Agenda item

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 not been passed between agencies and staff during Mrs E’s receipt of care.  Clarification that processes have been put in place to ensure a repeat of the communication issues in this case do not happen again was sought.

·  The Board explored the role of the family, as the guaranteed constant for a patient and therefore the importance of all agencies listening to their views. They questioned how much notice was taken of information provided by families.

·  Person centred care was discussed at length to seek assurance that the individual would be considered when planning care and each organisation was asked to explain what they were doing to ensure they had time to care for the individual.

·  Clarification on hospital discharge procedures and whether these had been amended since Mrs E’s death.

·  In complex cases with multiple agencies involved, who took responsibility to ensure a patient was taken through the correct healthcare pathway for that individual between the hospital and the community.  There was concern that there was often not a clear lead professional who was co-ordinating care.

·  Questions were asked about how to ensure that all staff treat patients and their families with dignity and respect.

RESOLVED that:

(1) The findings of the Serious Case Review and the recommendations, actions and progress in the action plans be noted.

(2) A letter be sent to the family of Mrs E expressing the Board’s condolences for their loss and thanking them for their moving and informative statement.

(3) The Cabinet Member for Health and Adult Services be requested to reiterate to the Coventry Safeguarding Adults Board the importance of ensuring that all the health organisations take account of the views of families, neighbours and carers relating to an individual’s care and that all the concerns raised about communications in this case are also addressed by those agencies involved.

(4) A progress report be submitted to a future meeting of the Board in six months.