Source · Prevention of Future Deaths

Carol Cole

Ref: 2022-0033 Date: 2 Feb 2022 Coroner: Rachael Griffin Area: Dorset Responses identified: 2 / 2 View PDF

A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial mental health concerns were not received, leading to missed patient assessments.

Date 2 Feb 2022

56-day deadline 30 Mar 2022 est.

Responses identified 2 of 2

Alcohol, drug and medication related deaths Mental Health related deaths

Coroner's concerns

AI summary

A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial mental health concerns were not received, leading to missed patient assessments.

View full coroner's concerns

1. During the inquest evidence was heard that: i. Following attendances upon Mrs Cole by officers from Dorset Police in the days and weeks leading up to her death, two Public Protection Notice (PPN) were submitted to the Multi Agency Safeguarding Hub (MASH) within Dorset Police. The first of these PPNs raised concerns about Carole’s mental health.

ii. When a PPN is received by the team within MASH, they forward the PPN onto the relevant agencies, or people, who can provide support to the individual, or take action. One of those to whom this can be shared is the person’s General Practitioner (GP).

iii. In Dorset there are 2 Local Authorities that cover the County, BCP Council and Dorset Council. If MASH receive a PPN about a resident in the BCP Council area the current arrangement is that MASH send the PPN directly to the GP as required. If they receive a PPN about a resident in the Dorset Council area the current process is that they do not send it directly to the GP but send it directly to the Dorset Adult Access team at Dorset Council, who will then send it to the GP.

iv. At the time of her death Carole resided within the Dorset Council area. A PPN was submitted to MASH regarding Carole on 25.4.20 which raised concerns regarding her mental health. The MASH team determined the PNN should be shared with the Dorset Adult Access team to share with the GP in line with the process.

v. At the Inquest the representative from the GP surgery confirmed there was no record of the PNN being received by them, which led to a missed opportunity for Carole to be assessed by her GP.

vi. The process currently in place, which I understand has been agreed by both Dorset Council and Dorset Police, of preventing the MASH team from sending the PNN directly to the GP, may result in the GP not being informed of the contents of the PPN which may result in a person not receiving an assessment, support or treatment. I am not aware of a reason why the MASH team cannot send it directly to the GP, as they do for those residents in BCP council area, to avoid such missed opportunities to take action which may lead to a future death.

2. I have concerns with regard to the following: i. There could be missed opportunities to share PPNs relating to residents within the Dorset Council area with agencies or professionals due to the current processes in place between Dorset Police and Dorset Council which could lead to a future death. I therefore request that Dorset Police and Dorset Council review their current processes in place regarding the sharing of PPNs by MASH, especially to General Practitioners for the residents within the Dorset Council area.

Responses

2 respondents

Dorset Police Police / Law Enforcement

2 Feb 2022 PDF

Action Planned

Dorset Council will fund a co-located member of staff in the MASH to share PPNs with GPs. A further review with Health partners commenced on 12 April 2022 to review the current process. (AI summary)

View full response

Dear Madam,

Regulation 28: Prevention of Future Deaths Report Response Deceased: Carole Patricia Cole

I write in respect of the above-mentioned report of 2 February 2022 (“the Regulation 28 report”).

Firstly, I would like to express condolences on behalf of myself and Dorset Police to the family and friends of Carole.

Secondly, I thank you for sending a copy of the Regulation 28 report that was made during the inquest into Carole’s death. As you would expect, we welcome any such opportunities for Dorset Police to consider whether there are any improvements that can be made to how we work.

In the Regulation 28 report, you confirm that the matter of concern that you wish to raise is that there could be missed opportunities to share PPNs relating to residents within the Dorset Council area with agencies or professionals due to the current processes in place between Dorset Police and Dorset Council which could lead to a future death.

You therefore requested that Dorset Police and Dorset Council review their current processes in place regarding the sharing of PPNs by MASH, especially to General Practitioners for the residents within the Dorset Council area.

The review took place between 16/02/2022 and 16/03/2022 with partners from Dorset and BCP Adult Social Care. This confirmed the process of sharing PPNs between the Police and BCP Council and Dorset Council differs. It has been acknowledged that the existence of two different systems can present a risk to safeguarding and the consistency of one process would be preferable. Chief Constable

Dorset Police Force Headquarters Winfrith DORCHESTER DT2 8DZ

30 March 2022 Mrs Rachel C Griffin Senior Coroner Coroner's Office County of Dorset Town Hall Bournemouth BH2 6DY

The review also identified that for the Police to carry out the sharing of PPNs to GPs there would be a requirement for Police to have access to the Dorset Care Record which it currently does not have.

On occasions officers will attend an incident whereby the GP is unknown or recorded incorrectly therefore it is necessary to confirm the correct GP details utilising the Dorset Care Record to ensure personal information is not being passed to the incorrect surgery.

Identification of this risk has prompted a further review with Health partners which is scheduled to commence on 12 April 2022. Police, Health and Social Care will work together to review the current process, what is working well and where improvements can be made based on national best practice from other areas.

On 28 March 2022, it was agreed that Dorset Council will fund a member of staff from Adult Social Care to co-locate with Dorset Police in the MASH. This role would be responsible for sharing with GPs and have access to the Dorset Care Record. In the interim I am aware that the Dorset Adult Access Team promptly streamlined their working practices in February 2022 to overcome the issue that resulted in the failure to share the PPN with the GP in the case of Ms Cole.

The learning from the Regulation 28 report has been passed to the Safeguarding Adult Review Board for further discussion and to secure partnership commitment to delivering the findings of the review.

As you would expect, correspondence from yourself is taken most seriously by myself and we will continue to work with our partner agencies to ensure that our processes are appropriate, proportionate and minimise any risk of missing opportunities to safeguard our residents.

Thank you again for your consideration and questioning of the Force through the Regulation 28 procedure and copying the report to us. I trust this response provides you with the further information that you require. Please do contact me should you wish for further clarification or information.

Dorset Council Local Authority / Fire Service

29 Mar 2022 PDF

Action Taken

Dorset Council amended its internal process on 25/02/22 so that the Adult Access Team forward PPNs to relevant agencies or professionals regardless of whether the person is known or not known to Adult Social Care. Dorset Council will provide additional staffing resources to MASH to assist with the sharing of PPNs to GPs pending a wider system review. (AI summary)

View full response

Dear Madam,

Regulation 28: Prevention of Future Deaths Report Response Deceased: Carole Patricia Cole

I am writing in response to the Regulation 28 report which was issued to both the local authority and Dorset Police regarding Carole Patricia Cole.

I know that you will share a copy of this response with Mrs Cole’s family and I would first like to express my condolences for their loss.

During the inquest, evidence was heard regarding the process for sharing Public Protection Notices (PPNs). The Regulation 28 report raised a specific concern in that:

i) There could be missed opportunities to share PPNs relating to residents within the Dorset Council area with agencies or professionals due to the current processes in place between Dorset Police and Dorset Council which could lead to a future death.

The request was made that Dorset Police and Dorset Council review their current processes in place regarding the sharing of PPNs by MASH, especially to General Practitioners for the residents within the Dorset Council area. We reviewed the current PPN process with Dorset Police and Bournemouth, Christchurch and Poole (BCP) Council between 16/02/2022 and 16/03/22. This involved members of the operational management team at Dorset Council and Bournemouth, Christchurch and Poole (BCP) Council and Dorset Police Public Protection Unit meeting to analyse current steps in the process. This identified the following areas of improvement:

i) When a PPN is received by the Multi-Agency Safeguarding Hub (MASH) within Dorset Police, information is shared differently depending on whether the person is a resident of Dorset Council local authority area or BCP. If the person is resident of the Dorset Council area the MASH team share PPNs with the Adult Access Team who then share them with the GP and other relevant organisations. If the person is a

resident of the BCP area MASH share directly with GPs. This was raised as a matter of concern within the Regulation 28 report. When a PPN is received into the Adult Access Team and a person is known or open to an Adult social care team, the PPN is passed to the relevant team to share with relevant agencies or professionals. Having different internal process for people known or not known to Adult Social Care could result in a delay in sharing PPNs.

The following actions were identified:

i) Amend the current process of sharing PPNs between Dorset Police and Dorset Council to align with BCP processes. This requires work to ensure the MASH has adequate capacity and access to up-to-date information about a person’s GP. To have an immediate impact on the current process, Dorset Council will provide additional staffing resources to MASH to assist with the sharing of PPNs to GPs to allow time for a wider system review of MASH to be completed. The plan is to complete recruitment by end of May 2022.

ii) A meeting has been arranged between Dorset Council, Dorset Police MASH, BCP and health partners including GP safeguarding leads in April 2022 to discuss current PPN sharing processes, including what is working well and areas for improvement. This was the earliest opportunity to do so, so that all parties could be represented.

iii) Share learning from the Regulation 28 report at Dorset’s Safeguarding Adult Review in April 2022 and seek approval to align a full partnership review of PPN sharing within Adult MASH with the Children’s MASH review which will take place in July
2022.

iv) Amend Dorset Council’s internal process so that the Adult Access Team forward PPNs to relevant agencies or professionals regardless of whether the person is known or not known to Adult Social Care. This was immediately actioned and implemented on 25/02/22.

I hope the above information provides assurance to the Chief Coroner that Dorset Council has taken the matter with due concern and an ongoing commitment with Dorset Police and wider partners to finding a resolution to this issue and in turn mitigate the risk of future deaths to the residents of Dorset. We would like to propose that we provide a further update after the wider system review in July 2022.

Your sincerely

Chief Executive Dorset Council

Report sections

Investigation and inquest

On the 20th May 2020, an investigation was commenced into the death of Carol Patricia Cole, born on the 21st November 1951. The investigation concluded at the end of the Inquest on the 21st January 2022. The Medical Cause of Death was: Ia Combined overdose

II Ischaemic Heart Disease The conclusion of the Inquest was suicide.

Circumstances of the death

On the 15th May 2020 the deceased, who was prescribed and medication, and who had a history of depression, unstable personality disorder and previous overdoses of medication, was found in a collapsed and unresponsive condition in the bedroom at her home address at , Weymouth.

Copies sent to

Dorset County Hospital NHS Foundation Trust

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Shared signals

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Report details

Reference: 2022-0033
Date of report: 2 February 2022
Coroner: Rachael Griffin
Coroner area: Dorset

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: 30 Mar 2022 (estimated).

Sent to

Dorset Council

Dorset Police

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.