Kent County Council
Local Authority
Action Taken
AI-generated response summary
Kent County Council has reviewed and rolled out new policy and guidance for multi-agency working, adopted Multi-Agency Review Meeting (MARM) procedures, and produced a multi-agency threshold tool. They have also established a partnership with the Royal British Voluntary Enterprise, including a monthly drop-in service and online meetings to address concerns for residents struggling to engage.
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[Page 1] RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an inquest into the death of Richard PREECE that concluded on 25 June 2026.
1. Respondent – Kent County Council, Department of Adult Social Care and Health
2. Date of Response – 1 October 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report as follows: Despite three separate safeguarding referrals for self-neglect (2022, 2024 and 2025), involving concerns about hoarding, poor personal care, social isolation, PTSD, anxiety/agoraphobia, chronic pain, financial difficulties and disengagement from services, there was no timely escalation to a multi-agency meeting. Adult Social Care was attempting assessment, but no earlier formal multi-agency review occurred. The case appears to have fallen between services because Mr Preece would not engage. Evidence was heard that suggested an earlier self-neglect meeting may have been beneficial and that the first time one was considered was towards the end of June 2025. Mr Preece had a military career and served multiple tours in Iraq and Afghanistan. He was medically discharged following serious injuries sustained in Afghanistan. The injuries resulted in chronic pain, multiple back operations and ongoing mobility difficulties. Evidence from his sister was that he suffered from PTSD, struggled to adapt to civilian life following discharge, and continued to experience significant physical and psychological difficulties, including problems managing his chronic pain. Opportunities to share information, co-ordinate agency responses and assess Mr Preece's needs appear to have been missed. The Coroner is concerned that, where vulnerable adults repeatedly decline engagement, there may be insufficient arrangements to ensure escalating safeguarding concerns are brought together and reviewed through a structured multi-agency process, creating a risk that future deaths may occur. The Coroner is also concerned as to whether existing procedures adequately identify when safeguarding concerns should be escalated to a multi-agency self-neglect process notwithstanding the absence of consent.
4. DETAILS OF ACTION TAKEN, how has the concern been addressed. Kent County Council Adult Social Care and Health (ASCH) has reviewed its policy and procedures in line with those of Kent and Medway Adult Safeguarding Adults Board (KMSAB). ASCH and has rolled out new guidance as part of its required training for our staff. 1
[Page 2] It includes: A briefing that has been shared with all ASCH staff - The Importance of Multi-Agency Working . This is Appended as Annex A. Kent County Council ASCH has also adopted the KMSAB Multi-Agency Review Meeting (MARM) procedures – How and when multi-agency meetings are organised. A copy of the policy can be found at Annex B. Kent County Council ASCH in partnership with Medway Council has produced the Kent & Medway threshold tool which can be found at Annex C. This tool provides staff with a framework to identify the level of risk associated with different scenarios. All of ASCH staff are required to keep up to date with training and follow the above guidance. In circumstances where a person with care and support needs consistently declines engagement, the policies provide a framework for agencies to move beyond single-agency responses and consider the wider pattern of risk. Escalating safeguarding concerns should be subject to structured multi-agency review (MARM’s).
5. DETAILS OF FURTHER ACTION PROPOSED Locally, the Community Team Manager for Tonbridge and West Malling, who works for Kent County Council ASCH, has met with the Head of Welfare at the Royal British Voluntary Enterprise (RBVE; Formally Royal British Legion Industries) at their Aylesford site in order to strengthen working relationships between the local ASCH community team and RBVE. From 13 October 2026 RBVE and the Tonbridge and West Malling Community Team will provide a monthly drop-in service where a social worker will attend the RBVE site with a member of their Welfare Team so that residents can meet in person with a social worker. RBVE will be advertising this service for their residents. It will provide an opportunity for the RBVE Welfare Team to discuss concerns they have for residents or people who have supported employment places on site, which will include conducting visits to people in their homes (this could include unannounced visits). 2
[Page 3] From 22 October 2026 an online monthly meeting will commence where the RBVE Head of Welfare and their team will meet with Senior Practitioners from Tonbridge and West Malling Community Team to discuss and review any concerns they have for residents and volunteers at RBVE. There will be a focus on people who struggle to engage with services and are at a risk of self-neglect. Referrals to adult social care and health will be discussed, whether MARMS’s need to be arranged as well as reviewing progress of open referrals to ASCH. , Assistant Director West Kent, Kent County Council. 3
1. Respondent – Kent County Council, Department of Adult Social Care and Health
2. Date of Response – 1 October 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report as follows: Despite three separate safeguarding referrals for self-neglect (2022, 2024 and 2025), involving concerns about hoarding, poor personal care, social isolation, PTSD, anxiety/agoraphobia, chronic pain, financial difficulties and disengagement from services, there was no timely escalation to a multi-agency meeting. Adult Social Care was attempting assessment, but no earlier formal multi-agency review occurred. The case appears to have fallen between services because Mr Preece would not engage. Evidence was heard that suggested an earlier self-neglect meeting may have been beneficial and that the first time one was considered was towards the end of June 2025. Mr Preece had a military career and served multiple tours in Iraq and Afghanistan. He was medically discharged following serious injuries sustained in Afghanistan. The injuries resulted in chronic pain, multiple back operations and ongoing mobility difficulties. Evidence from his sister was that he suffered from PTSD, struggled to adapt to civilian life following discharge, and continued to experience significant physical and psychological difficulties, including problems managing his chronic pain. Opportunities to share information, co-ordinate agency responses and assess Mr Preece's needs appear to have been missed. The Coroner is concerned that, where vulnerable adults repeatedly decline engagement, there may be insufficient arrangements to ensure escalating safeguarding concerns are brought together and reviewed through a structured multi-agency process, creating a risk that future deaths may occur. The Coroner is also concerned as to whether existing procedures adequately identify when safeguarding concerns should be escalated to a multi-agency self-neglect process notwithstanding the absence of consent.
4. DETAILS OF ACTION TAKEN, how has the concern been addressed. Kent County Council Adult Social Care and Health (ASCH) has reviewed its policy and procedures in line with those of Kent and Medway Adult Safeguarding Adults Board (KMSAB). ASCH and has rolled out new guidance as part of its required training for our staff. 1
[Page 2] It includes: A briefing that has been shared with all ASCH staff - The Importance of Multi-Agency Working . This is Appended as Annex A. Kent County Council ASCH has also adopted the KMSAB Multi-Agency Review Meeting (MARM) procedures – How and when multi-agency meetings are organised. A copy of the policy can be found at Annex B. Kent County Council ASCH in partnership with Medway Council has produced the Kent & Medway threshold tool which can be found at Annex C. This tool provides staff with a framework to identify the level of risk associated with different scenarios. All of ASCH staff are required to keep up to date with training and follow the above guidance. In circumstances where a person with care and support needs consistently declines engagement, the policies provide a framework for agencies to move beyond single-agency responses and consider the wider pattern of risk. Escalating safeguarding concerns should be subject to structured multi-agency review (MARM’s).
5. DETAILS OF FURTHER ACTION PROPOSED Locally, the Community Team Manager for Tonbridge and West Malling, who works for Kent County Council ASCH, has met with the Head of Welfare at the Royal British Voluntary Enterprise (RBVE; Formally Royal British Legion Industries) at their Aylesford site in order to strengthen working relationships between the local ASCH community team and RBVE. From 13 October 2026 RBVE and the Tonbridge and West Malling Community Team will provide a monthly drop-in service where a social worker will attend the RBVE site with a member of their Welfare Team so that residents can meet in person with a social worker. RBVE will be advertising this service for their residents. It will provide an opportunity for the RBVE Welfare Team to discuss concerns they have for residents or people who have supported employment places on site, which will include conducting visits to people in their homes (this could include unannounced visits). 2
[Page 3] From 22 October 2026 an online monthly meeting will commence where the RBVE Head of Welfare and their team will meet with Senior Practitioners from Tonbridge and West Malling Community Team to discuss and review any concerns they have for residents and volunteers at RBVE. There will be a focus on people who struggle to engage with services and are at a risk of self-neglect. Referrals to adult social care and health will be discussed, whether MARMS’s need to be arranged as well as reviewing progress of open referrals to ASCH. , Assistant Director West Kent, Kent County Council. 3