Jacob Sulaiman
PFD Report
All Responded
Ref: 2018-0252
All 1 response received
· Deadline: 15 Oct 2018
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
15 Oct 2018
All responses received
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
(1) Response officers from Careline visited Mr Sulaiman twice during the night of 7/8 December 2017. It is not usual practice to leave a written record of those visits in the property.
(2) In addition, Mr Sulaiman made a number of calls to Wellbeing which were referred to response officers for guidance.
(3) Response officers only know about calls made to Wellbeing if the information is placed on the shared database. Response officers did not know the outcome of the paramedics’ visit in the early hours of 8 December when they visited at 3.40 am.
(4) Information regarding the nature and number of recent contacts with Wellbeing is not easily accessible to response officers dealing with an emergency call out.
(5) From the evidence before me, it is evident that the services which visited Mr Sulaiman on the night of 7/8 December 2017 had an incomplete picture of the number of other services that Mr Sulaiman had contacted and his presentation at those times. In particular, had the London Ambulance Service had more information regarding the nature and number of calls that Mr Sulaiman had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr Sulaiman was managed.
(2) In addition, Mr Sulaiman made a number of calls to Wellbeing which were referred to response officers for guidance.
(3) Response officers only know about calls made to Wellbeing if the information is placed on the shared database. Response officers did not know the outcome of the paramedics’ visit in the early hours of 8 December when they visited at 3.40 am.
(4) Information regarding the nature and number of recent contacts with Wellbeing is not easily accessible to response officers dealing with an emergency call out.
(5) From the evidence before me, it is evident that the services which visited Mr Sulaiman on the night of 7/8 December 2017 had an incomplete picture of the number of other services that Mr Sulaiman had contacted and his presentation at those times. In particular, had the London Ambulance Service had more information regarding the nature and number of calls that Mr Sulaiman had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr Sulaiman was managed.
Responses
Response received
View full response
RESPONSE TO REGULATION 28 CORONER’S REPORT TO PREVENT FUTURE DEATHS
1 THIS RESPONSE IS MADE ON BEHALF OF
London Borough of Camden
2 THIS REPORT IS BEING SENT TO
Sarah Bourke, Assistant Coroner for the coroner area of Inner North London
3 CORONER’S LEGAL POWERS
Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
4 INVESTIGATION AND INQUEST
On 12 December 2017, Assistant Coroner Heather Williams commenced an investigation into the death of Jacob Sulaiman aged 65. The investigation concluded at the end of the inquest on 6 July 2018.
In relation to how, when and where Mr Sulaiman came by his death, the investigation found that:
Mr Sulaiman sustained carbon monoxide poisoning after a fire started in his bedroom. He died at his home on 8 December 2017. The medical cause of death was:
1a carbon monoxide poisoning 1b inhalation of products of combustion
The coroner concluded that Mr Sulaiman’s death was the result of an accident.
5 CIRCUMSTANCES OF DEATH
The circumstances of death are set out in the Coroner’s Regulation 28 Preventing Future Deaths Report
6 CORONER’S CONCERNS
(1) Response officers from Careline visited Mr Sulaiman twice during the night of 7/8 December 2017. It is not usual practice to leave a written record of those visits in the property.
(2) In addition, Mr Sulaiman made a number of calls to Welbeing, which were referred to response officers for guidance.
(3) Response officers only know about calls made to Welbeing if the
information is placed on the shared database. Response officers did not know the outcome of the paramedics’ visit in the early hours of 8 December when they visited at 3.40 am.
(4) Information regarding the nature and number of recent contacts with Welbeing is not easily accessible to response officers dealing with an emergency call out.
(5) From the evidence before me, it is evident that the services which visited Mr Sulaiman on the night of 7/8 December 2017 had an incomplete picture of the number of other services that Mr Sulaiman had contacted and his presentation at those times. In particular, had the London Ambulance Service had more information regarding the nature and number of calls that Mr Sulaiman had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr Sulaiman was managed.
7. RESPONSE
(1) Response officers from Careline visited Mr. Sulaiman twice during the night of 7/8 December 2017. It is not usual practice to leave a written record of those visits in the property;
In the first visit, the Response Officers were called as Mr Sulaiman had fallen and they supported him back to bed, as he was not injured. The second visit was requested when Mr Sulaiman’s alarm was triggered and he did not answer. Response Officer’s found that he was safely in bed asleep. Neither of these visits were out-of-the-ordinary for Careline Response Officers. At the first visit Mr Sulaiman did talk of his passport and wanting to go to the airport, however he was redirected to get some rest in bed as the hour was late.
The visits were recorded on the Careline client database and the recording procedure is outlined below.
(2) Mr. Sulaiman made a number of calls to Welbeing which were referred to response officers for guidance;
The calls were triaged by Welbeing and were passed to Careline response Team when action was required, such as a visit. There were no calls between Welbeing and Careline for ‘guidance’ – although there were two ‘for information’ to let Careline know the emergency services had been called. First the LAS service at 23.10 and later LFB at 07.57 the following morning. There were three calls from Welbeing to Careline to request visits, two of which resulted in visits at 22.59 and 04.35. During the third call, Welbeing call handler and Careline Response Officers mutually agreed that as Mr Sulaiman had not fallen and was mobile enough to reach his entrance hall, a visit was not required. Both the Welbeing call handler and Careline Response Officers were aware of Mr Sulaiman’s desire to go to the airport and they agreed to redirect him and asked him return to his flat, due to the hour – 05.30am.
(3) Response officers only know about calls made to Welbeing if the information is placed on the shared database. Response officers did not know the outcome of the paramedics visit in the early hours of 8 December
when they visited at 3.40am;
Welbeing pass on information to response officers when there is likely to be a need for a visit. A call that does not result in a visit is not routinely passed on to Careline, as no action from them is required.
When LAS are called, they do not routinely report back to Welbeing, however in the case of Mr Sulaiman, his community alarm made contact with Welbeing while LAS were still in attendance and the paramedic confirmed to Welbeing that was Mr Sulaiman had no medical needs that required taking him to hospital.
(4) Information regarding the nature and number of recent contacts with Welbeing is not easily accessible to response officers dealing with an emergency call out;
Please see answers to paragraph 8 below. The service will be changing to address these gaps.
(5) From the evidence before the Coroner, the Coroner considered it was evident that the services, which visited Mr. Sulaiman on the night of 7/8, December 2017 had an incomplete picture of the number of other services that Mr. Sulaiman had contacted and his presentation at those times. In particular had the London Ambulance Service had more information regarding the nature and number of calls that Mr. Sulaiman had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr. Sulaiman was managed.
It is correct to say that none of the individuals attending Mr Sulaiman’s property on the night of his death had a full picture of all the calls that day, however, Welbeing were aware of, and coordinated the responses, whether they were remotely or in person.
The main concern of Response Officers and LAS in attendance were related to his physical health and his repeated falls. Mr Sulaiman was reported to be quite fixed on his plans to travel to the airport and return to The Netherlands. He was however able to be redirected to return to his flat and there was no evidence that he lacked capacity. During the night, none of interactions with Mr Sulaiman were such as to require intervention relating to his mental health.
8 ACTION TAKEN/TIMESCALE
The following response sets out current practice (and practice as it was in December 2017). There have since been identified improvements to the service, which are outlined below and are already underway.
Unlike Domiciliary Care providers who visit regularly to support people with practical care tasks and record their activity, Careline Response Officers visit on an ad hoc basis following a connection to Welbeing. There is no written record left in the individual’s home.
A Careline call can be triggered by way of an individual pressing their emergency call button, on the Careline unit in their residence, or if a sensor detects a fall etc.
The call handler at Welbeing will triage the call and make a decision if the Response Team are required to visit.
A visit by the Response Team is recorded on the local customer records management system held by Careline.
In the case of Mr Sulaiman, who lived in Sheltered Housing, a message would be left by the Response Team for the Scheme Manager to follow up on the next day’s shift. For people in Sheltered Housing, Careline Response Team provides out-of-hours support only.
The Welbeing call handlers do not call the Response Team for guidance, but rather when action is required. As above, they triage the call and make contact with the individual to find out why the sensor has been triggered. In many calls, the person just requires reassurance. In some it is evident that a call is required to be made directly to the emergency services and the call handler will do this – without any reference to the Careline Response Team.
If the individual is distressed or is in need on non-medical assistance (e.g. fallen and needs help to get up) the call handler will make the decision to contact the Response Team to despatch them for a visit.
If the emergency services have already been called, the Careline Response Team do not attend. There are occasions when the Response Team attend and make a further decision to call emergency services when they are on site.
The current system is not joined up as the call handing and response teams are separate services run by different organisations. Welbeing record their calls and Careline record their response. When there is an issue the Welbeing records are requested by Careline.
The Careline records are updated by the Response Officers who go out on the visit. Where follow-up is required from Adult Social Care, this is flagged on a further database.
If there have been multiple calls received, Welbeing will have access to that record and be able to see it when they open the individual’s file. This is a similar picture in Careline. If either make a decision to call the emergency service as a result, they would be expected to pass on this information.
There is currently no feedback mechanism for the London Ambulance Service to update Wellbeing or Careline.
In 2017, Camden Council made the decision to end the contract with Welbeing and to bring the call handling function back in house (It had been outsourced approximately 10 years earlier).
The decision was made, as it was believed that quality would be improved, as potential gaps in the service would be eliminated, if it was joined-up and one organisation would be responsible for the triage and despatch of the Response Team.
In preparation for this move, a new IT platform was required to support the
records management and mobile working, to ensure recording is timely and complete.
This change is well underway, migrating records to the new IT system and training staff, so that it will be in place before the end of 2018. As part of working practices, there will be a checklist for referring to the emergency services, including ensuring that a full history is given to London Ambulance Service when a call is made. Careline, which will now have a full history, will pass on all the information to LAS call centre, to be recorded as a part of the callout.
A Safeguarding Adults Review (SAR) is a multi-agency review process which seeks to determine what relevant agencies and individuals involved could have done differently that could have prevented harm or a death from taking place.
In the London Borough of Camden, we have a SAR review panel, which considers whether referrals meet the requirements for a SAR. Following the concerns raised by the Coroner, we feel it appropriate that a referral is made to the SAR panel for Mr Sulaiman’s case to be reviewed. We want to review the case to determine whether or not it meets the threshold for SAR or any further work outside the SAR processes that will lead to better multi- agency working.
The London Ambulance Service is represented on the Adults Safeguarding Board and we would expect them to participate in any SAR. In addition, the senior manager responsible for the Careline service has already made contact with LAS to begin discussions about how information could be better shared in future.
9 THIS RESPONSE HAS BEEN PREPARED BY
10 DATE OF RESPONSE
3rd October 2018
1 THIS RESPONSE IS MADE ON BEHALF OF
London Borough of Camden
2 THIS REPORT IS BEING SENT TO
Sarah Bourke, Assistant Coroner for the coroner area of Inner North London
3 CORONER’S LEGAL POWERS
Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
4 INVESTIGATION AND INQUEST
On 12 December 2017, Assistant Coroner Heather Williams commenced an investigation into the death of Jacob Sulaiman aged 65. The investigation concluded at the end of the inquest on 6 July 2018.
In relation to how, when and where Mr Sulaiman came by his death, the investigation found that:
Mr Sulaiman sustained carbon monoxide poisoning after a fire started in his bedroom. He died at his home on 8 December 2017. The medical cause of death was:
1a carbon monoxide poisoning 1b inhalation of products of combustion
The coroner concluded that Mr Sulaiman’s death was the result of an accident.
5 CIRCUMSTANCES OF DEATH
The circumstances of death are set out in the Coroner’s Regulation 28 Preventing Future Deaths Report
6 CORONER’S CONCERNS
(1) Response officers from Careline visited Mr Sulaiman twice during the night of 7/8 December 2017. It is not usual practice to leave a written record of those visits in the property.
(2) In addition, Mr Sulaiman made a number of calls to Welbeing, which were referred to response officers for guidance.
(3) Response officers only know about calls made to Welbeing if the
information is placed on the shared database. Response officers did not know the outcome of the paramedics’ visit in the early hours of 8 December when they visited at 3.40 am.
(4) Information regarding the nature and number of recent contacts with Welbeing is not easily accessible to response officers dealing with an emergency call out.
(5) From the evidence before me, it is evident that the services which visited Mr Sulaiman on the night of 7/8 December 2017 had an incomplete picture of the number of other services that Mr Sulaiman had contacted and his presentation at those times. In particular, had the London Ambulance Service had more information regarding the nature and number of calls that Mr Sulaiman had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr Sulaiman was managed.
7. RESPONSE
(1) Response officers from Careline visited Mr. Sulaiman twice during the night of 7/8 December 2017. It is not usual practice to leave a written record of those visits in the property;
In the first visit, the Response Officers were called as Mr Sulaiman had fallen and they supported him back to bed, as he was not injured. The second visit was requested when Mr Sulaiman’s alarm was triggered and he did not answer. Response Officer’s found that he was safely in bed asleep. Neither of these visits were out-of-the-ordinary for Careline Response Officers. At the first visit Mr Sulaiman did talk of his passport and wanting to go to the airport, however he was redirected to get some rest in bed as the hour was late.
The visits were recorded on the Careline client database and the recording procedure is outlined below.
(2) Mr. Sulaiman made a number of calls to Welbeing which were referred to response officers for guidance;
The calls were triaged by Welbeing and were passed to Careline response Team when action was required, such as a visit. There were no calls between Welbeing and Careline for ‘guidance’ – although there were two ‘for information’ to let Careline know the emergency services had been called. First the LAS service at 23.10 and later LFB at 07.57 the following morning. There were three calls from Welbeing to Careline to request visits, two of which resulted in visits at 22.59 and 04.35. During the third call, Welbeing call handler and Careline Response Officers mutually agreed that as Mr Sulaiman had not fallen and was mobile enough to reach his entrance hall, a visit was not required. Both the Welbeing call handler and Careline Response Officers were aware of Mr Sulaiman’s desire to go to the airport and they agreed to redirect him and asked him return to his flat, due to the hour – 05.30am.
(3) Response officers only know about calls made to Welbeing if the information is placed on the shared database. Response officers did not know the outcome of the paramedics visit in the early hours of 8 December
when they visited at 3.40am;
Welbeing pass on information to response officers when there is likely to be a need for a visit. A call that does not result in a visit is not routinely passed on to Careline, as no action from them is required.
When LAS are called, they do not routinely report back to Welbeing, however in the case of Mr Sulaiman, his community alarm made contact with Welbeing while LAS were still in attendance and the paramedic confirmed to Welbeing that was Mr Sulaiman had no medical needs that required taking him to hospital.
(4) Information regarding the nature and number of recent contacts with Welbeing is not easily accessible to response officers dealing with an emergency call out;
Please see answers to paragraph 8 below. The service will be changing to address these gaps.
(5) From the evidence before the Coroner, the Coroner considered it was evident that the services, which visited Mr. Sulaiman on the night of 7/8, December 2017 had an incomplete picture of the number of other services that Mr. Sulaiman had contacted and his presentation at those times. In particular had the London Ambulance Service had more information regarding the nature and number of calls that Mr. Sulaiman had made to Careline, this may have had some bearing on the steps taken to assess his mental capacity and how Mr. Sulaiman was managed.
It is correct to say that none of the individuals attending Mr Sulaiman’s property on the night of his death had a full picture of all the calls that day, however, Welbeing were aware of, and coordinated the responses, whether they were remotely or in person.
The main concern of Response Officers and LAS in attendance were related to his physical health and his repeated falls. Mr Sulaiman was reported to be quite fixed on his plans to travel to the airport and return to The Netherlands. He was however able to be redirected to return to his flat and there was no evidence that he lacked capacity. During the night, none of interactions with Mr Sulaiman were such as to require intervention relating to his mental health.
8 ACTION TAKEN/TIMESCALE
The following response sets out current practice (and practice as it was in December 2017). There have since been identified improvements to the service, which are outlined below and are already underway.
Unlike Domiciliary Care providers who visit regularly to support people with practical care tasks and record their activity, Careline Response Officers visit on an ad hoc basis following a connection to Welbeing. There is no written record left in the individual’s home.
A Careline call can be triggered by way of an individual pressing their emergency call button, on the Careline unit in their residence, or if a sensor detects a fall etc.
The call handler at Welbeing will triage the call and make a decision if the Response Team are required to visit.
A visit by the Response Team is recorded on the local customer records management system held by Careline.
In the case of Mr Sulaiman, who lived in Sheltered Housing, a message would be left by the Response Team for the Scheme Manager to follow up on the next day’s shift. For people in Sheltered Housing, Careline Response Team provides out-of-hours support only.
The Welbeing call handlers do not call the Response Team for guidance, but rather when action is required. As above, they triage the call and make contact with the individual to find out why the sensor has been triggered. In many calls, the person just requires reassurance. In some it is evident that a call is required to be made directly to the emergency services and the call handler will do this – without any reference to the Careline Response Team.
If the individual is distressed or is in need on non-medical assistance (e.g. fallen and needs help to get up) the call handler will make the decision to contact the Response Team to despatch them for a visit.
If the emergency services have already been called, the Careline Response Team do not attend. There are occasions when the Response Team attend and make a further decision to call emergency services when they are on site.
The current system is not joined up as the call handing and response teams are separate services run by different organisations. Welbeing record their calls and Careline record their response. When there is an issue the Welbeing records are requested by Careline.
The Careline records are updated by the Response Officers who go out on the visit. Where follow-up is required from Adult Social Care, this is flagged on a further database.
If there have been multiple calls received, Welbeing will have access to that record and be able to see it when they open the individual’s file. This is a similar picture in Careline. If either make a decision to call the emergency service as a result, they would be expected to pass on this information.
There is currently no feedback mechanism for the London Ambulance Service to update Wellbeing or Careline.
In 2017, Camden Council made the decision to end the contract with Welbeing and to bring the call handling function back in house (It had been outsourced approximately 10 years earlier).
The decision was made, as it was believed that quality would be improved, as potential gaps in the service would be eliminated, if it was joined-up and one organisation would be responsible for the triage and despatch of the Response Team.
In preparation for this move, a new IT platform was required to support the
records management and mobile working, to ensure recording is timely and complete.
This change is well underway, migrating records to the new IT system and training staff, so that it will be in place before the end of 2018. As part of working practices, there will be a checklist for referring to the emergency services, including ensuring that a full history is given to London Ambulance Service when a call is made. Careline, which will now have a full history, will pass on all the information to LAS call centre, to be recorded as a part of the callout.
A Safeguarding Adults Review (SAR) is a multi-agency review process which seeks to determine what relevant agencies and individuals involved could have done differently that could have prevented harm or a death from taking place.
In the London Borough of Camden, we have a SAR review panel, which considers whether referrals meet the requirements for a SAR. Following the concerns raised by the Coroner, we feel it appropriate that a referral is made to the SAR panel for Mr Sulaiman’s case to be reviewed. We want to review the case to determine whether or not it meets the threshold for SAR or any further work outside the SAR processes that will lead to better multi- agency working.
The London Ambulance Service is represented on the Adults Safeguarding Board and we would expect them to participate in any SAR. In addition, the senior manager responsible for the Careline service has already made contact with LAS to begin discussions about how information could be better shared in future.
9 THIS RESPONSE HAS BEEN PREPARED BY
10 DATE OF RESPONSE
3rd October 2018
Report Sections
Investigation and Inquest
On 12 December 2017, Assistant Coroner Heather Williams commenced an investigation into the death of Jacob Sulaiman aged 65. The investigation concluded at the end of the inquest on 6 July 2018.
In relation to how, when and where Mr Sulaiman came by his death, I found that: Mr Sulaiman sustained carbon monoxide poisoning after a fire started in his bedroom. He died at his home on 8 December 2017.
I found that the medical cause of death was: 1a carbon monoxide poisoning 1b inhalation of products of combustion.
My conclusion was that Mr Sulaiman’s death was the result of an accident.
In relation to how, when and where Mr Sulaiman came by his death, I found that: Mr Sulaiman sustained carbon monoxide poisoning after a fire started in his bedroom. He died at his home on 8 December 2017.
I found that the medical cause of death was: 1a carbon monoxide poisoning 1b inhalation of products of combustion.
My conclusion was that Mr Sulaiman’s death was the result of an accident.
Circumstances of the Death
Mr Sulaiman had a long history of mental health problems and alcohol dependence. He also had poor mobility and used walking aids. He was a smoker. He lived in Robert Morton House which is a retirement housing scheme and subscribed to the Careline Telecare Service (“Careline”) which is a push button intercom service provided by Camden Council. Intercom calls connect to the manager of Robert Morton House during office hours. Out of hours, the service connects to “Wellbeing Lifeline” (“Wellbeing”) who can ask response officers employed by Careline to visit the service user if required. Mr Sulaiman was well known to make repeated calls to emergency services and Careline during episodes of low mood, particularly if he was intoxicated. During these calls, he would sometimes express suicidal thoughts. In November 2017, he had 2 hospital admissions related to falls. On 21 November 2017 he was taken to St Mary’s Hospital after contacting Careline stating that he wanted to die. He was discharged a few hours later. On 7 December 2017, he was again taken to St Mary’s Hospital after repeatedly pressing his call alarm. He was aggressive to hospital staff and denied any thoughts of harming himself. He returned home on the morning of 8 December. During the course of the day, he made a number of Careline calls to the manager of Robert Morton House. In addition, he also contacted the Police. When police officers attended the property during the early evening of 8 December, Mr Sulaiman asked them what the point in living was and stated that he wanted to return to Holland. Mr Sulaiman told police officers that he did not want to be taken to hospital and instead went to bed. The police officers asked for the out of hours GP to contact them and left Mr Sulaiman in the property. At 9.50 pm Wellbeing contacted Careline response officers as they had received a call from Mr Sulaiman but he had not responded when they had tried to speak to him. Response Officers visited the flat and found Mr Sulaiman on the floor next to the bed. He was confused. He wanted his passport and asked to be taken to the airport. At 11.10 pm Wellbeing contacted response officers as Mr Sulaiman had contacted them to say that he was on the floor again. Response officers asked Wellbeing to call the London Ambulance Service due to Mr Sulaiman’s responses and repeated falls. When paramedics attended at 12.10 am on 9 December Mr Sulaiman did not express any thoughts of harming himself and declined to be taken to hospital. He did however, ask if paramedics would take him to the airport so that he could return home. Mr Sulaiman made further contact with Wellbeing whilst paramedics were at the property. Paramedics updated Wellbeing during the course of that conversation. At 3.40 am Mr Sulaiman again activated his call alarm. He did not respond to Wellbeing. Response Officers attended at 4.06 am and found Mr Sulaiman asleep in bed. At 5.30 am Wellbeing contacted response officers to say that Mr Sulaiman had called from the entrance hall of Robert Morton House stating that he was waiting for a taxi to take him to the airport. Response officers advised that Wellbeing should suggest that Mr Sulaiman return to his flat and wait for the taxi there. At 7.44 am remote monitoring detected that the smoke and heat alarms in Mr Sulaiman’s flat had been activated. The London Fire Brigade was called. Mr Sulaiman was found sitting in a chair in the living room. He was unresponsive. Resuscitation was attempted but Mr Sulaiman died at the scene. The fire investigator found that the fire was likely to have started when a naked flame was applied to combustible material in Mr Sulaiman’s bedroom. It is unclear whether the fire had started as a result of an attempt to light a cigarette or whether Mr Sulaiman had deliberately started a fire as an attempt to get help to return to Holland from the Fire Service.
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