Norfolk County Council
Local Authority
Action Taken
AI-generated response summary
• Staff have been made aware that all contact attempts, including those with no response, must be documented and escalated to a senior worker. • A Best Practice factsheet is being developed to formalise actions for when contact cannot be made, including escalation conditions and identifying other involved professionals. • Current guidance on prioritising referrals and assessing individual risks is being reviewed, and the Coroner's concerns will be incorporated into a review of Duty Operational Instructions.
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Dear Madam Response on behalf of Norfolk County Council to Regulation 28 Report to Prevent Future Deaths dated 17 December 2014 Darren Hayes Deceased (1) Attempts to contact Mr Hayes by telephone were not documented nor escalated to a senior worker it is understood NCC taken steps to ensure Ihat staff are aware that all calls (even where there is no response are documented) and & senior member of stalf is made aware; Action has been taken in respect of the individual worker and the Adult Social Services Qualily Assurance Team is developing a Best Practice factsheet with Operational Managers setting out the actions to be taken when are unable to make contact with a person who has been referred to the Service. The intention is to formalise local custom and practice for wider use across the Service and set out clearly the conditions for escalation to senior management. The factsheet will also be aimed at identifying other people, including professionals, involved with the person concerned, and promoting good communication. (2) The time taken to contact Mr Hayes in the light of information provided and the risks with which Mr Hayes was presenting: The initial reterral t0 the ECCT was on 10.3.2014, he was allocated for initial assessment which was due to take placed on 28.3.14, 3 weeks later: The first attempt to telephone Mr Hayes was 0n 1.4.14. A letter was sent to Mr Hayes and on receiving no response, there was no further attempt t0 contact Mr Hayes until 16.4.14 almost 5 weeks after both the initial referral and his death www_norfolk gov.uk LYIESTOR LY PEOPLL Your have they
confirm a review of the Duty Operational Instructions is already in progress, and the Coroner's concerns will be built into this work: It is recognised that local custom and practice need to be formalised so that information about risk set out in the referrals is properly taken into account in determining when initial contact is made with people who have been referred to the Service. The Quality Assurance team are reviewing current guidance regarding the way in which such referrals are prioritised: (3) The risks with which Mr Hayes were not fully considered ie his diabetes being "out of control"; weighing less than 7 stone, lacking motivation, struggling to cope at home; alone and having no cooker: He was no longer receiving 3 daily visits from NFRS. The evidence was that Mr Hayes had a microwave and could make himself "a hot drink" As above, | confirm work is being done by the Quality Assurance team to review the current guidance which determines referrals are prioritised once they are received by the locality teams and this will include a review of how individual risks are identified and assessed_ Despite getting no response to telephone calls or letter, SW did not contact GP, District Nurse or Red Cross (who had discharged him) We will ensure that this is fully taken into account in the factsheet referred to in the response to (1) above_ trust this addresses your concerns
confirm a review of the Duty Operational Instructions is already in progress, and the Coroner's concerns will be built into this work: It is recognised that local custom and practice need to be formalised so that information about risk set out in the referrals is properly taken into account in determining when initial contact is made with people who have been referred to the Service. The Quality Assurance team are reviewing current guidance regarding the way in which such referrals are prioritised: (3) The risks with which Mr Hayes were not fully considered ie his diabetes being "out of control"; weighing less than 7 stone, lacking motivation, struggling to cope at home; alone and having no cooker: He was no longer receiving 3 daily visits from NFRS. The evidence was that Mr Hayes had a microwave and could make himself "a hot drink" As above, | confirm work is being done by the Quality Assurance team to review the current guidance which determines referrals are prioritised once they are received by the locality teams and this will include a review of how individual risks are identified and assessed_ Despite getting no response to telephone calls or letter, SW did not contact GP, District Nurse or Red Cross (who had discharged him) We will ensure that this is fully taken into account in the factsheet referred to in the response to (1) above_ trust this addresses your concerns