Dear Sir,

Inquest touching upon the death of Hadley Savory Kent County Council response to the Regulation 28 Report to Prevent Future Deaths

I am providing this further response to the Regulation 28 Report to Prevent Future Deaths that you issued to Kent County Council (KCC) and following my preliminary response dated 6th October 2021. I apologise for the delay in providing a final response but have been awaiting the conclusion of the review referenced in my first letter in order to fully respond to your matters of concern 1, 4 and 5. I set out below for ease of reference those matters of concern as they appear in your PFD Report together with KCC’s responses.

There was no evidence of a multi-agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September
2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care, and physical health needs.

Multi-agency planning:

Having reviewed the records, it appears that there were discussions between agencies and professionals and with Mr Savory himself regarding his discharge from hospital, but it is accepted that there is no evidence of a formal multi-agency planning meeting. It has been identified through review that a multi-agency meeting was required due to the various needs that Mr Savory had and that all agencies needed to joint work to fully consider how these impacted together. Mr Savory required a plan detailing how to support him and all the factors that affected his life.

Mr Savory had multiple needs, and these needed to be considered in tandem by all agencies. To support this now, there are multi-agency protocols in place around co- occurring conditions. An ‘Operational Protocol for Co-occurring Conditions (Mental Health and Substance Misuse Disorders)’ has been developed by Kent and Medway NHS and Social Care Partnership Trust (KMPT) with representatives from Kent and Medway Substance Misuse Services (including Forward Trust, Change Grow Live and Turning Point) and KCC Public Health. This protocol was published in November 2021 and states this as its purpose:

“This operational protocol is designed to give a clear framework within which all Kent and Medway Substance Misuse Services and Mental Health providers can operate with regard to providing comprehensive service user focused services to those with Co-existing Mental Health and Substance Misuse Disorders (Dual Diagnosis)”

When there are disagreements between agencies around decisions being made, the Safeguarding Adults Board (SAB) ‘Resolving Practitioner Differences: Escalation Policy for Referrals and Adult Safeguarding’ can be utilised. This Policy was reviewed and updated in July 2022; the purpose of the policy sets out when and how differences must be addressed:

“Members of the Safeguarding Adults Board are clear that whenever a practitioner, agency or service has a concern about the action or inaction of another, this must be addressed, and any challenges conducted in a professional and respectful manner. Practitioners and managers should always be prepared to review decisions and plans with an open mind”

Links to the SAB website and policies are provided on the KCC Safeguarding webpage.

Multi-agency procedures for safe discharge of patients with concurrent needs:

Following the sad death of Mr Savory and due to changes to practice following COVID, KCC updated its ‘Hospital Discharge Service Policy and Operating Model’. This new policy and operating model is designed to support the full implementation of discharge, and to aide this a set of discharge guidance action cards has been developed to summarise responsibilities for key roles within the hospital discharge process.

The policy sets out three clear stages of discharge and these provide the need for acute and community health and social care to work in a fully synchronised way to ensure people are discharged in a timely manner but also to ensure that any social care assessments can commence at the first opportunity once a person has been discharged.

There will be named leads for each Acute and Community Hospital which will be the KCC Short Term Pathways (STP) Team Manager, supported by the Senior Practitioner and Social Care Discharge Co-Ordinator in the first instance with escalation if required to the area Service Manager within STP. The expectation is that these named leads will attend discharge management meetings and together with health colleagues will provide social care advice and information, guidance as well as influencing and supporting the decision making process of the Multi-Disciplinary Teams (MDTs) for safe discharges of people via Discharge to Assess.

People/patients who require social care support/assessment will be identified at the MDTs and accepted as a referral via the Ready to Transfer (RTT) form. This new policy helps to ensure that individuals’ needs are identified and considered pre and post discharge from hospital to ensure that physical and social needs are factored in within the discharge process.

The evidence demonstrated that there was a lack of clarity as to the interrelationship between safeguarding duties under the Care Act and the operation of the Kent and Medway Multi-Agency Policy and Procedures to Support People that Self-Neglect or Demonstrate Hoarding Behaviour.

In the 3 years following the sad passing of Mr Savory, there has been considerable work undertaken around the area of self-neglect.

Kent and Medway Safeguarding Adults Board have recently published their updated ‘Policy and Procedures to Support People that Self-Neglect or Demonstrate Hoarding Behaviour’. Following this update, a briefing was sent to all Adult Social Care staff on 6th October 2022 and the changes were highlighted within that communication.

This self-neglect policy now includes clearer categories of low, medium, and high risk. The policy makes clear the need for practitioners to have awareness of different duties and powers provided by legislation and of enforcement powers where necessary. There is also greater clarity around medium risk instances that do not meet the criteria for a Care Act 2014 section 42 safeguarding enquiry and how to manage these.

In addition, KCC is currently developing a new self-neglect workflow within Mosaic (KCC information system). It is envisaged that this new workflow can be started at any point during Adult Social Care intervention with the person and will provide a complete summary of all actions taken related to self-neglect. The implementation of this workflow is anticipated by January 2023.

KCC has also continued to undertake activities to raise practitioners’ awareness around the important subject of self-neglect and the importance of acting appropriately in response. These have included:

• Specific self-neglect and hoarding training courses,
• A briefing around a published Safeguarding Adults Review (SAR) concerning self- neglect,
• Practitioner events discussing self-neglect with substance abuse and homelessness,
• A new self-neglect e-learning course and
• A section 11 Care Act briefing about when people decline or refuse an assessment and there are concerns about abuse, neglect, or mental capacity. It was unclear as to how information sharing operated in respect of service users who are identified as potentially having fluctuating mental capacity in respect of their care and support needs.

In review, the issue of information sharing appears inter-linked with the multi-agency working comments earlier in this letter. As agencies were not working together to discuss plans and options, they equally were not sharing the information that they each possessed regarding Mr Savory’s fluctuating capacity. Sharing information in this way in addition to breaking down decisions to a micro level should support a better understanding of capacity to make macro decisions such as decisions relating to residence and care.

The importance of assessing capacity at a micro level will be added to KCC training and learning resources in relation to capacity assessments. The following measures have already been taken to ensure that appropriate training and learning opportunities regarding mental capacity assessments and addictions are available to KCC practitioners:

• There is a Mental Capacity Assessment advanced training course which includes completions of complex capacity assessments. Learning and Development colleagues have confirmed that Information on substance misuse is included in the course content from November 2022,

• Within the Adult Social Care Core Skills Programme, ‘Topic 3’ includes an outline on responsibilities within the Mental Capacity Act for social care staff,

• All Adult Social Care staff can access on the Safeguarding KNet (KCC intranet) and Kent Academy Training pages the learning from tragedies and

• The Strategic Safeguarding Team have recently completed over 40 internal team talks across KCC. As part of these talks, teams were advised of the work that the Strategic Safeguarding Team complete and advised of the resources that are available on KNet and Training pages.

T h e n e e d f or a g e n ci e s t o pr o m ot e tr a n s p ar e n c y, a c c o u nt a bilit y, e vi d e n c e of d e ci si o n - m a ki n g pr o c e s s e s, a n d pr o m oti n g a n a p pr o pri at e l e v el of i nt er v e nti o n t hr o u g h a m ulti - a g e n c y a p pr o a c h ar e all k e y a s p e ct s of t h e af or e m e nti o n e d K M S A B ‘ P oli c y a n d Pr o c e d ur e s t o S u p p ort P e o pl e t h at S elf -N e gl e ct or D e m o n str at e H o ar di n g B e h a vi o ur’ w hi c h w a s u p d at e d i n S e pt e m b er 2 0 2 2.

I nf or m ati o n s h ari n g s h o ul d b e m or e r o b u st u n d er t h e s e n e w/r e vi s e d p oli ci e s a n d pr o c e d ur e s. I n a d diti o n, K C C r e m ai n c o m mitt e d t o a p pr o pri at e i nf or m ati o n s h ari n g b y c o nti n ui n g t o b e a si g n at or y o n t h e K e nt a n d M e d w a y I nf or m ati o n P art n er s hi p, w hi c h pr o m ot e s o p e n n e s s a n d tr a n s p ar e n c y i n i nf or m ati o n s h ari n g, a s w ell a s a p pr o pri at e g o v er n a n c e a n d s u p p ort, w hi c h a s si st s u s t o s h ar e p er s o n al i nf or m ati o n l a wf ull y, s af el y, a n d s e c ur el y.

K C C al s o w or k c oll a b or ati v el y wit h t h e K e nt a n d M e d w a y S af e g u ar di n g A d ult s B o ar d a n d a d h er e t o all m ulti -a g e n c y p oli ci e s s u c h a s t h e K M S A B g ui d a n c e c all e d ‘ A q ui c k g ui d e - l e g al b a si s f or i nf or m ati o n s h ari n g a n d w h at c a n l a wf ull y b e s h ar e d’. T hi s g ui d e w a s u p d at e d i n M a y 2 0 2 2.

All st aff m e m b er s wit hi n A d ult S o ci al C ar e r e c ei v e m a n d at or y s af e g u ar di n g a w ar e n e s s tr ai ni n g w hi c h e m p h a si s e s t h e i m p ort a n c e of u n d er st a n di n g t h e C ar e a n d S u p p ort St at ut or y G ui d a n c e f or s af e g u ar di n g. I n a d diti o n, t h er e ar e f urt h er v ari o u s c o ur s e s pr o vi d e d , w hi c h i n cl u d e i nf or m ati o n o n l e g al fr a m e w or k s s u c h a s t h e C ar e A ct 2 0 1 4, M e nt al C a p a cit y A ct 2 0 0 5, H u m a n Ri g ht s A ct 1 9 9 8, a n d t h e D at a Pr ot e cti o n A ct 2 0 1 8. All of t h e s e l e g al fr a m e w or k s will h a v e r el e v a n c e t o a p er s o n’ s w ell b ei n g a n d e m p h a si s e t h e i m p ort a n c e of a p pr o pri at e i nf or m ati o n s h ari n g.

I tr u st t h at t h e i nf or m ati o n c o nt ai n e d i n t hi s a n d m y pr e vi o u s r e s p o n s e t o y o ur P F D R e p ort pr o vi d e a d e q u at e a s s ur a n c e t o y o u t h at K C C h a s t a k e n st e p s t o u n d er st a n d a n d a d dr e s s y o ur m att er s of c o n c er n, b ot h i nt er n all y a n d i n p art n er s hi p wit h ot h er a g e n ci e s, a n d will c o nti n u e stri vi n g t o i m pr o v e t h e ar e a s i d e ntifi e d.

Y o ur s f ait hf ull y

C or p or at e Dir e ct or – A d ult S o ci al C ar e a n d H e alt h