Source · Prevention of Future Deaths

Anthony Wilkinson

Ref: 2021-0102 Date: 13 Apr 2021 Coroner: Abigail Combes Area: South Yorkshire (West District) Responses identified: 3 / 1 View PDF

The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical service user information.

Date 13 Apr 2021
56-day deadline 7 Jun 2021
Responses identified 3 of 1
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths

Coroner's concerns

AI summary
The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical service user information.
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Stars Social Support Limited

(1) Stars Social Support Limited have a culture which does not encourage transparency or embrace the duty of candour. This was evidenced throughout the inquest proceedings and in the lack of engagement with CQC during the inspection regime.

(2) Stars Social Support Limited do not utilise their own website to ensure that policy and legislative changes can be adequately and promptly shared with service users, their families, and staff.

(3) Stars Social Support Limited do not have appropriate policies, procedures and checks in place to ensure that updates to care plans are communicated to all staff caring for service users or that the correct care and support plans, and risk assessments, are in the service users home address.

(4) Stars Social Support Limited have implemented the use of WhatsApp to ensure staff are aware of updates to service users plans and they require staff to confirm they have read and understood the update prior to caring for an individual. Whilst this is a positive use of technology to support staff in caring for service users it is in itself a safeguarding issue to hold personal information about the service user on personal mobile phones; this is especially the case where there are not adequate policies in place around the use of personal phones by staff members.

(5) The use of the WhatsApp group adds in two risks of its own, the first is that there is an over reliance on this being the means by which service users care plans are updated and by default this ends up being the service users care plan. This makes it more likely rather than less likely in my view that support plans in the service users’ home will not be updated in a timely fashion.

(6) Secondly, visiting professionals are not able to access the WhatsApp group and therefore will not be in receipt of this updated information which may be important for some service users.

(7) There was no evidence that fundamental matters such as standard operating procedures for displaying SALT advice or allergy advice in a service users’ kitchen where all can see it have been implemented by the Stars Social Support Limited.

(8) There remained a lack of understanding about the mental capacity act and how that may affect the care delivery to service users where it meant that a carer or senior manager had to be the decision maker for specific aspects of their care such as nutrition or medication (9) There is now a significant reliance on the Director updating all records and delivering care and undertaking audits whilst she improves the culture of the organisation. There was no adequate description of contingency plans in the event of sickness of this individual.

(10) The Director, in evidence, did not describe consideration of a lead carer for service users who would hold some responsibility for ensuring documentation in the service users’ home was accurate and up to date.

(11) I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented; how technology will be used; how data will be safeguarded; how audits will be undertaken; how handovers will be undertaken. This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.

(12) I would like to see evidence of how Stars Social Support Limited will positively engage with Regulators and other bodies to enhance the quality of their services.

Care Quality Commission

(13) CQC did not take adequate steps to access records held by the Police or the provider in a timely fashion following Tony's death. This potentially created risk to other service users as the Regulator had not inspected the service promptly following a significant event.

(14) CQC too readily accepted the lack of an action plan from the provider and did not use this lack of engagement from the provider to increase the risk profile for this provider. Had they done so an earlier re inspection may have been triggered or further regulatory action. This failure may have exposed other service users to unnecessary risk of harm as a result of an inaccurate risk picture being provided by the CQC.

(15) CQC did not take into consideration significant relevant factors when risk assessing this care provider at the start of the pandemic leading to an inappropriate risk profile being established and an exaggerated level of confidence being placed in the provider to provide safe services to residents without appropriate monitoring and oversight from the Regulator.

(16) The report from the August 2020 inspection was inaccurate and misleading and may have caused service users to be added to this service where that ought not to be the case. The report published in October 2020 refers to their being no evidence of harm however there is a woeful lack of detail about the context of this within the report. CQC should review this particular report for this provider and also reconsider the way in which reports are written to ensure that they are not misleading and therefore dangerous. This includes either omitting from the report any comment about harm where there is clearly a context and evidence of harm to service users previously, which is open and live, but which does not form part of the inspection or very clear confirmation in the report that there has been evidence of harm which does not form part of the specific inspection report.

(17) Where CQC are required to decide whether evidence ought to be used for the basis of an inspection OR for regulatory action, they ought to ensure there is a consistent approach to this including the consideration of polices and standard operating procedures. This should be approached on the basis of safeguarding the majority of remaining service users from harm being the priority even where that means prosecutions for breaches of Regulation may be compromised.

South West Yorkshire Partnership NHS Foundation Trust

(18) The advice from SALT was not an issue in this case, it was the application of this advice which was the primary concern. I would like to commend the approach that the Trust have taken in learning from the issues which I raised at the conclusion of the proceedings and the openness with which the Trust have received the concerns I had. The guidance sheets which have been produced are still not clear enough and will lead to confusion including around the consistency description and a list of foods which can be modified or should be avoided. This needs to be reviewed to avoid confusion.

Responses

3 respondents
South West Yorkshire Partnership NHS Foundation Trust NHS / Health Body
8 Jun 2021 PDF
Action Taken

The Trust has amended its Level 6 food consistency advice sheets by removing picture anomalies and amending statements to remove ambiguity, based on IDDSI Framework reviewed in May 2021. (AI summary)

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Dear Ma'am, Regulation 28 Report Response Anthony Wilkinson Inquest Concluded 26th March 2021 In response to the Regulation 28 the Trust wish to respond with the following information. The guidance sheets which been produced are still not clear enough and will lead to confusion including around the consistency description and a list of foods which can be modified or should be avoided: As you will be aware Speech and Language Therapist Lead for Learning Disability Services gave evidence in respect of the Level 6 food consistency advice sheets provided by the Learning Disability Speech and Language Therapy (SALT) Service. As part of both her written and oral evidence, agreed that these advice sheets could, subject to review via the appropriate governance procedures, be updated to address the concerns you raised during the course of the inquest proceedings_ On 18th 2021 lalong with other Learning Disability Speech and Language Therapists , met and reviewed the services level 6 food consistency advice sheets in their Dysphagia Speech and Language Therapy Learning Disability meeting: As a result of this review, the advice sheets were amended in response to your concerns as follows: Removal of the picture anomalies, such as the removal of the image depicting cut up melon, which was in-fact a food to be 'avoided' . 2 Amendment of statements and wording to remove potential ambiguity. For example: Old wording: With all 0f us in mind. UNIVERSITY OF LEEDS Associated teaching trust status CCetiii canie To protect the environment and save money this letter is printed on recycled and unbleached paper. have May

NHS South West Yorkshire Partnership NHS Foundation Trust "These foods can be especially hard to chew or swallow SO need to be avoided or specially prepared so that meet the consistency description. New wording: "These foods are considered high risk for people with chewing and swallowing difficulties For safety, AVOID these food textures that pose choking risk for people on soft and bite sized consistency Some foods can be modified to meet the consistency recommendation_ Any food that cannot be suitably modified MUST BE AVOIDED.
3. Amendment of the 'high risk' food information list to contain two distinct columns: Column 1: 'Food types and examples of food to AVOID'; contains food types and examples of foods that must be avoided, Column 2: 'Modified Options'; this is left blank in order to enable personalised and person-centred approach to identify foods that can be modified for the service user. have enclosed copy of the Learning Disability SALT Services updated level 6 food consistency advice sheet to this letter can confirm this sheet was implemented within the service on 2nd June 2021_ The Trust remains committed to learning from incidents and we will continue to apply a quality improvement approach to ensure required changes are embedded within our clinical services. do hope the above information is of assistance and answers the concerns raised within your Regulation 28 report following the sad death of Anthony Wilkinson.
CQC Regulator / Inspectorate
PDF
Action Taken

CQC has reviewed the concerns raised, contacted Stars Social Support Limited, and referred the report to CQC's policy team to review. The shorter report guidance was implemented in January 2019. (AI summary)

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Dear HM Assistant Coroner Abigail Combes Prevention of future death report following inquest into the death of Anthony Wilkinson Thank you for sending CQC a copy of the prevention of future death report issued following the death of Anthony Wilkinson: CQC has contacted the provider Stars Social Support Limited 'Stars Social Support") to request written confirmation and evidence of the action they have taken to date following this death and any additional action intend to take in response to the prevention of future death report: CQC has reviewed all the concerns contained in the Regulation 28 report; as well as the subsequent suggested actions contained in Section 6. We will respond to each point addressed to CQC in order as set out in the Regulation 28 report Section 5, Point 13 CQC did not take steps to access records held by the Police or the provider in timely fashion following Tony's death. This potentially created risk to other service users as the Regulator had not inspected the service promptly following a significant event CQC has reviewed chronology of steps taken by the local inspection team to access records held by the Police or the provider to consider the timeliness of the actions taken: The team requested Anthony Wilkinson's care records from the provider less than a week after being notified of his death on 5 April 2018 At this time the police were carrying out a criminal investigation following the incident and held primacy of the investigation. In line with The Work Related Deaths Protocol CQC made contact with the Police on 3
2018. The Police had seized original records from Stars Social Support as part of their investigation. CQC progressed they May

their parallel investigation as much as they reasonably could, however access to records was limited in the beginning of our initial enquiries due to the police seizing these, however CQC were in regular contact with the Police to ensure we adopted cooperative and coordinated approach. CQC received copies of all records held by the Police on 29 November 2018 at the conclusion of their investigation. CQC has reviewed whether; as a result of Anthony Wilkinson's death, Stars Social Support should have been inspected sooner than the comprehensive inspection which was completed on 29 and 30 May 2018. This inspection did not lead to rating ora report published as at that time, the Police had seized Stars Social Support's computer servers as part of their investigation, which in turn, impacted on the availability of records necessary to make fair and complete assessment about the service against all of CQC's line of enquiries (KLOE's). We have concluded from our review that the inspection of 29 and 30 May was completed promptly, based on the information and risks we were aware of at that time_ The local inspection team followed internal guidance responding to specific incidents, assessed the level of risk of harm this incident posed to others at the service, in conjunction with known CQC intelligence, the service's regulatory history, as well as taking into account any relevant stakeholder feedback or actions to mitigate potential wider risk at the service. CQC were aware Barnsley Local Authority's safeguarding team had visited Stars Social Support in April 2018 shortly after Anthony Wilkinson's death and implemented voluntary embargo on admissions. Following receipt of the specific incident the local inspection team assessed the level of risk at the service did not necessitate urgent regulatory action or an inspection: CQC's inspection findings on 29 and 30 May 2018,and again on 12 and 13 February 2019, confirmed that our assessment of risk was accurate as at that time no seriouslurgent concerns were identified. Although the inspection on 29 and 30 May 2018 did not lead to rating or report; the information gathered from our visit to Stars Social Support's office and a selection of service user's homes, assured CQC that people were receiving a safe service at that time. Therefore, the overall risk level of the service could be de-escalated_ Section 5, Point 14 CQC too readily accepted the lack of an action plan from the provider and did not use this lack of engagement from the provider to increase the risk profile for this provider. Had done so an earlier re- inspection may have been triggered for further regulatory action. This failure may have exposed other service users to unnecessary risk of harm as result of inaccurate picture being provided by the CQC. We understand point 14 refers to the re-inspection of Stars Social Support following the February 2019 inspection, where the local team identified two breaches of regulations. Civil enforcement action was taken; a Warning Notice was served against the breach of regulation 17; and Requirement Notice was serviced against the breach of regulation 19.As a Warning Notice was served, we did not request an action plan in line with CQC Enforcement Policy. We did, however, request an action plan be submitted to CQC by 29 May 2019 for the being key key they

breach of regulation 19. This breach concerned failure to complete all staff recruitment checks in line with regulatory requirements and was assessed as posing no serious risk to people who used the service_ CQC acknowledged at the Prevention of Future Deaths hearing that the re- inspection of Stars Social Support (completed on 27 August 2020 to 3 September
2020) fell outside of our usual timeframe of re-inspecting a service, rated requires improvement; 12 months from the last inspection publication date. However at that time, the decision not to inspect the service sooner we feel was justified and proportionate_ COVID-19 resulted in CQC adapting its inspection priorities during the pandemic to ensure risk and people's safety were the highest priority. A decision was taken by the CQC that during the pandemic, CQC would take on a more supportive role as well as not adding to the overall risk and pressures COVID-19 presented to the rest of the health and social care sector As at 2020, there needed to be an "extreme" level of risk for CQC to cross the threshold for inspection: This ensured during the pandemic, that CQC continued to carry out their regulatory function when there was extreme risk at service_ This was determined on a case by case basis. CQC's inspection priorities remained under continuous review in line with national priorities, but our monitoring of Stars Social Support as well as their failure to provide a completed action plan in relation to the breach of regulation 19, was not assessed as an 'extreme' risk in all of the circumstances CQC monitored all ASC care providers throughout the pandemic and has implemented several systems to support remote monitoring of services. A decision was taken not to inspect the service at this time and the team considered the providers failure to submit an action plan when reaching this determination: Section 5, Point 15 CQC did not take into consideration relevant factors when risk assessing this care provider at the start of the pandemic leading to an inappropriate risk profile established and an exaggerated level of confidence placed in the provider to provide safe services to residents without appropriate monitoring and oversight from the Regulator: Following receipt of the Regulation 28 report; CQC has reviewed assessments and monitoring decisions made about the service At the beginning of the pandemic CQC monitoring consisted of reviews to intelligence we held about service, reviewing received statutory notifications or provider requested information in surveys_ We also reviewed information or concerns received from stakeholders or the general public_ As mentioned in our response under Point 14, our monitoring of Stars Social Support did not suggest urgent or emergent risk, which would necessitate different regulatory approach; such as inspecting sooner, or enhanced monitoring: CQC's approach to monitoring services at the beginning of the pandemic in lieu of changes to routine inspections was reviewed in December 2020 and CQC implemented monitoring system to improve the approach that had been taken up until that date. This system analyses intelligence we hold about services and May being being

generates prioritisation score to support operational colleagues to prioritise services most at risk This system is used in conjunction with more 'traditional' monitoring activities described in the first paragraph of Point 15_ This system continues to inform our regulatory approach to Stars Social Support: In relation to observations that CQC had an exaggerated level of confidence in the provider to provide safe services to residents without appropriate monitoring or oversight: CQC did monitor the service during the pandemic. After the 12 and 13 February 2019 inspection, management review meeting took place to assess the seriousness of the breaches identified_ risks to people, as well as the provider's capabilities to improve the service. This management review meeting concluded that it was appropriate and proportionate to give the Stars Social Support the opportunity to address concerns identified at inspection. The assessment was evidence based, robust and balanced. Assessing a care provider's capability to improve or operate a service safely is factor in all CQC's decision-making where a breach of regulation is identified_ Where appropriate, if the provider can improve the service on their own and the risks to people who use services are not immediate, we will generally work with them to improve standards rather than taking enforcement action_ We will intervene if there is evidence that people may be exposed to the risk of harm, there is serious risk to person's life , health or wellbeing, or providers are repeatedly or seriously failing to comply with their legal obligations Section 5, Point 16 The report from the August 2020 inspection was inaccurate and misleading and may have caused service users to be added to his service where that ought not to be the case. The report published in October 2020 refers to their being no evidence of harm however there is woeful lack of detail about the context of this within the report: CQC should review this particular report for this provider and also reconsider the way in which reports are written to ensure that are no misleading and therefore dangerous. This includes either omitting from the report any comment about harm where there is clearly a context and evidence of harm to service users previously, which is open and live, but which does not form part of the inspection or very clear confirmation in the report that there has been evidence of harm which not form part of the specific inspection report: Stars Social Support has been under voluntary admissions embargo since April 2018 and remains under embargo. Therefore, there is no risk this report have caused service users to be placed at the service_ We have reviewed all Stars Social Support inspection reports since April 2018 to present and found the information contained in CQC reports is accurate and adheres to CQC guidance available at the time the reports were written. In January 2019 after period of consultation, the style of CQC reports were reviewed to become shorter, clearer and easier to understand: The comment in the report that there was no evidence of harm refers to the period of time since we last inspected key they may

the service (in February 2019) to the inspection date (referenced in the August 2020 report) , and in that period we found no evidence of harm. It is recognised that it doesn't detail the service's entire and does not detail that a service user had died. However, as the criminal investigation was ongoing at that time this inspection did not examine the circumstances of this incident: Had the report examined the circumstances of the incident it may have prejudiced future proceedings or caused unfair reputational harm towards the care provider: The February 2019 inspection report referenced the specific incident and stated in the summary section, The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to criminal investigation and as a result this inspection did not examine the circumstances of the incident At that time CQC guidance in relation to report writing, did not require CQC inspection reports to reference the specific incident in future reports, only in the report where the incident prompted the inspection. This remains CQC's guidance on reporting on specific incidents. This regulation 28 report will be referred to the CQC policy team to consider whether the guidance needs to be reviewed, Section 5, Point 17 Where CQC are required to decide whether evidence ought to be used for the basis of an inspection or regulatory action, they ought to ensure there is consistent approach to this including consideration of policies and standard operating procedures. This should be approached on the basis of safeguarding the majority of remaining service users from harm being the priority even where that means prosecutions for breaches of regulations may be compromised_ CQC's main objective in performing its functions is to protect and promote the health, safety and welfare of people who use health and social care services_ When CQC are made aware of concerns at a service, the priority will be to ensure that current service users are safe, and then consideration will be given to whether a prosecutable offence has occurred. The inspection report details the current findings at service, specifically whether provider is meeting the regulatory requirements required to be a registered provider: Civil enforcement;, (for example removing a location or cancelling provider's registration) will be taken if there is evidence that people may be exposed to the risk of harm or there is serious risk to person's life, health or wellbeing: Criminal enforcement action will be considered in relation to the specific incident, namely whether there was registered person failure to provide safe care and treatment which resulted in avoidable harm to service user Or a service user being exposed to significant risk of such harm occurring: In the matter of Anthony Wilkinson and Stars Social Support; there was no observed difficulties deciding whether evidence ought to be used for the basis of an inspection or regulatory action. CQC methodology is clear that these processes should be conducted separately. There had been no observed delays inspecting Stars Social Support after the specific incident, to ensure people who used the service were safeguarded from unsafe care through CQC's regulatory model. Whilst evidence from the specific incident was not directly used to inform history

inspection judgements, it was still used to help us plan inspections in a manner that focussed on known risks or potential areas of concern, to robustly assure ourselves that similar incidents, would not be repeated. Section 6, Point 8 Care Quality Commission should urgently review the report related to this provider from October 2020 and correct any errors or misleading statements within it: CQC has reviewed the report (publication date 29 October 2020) in respect of the inspection completed on 27 August 2020 and 3 September 2020. The report was accurate at the time of publication and followed the house reporting style. Although it did not detail the specific incident in relation to Anthony Wilkinson, it had been referenced in the previous inspection report: It would not be appropriate to make changes to the October 2020 report retrospectively because it remains CQC's guidance to not report on specific incidents, unless the specific incident prompted the inspection, which in this inspection it did not: This regulation 28 report has been referred to CQC's policy team to consider the guidance in relation to report writing: Section 6, Point 9 Care Quality Commission should review its processes where their regulatory functions collide with criminal investigations to ensure that timely regulatory oversight and action is taken notwithstanding, HSE or indeed CQC prosecution activity: When CQC are made aware of incident such as the circumstances of the death of Anthony Wilkinson , the CQC applies Specific Incidents Guidance. The initial assessment is framed around two questions and will generate two separate workstreams, and those workstreams can run concurrently_ The first question (Q1) in Specific Incidents Guidance for inspectors generally serves the first purpose of CQC Enforcement Policy to protect service users from harm and the risk of harm, and to ensure they receive health and social care services ofan appropriate standard. The actions generated will be the priority. The workstream could be to carry out an inspection where appropriate to consider ongoing risk in answer to Question In the matter of Stars Social Support, the assessment of Q1 precipitated an action to inspect the service in May 2018, shortly after Anthony Wilkinson's death. Provider assurances and Stakeholder actions taken or planned at that time fed into CQC's assessment of Q1_ The second question (Q2) in Specific Incidents Guidance for inspectors determines whether to progress to formal criminal investigation of the historic specific incident of avoidable harm under Reg 22(2) , Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The second active work stream may, in answering Question 2, be to carry out a formal criminal investigation to investigate historical non-compliance relevant to that historic specific incident In

the matter of Anthony Wilkinson, a criminal investigation was completed, and the outcome was no further action. Section 6, Point 10 Quality Commission should review the presentation of its report to ensure that where statements such as 'we found no evidence of harm to service users' are placed in the context of the inspection: For example, statements should be read as This service has 90 service users. We inspected 9 records as part of our inspection; and we validated these records against the care provided to those service users. We checked the records held by the Head Office and did not confirm that these were replicated in the service users home address. Of those records we did not find any evidence which would support breaches of Regulations relating to the delivery of safe care' The organisational context of an inspection is as important as the individual outcomes found on the of inspection; indeed, it is the context which sets the inspection intervals. We have addressed some of your comments in our earlier response (Section 5_ Point 16). As stated in our earlier response we have reviewed the report in question, and we are satisfied that the content is accurate and complies with cQC's house style_ Historically CQC did have lengthier reports, which similarly conveyed the level of detail as explained in your example: However, following lengthy reviewl consultation period with commissionerslprovidersland the general public, about what information we should include in CQC reports, it highlighted a need to change our house style. The results of this review showed some reports were inconsistent in content from service to service, were difficult to understand, and did not effectively support people or commissioners to make an informed choice about care services. Another common theme was that many people who accessed our reports on our website did not read the inspection reports beyond the first page. The shorter report guidance was implemented in January 2019 to address comments from our main audience, commissioners and the general public. In the guidance it directs inspectors to write 'judgment statements' instead of providing detail about context to support this statement, which is not always necessary or appropriate_ The shorter report format includes important contextual information about the service in the summary and background sections. For example, it includes details like when we last inspected, records we looked at, the number of people we spoke to, previous ratings and (publishable) enforcement actions_ This Regulation 28 report has been referred to CQC's policy team to review this further. Section 6, Point 11 Care Quality Commission should review the way in which it treats evidence which relates to inspection standards and breaches Care day

of Regulations (including criminal offences) where that evidence relates to the same actions. Evidence gathered during the course of an inspection feed into inspection reports and where relevant civil enforcement action. The information may lead CQC to carry out a criminal investigation, but the evidence gathered during criminal investigation will not be detailed in an inspection report A report must provide an accurate reflection of what is happening at a service, but that does not require the report to detail the criminal investigation. As your comment concerns CQC policy around how we treat evidence, the relevant team in the Commission will review this further. Thank you for your assistance bringing certain concerns and actions to CQC's attention. CQC will continue to monitor; inspect and regulate Stars Social Support in a manner which places service user safety at the forefront of what we do.
Stars Social Support Ltd Other
PDF
Action Taken

The organisation has ceased trading and is liaising with the Local Authority and CQC to transfer service users. (AI summary)

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RESPONSE QF STARS SOCIAL SUPPORT LIMITED A decision has been taken by the Registered Manager and Director of Stars Social Support Limited for the organisation t0 cease to continue: The Registered Manager and Director at Stars Social Support Limited has contacted the Local Authority and the Care Quality Commission to notify them that Stars Social Support Limited will cease t0 continue The Registered Manager and Director at Stars Social Support Limited is now liaising with the Local Authority and the Care Quality Commission to ensure provisions are in place for the transfer of the existing service users In view of the above decision; a delailed response in relation to the corrective actions indicated in the above report is not be provided, Signed Registered Manager and Director of Stars Social Support Limited Date of Response shhl put

Report sections

Investigation and inquest
On 10 April 2018 I commenced an investigation into the death of Anthony Wilkinson born on 31 December 1960. The investigation concluded at the end of the inquest on 26 March 2021. The conclusion of the inquest was Unlawful Killing. Anthony died as a result of

1a: Foreign Body obstruction of the airway
Circumstances of the death
Anthony Wilkinson ("Tony") was diagnosed with Fragile X syndrome. He lived relatively independently with support for much of his adult life and was able to access the community and undertake hobbies and interests without too much difficulty for much of his life. His overall health started to decline in late 2017 and he began having investigations for dementia or similar neurological decline.

The primary symptom of this which was exhibited was of unusual and more erratic behaviours including aggression and physical and verbal confrontations. One additional issue which arose with Tony was some swallowing difficulties. This led to Speech and Language Therapy Assessments being undertaken in 2017 and 2018. The first regarded Tony has having behavioural swallowing difficulties which meant that he crammed too much food into his mouth or put food into his mouth without swallowing what was already in his mouth.

Speech and Language Advice in 2017 was that Tony should be supervised at all times when eating and should have a softened diet. This advice was never incorporated into Tony's support plans or risk assessments by the care provider.

Tony was provided with a meal on 18 February 2018 which resulted in him choking and having to be admitted to hospital. The meal that he was provided with in February 2018 was in line with the SALT advice from 2017 but resulted in a further referral to the SALT team. When SALT visited on 5 and 6 March 2018 it was apparent that there was a deterioration in Tony and that his swallowing difficulties were now due to a mechanical issue with his swallow. As a result, they advised that Tony should have a fork mashable diet and thickened fluids. Again, this was not incorporated into a support plan at Tony's address for carers to access and utilise. Staff did indicate that they were aware of the need for fork mashable diet and thickened fluids however the communications log showed variable compliance with the specialist diet.

The care provider advised that support plans were generated at the head office and was then printed twice with a duplicate copy taken to the resident's home address. The care provider also advised that they would collect the communication logs and important issues sheets along with some other documentation from the resident's file once a month to audit for compliance and recording standards and then archive these at Head Office. It was apparent that the care co-ordinator in Tony's case was on annual leave and sick leave in the two weeks prior to Tony's death and was not able to advise when the sheets had last been collected but when the police took Tony's record from his home address the communication logs only went back to 28 March 2018 (Tony having died on 4 April 2018)

The Police carried out an investigation into Tony's death and found that no criminal charges would follow his death as matters could not be proven beyond reasonable doubt. Of course, the coroner’s proceedings only require matters to be proven on the balance of probabilities even where that relates to a finding of unlawful killing.

Following the evidence at the inquest the jury concluded that Tony had been unlawfully killed. They were asked a series of questions which formed box 3 of the record of inquest which required unanimous yes or no answers. They were answered as follows:-

a. Were Stars Social Support Limited responsible for the care and support needs of Tony between 4 December 2017 and 4 April 2018? Yes
b. Was part of the role which Stars Social Support Limited had translating specialist advice into support plans and risk assessments for Tony? Yes
c. Following the SALT assessments of 4 December 2017 and 5/6 March 2018, did Stars Social Support Limited put in place a robust procedure to implement the advice provided in Tony’s support plans and risk assessments? No
d. Did the support plans for Tony which were at adequately reflect the risks posed to Tony following the assessment by SALT on 5/6 March 2018? No
e. Were the support plans and risk assessments at Midland Road between 5 March 2018 and 4 April 2018 adequate to enable staff to mitigate the risks posed to Tony as a result of his swallowing difficulties? No
f. Following the SALT assessments of 4 December 2017 and 5/6 March 2018, did Stars Social Support Limited put in place adequate and robust communications to staff caring for Tony so that they were aware of the advice? No
g. Following the SALT assessment on 5/6 March 2018 did Stars Social Support Limited senior managers review whether staff were implementing the advice? No
h. Were staff aware of the expectation that they would attend head office to review service user support plans and risk assessments as part of their role in supporting Tony? No
i. In view of the SALT advice, was Tony provided with appropriate food when he visited the Manchester Airport pub with a support worker from Stars Social Support Limited? No
j. Was Tony provided with safe care by Stars Social Support Limited between 5 March 2018 and 4 April 2018? No Following Tony's death, the Care Quality Commission inspected Stars Social Support. They attempted to do so in 2018 however the Police had seized a significant amount of documentation and therefore they believed that they were not in a position to carry out an inspection of the services at this time. As a result of that the inspection triggered by Tony's death was not until 13 February 2019 and the subsequent report was released in May 2019. This inspection found that the services 'required improvement' overall with breaches of the Regulations. This would automatically trigger the requirement for a re inspection within 12 months of the published report (therefore the next inspection was required by 8 May 2020) Due to the breaches of the Regulations found, Stars Social Support were also required to provide an action plan within 28 days of the rating to commence improvements. CQC state they did not receive any action plan from Stars Social Support Limited following this inspection.

CQC did not return to the Provider to inspect until August 2020 which they confirm was due to the pandemic and not entering providers to inspect during this time. To mitigate this CQC determined they would risk stratify the providers and those that were high risk would receive priority monitoring and be the first inspected when they were able to return to inspection activity. CQC did not rate Stars Social Support as one of their higher risk providers at this time.

When CQC returned in August 2020 and reported on this inspection in October 2020 they determined that the provider was now rated as 'inadequate' overall. There were further breaches of the Regulations at this time. Again, the provider did not provider an action plan following this inspection.

Although the advice which Tony was given by Speech and Language Therapy was not a feature of the inquest proceedings the SALT team have subsequently updated their advice and guidance sheets and I will return to this feature of the proceedings below.
Action should be taken
I would ask that your responses specifically consider the following:-

Stars Social Support Limited

1. Stars Social Support Limited should reconsider its use of technology in support service users including the use of software applications for the storing and creation of records.
2. Stars Social Support Limited should review its use of its own website for the updating and storing of policies.
3. Stars Social Support Limited should urgently put in place processes for the development of training and mentoring in relation to the culture of the organisation to encourage openness, transparency and the duty of candour which is a fundamental part of care delivery.
4. Stars Social Support Limited should review its processes around the displaying of critical advice around service users’ homes
5. Stars Social Support Limited should give consideration to the use of a single member of a service user care team to act as the lead for ensuring the plans in the service users home are up to date and maintained appropriately
6. Stars Social Support Limited should urgently ensure that it has adequate policies and procedures in place which ensure the safety of all of its service users. The Induction Booklet alone is not sufficient to achieve this aim.
7. Stars Social Support Limited should consider a pledge and commitment to work collaboratively and co-operatively with the Care Quality Commission and other statutory partners to ensure high quality and safe care can be provided to service users. Care Quality Commission

8. Care Quality Commission should urgently review the report related to this provider from October 2020 and correct any errors or misleading statements within it.
9. Care Quality Commission should review its processes where their regulatory functions collide with criminal investigations to ensure that timely regulatory oversight and action is taken notwithstanding police, HSE or indeed CQC prosecution activity.
10. Care Quality Commission should review the presentation of its reporting to ensure that where statements such as 'we found no evidence of harm to service users' are placed in the context of the inspection. For example, statements should be read as 'This service has 90 service users. We inspected 9 records as part of our inspection, and we validated these records against the care provided to those service users. We checked the records held by the Head Officer and did not confirm that these were replicated in the service users home address. Of those records we did not find any evidence which would support breaches of Regulations relating to the delivery of safe care'. The organisational context of an inspection is as important as the individual outcomes found on the day of the inspection; indeed, it is the context which sets the inspection intervals.
11. Care Quality Commission should review the way in which it treats evidence which relates to inspection standards and breaches of Regulations (including criminal offences) where that evidence relates to the same actions.

South West Yorkshire Partnership NHS Foundation Trust

12. The Trust is invited to consider the guidance leaflet in the context of the statement provided to me for the hearing on 9 April 2021. This includes separation of the columns related to foods to avoid and those which can be manipulated; correction of the images which appear to endorse foods which ought not to be endorsed and clarity around the consistency of the diet not to sit alongside potentially confusing statements such as fork mashable meaning something which can be picked up with chopsticks.

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Report details

Reference
2021-0102
Date of report
13 April 2021
Coroner
Abigail Combes
Coroner area
South Yorkshire (West District)

Responses identified

Responses identified 3 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Jun 2021.

Sent to

Stars Social Support Ltd, Care Quality Commission and South West Yorkshire Partnership NHS Foundation Trust

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