May Miller

Dear Julie.

The Limes comprises 30 properties owned on a leasehold basis. The owners of the properties are encouraged to live independently and previously any concern the warden may have had on a resident has been passed on to their families who it has been expected would discuss their relatives needs with professional agencies, care homes etc. We believed this to have happened in this case.

We employ a warden who lives on site but her role is limited to that of a good neighbour. The warden would normally visit each resident once a week. If required this is increased but we are not a care home and any daily care needs would need to be arranged by the wider family.

Prospective residents are interviewed by the warden and the manager. A letter of suitability is always obtained from the G.P. but they seemed to be bound by confidentiality and the information is received is very limited.

We have always taken the view that it’s up to the care home to consider the suitability of a resident? and undertake an assessment prior to admission. On admission I would have expected given their lack of information that an assessment would have started straightaway. Had we been approached by Beach House we would have shared what knowledge we had.

In light of the above case and on reflection the following changes will be made to our working practice. The residents will be informed of the changes to our policy immediately by letter and our handbook will also be amended to reflect the changes.

On hearing that a resident is considering a move into residential care, contact will be made immediately with the receiving care home and all information will be shared. This would initially be by phone (warden) and would always be followed up in writing (manager)

I will also be writing to our local Social Services and G.P. practice and invite them to a coffee morning with the intention of building up a working relationship. Initially I would like to see this happen twice yearly. I would hope that from this clearer communication was possible and advice and support forthcoming when requested.

Company Secretary and Manager

The Limes Residents Association Limited: Company registration number: 2682550. Registered in England. Registered Office: The Garden Room, ‘The Limes’, 41 London Road, Halesworth, Suffolk IP19 8LT

May Miller - REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

This report has been prepared by , Head of Safeguarding Adults, Suffolk County Council and Chair of the Safeguarding Adult Review Panel on behalf of , Executive Director People Services, Suffolk County Council

The preparation of the report included discussion with , author of the witness statement offered to the inquest hearing and , Professional Advisor to the Safeguarding Partnership and lead professional for the May Miller Safeguarding Adults Review.

1. Matters of Concern: Coroner findings. In light of the data sharing and confidentiality requirements under GDPR, the GP was unable to disclose full information to the Limes or to Beech House about any previous conduct or assessments of .

At no time was the family of Mr asked to sign a letter giving consent to disclosure to other agencies before or after the residency.

It was not known whether the GP could have been the central point of contact for all investigative agencies and the Care Homes.

It was established during the evidence that multiple investigative agencies may have been aware of Mr ’s risk factors but that due to his not having been admitted to Beech House from a registered facility, that information sharing was not possible.

Had there been in place a system for sharing safeguarding information with the Limes and Beech House, there may have been an opportunity to safeguard May Miller.

2. Decision to undertake a Safeguarding Adults Review The purpose of a SAR is described in the statutory guidance as to ‘promote effective learning and improvement action to prevent future deaths or serious harm occurring again’. The aim is that lessons can be learned from the case and for those lessons to be applied to future cases to prevent similar harm re-occurring. Further information regarding SARs can be found

reviews/

On 30 June 2020, the Safeguarding Adult Review Panel (SARP) received a referral for consideration for a Safeguarding Adults Review. Thereafter discussion was held with the deceased’s family with regards to the proposal to undertake a Safeguarding Adult Review and its intended purpose.

On 14 October 2020, the agreed to proceed as a full SAR Review in Rapid Time.

The Review in Rapid Time is a pilot project delivered by the Social Care Institute for Excellence, with Local Authorities participating voluntarily. COVID-19 has created a new urgency to identifying and sharing learning from certain cases, and this project looks to align the timescales of completing adults’ reviews in the same way as serious safeguarding incidents involving children (15 working days)

As part of Department of Health and Social Care’s COVID-19 Action Plan for Social Care, SCIE has worked with Safeguarding Adults Boards to develop and test a new model for conducting SARs In Rapid Time.

3. Terms of reference: Themed learning points to be included in the SAR The Review Group set up meeting with relevant leads will be held on 19 November 2020, where the key themes for the SAR will be defined. However, from the safeguarding investigation report undertaken by Adult and Community Services, it is thought that the key themes will be as follows:

a) Assessment and admission of customers to care settings who are self-funding. To identify barriers to robust information sharing across partner agencies with regards to safeguarding concerns and wider risk factors. This is to include any barriers to information sharing between housing providers and care providers in the placement of an adult who may pose a risk to others. b) Responses to older people with dementia who have high additional needs in a crisis situation, and appropriate placements of those people c) Availability of hospital and community beds for older people with dementia who have mental health needs d) Who should undertake mental health act assessments under the Mental Health Act 1983, when they should undertake them, and when particular agencies should/can request them.

4. Timeframe It is anticipated that the review will be completed by mid-December 2020, after which it will be presented to the SARP for further critique and development of the action plan. Full sign off will be undertaken by the SAB in February 2021 Any urgent matters arising from the review and action plan will be addressed with relevant senior leaders before February.