Derek Larkin

Dear Sir Regulation 28: Prevention of Future Deaths Report Response Deceased: Mr Derek Larkin (DOB 10 Jan 1964, DOD: 1 Jun 2021) I write following the inquest held on 12 January 2023 following the investigation into the death of Derek Larkin. I would firstly like to offer my condolences to the family and friends of Mr Derek Larkin. This is a response to the Regulation 28 report issued to Dorset Council dated 19 January 2023. The Regulation 28 report sets out the following concerns affecting Dorset Council: “There is no evidence that the Dorset Council Adult Social Care computer system Mosaic can communicate with the NHS SystemOne. The Adult Social Care team would benefit from having information about the medication being prescribed to a patient, with the patient’s consent, and when that medication was last reviewed. Dorset Council Adult Social Care would benefit from information held by a current or former GP practice as to a patient’s medication and how to manage any particular concerns raised by health care professionals or family where a patient is able to independently manage his medication.” Background to Dorset Council’s involvement Dorset Council assessed Mr Larkin on 23rd April 2021 under the Care Act 2014 and he was found to have eligible needs for care and support. At this time Mr Larkin was considered to have mental capacity to make his own decisions, as per the principles of s.1 of the Mental Capacity Act 2005. Dorset Council supported Mr Larkin with his discharge from hospital back home on 20th May 2021 with a package of care. For a number of years prior to this discharge from hospital Mr Larkin had owned a medicine safe as a mechanism to manage his addiction to opioids. Response to Concerns Dorset Council have consulted with Dorset Healthcare about the medication management issues raised by this Regulation 28 report. Dorset Council understand that a separate response to the report in relation to medication management will be submitted on behalf of Dorset Healthcare/NHS Dorset Integrated Care Board. It is recommended that this response be read in the context of the response from Dorset Healthcare.

Of the points that Dorset Council is able to comment upon, the Regulation 28 report highlighted that: “Dorset Council Adult Social Care would have benefitted from having knowledge of the medications that had been prescribed, together with further information from the GP practice.” And that: “There is no evidence that the Dorset Council Adult Social Care computer system can communicate with the NHS SystemOne.” In addition: Plus: “Dorset Council Adult Social Care would benefit from information held by a current or former GP practice as to a patient’s medication and how to manage any particular concerns raised by health care professionals or family where a patient is able to independently manage his medication.” It is acknowledged that health and social care services do not have one universal record keeping system. This is both a local and national issue. Due to this, various efforts have been made to create ‘bridging’ systems to improve record sharing where a patient consents for this to happen. SystemOne (a health service record keeping system) and Mosaic (Dorset Council’s social care record keeping system) are not designed to communicate with one another and are owned and regulated by separate organisational data controllers under the General Data Protection Regulation (GDPR) and Data Protection Act 2018. A System called Dorset Care Record (DCR) has been put in place which enables some information from health and social care systems, subject to an individual’s consent, to be shared across both systems on a view only access basis. The DCR is a partnership supported by NHS Dorset Integrated Care Board, Dorset County Hospital, University Hospitals Dorset, Dorset HealthCare, Dorset Council, and Bournemouth, Christchurch and Poole Council. This system was in place during the events that lead to Mr Larkin’s death. Information about medication was viewable by users of Dorset Care Record during this time. However, even with improved systems, such as these, the following points apply:
1. A person with capacity to make decisions for themselves will need to consent to sharing of information between different organisations and individuals can opt out of the DCR.
2. If a person lacks capacity to make decisions for themselves, in particular, about their care and support or medication the process in terms of sharing information between organisations may differ. Following an assessment of capacity that determines the person lacks capacity to make the particular decision in question will thereafter require best interest decision making on their behalf which will include relevant persons involved in their care. With decisions relating to medication, this will often be led by Health rather than Adult Social Care.
3. It is down to each contributing organisation as to what level of patient data is shared across the Dorset Care Record platform. For these reasons, record sharing between local authority and NHS based records is not integrated and relies upon these two standalone systems having content shared via third party applications, or manually by users, to the extent permitted by law. Due to DCR, Dorset Council did have access to medication information and did act upon the presenting risks during the events leading up to Mr Larkin’s death. It is accepted that the health service must be consulted on medication, its use/storage and risks. However, beyond this, there are prescriber risk management issues raised in the report that a local authority is unable to accept responsibility for (medication prescription and medication risk management is not a function of a local authority under the Care Act 2014) and must therefore direct the coroner to responses from the NHS.

Further to this, an action plan was completed by Adult Social Care, which was provided to the Coroner in advance of the inquest setting out other actions to be taken by Dorset Council following Mr Larkin’s death. This confirms at point 5 of the action plan: “Liaison with Health professional/prescriber for reviews of medication, options appraisal and confirmation of risks and safe management” As actions around this Adult Social Care considered the following is required in future cases:
1. Ensure that Health is consulted on medication, its use, storage and any risks at assessment and review points.
2. Confirmation from Health in writing of any known risks linked to the use of specific medications for named individuals and how to safely manage these. The learning recommended from the action plan was shared with relevant managers in February 2023, as indicated would occur in the action plan. The Care Act 2014 and the statutory Care and Support Guidance does require and allow collaboration, cooperation and sharing of information between local authorities and other organisations that have functions in relation to care and support, in particular sections 6 and s.7 of the Care Act 2014. Dorset Council will continue to have regard to the relevant law and guidance for sharing of information with other organisations in cases where this is required. I hope that the information outlined in this response assists the coroner and responds to the key concerns highlighted in respect of sharing of information between organisations, in particular in respect of medication.