deaths

Coroner's concerns

AI summary
DWP staff failed to record and act upon a customer's known vulnerability and requests for communication through her daughter, indicating inadequate training and use of existing support tools.
View full coroner's concerns
1. Despite the DWP case workers and call handlers having the availability of an additional support tab on a profile of a customer on the DWP computer system; there were 6 missed opportunities to use this facility to record vital information about Naz’s vulnerability; despite Naz being tearful and distressed on the telephone on more than one occasion and advising the DWP of information surrounding her mental health and her inability to cope. This meant there was no alert to DWP staff of Naz’s vulnerability and consequently no adjustment to how communication was made with Naz. The trigger for mental health decline and Adjustment Disorder continued.
2. The failure to act upon a simple request for the DWP to direct communication through Naz’s daughter. This was a simple request and had been renewed by Naz during telephone calls and journal entries to the DWP. The request which had been made in writing by Naz’s daughter sat in another DWP computer system for a period of 4 months but even when uploaded to the main DWP computer system was not acted upon. In addition to the active requests of Naz and her daughter being overlooked, DWP staff did not proactively consider the need for communication to be directed to someone else to safeguard Naz, given her obvious vulnerability.
3. I heard evidence from the DWP of plans to introduce a number of changes. What I did not hear was evidence about how DWP operatives were going to be trained, upskilled and refreshed in their knowledge (given the toolkit already available to them) to ensure the issues identified at 1 and 2 above aren’t repeated with other vulnerable individuals.

Responses

1 respondent
Department for Work and Pensions Central Government
5 Apr 2024 PDF
Action Planned

DWP will deliver training sessions to 170 Performance Management team members by the end of June 2024, focusing on identifying and supporting vulnerable customers, including prioritizing the use of the additional support tab in UC system. Upskilling sessions for colleagues who worked on the case are planned. Appointeeship process is also being reviewed with upskilling and system upgrades already concluded. (AI summary)

View full response
Dear Miss Butler, RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

We write on behalf of the Department for Work and Pensions (“DWP”) in response to your Prevention of Future Deaths Report made under Regulation 28 of the Coroners (Investigations) Regulations 2013.

We would like to take this opportunity to express our condolences, both personally and on behalf of DWP, to Ms Anderson’s family.

You raised the following concerns in your report:

1) Despite the DWP case workers and call handlers having the availability of an additional support tab on a profile of a customer on the DWP computer system; there were 6 missed opportunities to use this facility to record vital information about Naz’s vulnerability; despite Naz being tearful and distressed on the telephone on more than one occasion and advising the DWP of information surrounding her mental health and her inability to cope. This meant there was no alert to DWP staff of Naz’s vulnerability and consequently no adjustment to how communication was made with Naz. The trigger for mental health decline and Adjustment Disorder continued.

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2) The failure to act upon a simple request for the DWP to direct communication through Naz’s daughter. This was a simple request and had been renewed by Naz during telephone calls and journal entries to the DWP. The request which had been made in writing by Naz’s daughter sat in another DWP computer system for a period of 4 months but even when uploaded to the main DWP computer system was not acted upon. In addition to the active requests of Naz and her daughter being overlooked, DWP staff did not proactively consider the need for communication to be directed to someone else to safeguard Naz, given her obvious vulnerability.

3) I heard evidence from the DWP of plans to introduce a number of changes. What I did not hear was evidence about how DWP operatives were going to be trained, upskilled and refreshed in their knowledge (given the toolkit already available to them) to ensure the issues identified at 1 and 2 above aren’t repeated with other vulnerable individuals.

Our response to your concerns is as follows:

The Additional Support tab

Universal Credit (“UC”) is an online service, meaning a certain amount of written record keeping is automatically built in. Customers are encouraged to use an online ‘journal’ to share information with their work coach or case manager via online messages, which are free text in format. Similarly, case managers and work coaches communicate with customers in the same way. Journal messages remain on a customer’s UC record for future reference for the duration of the claim, forming a permanent written record of conversations. There is a risk that key information could be lost within the detail of what can be lengthy conversations with a customer. To guard against this, the UC system enables case managers and work coaches to ‘pin’ information shared either via the journal or as the result of a conversation with a customer (face-to-face or by telephone) that they deem critical. Pinning a note to the claim means it will be flagged to anyone viewing a customer record as soon as they open it. DWP guidance states any complex need or vulnerability that is considered an urgent risk must be pinned to the customer’s profile. A maximum of three notes can be pinned at any one time. Colleagues working on UC claims are trained on the effective use of journal messages and pinned notes, and also on the standard of messaging and notetaking required. Another area where effective notetaking is vital is on the ‘additional support’ tab, a function introduced to allow a customer’s complex needs to be recorded. Once the tab is populated an alert will display prominently on the customer’s UC account to ensure that colleagues are aware of those additional support needs. By making this information easily identifiable, colleagues can tailor the support they offer accordingly to address those complex needs during interactions with the customer. Unlike a pinned note, which flags an urgent issue, the additional support tab is used to record long term or temporary complex needs, and how these affect the customer's ability to use the Service.

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The department acknowledges that there were missed opportunities to record additional support information in Ms Anderson’s case, despite the existing guidance on how the tab should be utilised. An internal review identified learning for the individuals involved.

To investigate how to increase UC colleagues’ use of the additional support function, DWP conducted user research between July and September 2023. Insight sessions were held with UC colleagues to explore what they understood about the concept of additional support and how it relates to a customer’s additional support needs. Following these insight sessions, workshops were conducted between December 2023 and January 2024 with stakeholders from different business areas within DWP (for example colleagues from telephony, Customer Experience, Quality Assurance and product managers) to develop an improved and more comprehensive approach regarding the purpose of the additional support tab.

As a result of the insight sessions and the workshops, the UC design team developed a prototype of what the improved additional support tab would look like. Plans to finalise and launch this improved additional support tab are a priority for the UC design team. User research is now being undertaken with UC customers to gather feedback to shape future amendments to the additional support tab.

A campaign to promote awareness and understanding of the additional support tab amongst UC colleagues is planned for the second half of 2024. This campaign will include upskilling on refreshed guidance and training sessions for colleagues on the additional support tab. It is intended that this will translate to an increase in the use of the additional support function. As with all colleague training, the package will be followed by an assessment to ensure that the training has been effective in improving colleague understanding of the additional support function, and when it should be used. Colleagues who worked on Ms Anderson’s case will take part in the additional support tab awareness campaign.

As a learning organisation, the department takes its responsibility to training and upskilling seriously and has made improvements in the way it trains colleagues to deal with vulnerable customers. One such training package is the detailed mental health training which all customer facing colleagues undertake. This provides colleagues with learning that they can then apply to the different scenarios with which they may be faced. The training includes modules on appropriate actions to take to support customers with vulnerabilities including mental health issues.

DWP has also launched Complex Needs training events which encourage participants to reflect on tailored customer service. It consists of two versions: one for customer-facing colleagues and another for leaders driving a customer focused experience. These events are different to others as delegates are encouraged to view the customer journey through the lens of the customer, highlighting the potential consequences of getting this wrong, as well as the positive impact of getting it right. To date, around 40% of leaders nationwide (2,391) and an initial 2,232 UC colleagues have attended. The department plans to deliver the event to the entire service delivery team by the end of 2024. DWP’s training package is constantly evolving, and work is ongoing to further strengthen guidance and training as part of continuous improvement activities. These activities often take some time to plan and deliver allowing the department to ensure the learning is accurate and effective. The aim of this considered approach is to benefit all our customers, especially the many vulnerable people who rely upon us. However, as a direct result of Ms Anderson’s case,

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improvements have already been made to UC guidance covering pensions and their impacts on a UC claim.

Quality Assurance

Aside from large scale upskilling campaigns, the department has robust quality assurance processes to ensure colleagues are adhering to DWP’s Quality Framework. The newly developed Customer Support Standards were designed specifically to improve the experience of customers with complex needs and significantly reduce instances of serious cases by providing the right support at the right time. The four Customer Support Standards are;
• Advance Customer Support
• Accessibility Requirements
• Appointees
• Six Point Plan (DWP’s response to declarations of suicide or self-harm) The standards were trialled and implemented across DWP service lines in the second half of
2023.

The Customer Support Standards are incorporated in both tiers of the department’s quality assurance process and focuses on customer experience. The first tier sees line managers checking their team’s work. This identifies individual errors or non-compliance with guidance and allows for immediate feedback and coaching. The second tier sees a dedicated quality team checking a sample of customer cases to assure compliance against the Customer Support Standards. Where an error is identified at Tier 2, a check is put in place to consider how any correction activity might affect a customer’s vulnerability. This is fed back directly to the service line to make colleagues aware of the risk to be managed when rectifying the error.

The improvements to the department’s Quality Assurance processes are intended to reinforce training and upskilling campaigns. They enable DWP to identify where additional support could have been provided to customers with varying needs or vulnerabilities, reducing the risk of a negative customer experience and potential development into serious cases.

Appointeeships and Explicit Consent on Universal Credit

In cases where a customer cannot manage their own affairs because they are mentally incapable or severely disabled, an appointee may be required to manage the customer’s benefit claim. An appointee can be an individual or an organisation who will act on behalf of, or make enquiries for, a customer. This can be at any stage of a customer’s UC claim.

Customers who require an appointee are naturally considered to be vulnerable, and whilst DWP has taken significant steps since 2018 to improve colleagues’ ability to understand the wide range of mental health issues that benefit customers may face, there is more work being undertaken.

In response to learning from serious cases DWP has acknowledged that the appointee process requires strengthening and, as a result, an end-to-end review of the appointee process is currently in progress. This is a significant piece of work undertaken by a multi- disciplinary team and impacts customers across every benefit line. This work involves exploring development of digital solutions, a number of legislative changes as well as improved guidance and supporting products to build colleague capability. The work will also consider the appointee review process, including the timescales for reviewing the appropriateness of appointees once in place.

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Separate to appointeeships is explicit consent. This is used in cases where a customer is unable to find information held on their account or understand more complex issues. With explicit consent they may ask a representative (which can be an individual or an organisation) to contact DWP on their behalf to obtain the information. Under DWP policies, this information can usually be provided if the customer gives explicit consent. Explicit consent can be provided by the customer as long as they state (no particular form of words is required):
• that they give consent for their personal information to be disclosed
• what information they want to be disclosed
• why the information is needed
• the relationship between the representative and the customer
• the name of the representative

In December 2023, the UC computer system was updated to include a banner which displays on a customer’s account when explicit consent is recorded. This immediately identifies that there is explicit consent given by a customer and allows colleagues to see what consent has been given and whether it is current. To support this, an explicit consent information campaign was launched on DWP’s intranet and broadcast to all colleagues working in UC. The campaign clearly explained what explicit consent is and how to record this consent on the UC system and was accompanied by training videos. Training events have been delivered to UC colleagues detailing how to record explicit consent actions to alert other colleagues dealing with the claim. As with all training, this has involved an assessment component to ensure that the training has been effective.

UC received extremely positive feedback from colleagues for this campaign and so are currently planning to run similar campaigns for other areas of the Complex Needs programme. The consent and disclosure guidance was most recently updated in January 2024 to allow UC colleagues to extend the review period on explicit consent up to six months where appropriate (for example, where someone is supporting a customer with an appeal which is expected to take longer than one month). Guidance previously advised colleagues to review explicit consent every month, but the department recognised this was not always the best approach and made the amendment. This change was cascaded through DWP communication channels.

The department acknowledges that there were missed opportunities during Ms Anderson’s claim to consider the appropriateness of gaining her explicit consent to speak to a third party about her UC claim. Colleagues who worked on Ms Anderson’s case have taken part in the explicit consent information campaign.

Your report states there was a delay between information being received by the department and it being acted upon. This delay was, in part, due to the information being recorded in standalone computer systems where the onus is on the individual to share. Therefore, the department acknowledges there were opportunities for colleagues to have shared information sooner, and the need to consider an appointee to manage the claim could have been considered. Unfortunately, these opportunities were missed.

An issue that has been identified is that of system access levels. Different DWP colleagues have different access levels on departmental systems, and this is done deliberately to ensure

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information remains secure. However, as a result of this, some colleagues cannot pin information to claims or use the additional support function on the UC system. To counteract this, Performance Management team colleagues will be delivering sessions to all 170 members of the team by the end of June 2024, which will promote awareness and improve understanding of dealing with vulnerable customers. This will provide colleagues with learning that they can apply to different scenarios. There will be a focus on the importance of prioritising sharing information relating to a customer’s vulnerabilities with UC colleagues to allow them to complete the additional support tab. Colleagues who worked on Ms Anderson’s case will take part in planned upskilling sessions.

Conclusion

The full circumstances of this case have been reviewed, and the department acknowledges that there is further work to be undertaken in order to satisfy HM Coroner’s concerns. This work includes plans to improve colleague awareness of how the additional support tab should be used to identify customer vulnerabilities. Plans are also in place to launch an improved version of the tab, based on colleague feedback, as a priority. Feedback is currently being sought from UC customers to shape future amendments to the additional support tab. Training sessions to upskill UC colleagues on how to best use the additional support tab will be delivered by the end of 2024.

The appointeeship process is also being reviewed currently, with a view to making improvements to how these vulnerable customers are supported. An upskilling campaign dedicated to the use of explicit consent, and a system upgrade to improve visibility, has recently concluded.

We hope that our response addresses your concerns and helps to assure you of DWP’s commitment to improving the service it provides to vulnerable customers.

Report sections

Investigation and inquest
On 28 June 2023 I commenced an investigation into the death of Nazerine Frances Anderson aged 52. The investigation concluded at the end of the inquest on 12 February 2024. The conclusion of the inquest was that: Nazerine Frances Anderson (‘Naz’) had a medical history of anxiety and depression which had been managed with medication in primary services until October 2022. Naz was referred to secondary mental health services in November 2022 after a decline in her mental health. Following a voluntary admission to the Bradgate Unit in December of 2022, Naz was diagnosed with Adjustment Disorder the trigger for this having been notification that she was facing a performance review by the Department for Work Pensions (‘DWP’). Naz was discharged from the Bradgate Unit in January 2023 and was managed in the community by the Crisis Resolution & Home Treatment team. Naz’s mental health presentation fluctuated and the DWP review continued to preoccupy Naz’s thoughts. The review concluded in May 2023 and between 03 May and 11 May 2023 Naz received 3 different letters setting out different sums of money owed to the DWP. These were sent directly to Naz despite the DWP being in receipt of correspondence from Naz’s daughter asking for all correspondence to be sent through Naz’s daughter, because continued correspondence would be of serious detriment to her mental health. On 17 May 2023, Naz took an overdose . She was subsequently admitted to the Leicester Royal Infirmary Emergency Department and transferred to the liver transplant unit at the Queen Elizabeth Hospital in Birmingham. Unfortunately, Naz was not a candidate for liver transplant and developed complications as a result of the irreversible damage caused to her liver. Naz was transferred to the Melton Community Hospital on 17th June 2023, for palliative care and passed away at 19.30 hours on the 19th June 2023 with her family present. Naz did not intend to die as a result of taking the paracetamol overdose, but sadly developed complications as a result of the damage caused to her liver, which were irreversible.
Circumstances of the death
Nazerine Frances Anderson (Naz) had a history of anxiety and depression stretching back over 20 years. She had no active symptoms of these conditions until 2021 and until November 2022 her symptoms had been managed in primary care services with medication. Naz’s referral into secondary mental health services in November 2022 followed notification by the DWP that she would have her universal credit reviewed, by the Performance Review Team. Naz’s mental health deteriorated necessitating a period of informal admission to the Bradgate Unit on the 5th December 2022 and she was diagnosed with Adjustment Disorder, an excessive reaction to stress that involves negative thoughts, strong emotions and changes in a person’s behaviour. I heard evidence from a Consultant Psychiatrist that the trigger stressor for this was the DWP performance review, suggested overpayment and potential debt. It took 6 months for the DWP review to be completed. During which time there:
a. were at least 6 missed opportunities to use an additional support tab on Naz’s DWP profile to record the details of her vulnerability and alert other DWP personnel.
b. was a failure to pass vital information between the performance review team and universal credit case handling team of the need to correspond with Naz’s daughter, because corresponding with Naz was of serous detriment to her mental health. Naz’s mental health was managed throughout this time by the secondary heath teams, and for the majority by the Crisis Resolution & Home Treatment team. The Crisis team were responsive throughout this time to Naz’s fluctuating symptoms and needs. In the 4 weeks prior to the paracetomol overdose, despite a request for all correspondence to be directed through her daughter, Naz received 6 communications from the DWP, 2 telephone calls requiring detailed information of Naz, a journal log she didn’t understand and 3 separate letters which had a cumulative increase of the amount Naz owed of 75%. 6 days after receiving the last piece of correspondence from the DWP Naz took an overdose

. Those mental health professionals who had worked with Naz throughout 7 months in which her mental health had deteriorated gave evidence to me that the recurrent and predominant cause of Naz’s increased anxiety was the DWP performance review. I find of the basis of the evidence I have heard and read that this was the case.
Copies sent to
3. Leicestershire County Council

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Report details

Reference
2024-0080
Date of report
13 February 2024
Coroner
Fiona Butler
Coroner area
Rutland and North Leicestershire

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Apr 2024 (estimated).

Sent to

Department for Work and Pensions

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