Regina Ademiluyi
22 Mar 2024 · Coroner Graeme Irvine · East London
The coroner's concerns
1. deprivation of state-funded domiciliary care
“From October 2023 until her death in March 2024, [the deceased] was deprived of the state-funded domiciliary care to which she was entitled”
2. insufficiently detailed safeguarding report
“A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased”
3. failure to seek further information
“When faced with the limited information withing the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report”
4. lack of mental capacity assessment
“The Trust failed to formally assess Mrs [name redacted] mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice”
5. absence of carer assessment
“Despite the concerns raised regarding the behaviour of Mrs [name redacted] daughter no effort was made to offer a carer assessment to address whether she was overwhelmed by the task in hand”
6. lack of remediation and reflection
“no meaningful reflection or remediation had been undertaken by the Local Authority into the failings in care by the time of the inquest almost a year later”
Responses
2024-0161-Response-from-East-London-NHS-Foundation-Trust.pdf ↗· East London Foundation NHS Trust
Stated action · monthly
“The Trust recognises that all public bodies are currently under pressure. Therefore, it is more important than ever that they (the public bodies) work together to ensure that vulnerable adults do not slip through the net.”
2024-0161-Response-from-London-Borough-of-Newham.pdf ↗· East London Foundation NHS Trust
Stated action · 7th May 2024
“Immediate s.44 Safeguarding Adult Review (SAR) Team Manager 27.03.24 Referral completed and submitted for presentation at Neighbourhood the next SAR subcommittee of Newham's Team Safeguarding Adults Board on 7th May 2024”
Stated action · July 2024
“Review and improve training and awareness of Strategic July 2024 pressure care and risks for ASC staff. This will Safeguarding, include: Practice and - Incorporating mandatory pressure care Workforce refresher training for all Operational ASC staff Development into 2024/25 training plan.”
Stated action · December 2024
“Convene focussed reflective practice sessions for Strategic December frontline operational staff based around Safeguarding, 2024 circumstances highlighted in Mrs [name redacted] care, Practice and thematically orientated”
Stated action · June 2024
“Creation of an anonymised '7 minute briefing' note Strategic June 2024 concerning the lessons learned from this case for Safeguarding, circulation across all Adults and Health staff groups”
Stated action · End of May 2024
“with double- Direct End of handed packages for indicators of under-utilisation of Payments May 2024 care. Team Through 2022/23 work took place to review and improve DP monitoring processes with a series of changes coming into effect from August 2023. This included an increase to the number of established posts for DP Monitoring Officers. This has allowed for faster feedback to operational teams on any future monitoring issues/irregularities”
Stated action · December 2024
“Undertake a review of the Council's Direct Payment Direct December Policy, and develop associated practice guidance Payments 2024 (including a practitioner checklist).”