Linda Sitch

“Although not determined to be probably causative of the death, by the date of [the deceased]'s death ASC had failed to respond substantively or at all to the Adult Safeguarding Referral dated 29th September 2023; the referral for a Carer's Assessment for [the deceased] herself, received by ASC on 2nd October 2023; the concerns reiterated by [the deceased]'s family when chasing the 2nd October referral on 16th October 2023. These failures were explained as 'human error'.”

“in her statement prepared for the purposes of the inquest), confirmed that the Team Manager responsible for downgrading the Priority 1 status of the carer's assessment referral on 2nd October to Priority 2, without recording a rationale, had likely done so without undertaking the required consideration of either the readily available ASG referral of the 29th September, or the Mental Health Act assessment of [the deceased] herself from the previous year. She agreed that, had an estimated "ten minute" review”

“Absent a sufficiently robust system for providing oversight and identifying and significantly mitigating (if not entirely removing) such individual human error, alongside, for example, the inclusion of simple auditable check lists of matters to be accessed, reviewed and documented whenever a referral is received, then there is a continuing risk of urgent future referrals being inappropriately graded as Priority 2 (and/or being downgraded from Priority 1) without the requisite thorough and professional”