Brian MaClean

Nigel​ ​S.​ ​Meadows​ ​-​ ​H.M.​ ​Senior​ ​Coroner H.M​ ​Coroner’s​ ​Office PO​ ​Box​ ​532 Manchester​ ​Town​ ​Hall Albert​ ​Square M60​ ​2LA

Adult’s​ ​Social​ ​Services

Manchester​ ​City​ ​Council P.O​ ​Box​ ​532 Town​ ​Hall Manchester M60​ ​2LA Date:​ ​6th​ ​November​ ​2017

Dear​ ​Mr​ ​Meadows,

Report to HM Coroner Mr Nigel Meadows in response to the Regulation 28 Report

Dated​ ​11​ ​September​ ​2017

Subject: Brian Maclean (d.o.b 20/12/1957), ,

Background

Mr Maclean died in a fire at his home on 19 March 2016. He lived alone and was known to

have a long standing alcohol abuse and health problems. On the day of his death, it is

understood Mr Maclean had consumed a significant amount of alcohol and had caused a fire.

A Fire and Rescue Report by Greater Manchester Fire and Rescue Service's (GMFRS)

identified​ ​the​ ​likely​ ​cause​ ​of​ ​the​ ​fire​ ​to​ ​have​ ​been​ ​“​carelessly​ ​discarded​ ​smoking​ ​materials​”.

The Coroner concluded the inquest into the death of Mr Maclean on 6 September 2017 and

recorded that he died from smoke inhalation contributed to by alcohol toxicity. A conclusion

of​ ​“​alcohol​ ​related​”​ ​was​ ​recorded.

The Coroner identified a number of areas of concern in a Regulation 28 Report to Prevent

Future Deaths including: “​That Social Services did not take a more proactive role in pursuing

any referral and understanding the risks presented by the deceased. This requires joined up

thinking​ ​and​ ​working​ ​with​ ​GPs,​ ​the​ ​NHS​ ​locally,​ ​the​ ​housing​ ​provider​ ​and​ ​finally​ ​GMFRS​.”

The Coroner directed that action be taken to prevent future deaths, such response to contain

details of action taken or proposed to be taken and to set out the timetable for action or,

alternatively,​ ​to​ ​explain​ ​why​ ​no​ ​action​ ​is​ ​proposed.

Response​ ​on​ ​behalf​ ​of​ ​Manchester​ ​City​ ​Council

A referral was made via an online form to Manchester City Council’s (MCC) Contact Centre

for Children, Families and Adult Social Care on 26 January 2016 by Mr Macleans support

worker​ ​from​ ​Great​ ​Places,​ ​a​ ​housing​ ​provider.

The Contact Centre acts as the initial point of contact for all queries, concerns and referrals

raised​ ​in​ ​connection​ ​with​ ​a​ ​child​ ​or​ ​adult​ ​at​ ​risk.

The referral expressed concerns about Mr Maclean’s living conditions, personal hygiene,

levels​ ​of​ ​nutrition,​ ​mental​ ​capacity​ ​and​ ​rent​ ​arrears.

The referral was read and prioritised as 'not urgent' by a Customer Service Officer (Officer A)

on the 26 January 2016. This referral was subsequently placed into a non-urgent folder to be

processed.

On 12 February 2016 another Customer Service Officer (Officer B) was allocated the referral

and began processing it that day. Officer B contacted the referrer (Great Places) to request

the GP details of Mr Maclean and to request the referrer contact him back when Mr Maclean

was present to enable him to speak to the gentleman as there was no telephone number for

Mr Maclean on the referral. This was to enable Customer Services to establish further

information​ ​and​ ​to​ ​gain​ ​consent​ ​from​ ​Mr​ ​Maclean.

An email was subsequently received from the support worker from Great Places on the 17

February 2016 with the GP details for Mr Maclean. Officer B then contacted Mr Maclean's GP

on the 19 February 2016 to establish Mr Maclean's health condition and his capacity to

consent to the referral. Following the discussion with Mr Maclean's GP Officer B took the

decision to take no further action in respect of the referral. Officer B subsequently recorded

onto the electronic recording system: “​no consent/concerns not substantiated by GP/NFA.

Letter​ ​sent​.”

The letter to Mr Maclean stated that contact has been received from Great Places to advise

that he may need support, that an officer had attempted to contact Mr Maclean to gather

further information without success and Mr Maclean should contact the service again should

he​ ​wish​ ​to​ ​access​ ​services​ ​in​ ​the​ ​future.

Findings​ ​of​ ​the​ ​management​ ​investigation

Following the concerns raised by the Coroner a management investigation has taken place.

It is evident from the investigations of the actions taken by Officers A and B that internal

procedures​ ​were​ ​not​ ​followed.

Based on the information provided by the referrer the original officer, Officer A, who classified

the referral should have identified that an urgent response was required and it should have

been placed into the urgent folder to be processed immediately. The concerns expressed in

the referral meet the criteria for urgent action in that Mr Maclean was clearly eligible for an

assessment​ ​under​ ​the​ ​Care​ ​Act​ ​and​ ​potentially​ ​at​ ​risk​ ​of​ ​significant​ ​harm.

Officer​ ​A’s​ ​conduct​ ​is​ ​currently​ ​being​ ​addressed​ ​through​ ​MCC​ ​disciplinary​ ​procedures.

Based on the information provided in the referral by the referrer in respect of Mr Maclean the

second officer, Officer B, should have passed it to the Primary Assessment Team for further

assessment once he had established that he was unable to make contact. The referral also

indicated​ ​consent​ ​had​ ​in​ ​fact​ ​been​ ​received​ ​from​ ​Mr​ ​Maclean.

Officer B’s conduct is also being addressed through MCC disciplinary procedures and the

officer​ ​is​ ​currently​ ​on​ ​alternative​ ​duties

Actions

In response to the concerns raised by the Coroner and the outcome of the management

investigation​ ​the​ ​following​ ​actions​ ​have​ ​taken​ ​place​ ​or​ ​are​ ​to​ ​be​ ​taken:

1. All contacts which have been closed or viewed as non-urgent by Officers A and B

have​ ​been​ ​reviewed.

2. An audit of 20% of all contacts classed as “NFA” (No Further Action) by the Contact

Centre​ ​between​ ​July​ ​2017​ ​and​ ​September​ ​2017​ ​is​ ​being​ ​undertaken

3. Further training will be provided for all Contact Centre staff in respect of the Care Act,

safeguarding and consent. This will be arranged immediately and will be provided by

MCC’s​ ​Quality​ ​Assurance​ ​Team.

4. The Quality Assurance Team are to undertake regular audits of the work undertaken

by​ ​the​ ​Contact​ ​Centre.

5. MCC is currently exploring increasing social work supervision and oversight of the

Contact​ ​Centre​ ​officers

6. MCC has considered the recommendations of the GMFRS report and will continue

with the work currently underway to raise the awareness of the services offered by

GMFRS among adult social care staff. There are regular meeting between the

Community Safety Officer from GMFRS and MCC to ensure that all options for

extending​ ​partnership​ ​working​ ​are​ ​considered.

7. MCC will be referring this matter to Manchester Safeguarding Adults Board for their

consideration​ ​as​ ​to​ ​whether​ ​this​ ​meets​ ​the​ ​criteria​ ​for​ ​a​ ​Safeguarding​ ​Adults​ ​Review.

Yours​ ​sincerely,

Deputy​ ​Director​ ​of​ ​Adult’s​ ​Social​ ​Service​ ​-​ ​Manchester​ ​City​ ​Council