Cumbria County Council
Local Authority / Fire Service
Action Taken
The Council has reviewed self-neglect policies, revised operational practice guidance, implemented a countywide operational Safeguarding Adults service, and is delivering training sessions; a practice learning session will be undertaken with the team directly involved in this case. (AI summary)
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Dear Dr Shaw
Re: Regulation 28 Report to prevent future deaths
Further to your Regulation 28 report of the 5th October 2021, I write with confirmation of actions taken by Cumbria County Council (CCC). The safety of service users is of the utmost importance to CCC. We take your finding that there were matters giving rise to concern, and your opinion that there was a risk that future deaths may occur, extremely seriously. I wish to assure the Coroner that we proactively review our processes, and that the actions set out in this letter have been in place for many months. It is unfortunate that CCC were not provided the opportunity to present the work undertaken in advance of a Regulation 28 report being issued.
Within the Regulation 28 report concerns were raised that the operational response in this situation would leave others at risk if further action was not taken. The report implied that where concerns of self-neglect are identified, or following a referral, a direct face-to-face intervention would be required in order for the council to satisfy its duties.
To satisfy ourselves, and offer assurance to yourself, the Council confirms the following steps have been taken:
1. A systematic review of Cumbria Safeguarding Adults self-neglect policy and procedure documentation has been completed to clarify the roles, responsibilities, and duties across the safeguarding system.
2. The operational practice guidance in relation to self-neglect concerns has been reviewed and revised. The guidance reinforces the Council’s position that a face-to-face visit, in order to complete assessment and ensure the safety of the person at risk, must be undertaken to satisfy operational practice requirements and standards.
3. The Council has implemented a countywide operational Safeguarding Adults service, a dedicated safeguarding team providing support across the county, to ensure a consistent and compliant response for all safeguarding concerns, including concerns of self-neglect.
4. This dedicated Safeguarding Adults service is undertaking the delivery of training sessions across all partners to embed the review of self-neglect policy, procedure, and guidance.
5. Finally, a discrete practice learning session is being undertaken with the team directly involved in this case to ensure, from an operational point of view, that there is a clear and unequivocal position on how to respond to self-neglect concerns. I trust the information and confirmation of action detailed in this letter give you assurance that suitable action has taken place to address your concerns.
Re: Regulation 28 Report to prevent future deaths
Further to your Regulation 28 report of the 5th October 2021, I write with confirmation of actions taken by Cumbria County Council (CCC). The safety of service users is of the utmost importance to CCC. We take your finding that there were matters giving rise to concern, and your opinion that there was a risk that future deaths may occur, extremely seriously. I wish to assure the Coroner that we proactively review our processes, and that the actions set out in this letter have been in place for many months. It is unfortunate that CCC were not provided the opportunity to present the work undertaken in advance of a Regulation 28 report being issued.
Within the Regulation 28 report concerns were raised that the operational response in this situation would leave others at risk if further action was not taken. The report implied that where concerns of self-neglect are identified, or following a referral, a direct face-to-face intervention would be required in order for the council to satisfy its duties.
To satisfy ourselves, and offer assurance to yourself, the Council confirms the following steps have been taken:
1. A systematic review of Cumbria Safeguarding Adults self-neglect policy and procedure documentation has been completed to clarify the roles, responsibilities, and duties across the safeguarding system.
2. The operational practice guidance in relation to self-neglect concerns has been reviewed and revised. The guidance reinforces the Council’s position that a face-to-face visit, in order to complete assessment and ensure the safety of the person at risk, must be undertaken to satisfy operational practice requirements and standards.
3. The Council has implemented a countywide operational Safeguarding Adults service, a dedicated safeguarding team providing support across the county, to ensure a consistent and compliant response for all safeguarding concerns, including concerns of self-neglect.
4. This dedicated Safeguarding Adults service is undertaking the delivery of training sessions across all partners to embed the review of self-neglect policy, procedure, and guidance.
5. Finally, a discrete practice learning session is being undertaken with the team directly involved in this case to ensure, from an operational point of view, that there is a clear and unequivocal position on how to respond to self-neglect concerns. I trust the information and confirmation of action detailed in this letter give you assurance that suitable action has taken place to address your concerns.