Response for Irene Esaw
Action Planned
Tameside MBC has developed a comprehensive multi-agency action plan to address concerns regarding mental capacity assessment and multi-agency working, which will be shared in December 2021. A Multiagency Action Plan Group and a Quarterly Multiagency Learning Forum will be established to monitor and support learning. (AI summary)
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Dear Ms Morris Re: Regulation 28 Report into the death of Irene Ann Esaw (dob 13/11/1934, dod 11/11/2018) Further to your letter and Regulation 28 Report to Prevent Future Deaths dated 16 September 2021, regarding the tragic case of Irene Ann Esaw please find my response outlined below. The untimely death of a person is distressing for their family and any others affected by their death and loss, and all the more so if there is any belief that but for the actions of any public sector organisation it could have been avoided. I would like to record my sincere condolences to the family of Irene Ann Esaw for their loss and I hope through this process they can obtain some closure. The matters of concern identified by the Coroner and directed to the Chief Executive of Tameside Metropolitan Borough Council were as follows:
1. Identifying and Assessing Mental Capacity My findings in relation to Mrs. Esaw’s death were that there was a fundamental failure by the local authority staff to adequately consider and assess Mrs. Esaw’s capacity to make decisions about her own care needs whilst she was a patient at Tameside General Hospital between 12th September 2018 and the time of her death. This failure in my view, undermined her discharge planning and was one of the key reasons why the discharge was unsafe. I understand that work is ongoing in this area by in relation to prompting and recording of consideration of capacity concerns but, I also have concerns about a lack of professional curiosity by social workers, which I understand is still to be addressed in an ongoing piece of work for the new Safeguarding Lead who has yet to start in post. Therefore, I am concerned that the area of inquiring about and assessing capacity continues to need to be addressed.
2. Multi-agency Working My findings reveal that in the Care assessments of Mrs. Esaw, there were assumptions made by the clinical team and the IUCT that the other agency was responsible for capacity and needs assessments. The effect of this was that there was never an adequate assessment of her needs completed. , the Principal Social Worker for Adult Social Care told me in her evidence that even though IUCT are on the wards at Tameside, there is still further work to be done to understand the roles that the IUCT and the clinical team are undertaking. I am concerned that this continues to need to be addressed.
Ms Anna Morris Assistant Coroner Coroner's Court 1 Mount Tabor Street STOCKPORT SK1 3AG CHIEF EXECUTIVE
Chief Executive, Tameside MBC and Accountable Officer, Tameside & Glossop CCG Tameside One, Market Place, Ashton under Lyne, OL6 6BH
Doc Ref let/sp1211
Date 10 November 2021 B1 1 | P a g e
Identifying and Assessing Mental Capacity Since 2019, one of Adult Social Care work force development priorities has been to improve our staff knowledge and application of the Mental Capacity Act. Tameside MBC has recognised that there is a need to invest in their workforce to ensure that they are appropriately trained and that skills are updated and developed through a number of means. In order to do this a number of priorities were agreed: To improve social work standards and the quality of social work practice, assessment and care planning. To ensure the provision of effective support and development to managers and practitioners to develop a skilled and confident workforce which meets the needs of the service and the people it supports. To offer high-quality advice, support and consultancy to social work managers to develop social work services locally and with our partners. A programme to embed the Mental Capacity Act in practice is underway including Mental Capacity Assessment Forums and Social Work Forums A Quality Assurance Framework and a Workforce Development Framework are being developed with the aim to embed professional confidence, curiosity and development in practice. Adult Services has registered with Research in Practice for Adults (RiPfA) to support managers and staff A Social Work Consultant post has been recruited to. This post does not carry a caseload and does not directly line manage any staff. The purpose of this management level post is to support our professional teams, managers and staff to improve outcomes for individuals through their improved practice. On the 22 July 2020, a 12 month improvement plan was launched, which incorporates standards of practice, themed audits and themed Continuing Professional Development. The Individual Management Report (IMR) recommendations and action plan are annexed to this report as Appendix A. Some of the work completed has included reviewing the documentation for recording Mental Capacity Assessments and Best Interest decisions. These have been linked to other assessments such as the Needs assessment and Risk assessment to ensure the Mental Capacity Act is at the heart of social work practice with adults. The revised and updated assessments (Appendix B &C refers) and Care Act guidance for staff (Appendix D refers) are annexed to this response. A programme of regular training has taken place and will continue as this is an area of law and practice which changes and evolves with the changing nature of practice and case law. The Safeguarding Lead started in their role on the 13 September 2021, they are responsible for the implementation of the new Safeguarding Policy and Procedure within Tameside Adult Services. One of the priorities that will run throughout all of their work will be to ensure staff feel confident and equipped to be more ‘professionally curious’. This is recognised safeguarding training and the toolkit, advises that social workers can become more professionally curious and respectfully uncertain by following the points below:
1) “Question why someone is behaving in a certain way. Consider what these behaviours could indicate.
2) Find out more about someone’s personal circumstances. Assess their behaviour in light of what you know about them and their situation.
3) Question the motives of anyone who is with the person. Why are they there? What is their relationship to the person? Do they appear controlling? Do they dislike leaving the person alone? Even if they appear kind and supportive, could this be a way of hiding their role in harming the person? B2
4) Recognise when someone is reluctant to provide a full or accurate account of events or is pretending to cooperate to avoid raising suspicions.
5) Think outside the box. Consider the person or situation from the viewpoint of other workers. What might they look out for and notice? What would they think about the situation?
6) Maintain an open mind. Avoid making assumptions, taking information at face value and jumping to conclusions. Take account of changing information and different perspectives. Consider if you need to adapt your views.
7) Ask questions and challenge what you believe to be untrue.
8) Notice if you or someone else starts to doubt that someone is a victim – consider the reasons for these doubts. Are they fair? It might be helpful to read more about how victims of exploitation are perceived.
9) Trust your instinct and raise concerns if something about someone’s behaviour or situation does not feel right.
10) Think vulnerability and exploitation – be actively aware of how anyone you come across may be vulnerable and could be experiencing exploitation.
11) Think and act outside of your immediate job role – take action to investigate and act on your concerns, even if this goes beyond the immediate remit of your role and responsibilities.
12) For example, a professionally curious health professional who is treating someone for physical injuries would also question why these injuries have been sustained and assess the person’s wider appearance and behaviour – do they seem distressed? Are they reluctant to say how they received their injuries? Do they seem to be hiding something? Is there anything about them that raises concerns or suspicions?
13)If you are concerned about someone, take action to find out more about their situation and protect their safety and wellbeing.” Within the first month of being in the role, the Safeguarding Lead delivered a session for all social workers and managers on the learning from this case. The session was very well attended with over 100 attendees. Following the event, staff have been asked to discuss the learning in their teams and then share feedback with the Safeguarding Lead on how the learning will be applied in practice and what further support they may need. This feedback will inform their work plan. The Safeguarding Lead’s work plan includes gaining feedback on practice in a number of ways including conducting regular case file audits, learning reviews and consulting with all staff on a regular basis through surveys and forums to ensure that the support provided meets the needs of the organisation and social work standards. This approach aims to improve social worker’s confidence, knowledge and skills in safeguarding practice and ensure staff demonstrate professional curiosity in practice. The Safeguarding Lead has arranged quarterly Safeguarding Practice Forums. The first of these is planned in December 2021 and the theme will be Domestic Abuse. The ongoing training programme for social workers and managers will be reviewed and developed by the Safeguarding lead ensuring that staff have up to date knowledge and skills in this area of practice. There will be a rolling programme of essential training for all practitioners to complete every 2 years, this includes new and existing staff. The Principal Social Worker is currently reviewing the implementation of the quality assurance framework for social work practice, the application of the Mental Capacity Act will feature in this work. The aim is that a new framework will be in place from January 2022. Part of this work will include implementing the National Mental Capacity Act Competency Framework, developed by Bournemouth University. A skills and knowledge audit will take place of social workers and managers and the outcome will inform the ongoing training programme. Multi-agency Working Tameside MBC and Tameside and Glossop Integrated Care NHS Foundation Trust both received similar Prevention of Future Death reports. In response to this and in line with Tameside MBC’s Domestic Homicide Action Plan, a learning meeting took place on the 12 October 2021. B3
Senior staff from both the Tameside and Glossop Integrated Care NHS Foundation Trust and Tameside MBC met to reflect on the mechanisms in place for multiagency working at discharge between the Integrated Urgent Care Team, the Wards, the Medics and the community Neighbourhood Teams. The meeting was chaired by the Principal Social Worker, TMBC and the Head of Nursing for Integrated Safeguarding, Tameside and Glossop Integrated Care NHS Foundation Trust. The following themes were identified as areas for development in terms of multiagency working:
• Safe Discharge
• Recognising Adults at Risk
• Roles and Responsibilities
• The Application of the Mental Capacity Act A joint action plan for the Tameside and Glossop Integrated Care NHS Foundation Trust and Tameside MBC has been developed, which includes developing the knowledge and skills of all the staff involved in hospital discharge on the ward and in the community on ‘What is a Safe Discharge?’ and ‘Who are the adults at risk? ’ through a number of ways such as training, forums, audits and revised procedures. The joint action plan is also annexed to this response – Appendix E refers. Integral to this, is ensuring that the multidisciplinary team have a good understanding of one another’s roles and responsibilities. Work will take place to ensure that this is embedded in practice. This will include ensuring that roles and responsibilities feature in the induction of all staff, in ongoing clinical supervision and in multiagency procedures and standards. A multiagency review and refresh of the Mental Capacity Act procedures and training regarding adults with care needs on discharge, will take place. The finalised joint action plan will be shared with Tameside Adult Safeguarding Board at the next Board meeting in December 2021. A Multiagency Action Plan Group will be established to monitor the action plan, this will in place by December 2021. Alongside this a Quarterly Multiagency Learning Forum will be established as a mechanism to monitor the implementation of the action plan and to support a culture of reflection and learning across the multiagency partnership associated with hospital discharge. Conclusion Tameside MBC trusts that these actions and proposals are sufficient to satisfy that Coroner that the Council does take these concerns seriously, and that there is a continuous programme in place to support staff knowledge in identifying and their application of the Mental Capacity Act. Furthermore that the implementation of the joint action plan between the Council and Tameside and Glossop Integrated Care NHS Foundation Trust will minimise the risk of inadequate multi agency working. I hope that we have provided you with the necessary assurances in relation to your concerns. Please contact me if you require any further information or if I can assist further in any way.
1. Identifying and Assessing Mental Capacity My findings in relation to Mrs. Esaw’s death were that there was a fundamental failure by the local authority staff to adequately consider and assess Mrs. Esaw’s capacity to make decisions about her own care needs whilst she was a patient at Tameside General Hospital between 12th September 2018 and the time of her death. This failure in my view, undermined her discharge planning and was one of the key reasons why the discharge was unsafe. I understand that work is ongoing in this area by in relation to prompting and recording of consideration of capacity concerns but, I also have concerns about a lack of professional curiosity by social workers, which I understand is still to be addressed in an ongoing piece of work for the new Safeguarding Lead who has yet to start in post. Therefore, I am concerned that the area of inquiring about and assessing capacity continues to need to be addressed.
2. Multi-agency Working My findings reveal that in the Care assessments of Mrs. Esaw, there were assumptions made by the clinical team and the IUCT that the other agency was responsible for capacity and needs assessments. The effect of this was that there was never an adequate assessment of her needs completed. , the Principal Social Worker for Adult Social Care told me in her evidence that even though IUCT are on the wards at Tameside, there is still further work to be done to understand the roles that the IUCT and the clinical team are undertaking. I am concerned that this continues to need to be addressed.
Ms Anna Morris Assistant Coroner Coroner's Court 1 Mount Tabor Street STOCKPORT SK1 3AG CHIEF EXECUTIVE
Chief Executive, Tameside MBC and Accountable Officer, Tameside & Glossop CCG Tameside One, Market Place, Ashton under Lyne, OL6 6BH
Doc Ref let/sp1211
Date 10 November 2021 B1 1 | P a g e
Identifying and Assessing Mental Capacity Since 2019, one of Adult Social Care work force development priorities has been to improve our staff knowledge and application of the Mental Capacity Act. Tameside MBC has recognised that there is a need to invest in their workforce to ensure that they are appropriately trained and that skills are updated and developed through a number of means. In order to do this a number of priorities were agreed: To improve social work standards and the quality of social work practice, assessment and care planning. To ensure the provision of effective support and development to managers and practitioners to develop a skilled and confident workforce which meets the needs of the service and the people it supports. To offer high-quality advice, support and consultancy to social work managers to develop social work services locally and with our partners. A programme to embed the Mental Capacity Act in practice is underway including Mental Capacity Assessment Forums and Social Work Forums A Quality Assurance Framework and a Workforce Development Framework are being developed with the aim to embed professional confidence, curiosity and development in practice. Adult Services has registered with Research in Practice for Adults (RiPfA) to support managers and staff A Social Work Consultant post has been recruited to. This post does not carry a caseload and does not directly line manage any staff. The purpose of this management level post is to support our professional teams, managers and staff to improve outcomes for individuals through their improved practice. On the 22 July 2020, a 12 month improvement plan was launched, which incorporates standards of practice, themed audits and themed Continuing Professional Development. The Individual Management Report (IMR) recommendations and action plan are annexed to this report as Appendix A. Some of the work completed has included reviewing the documentation for recording Mental Capacity Assessments and Best Interest decisions. These have been linked to other assessments such as the Needs assessment and Risk assessment to ensure the Mental Capacity Act is at the heart of social work practice with adults. The revised and updated assessments (Appendix B &C refers) and Care Act guidance for staff (Appendix D refers) are annexed to this response. A programme of regular training has taken place and will continue as this is an area of law and practice which changes and evolves with the changing nature of practice and case law. The Safeguarding Lead started in their role on the 13 September 2021, they are responsible for the implementation of the new Safeguarding Policy and Procedure within Tameside Adult Services. One of the priorities that will run throughout all of their work will be to ensure staff feel confident and equipped to be more ‘professionally curious’. This is recognised safeguarding training and the toolkit, advises that social workers can become more professionally curious and respectfully uncertain by following the points below:
1) “Question why someone is behaving in a certain way. Consider what these behaviours could indicate.
2) Find out more about someone’s personal circumstances. Assess their behaviour in light of what you know about them and their situation.
3) Question the motives of anyone who is with the person. Why are they there? What is their relationship to the person? Do they appear controlling? Do they dislike leaving the person alone? Even if they appear kind and supportive, could this be a way of hiding their role in harming the person? B2
4) Recognise when someone is reluctant to provide a full or accurate account of events or is pretending to cooperate to avoid raising suspicions.
5) Think outside the box. Consider the person or situation from the viewpoint of other workers. What might they look out for and notice? What would they think about the situation?
6) Maintain an open mind. Avoid making assumptions, taking information at face value and jumping to conclusions. Take account of changing information and different perspectives. Consider if you need to adapt your views.
7) Ask questions and challenge what you believe to be untrue.
8) Notice if you or someone else starts to doubt that someone is a victim – consider the reasons for these doubts. Are they fair? It might be helpful to read more about how victims of exploitation are perceived.
9) Trust your instinct and raise concerns if something about someone’s behaviour or situation does not feel right.
10) Think vulnerability and exploitation – be actively aware of how anyone you come across may be vulnerable and could be experiencing exploitation.
11) Think and act outside of your immediate job role – take action to investigate and act on your concerns, even if this goes beyond the immediate remit of your role and responsibilities.
12) For example, a professionally curious health professional who is treating someone for physical injuries would also question why these injuries have been sustained and assess the person’s wider appearance and behaviour – do they seem distressed? Are they reluctant to say how they received their injuries? Do they seem to be hiding something? Is there anything about them that raises concerns or suspicions?
13)If you are concerned about someone, take action to find out more about their situation and protect their safety and wellbeing.” Within the first month of being in the role, the Safeguarding Lead delivered a session for all social workers and managers on the learning from this case. The session was very well attended with over 100 attendees. Following the event, staff have been asked to discuss the learning in their teams and then share feedback with the Safeguarding Lead on how the learning will be applied in practice and what further support they may need. This feedback will inform their work plan. The Safeguarding Lead’s work plan includes gaining feedback on practice in a number of ways including conducting regular case file audits, learning reviews and consulting with all staff on a regular basis through surveys and forums to ensure that the support provided meets the needs of the organisation and social work standards. This approach aims to improve social worker’s confidence, knowledge and skills in safeguarding practice and ensure staff demonstrate professional curiosity in practice. The Safeguarding Lead has arranged quarterly Safeguarding Practice Forums. The first of these is planned in December 2021 and the theme will be Domestic Abuse. The ongoing training programme for social workers and managers will be reviewed and developed by the Safeguarding lead ensuring that staff have up to date knowledge and skills in this area of practice. There will be a rolling programme of essential training for all practitioners to complete every 2 years, this includes new and existing staff. The Principal Social Worker is currently reviewing the implementation of the quality assurance framework for social work practice, the application of the Mental Capacity Act will feature in this work. The aim is that a new framework will be in place from January 2022. Part of this work will include implementing the National Mental Capacity Act Competency Framework, developed by Bournemouth University. A skills and knowledge audit will take place of social workers and managers and the outcome will inform the ongoing training programme. Multi-agency Working Tameside MBC and Tameside and Glossop Integrated Care NHS Foundation Trust both received similar Prevention of Future Death reports. In response to this and in line with Tameside MBC’s Domestic Homicide Action Plan, a learning meeting took place on the 12 October 2021. B3
Senior staff from both the Tameside and Glossop Integrated Care NHS Foundation Trust and Tameside MBC met to reflect on the mechanisms in place for multiagency working at discharge between the Integrated Urgent Care Team, the Wards, the Medics and the community Neighbourhood Teams. The meeting was chaired by the Principal Social Worker, TMBC and the Head of Nursing for Integrated Safeguarding, Tameside and Glossop Integrated Care NHS Foundation Trust. The following themes were identified as areas for development in terms of multiagency working:
• Safe Discharge
• Recognising Adults at Risk
• Roles and Responsibilities
• The Application of the Mental Capacity Act A joint action plan for the Tameside and Glossop Integrated Care NHS Foundation Trust and Tameside MBC has been developed, which includes developing the knowledge and skills of all the staff involved in hospital discharge on the ward and in the community on ‘What is a Safe Discharge?’ and ‘Who are the adults at risk? ’ through a number of ways such as training, forums, audits and revised procedures. The joint action plan is also annexed to this response – Appendix E refers. Integral to this, is ensuring that the multidisciplinary team have a good understanding of one another’s roles and responsibilities. Work will take place to ensure that this is embedded in practice. This will include ensuring that roles and responsibilities feature in the induction of all staff, in ongoing clinical supervision and in multiagency procedures and standards. A multiagency review and refresh of the Mental Capacity Act procedures and training regarding adults with care needs on discharge, will take place. The finalised joint action plan will be shared with Tameside Adult Safeguarding Board at the next Board meeting in December 2021. A Multiagency Action Plan Group will be established to monitor the action plan, this will in place by December 2021. Alongside this a Quarterly Multiagency Learning Forum will be established as a mechanism to monitor the implementation of the action plan and to support a culture of reflection and learning across the multiagency partnership associated with hospital discharge. Conclusion Tameside MBC trusts that these actions and proposals are sufficient to satisfy that Coroner that the Council does take these concerns seriously, and that there is a continuous programme in place to support staff knowledge in identifying and their application of the Mental Capacity Act. Furthermore that the implementation of the joint action plan between the Council and Tameside and Glossop Integrated Care NHS Foundation Trust will minimise the risk of inadequate multi agency working. I hope that we have provided you with the necessary assurances in relation to your concerns. Please contact me if you require any further information or if I can assist further in any way.