Agenda and minutes

There were no declarations of interest.

The minutes of the meeting held on 3^rd November, 2015 were signed as a true record. There were no matters arising.

Briefing Note of the Executive Director of People

David Watts, Assistant Director, Adult Social Care Operations, Chair of the Review Board and Chris Babbs, 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, Independent Chair of the Safeguarding Adults Board

Cat Parker, Coventry City Council

Mark Radford, University Hospitals Coventry and Warwickshire

Jamie Soden, Coventry and Warwickshire Partnership Trust

Glynis Washington, Coventry and Rugby CCG 

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 Adults Board Serious Case Review which followed the death of Mrs E in the spring of 2013. Appended to the summary report were the associated actions plans from both the review and the learning from the case.

Joan Beck, Chair of the Safeguarding Adults Board and David Watts, Chair of the Review Group attended the meeting for the consideration of this item along with Mark Radford, University Hospitals Coventry and Warwickshire Jamie Soden and Donna Reeves, Coventry and Warwickshire Partnership Trust 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 14^th December, 2015 and Councillor Caan and Councillor Clifford, Deputy Cabinet Member also attended the meeting.

Mrs E was 66 years of age and led a busy and fulfilling life. She lived in a Housing with Care Scheme with her husband so he could receive additional support. Mrs E had received treatment in hospital in relation to a fracture to her spine as a result of a fall and had returned to her own home. She was subsequently admitted to a Coventry Care home for rehabilitation when her GP felt her recovery could be improved with a period of residential rehabilitation. Her health deteriorated while she was in the care home which led to an emergency admission to hospital. She was critically ill on admission to hospital and died 5 days later.

The Chair of the Safeguarding Adults Board expressed her condolences to the family and apologised for the length of time that it had taken to reach this stage in the review process. She read out a very moving and informative statement from the family about their experiences and the impact that this has on them.

The summary report highlighted that a serious case review took place because Mrs E was an adult at risk and neglect may have been a contributory factor. The report set out a chronological summary of events followed by an overview of the actions taken by professionals in respect of some key issues. Key learning was outlined along with the multi-agency recommendations which were organised around the following three key themes: Safeguarding Processes; Assessment and Treatment Issues; and Continuity of Care, including Hospital Discharge Arrangements. The action plans set out recommendations with actions required, gave target dates and 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 the length of time taken for this review to be completed and the number of missed opportunities by agencies prior to Mrs E’s death.

·  Asked for further information about measures already implemented to improve communication and clarification about why information had  ...  view the full minutes text for item 39.

Briefing Note of the Executive Director of People

Simon Brake, Director of Primary Care Sustainability and Integration, Coventry City 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, along with David Watts, Coventry City Council.

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 Adults Board System Wide Review which followed the death of Mrs F in the spring of 2013. Appended to the summary report were the associated actions plans from both the review and the learning from the case.

Joan Beck, Chair of the Safeguarding Adults Board and Simon Brake, Chair of the Review Group attended the meeting for the consideration of this item along with Mark Radford, University Hospitals Coventry and Warwickshire Jamie Soden and Donna Reeves, Coventry and Warwickshire Partnership Trust 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 14^th December, 2015 and Councillor Clifford, Deputy Cabinet Member also attended the meeting.

Mrs F was 80 years old when she died and had been residing in a Coventry Nursing Home. She had chronic vascular disease which she was aware would be life limiting if she declined any surgical intervention. She received hospital treatment in relation to pressure ulcers. She was discharged from hospital and transferred to a care home where she could receive significant support from health care professionals. Whilst in the care home she developed tissue damage which became infected and was re-admitted to hospital. She died 5 days later as a result of the infection.

The Chair of the Safeguarding Adults Board expressed her condolences to the family, in particular to Mrs F’s granddaughter and apologised for the length of time that it had taken to reach this stage in the review process.

The summary report highlighted that a system wide review took place when a vulnerable adult had died or had been seriously injured or impaired, abuse or neglect was known or suspected and broader system issues were believed to have been a significant factor. The report set out the facts of the case, a summary and overall analysis and conclusions. A summary of the recommendations that applied to all agencies were highlighted along with those for the individual agencies. The action plans set out recommendations with actions required, gave target dates and appropriate lead officers as well detailing progress and 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:

·  Clarification about the monitoring process for the quality and standards of care homes in the city

·  Concerns about the on-going financial viability of care homes in the current austerity climate and the introduction of the living wage

·  Whether there were any concerns about the viability of care homes in the city in light of press reports that national care home providers could withdraw services

·  Details about funding by the Council to care homes with financial difficulties

·  The use of regulatory tools where there were concerns about care homes and  ...  view the full minutes text for item 40.

Briefing Note of the Executive Director of People

Joan Beck, Independent Chair of the Safeguarding Adults Board has been invited to the meeting for the consideration of this item

The Scrutiny Board considered a briefing note appended to which was Coventry Safeguarding Adults Board Annual Report for 2014/15. The Board also received a presentation on the Annual Report from Joan Beck, Independent Chair of the Adults Safeguarding Board.

The Safeguarding Board was required to publish an annual report and business plan. The report provided an introduction to safeguarding; detailed the responsibilities of the Board; highlighted the key achievements of the individual sub-groups and reviewed progress against priorities. The report concluded with the Board’s business plan. A performance dashboard was set out at an appendix.   

The presentation set out the Board’s accomplishments; successes and challenges along with the priorities for the future. Accomplishments included the implementation of the Care Act, working more closely with other Boards, completing three multi-agency reviews and developing the performance dashboard. Priorities for the future included using performance information to drive improvement; Care Act compliance; Transforming Care; making safeguarding personal; and working across Boards.

Members expressed support for the excellent report and questioned about the importance placed on dealing with mental health issues.

RESOLVED that the Annual Report of the Coventry Safeguarding Adults Board for 2014/15 be noted.

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 year.

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.