Jeffrey Warren

Dear Ms Dolan Inquest into the death of Mr Jeffrey Warren 21st 2015 Regulation 28 Report to Prevent Future Deaths am writing to you to respond to the matters of concern raised in your Regulation 28 Report to Prevent Future Deaths report following the Inquest in to the death of Mr Jeffrey Warren: Your report and the Council's response have been carefully considered by the Council's Cabinet at their meeting on 9 September 2015. There are some matters of fact which would like to correct in the Report CBC do not have a Tenancy Support Team; there is only one officer (TSO) within a housing management team (Circumstances of Death ref para 3): The fire officer did not request an oil heater. The Council had already supplied two new oil filled electric radiators to Mr Warren on 15 April 2014 These have castors on them to aid moving around a room It was one of the castors that had detached that was observed on the fire officer's visit (Circumstances of Death ref para 6). There was some confusion by Council staff following the visit of the fire officer regarding installing oil filled radiators, however, when records were properly checked it was clear that oil filled radiators had already been supplied. Enciosed with this letter are the Council's record n this matter. At the time of the Inquest the Council had carried out a Review, had spoken to the staff involved and reviewed all of the case notes. The manager of the housing management team initially carried out this review as part of the preparation of the report for the Inquest and this was then reviewed by the Head of Service with the service recommendations coming from further discussions The recommendations were not contained in the report for the Inquest. Recommendations and 2 below had come out of this Review. We are of the view that the line of questioning of the Council witness TSO1 meant that she thought there was something other than the discussion she had had with her line manager: Switchboard: 01293 438000 Town Hall Living Main fax: 01293 511803 The Boulevard Wage Minicom; 01293 405202 Crawley Exabl DX: 57139 Crawley West Sussex Templates Let lettter.dot WWW crawley gov.uk RHIO IUZ July Wearee

Crawley Borough Council Following the Regulation 28 Report to Prevent Future Deaths and with respect to the matters of concern the Council has reviewed the circumstances of its involvement and responds as follows: The Council's involvement with Mr Warren stemmed from the need to replace the heating system to his flat It is the Council's policy to install gas central heating in all of its properties (where possible) as this provides the most cost effective and efficient form of heating for well-being Installing central heating was the focus of staff' effort with Mr Warren but where tenants remain adamant that they do not want such system installed then other options should be considered and in Mr Warren's case this may have been a replacement gas fire to the wall or storage heaters, which would have provided a permanent solution to the heating problem. While not ideal as space heating solution it was clear that he was not going to accept a central heating system. This has been actioned, although such circumstances are rare. 2 The Council has reviewed the terms of its contract to provide housing support for older people One of the eligibility criteria is that "the customer must be willing to accept support as a condition of the support agreement" . In this instance Mr Warren was very clear that he did not want the service but we accept that there may need to be more effort to engage people whose very independence can be a barrier to accepting the help may need: In this case the TSO had maintained a relationship and managed to engage and therefore although difficult more could have been done to assist Mr Warren_ This has been actioned although again the circumstances are rare 3 The officer contacted the Council on 14 January 2015 via generic email address_ Although the email was passed to the heating team on the same it took two days for the repair to be issued to an engineer: We will review all of the generic emails to ensure only those people who can action the requests are recipients and then ensure that all of those staff can input the service request on all work streams This will be completed by 30 September 2015_ The heating engineer visited 5 or 6 times between 16 January and 27 January when he reported back to the TSO that he was unable to gain access. Unfortunately, the engineer did not go beyond the phone door after 24 January 2015 so did not observe Mr Warren's keys in the front door. Currently phone door keys are not available to our contractors and we intend to change this to ensure that they can access the building and the front door to the property. Initially we will out a review f all of the door systems which we intend to complete 30 September 2015, and then we will carry out an upgrade programme so that we can have systems with either a master or master switch. This will overcome the problem of having to have a large set of door keys for all of our properties. This is a longer term plan as there are numerous systems but we will prioritise the older systems Where there is a known access problem the contractor will be provided with the specific door key (linking with 5 below)_ 5 also accept that the difficulty in gaining access should have been referred back to the TSO more promptly and where there are concerns this needs to be highlighted within the repairs system: Action has been taken to cases where the TSO or floating support team are involved on the repairs system. Waaiea Swilchboard: 01293 438000 Town Hall Living Main 01293 511803 The Boulevard Minicom; 01293 405202 Crawley Edloyer DX: 57139 Crawley Wesl Sussex WWW: crawley gov.uk RHIO 1UZ they fire day entry entry carry entry key entry entry We flag fax: Wage

Crawley Borough Council 6 Finally, the Council did not have a procedure for immediately reviewing a death where a safeguarding alert had been made. The Council's review was prompted by contacted by the Coroner's office on 11 February 2015. Safeguarding alerts will be followed and reported to senior managers and any future deaths where safeguarding alert has been made will immediately be subject to review. This has been actioned . CBC has been working with West Sussex County Council in respect of its review, and we will add any additional recommendations as part of that joint work: