Oxfordshire County Council
Local Authority
Action Taken
Oxfordshire County Council conducted a full review of processes in July 2024 and reinforced existing changes from August 2023, emphasizing professional curiosity. They implemented a new procedure for the Social and Health Care Team to immediately email the Adult Mental Health Team (AMHT) and follow up if direct online record access is not possible, with escalation pathways. (AI summary)
View full response
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response Contents
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response Coroners matters of concern 2 Executive Summary 3 Social and Health Care Response 4
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response The Coroner’s matters of concern as detailed in the Regulation 28 report are as follows: Background: In March 2023, Thames Valley Police passed on a report about Caroline (Miss Caroline HARRIS) to the Mult-Agency Safeguarding Hub (MASH) which raised concerns about her behaviour and mental state and dishevelled appearance. The report stated that it was, ‘Shared in the interests of safeguarding as may be having relapse’. MASH undertook a review of the report and concluded that Caroline was not at risk but may have needs for care and support from the local authority. The information was passed to the Council’s Adult Social Care Team (ASCT) who in turn passed the information onto Caroline’s GP. At the Coroner’s inquest evidence was given that the ASCT were unable to directly refer to Adults Mental Health Team (AMHT), even if they had considered it necessary. As the GP was not made aware that Caroline had declined to attend the clinic to receive her medication, she saw no need to refer the Police report to AMHT. Evidence was given that AMHT took a different view regarding the Police report and would have viewed the report as evidence of Caroline relapsing. AMHT’s view was that such a report met the criteria for being shared with them, and with their knowledge of Caroline’s past history of self-neglect and non-compliance with taking medication, it ought to have been shared with them; and had it been done so it would have been followed up assertively and urgently including undertaking home visits and the possible use of compulsory powers under the Mental Health Act. Reg 28 extract of concerns raised: My concern is that important information regarding a deterioration in mental health was not shared with the appropriate Team who may have been able make appropriate interventions and to have taken steps to avoid a fatal outcome. You should consider a review of how such information is assessed and shared between the respective agencies.
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response Executive Summary This document is in response to the Regulation 28 report from the Coronors, relating to Caroline Harris (died on or before 27/07/2023), for the purpose of Prevention of Future Deaths. The document describes the steps already taken prior to the hearing by The Social and Health Care Team, who are the initial point of contact for Adult Social Care into Oxfordshire County Council, regarding potential safeguarding concerns for Oxfordshire residents. The Social and Health Care Team act as the ‘Front Door’ to Adult Social Care within Oxfordshire. The team, as that initial point of contact, support Oxfordshire residents through strength based conversations to ascertain their needs and either signpost them to the voluntary care sector or begin their journey within Oxfordshire County Council’s (OCC) Adult Care Service. The team can also order basic equipment for residents, reducing unnecessary waiting times for simple but meaningful tools to improve their lives. The Social and Health Care Team also screen out of hour contacts predominantly from Thames Valley Police and South Central Ambulance Service, which highlight potential safeguarding concerns of vulnerable adults residing in Oxfordshire. As it stands, the team deals with approx. 20,000 out of hours contacts each year. The Social and Health Care Team acknowledges that action should have been taken to share the Police report with Adult Mental Health Teams (AMHT), as Caroline Harris had been open to that team previously.
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response Coroner’s concern: My concern is that important information regarding a deterioration in mental health was not shared with the appropriate Team who may have been able make appropriate interventions and to have taken steps to avoid a fatal outcome. Action taken prior to the inquest:
1. Oxfordshire Safeguarding Adults Board Safeguarding matrix states for situations where self-neglect is reported: "All standard interventions must be used first to manage risk e.g. Care Management/Care Plan Approach/Multi- Disciplinary Team”; The Social and Health Care Team will primarily complete referrals to Adult Social Care, Mental Health Care (via GP) or other appropriate services, such as housing or voluntary sector agencies. The team will raise a safeguarding referral if a person does not consistently engage with offered services or where there are concerns about their mental capacity to make decisions about their care and support.
2. Where the person is presenting primarily with a mental health concern and additional concerns about self-neglect, lack of access to food and/ or medication or difficulties with finances or tenancy, the report is shared with the person’s GP for mental health assessments and referrals; in addition, Social and Health Care Team will make direct contact with the person in order to signpost them to other appropriate agencies Oxfordshire County Council has worked with healthcare partners and was able to reinstate access to mental health records on the 16 August 2023, following a critical incident where access was removed by the NHS.
3. A critical incident took place in August 2022, and had an impact on how the Social and Health Care Team processed reports from the Police and Ambulance Service. To mitigate the loss of mental health systems, where mental health involvement needed verification, the Social and Health Care Team would contact AMHT. This was achieved by telephone or email. Through the screening process, each report is discussed and the necessary action agreed with a Social Worker before action was taken.
4. Once access to mental health records was reestablished, process improvements and changes to all incoming safeguarding reports were implemented from August 2023, guidance/training material on this task was updated and shared to all members of the team.
5. As a learning from the critical incident in August 2022, where online systems failed, we have worked with partners to ensure that there are robust business continuity plans in place. These include the use of manual processes to ensure that checks are still being made on all instances where there are potential safeguarding concerns.
6.
7. Training was undertaken by the Specialist Customer Service Advisors and Professional Support Team in August 2023. At this time the reintroduction that all reports are checked against health databases (EMIS, HIE, RIO) to confirm
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response GP details and NHS numbers, and to establish active or recent involvement with mental health services/and or other health professionals. As these systems give a broader view of the person referred across Health records.
8. This is in addition to checks made to the Council’s own Adult Social Care systems, which will provide records of any previous interactions or involvements. The collective data gathering cross checking across multiple systems plus verification from the Professional Support Team (Social workers and Occupational Therapists), who sit within the Social and Health Care Team, gives us robust decision making and corroboration.
9. For quality assurance, decisions made by Specialist Customer Service Advisors are checked by Social Workers, Occupational Therapists, Team Leaders and the Training Officer. This forms part of the quality assurance undertaken monthly to upskill the Customer Service Advisors and ensure that the correct decisions are being made. This is done across all of their work and various contact channels.
10.The guidance issued to the Social and Health Care Team in August 2023, states that a report is shared with the person’s GP in the following circumstances.
a. Where the main concern expressed is of mental health difficulties, and;
b. Where the person is not recorded under any health database to be already supported by a secondary mental health team. The team will send an accompanying email to the GP making clear the reasons why the report has been shared and request that the GP informs the Social and Health Care Team of any follow-up. The email will also request that the GP informs the team of any needs that may fall under the social care remit requiring further contact from the Social and Health Care Team.
11.Where the situation appears to be urgent the team will either:
a. Immediately contact the GP via telephone and discuss concerns, or;
b. Escalate the case to the Professional Support Team for further evaluation and decision. Action Taken immediately following the inquest:
1. A full review of the process and decision making in regard to decision making was made in July 2024 to ensure that this situation does not arise again.
2. All staff involved in decision making were reminded in the daily team huddle of the process changes implemented in August 2023 and to be ‘professionally curious’ when looking at persons records and using all tools available to paint a picture of that person’s circumstances. As this has been standard practice since August 2023, we are now confident that this is fully embedded into the
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response Social and Health Care Team.
3. Where access to online records like RIO for mental health, is not possible the team must immediately email AMHT to check for mental health involvement before action is taken. The Social and Health Care Team will continue to follow up with AMHT until a response and decision is reached. In the unlikely event that contact cannot be made with AMHT, this is escalated to Team Leaders who will contact their counterparts in AMHT. Summary Since the Regulation 28 Order was received in July 2024, and the Social and Health Care Team have reviewed and improved processes, to make sure that appropriate checks, sharing of reports and decisions are made in conjunction with their updated guidance when screening safeguarding reports. This has been done to avoid any future issues and to ensure that important information is shared with the appropriate internal teams and external partners. The additional layers of checking online systems and liaising with the Professional Support Team, gives added assurance that there is consistency in decision making and ongoing learning for the Specialist Customer Service Advisors within the Social and Health Care Team
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response Coroners matters of concern 2 Executive Summary 3 Social and Health Care Response 4
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response The Coroner’s matters of concern as detailed in the Regulation 28 report are as follows: Background: In March 2023, Thames Valley Police passed on a report about Caroline (Miss Caroline HARRIS) to the Mult-Agency Safeguarding Hub (MASH) which raised concerns about her behaviour and mental state and dishevelled appearance. The report stated that it was, ‘Shared in the interests of safeguarding as may be having relapse’. MASH undertook a review of the report and concluded that Caroline was not at risk but may have needs for care and support from the local authority. The information was passed to the Council’s Adult Social Care Team (ASCT) who in turn passed the information onto Caroline’s GP. At the Coroner’s inquest evidence was given that the ASCT were unable to directly refer to Adults Mental Health Team (AMHT), even if they had considered it necessary. As the GP was not made aware that Caroline had declined to attend the clinic to receive her medication, she saw no need to refer the Police report to AMHT. Evidence was given that AMHT took a different view regarding the Police report and would have viewed the report as evidence of Caroline relapsing. AMHT’s view was that such a report met the criteria for being shared with them, and with their knowledge of Caroline’s past history of self-neglect and non-compliance with taking medication, it ought to have been shared with them; and had it been done so it would have been followed up assertively and urgently including undertaking home visits and the possible use of compulsory powers under the Mental Health Act. Reg 28 extract of concerns raised: My concern is that important information regarding a deterioration in mental health was not shared with the appropriate Team who may have been able make appropriate interventions and to have taken steps to avoid a fatal outcome. You should consider a review of how such information is assessed and shared between the respective agencies.
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response Executive Summary This document is in response to the Regulation 28 report from the Coronors, relating to Caroline Harris (died on or before 27/07/2023), for the purpose of Prevention of Future Deaths. The document describes the steps already taken prior to the hearing by The Social and Health Care Team, who are the initial point of contact for Adult Social Care into Oxfordshire County Council, regarding potential safeguarding concerns for Oxfordshire residents. The Social and Health Care Team act as the ‘Front Door’ to Adult Social Care within Oxfordshire. The team, as that initial point of contact, support Oxfordshire residents through strength based conversations to ascertain their needs and either signpost them to the voluntary care sector or begin their journey within Oxfordshire County Council’s (OCC) Adult Care Service. The team can also order basic equipment for residents, reducing unnecessary waiting times for simple but meaningful tools to improve their lives. The Social and Health Care Team also screen out of hour contacts predominantly from Thames Valley Police and South Central Ambulance Service, which highlight potential safeguarding concerns of vulnerable adults residing in Oxfordshire. As it stands, the team deals with approx. 20,000 out of hours contacts each year. The Social and Health Care Team acknowledges that action should have been taken to share the Police report with Adult Mental Health Teams (AMHT), as Caroline Harris had been open to that team previously.
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response Coroner’s concern: My concern is that important information regarding a deterioration in mental health was not shared with the appropriate Team who may have been able make appropriate interventions and to have taken steps to avoid a fatal outcome. Action taken prior to the inquest:
1. Oxfordshire Safeguarding Adults Board Safeguarding matrix states for situations where self-neglect is reported: "All standard interventions must be used first to manage risk e.g. Care Management/Care Plan Approach/Multi- Disciplinary Team”; The Social and Health Care Team will primarily complete referrals to Adult Social Care, Mental Health Care (via GP) or other appropriate services, such as housing or voluntary sector agencies. The team will raise a safeguarding referral if a person does not consistently engage with offered services or where there are concerns about their mental capacity to make decisions about their care and support.
2. Where the person is presenting primarily with a mental health concern and additional concerns about self-neglect, lack of access to food and/ or medication or difficulties with finances or tenancy, the report is shared with the person’s GP for mental health assessments and referrals; in addition, Social and Health Care Team will make direct contact with the person in order to signpost them to other appropriate agencies Oxfordshire County Council has worked with healthcare partners and was able to reinstate access to mental health records on the 16 August 2023, following a critical incident where access was removed by the NHS.
3. A critical incident took place in August 2022, and had an impact on how the Social and Health Care Team processed reports from the Police and Ambulance Service. To mitigate the loss of mental health systems, where mental health involvement needed verification, the Social and Health Care Team would contact AMHT. This was achieved by telephone or email. Through the screening process, each report is discussed and the necessary action agreed with a Social Worker before action was taken.
4. Once access to mental health records was reestablished, process improvements and changes to all incoming safeguarding reports were implemented from August 2023, guidance/training material on this task was updated and shared to all members of the team.
5. As a learning from the critical incident in August 2022, where online systems failed, we have worked with partners to ensure that there are robust business continuity plans in place. These include the use of manual processes to ensure that checks are still being made on all instances where there are potential safeguarding concerns.
6.
7. Training was undertaken by the Specialist Customer Service Advisors and Professional Support Team in August 2023. At this time the reintroduction that all reports are checked against health databases (EMIS, HIE, RIO) to confirm
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response GP details and NHS numbers, and to establish active or recent involvement with mental health services/and or other health professionals. As these systems give a broader view of the person referred across Health records.
8. This is in addition to checks made to the Council’s own Adult Social Care systems, which will provide records of any previous interactions or involvements. The collective data gathering cross checking across multiple systems plus verification from the Professional Support Team (Social workers and Occupational Therapists), who sit within the Social and Health Care Team, gives us robust decision making and corroboration.
9. For quality assurance, decisions made by Specialist Customer Service Advisors are checked by Social Workers, Occupational Therapists, Team Leaders and the Training Officer. This forms part of the quality assurance undertaken monthly to upskill the Customer Service Advisors and ensure that the correct decisions are being made. This is done across all of their work and various contact channels.
10.The guidance issued to the Social and Health Care Team in August 2023, states that a report is shared with the person’s GP in the following circumstances.
a. Where the main concern expressed is of mental health difficulties, and;
b. Where the person is not recorded under any health database to be already supported by a secondary mental health team. The team will send an accompanying email to the GP making clear the reasons why the report has been shared and request that the GP informs the Social and Health Care Team of any follow-up. The email will also request that the GP informs the team of any needs that may fall under the social care remit requiring further contact from the Social and Health Care Team.
11.Where the situation appears to be urgent the team will either:
a. Immediately contact the GP via telephone and discuss concerns, or;
b. Escalate the case to the Professional Support Team for further evaluation and decision. Action Taken immediately following the inquest:
1. A full review of the process and decision making in regard to decision making was made in July 2024 to ensure that this situation does not arise again.
2. All staff involved in decision making were reminded in the daily team huddle of the process changes implemented in August 2023 and to be ‘professionally curious’ when looking at persons records and using all tools available to paint a picture of that person’s circumstances. As this has been standard practice since August 2023, we are now confident that this is fully embedded into the
Prevention of Future Deaths Report (Regulation 28): Oxfordshire County Council’s response Social and Health Care Team.
3. Where access to online records like RIO for mental health, is not possible the team must immediately email AMHT to check for mental health involvement before action is taken. The Social and Health Care Team will continue to follow up with AMHT until a response and decision is reached. In the unlikely event that contact cannot be made with AMHT, this is escalated to Team Leaders who will contact their counterparts in AMHT. Summary Since the Regulation 28 Order was received in July 2024, and the Social and Health Care Team have reviewed and improved processes, to make sure that appropriate checks, sharing of reports and decisions are made in conjunction with their updated guidance when screening safeguarding reports. This has been done to avoid any future issues and to ensure that important information is shared with the appropriate internal teams and external partners. The additional layers of checking online systems and liaising with the Professional Support Team, gives added assurance that there is consistency in decision making and ongoing learning for the Specialist Customer Service Advisors within the Social and Health Care Team