Source · Prevention of Future Deaths

Keith Samuel Peters

Ref: 2013-0378 Date: 20 Dec 2013 Coroner: Jennifer Leeming Area: Manchester (West) Responses identified: 1 / 1 View PDF

Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers cannot meet deadlines, caused significant delays.

Date 20 Dec 2013
56-day deadline 14 Feb 2014 est.
Responses identified 1 of 1
Community health care and emergency services related deaths

Coroner's concerns

AI summary
Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers cannot meet deadlines, caused significant delays.
View full coroner's concerns
In the circumstances it is my statutory to report to you_ Brief circumstances of matters of concern (1) Mr Peters' case was allocated to Community Assessment Officer who was on leave at the time, and whose future leave commitments resulted in her having limited time to complete Mr Peters' assessment within the required period (2) During_the periods when the Community Assessment Officer was 19t during 21st day days day duty available there is no evidence of Mr Peters" case being prioritised, neither when the twenty eight period allowed for the assessment to be completed was approaching expiry, nor when that period had expired.

(3) The manager of the North STARS team gave evidence at the Inquest that there was no system in place for Officers to refer a case back to the Manager for re allocation to another Officer when it became clear that an assessment was not going to be completed within the twenty eight required_

Responses

1 respondent
Bolton Council Local Authority / Fire Service
31 Jan 2014 PDF
Action Planned

Bolton Council has cascaded lessons learned and has an action plan in place to improve systems, processes, and officer training, which they will oversee the full implementation of. (AI summary)

View full response
Dear Mrs J, Leeming, am writing to You in relation to the Regulation 28 'Report to prevent future deaths' notification issued on 12th December 2013 to Bolton Council regarding the death of Mr Keith Peters D.O.D: 12/09/2013. The Council has taken steps to ensure that the lessons learned from this case have been cascaded appropriately throughout the organisation. The council has also in place developments and measures to improve where possible systems, processes and officer training: These matters have been taken seriously and the Council will oversee the full implementation of the enclosed action plan: Please do not hesitate to contact me should you require any further information or clarification of any aspects of the plan.

Report sections

Circumstances of the death
Keith Samuel Peters lived alone at 4, Royston Avenue, Bolton. He suffered from Type II diabetes, chronic pancreatitis and alcohol dependence. His only carer was sister_ who lived some distance away, but visited her brother each week:
2. On the 1st of August 2013 Mr Peters was visited by his General Practitioner , (GP) who was concerned about his condition: The Doctor was particularly concerned that Mr Peters was not eating properly: He therefore referred Mr Peters to Bolton Council Social Care Services on the basis that Mr Peters was having problems with self care and meal preparation. The referral was made with normal priority. The referral was received by Bolton Council North STARS team on the 2nd of August 2013. The policy of that team is that there should be meaningful contact with the subject Of such a referral, in this case Mr Peters, within two weeks of the receipt of the referral and that the needs of the subject should be assessed within twenty eight days of such receipt. A member of the North STARS Team did contact Mr Peters promptly and arrangements were made for him to have a safe installed and for him to receive hot meals the Meals on Wheels Service. However these arrangements_were made without there having_been any assessment of Mr To the the his key from

Peters' needs and the North STARS Team were therefore unaware that Mr Peters was unable to eat solid food. Accordingly Mr Peters could not eat the meals that were delivered and he telephoned the Community Meals Office on the 3r of September 2013 and cancelled the meals, explaining that he was not eating them:
5. Meanwhile on the 15th of August 2013 Mr Peters' case was allocated to a Community Assessment Officer within the North STARS team with a view to Mr Peters' needs being assessed on or before the 29t of August 2013 as the Team's Policy required. However the Officer to whom the case was allocated was on annual leave at that time: The Officer was due to return to work on the of August; but had arranged further leave from the 22nd to the 28th of August; This meant that there were only four days within the twenty eight days allowed by the Policy which the Officer could contact Mr Peters, arrange to interview him and complete the assessment process:
6. The Officer telephoned Mr Peters on the of August 2013, the day before she was due to go on leave again, in order to arrange a appointment to see him. There was no answer to her call and she left a message asking Mr Peters to contact her: Mr Peters responded to the message on the 23r of August by telephoning the North STARS Office. It was recorded that he was told that the relevant Officer was on leave and that she would telephone him upon her return.
7. The Officer telephoned Mr Peters on the 3rd of September, which was the fifth working after her return from leave, and five outside the twenty eight period allowed for his assessment to be completed. She reported that the telephone number was unobtainable and she arranged for a letter to be sent to Mr Peters asking him to make contact with her.
8. On the 5t of September Mr Peters responded to the letter by telephoning the Office of the North STARS team, and the Officer was advised of his call,
9. On the 8t of September Mr Peters was visited by his sister, who was sO concerned about his condition that an ambulance was called and Mr Peters was taken to the Royal Bolton Hospital where he was found to be extremely cachectic and was admitted to the High Dependency Unit where he died on the 12th of September 2013.
10. On the same date, the 12t of September, Mr Peters' Community Assessment Officer returned the call that Mr Peters had made to her Office on the 5th of September. She received no reply.

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Report details

Reference
2013-0378
Date of report
20 December 2013
Coroner
Jennifer Leeming
Coroner area
Manchester (West)

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: 14 Feb 2014 (estimated).

Sent to

Bolton Council

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