Source · Prevention of Future Deaths

Christopher Watson

Ref: 2015-0133 Date: 1 Apr 2015 Coroner: Jacqueline Lake Area: Norfolk 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner raised concerns that files were closed after letters instructing recipients to ignore them if no action was needed were sent, without verifying receipt or comprehension. Direct contact was also not made with a vulnerable individual to ensure they understood available help or to assess their capacity.

Date 1 Apr 2015

56-day deadline 27 May 2015 stated in the report

Responses identified 1 of 1

Other related deaths

Coroner's concerns

AI summary

The coroner raised concerns that files were closed after letters instructing recipients to ignore them if no action was needed were sent, without verifying receipt or comprehension. Direct contact was also not made with a vulnerable individual to ensure they understood available help or to assess their capacity.

View full coroner's concerns

his being my

_ (1) There is no concern over the actions of ASC prior to the letter sent to Mr Watson. The concern is over the contents of the letter to the effect that if Ihe person does not require action then they are to ignore the letter and the file is then closed, No steps are taken to ensure that the person actually receives, opens and understands (he" letter or whether they can read for instance_ (2) Mr Watson was clearly vulnerable from the description provided by the Police i.e "painfully thin, unwashed and dishevelled"_ Direct contact was not made with Mr Watson t0 ensure he understood help is available should he wish to take advantage of His capacity may have needed to have been assessed.

Responses

1 respondent

Norfolk County Council

Local Authority

Letter dated 26 May 2015 PDF

AI-classified response stance Action Taken

AI-generated response summary

• Norfolk County Council has ceased the practice of sending letters to individuals about whom concerns have been raised. • Staff have been instructed to make face-to-face contact with individuals if they are unable to be contacted by telephone. • Staff have been reminded to record all contact steps and risk assessments, with instructions for immediate home visits for significant risks and escalation of low-risk cases after two days without contact. This advice is being formalised as a new Operational Instruction.

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Dear Ms Lake Response on behalf of Norfolk County Council to Regulation 28 Report to Prevent Future Deaths dated Ist Aprii 2015 regarding Christopher Watson (1) There is no concern over the actions of ASC to the letter being sent to Mr Watson. The concern is over the contents of the letter to the effect that if the person does not require action then they are to ignore the letter and the file is then closed: No steps are taken to ensure that the person actually receives, opens and understands the lelter or whatever can read for instance; can confirm that action has been taken t0 ensure that practice across all Adult Social Services teams has been changed_ An instryction has been issued to staff to ensure that the practice of sending a letter to individuals about whom concerns have been raised is ceased with immediate effect; In cases where the Department is unable to contact an individual by telephone, staff have been instructed to ensure that face-to-face contact is made with the person. (2) Mr Watson was clearly vulnerable from the description provided by the Police
i.e. . 'painfully thin, unwashed and dishevelled : Direct contact was not made with Mr Watson to ensure he understood help is available should he wish to take advantage of it. His capacity may have needed to have been assessed can confirm that staff have been reminded to record all the steps they have taken to make contact with the person about whom concerns have been raised. At each attempt; the level of risk must be assessed and recorded_ If the risk to the person is thought to be significant, staff have been instructed that an immediate home visit will: be arranged: Even where the risk to person is thought to be Iow, if the time_ taken to make contact extends to two days, the case must be escalated to a senior member of staff; either a Practice Consultant or Team Manager; The manager will

INVESTOR M !EuFLE prior they the

be required to make a timely and appropriate decision regarding the next course of action; For example, this may mean a welfare check or emergency visit. This advice has been re-issued to staff in the.form of a best practice factsheet. It is also being formalised as a new Operational Instruction which will be completed shortly. trust this addresses your concerns_

Report sections

Investigation and inquest

On 9 January 2015, commenced an investigation into the death of CHRISTOPHER WATSON, AGED 53 YEARS: The investigation concluded at the end of the inquest on 31 MARCH 2015_ The conclusion of the inquest was medical cause of death: 1a) Exsanguination b) Deep laceration to left forearm and short-form conclusion: Mr Watson cut his own arm and died as a result of his action. His intention at the time is not known

Circumstances of the death

Mr Watson lost his job about 4 years prior to his dealh and since then general well:- deteriorated. He became isolated. A neighbour contacted Norfolk County Council Adult Social Care Department (ASC) on 9 July 2014 raising concern that Mr Watson had not been seen for some time: As telephone contact was unsuccessful ASC asked Police to carry out a welfare check and t0 report back to them The Police forced entry and found Mr Watson "painfully thin, unwashed and dishevelled" _ The Police reported this to ASC who telephoned Mr Watson but the telephone number was unrecognised. A letter was sent to offer support and advice and stating "If you do not require any care or support please ignore this letter: No response was received and Mr Watson's file was marked "No further action on 22 July 2014. Another neighbour became concerned at not seeing Mr Watson over Christmas &d New Year and on January 2015 entry was gained to Mr Watson's property: He was found dead in his bedroom: He had been dead for some weeks

Action should be taken

In my opinion action should be taken t0 prevent future deaths and believe your organisation has the power to take such action

Similar PFD reports

Shared signals

Report details

Reference: 2015-0133
Date of report: 1 April 2015
Coroner: Jacqueline Lake
Coroner area: Norfolk

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 May 2015 (stated in the report).

Sent to

Norfolk County Council

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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