William Lugg
25 Jun 2018 · Coroner Heather Williams QC · London Inner (North)
The coroner's concerns
1. failed care visits during weekend
“Tower Hamlet's Failed Visits Procedure was poorly understood and not followed by Careworld staff”
2. inconsistent failed visits procedures
“Careworld's own Failed Visits Procedure does not mirror or reflect aspects of Tower Hamlet's prescribed procedure”
3. missing keyholder contact details
“Vital information regarding the identity of and contact details for the only other keyholder to the premises in this instance was not clearly recorded by either Tower Hamlets or Careworld”
4. inadequate call recording
“No adequate record of calls from a carer to the Careworld Care Co-ordinator regarding failed visits was made”
5. lack of police involvement guidance
“Neither Tower Hamlets or Careworld's Failed Visits policy gives any / any sufficient prominence to the possibility of involving the police if other attempts to confirm the individual's welfare following a failed visit have proved unsuccessful”
6. unclear referral priority system
“The absence of a clear / clearly understood system for the Adult Social Care Team to use on a Monday morning for assessing and deciding the priority of referrals from the Out of hours service made over the weekend (and for recording this decision-making)”