Jake Baker
8 Feb 2024 · Coroner Caroline Topping · Surrey
The coroner's concerns
1. inadequate pathway plan for care leavers
“The issues surrounding the inadequacy of [the deceased]'s pathway plan have not been addressed comprehensively in the last 4 years. Training for personal advisers is not mandatory and is only now being rolled out. The court was not provided with copies of the training or any protocol in relation to it so as to be assured of the adequacy of the training and its implementation.”
2. opaque learning disability diagnosis process
“The process by which diagnoses of learning disabilities can be obtained remains opaque. There is no protocol in relation to this. The current situation leaves those making decisions in relation to young people struggling to obtain this vital information.”
3. confusion and delays in accessing adult social care assessments
“The issue of how the numerous adult social care teams are accessed to obtain adult social care assessments for care leavers leads to confusion and delays. Vulnerable care leavers are at risk of being denied necessary support.”
4. lack of protocol for internal and review meetings
“How internal meetings and formal review meetings with other interested parties are informed and recorded is not subject to a protocol and the risk remains that decisions will be taken without adequate information and inquiry as to the risks inherent in those decisions.”
5. absence of practice standards for risk assessments of care leavers
“Practice standards have not been put in place in relation to risk assessments of care leavers to inform their needs.”
6. inadequate Mental Capacity Act training in children's services
“Mental Capacity Act training is not mandatory in children's services and the adult services have no audit of the effectiveness of the mandatory training provided and how it is being used in practice. There is therefore a risk that erroneous assumptions as to capacity will continue to be made.”