Geoffrey Banks

Dear Madam Regulation Report to Prevent Future Deaths – Geoffrey BANKS Thank for your reg.28 report of 27th November 2020 following the conclusion of the inquest into the death of the aforementioned Mr Banks. Firstly, I regret I must inform you that despite repeated attempts to engage with Stoke on Trent City Council in preparation of this response, I have to date received no substantive contact at all from them. My understanding from (Senior Commissioning Officer) is that the matter was passed to the Council’s Legal and Quality Assurance Departments for consideration, but I have not been given any named contacts and have had no correspondence or acknowledgement from either department. Owing to the particular circumstances of the case, this is most regrettable, as will become apparent in what follows. Before I turn to the concerns raised in your report, I should inform you that following a recent re- tender by Stoke City Council, Comfort Call will no longer be providing the care services at Oak Priory Extra Care scheme from April 2020 and it will therefore be for the Council, the housing provider and the new incumbent to consider what changes may be needed to implemented at the site once we have left. Although we will no longer be providing care at Oak Priory after March, we do intend to take Mr Banks’s sad death as an opportunity to reflect on practice across our Extra Care services in other locations across England. Storage of medication You express your concern that Mr Banks, who had been assessed as not being able to safely manage his own medicines, was able, with some ease, to break into the kitchen cabinet used to store his medicines and to take an overdose of Co-codamol, which contributed to his death.

Addressing the situation that allowed Mr Banks access to his medicines is more complicated than might appear at first glance, owing to the particular context of an Extra Care Scheme (“ECS”) like Oak Priory. An ECS is fundamentally an independent living model and thus quite distinct from residential or nursing care in a number of ways:
- Those living in the scheme are usually private tenants and their flats are separate private homes within the building;
- Primary control of the fabric of the building, including fixtures and fittings within each tenant’s home, rests with the tenant and the housing provider, not the care provider;
- Whilst the care provider typically has a 24-hour presence on site, it does not necessarily provide a service to every tenant at the location (although it may be required to be available for emergency response);
- The service provided is, from a regulatory perspective, essentially the same as home care delivered to people living in their own homes in the community. Whilst an ECS like Oak Priory looks superficially like a residential home, it is in fact nothing of the kind for the purposes of managing and delivering care. For example, in a residential or nursing home, medication would typically be stored and dispensed centrally by staff, and centralised records maintained. Such an arrangement at Oak Priory would clearly have prevented Mr Banks from accessing his medicines unsupervised, but it could not be done lawfully in an ECS under Comfort Call’s CQC registration because his medicines belonged to him and it was therefore required that they remain in his home (i.e. his flat). This does of course raise the question of whether the problem was in fact that Mr Banks was not in the correct care setting for his needs. It is certainly our experience that some people are placed in ECS inappropriately where their care needs are such that they really require a higher level of supervision than such a setting can realistically provide. There are also often challenges where people with e.g. dementia are placed in ECS presenting either a risk to themselves (from e.g. wandering out of the scheme) or to others (by e.g. entering others’ flats uninvited and occasionally presenting challenging behavior). In Mr Banks’s case, however, there were no obvious signs that the ECS was an inappropriate care setting. He had no previous history of overdose or any other form of self-harm, nor of trying to access his medicines and as such, there was no indication that he was at risk in that way. Had there been any indication that he was a danger to himself or others, we would certainly have raised this as a safeguarding matter, which may well have led to the Council considering alternative accommodation for him. In view of the fact that his actions could not reasonably have been foreseen and that Comfort Call could not have taken his medicines out of his flat, the only conceivable remaining measure in the context of the ECS that might have prevented him taking the overdose would have been a medicines cabinet in his flat sufficiently secure that he could not have broken into it. The use of such a secure cabinet would raise further issues around mental capacity, consent, restrictive practice etc., but these could have been addressed with reference to the usual ‘best interests’ principles (within the meaning of the Mental Capacity Act 2005). Unfortunately, as noted above, Comfort Call has no remit or capability to mandate, purchase or install fittings and fixtures in flats at Oak Priory or any other ECS. We are entirely dependent on the housing provider and commissioning authority in that regard. We could, however, at least bring our influence to bear in that regard, by:
1. Raising a safeguarding concern where there is a perceived risk that an individual may be at risk from gaining access to their own medicines; and
2. Ensuring that as a matter of course, we discuss and agree protocols for the secure storage of medicines with the housing provider at each EC.

Point 1 is already incorporated into our safeguarding procedures. In Mr Banks’s case, it would not have made a difference, however, because there was no obvious reason to consider him at particular risk from self-harm, either intentionally or as a result of dementia/confusion. Point 2, however, can absolutely be incorporated into our standard procedures, which include setting up written protocols with partner housing providers addressing the whole range of joint working arrangements in each ECS. Our plan for organisational learning is, therefore, to review our standard ECS protocols template to consider the question of secure medicines storage in each flat and to require all our ECS managers to undertake a review at their schemes to consider whether this issue should be raised with the housing provider. We will complete this by the end of March 2021. Incident investigations You also raise a concern that the member of staff that initially investigated following Mr Banks’s admission to hospital had not received formal investigation training and that the written report was “perfunctory”. In mitigation, we would point out that at the time of the investigation, Mr Banks was unwell in hospital, but was not expected to die. We do not doubt that had he died sooner, the investigation would have been taken over by the Registered Manager rather than being left to a Team Leader as in fact happened. However, we do accept that the investigation was not as thorough or as detailed as we would have liked. The inquest heard that neither the Team Leader nor the Registered Manager (when she arrived on shift) actually visited Mr Banks’s flat to see for themselves the damage to the medicines cabinet, an omission that we agree was regrettable. Whilst the Team Leader had not received formal investigation training, the Registered Manager had received such ‘Event Management’ training and ideally would have followed up on the initial report with a more thorough investigation of her own and would have certainly taken the time to look at the damage in the flat herself. We are at present in the process of developing our management training programmes and this includes Event Management training as part of our onboarding programme for Team Leaders, Care Coordinators and others. The new programme will roll out during 2021. In the meantime, we will communicate to ECS managers during February 2021 that they must at the very least review investigations carried out by others at their schemes to ensure that they are adequate. I trust that this letter addresses your concerns and we once again offer our sincere condolences to Mr Banks’s family. Please do not hesitate to contact me if I can provide any further information to assist you.