Agenda and minutes

There were no disclosable pecuniary interests declared.

The minutes of the meeting held on 1^st July, 2015 were signed as a true record.

With reference to Minute 10 headed ‘Reducing Health Inequalities in Coventry’, in particular the request that the Communities and Neighbourhoods Scrutiny Board (4) considers how the Community Development Team works in the neighbourhoods with particular reference to the hard to reach and disadvantaged communities and individuals, and how support is offered to the most vulnerable, the Board were informed that the item had been added to the Scrutiny Board (4) work programme and feedback would be provided to Board members at the appropriate time.

Report of the Executive Director of People

David Smithson, West Midlands Fire Service Station Commander, Chair of the Review Board and Jane Lawson, Independent Author of the Review Report have been invited to the meeting for the consideration of this item.

The following have also been invited for this issue and for item 5 below:

Joan Beck, Chair, Coventry Safeguarding Adults Board

Representatives of:

University Hospitals Coventry and Warwickshire

Coventry and Warwickshire Partnership Trust

Coventry and Rugby Clinical Commissioning Group

The Scrutiny Board considered a briefing note of the Executive Director of People attached to which was the Executive Summary report which presented the findings of a Coventry Safeguarding Serious Incident Review which followed the death of Miss G in the spring of 2013. Appended to the summary report was an action plan incorporating the lessons learnt from the review.

Joan Beck, Chair of the Safeguarding Adults Board and David Smithson, Chair of the Review Group attended the meeting for the consideration of this item along with Mark Radford, University Hospitals Coventry and Warwickshire and Sue Davis and Glynis Washington, Coventry and Rugby Clinical Commissioning Group. The report was also to be considered by the Cabinet Member for Health and Adult Services at his meeting on 12^th October, 2015 and Councillor Clifford, Deputy Cabinet Member also attended the meeting.

Miss G was a vulnerable 40 year old who was part of a loving and supportive family. She suffered from a long term degenerative neurological disease and was confined to a wheelchair. She lived in independent accommodation and received 22 hours of support a day which was funded by adult social care. She died in a fire which was intense and took hold rapidly when she was alone. The likely cause of the fire was from a dropped cigarette or cigarette ignition source.

The Chair of the Review Board expressed her condolences to the family and apologised for the length of time that it had taken to reach this stage of the review process.

The summary report highlighted that a serious incident review took place because an adult had died or had been seriously injured or impaired and abuse or neglect was known or suspected to be a factor. The process was about learning lessons and not apportioning blame. The report set out the background to the case; provided a summary of facts and findings of the case; included an analysis of the circumstances; detailed conclusions which formed the basis of a commitment to action across organisations in the city to prevent such a situation occurring in the future; and set out what would happen next. The action plan set out recommendations with actions as required, gave target dates and the appropriate lead officers as well as highlighting expected outcomes. 

The Board questioned those present on a number of issues relating to the circumstances of the case and responses were provided, matters raised included:

·  Concerns about why reviews hadn’t been undertaken when the 2007 psychology report should have precipitated a thorough multi-agency review and there had been recurrent concerns and issues raised by the family relating to care provision, risk assessment and record keeping.

·  Had the lessons learnt from the case and the resulting actions been implemented already

·  When a number of agencies had recommendations to implement, who was responsible for ensuring these were carried out

·  A concern that the action plan did not contain a recommendation/action covering a requirement to ensure that regular reviews would be undertaken

·  Clarification about  ...  view the full minutes text for item 16.

Report of the Executive Director of People

Simon Brake, Director of Primary Care Sustainability and Integration, Coventry Council, Chair of the Review Board and Laurence Tennant, Independent Author of the Review Report have been invited to the meeting for the consideration of this item.

RESOLVED that consideration of the report and action plan concerning the System Wide Review following the death of Mrs F be deferred to the Board meeting scheduled for 18^th November, 2015.

Outstanding issues have been picked up in the Work Programme

The Scrutiny Board noted that all outstanding issues had been included in the Work Programme for 2015-16.

Report of the Scrutiny Co-ordinator

The Scrutiny Board noted their Work Programme for the current municipal year. The Board were informed that an additional meeting had been arranged for 2.00 p.m. on Tuesday, 3^rd November, 2015 to consider a report on Improving Accommodation for Older People and the Director of Public Health Annual Report.

Any other items of public business which the Chair decides to take as matters of urgency because of the special circumstances involved

There were no additional items of public business.